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Cardiopulmonary > Lymphedema > Flashcards

Lymphedema Flashcards

1
Q

Lymphedema Definition

A
  • Abnormal accumulation of protein rich fluid and water
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2
Q

What 4 things does lymphatic load made up of?

A
  • Water
  • Protein
  • Fatty Acids
  • Cells
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3
Q

What are the two functions of the lymphatic system?

A
  • Immune response (defense - bacteria, viruses, fungi and toxins)
  • Facilitates fluid movement from tissues back to circulatory system
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4
Q

Superficial Lymphatic Vessels

Initial lymphatic vessels

A
  • Located in subcutaneous layer of skin, mucous membrane and almost all tissues and organs of body (Not CNS and retina)
  • Drain lymphatic load from skin
  • 1 mm deep; larger than capillaries
  • Lymph formation begins here
  • Pressure opens vessels (external - manual or internal fluid pressure)
  • No valves (flow in either direction)
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5
Q

Describe how movement allows fluid into lymphatics

A
  • It is like a puzzle piece. The corners of the puzzle have anchors. When the anchors are pulled opens the piece allowing for fluid to come in. When pressure comes off the anchoring filaments goes back to normal puzzle piece.
  • Any cell debris, FA, proteins and water can get in
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6
Q

Pre-Collectors

A

Two types:
- Connects initial vessels to superficial collectors
- Connects initial vessels to perforating deep collector

Role of Pre-Collector:
- Connect initial lymph vessels to lymph collectors

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7
Q

Collectors

A
  • Transport lymph to larger vessels (lymph nodes and lymphatic trunks)
  • Have valves and Smooth Muscle (Unidirectional flow)
  • .1-.6 mm diameter
  • Drain body areas and run directly to regional lymph nodes
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8
Q

Lymphangion

A
  • Valve to valve in the collector = lymphangion
  • Smooth muscle helps with unidirectional flow
  • Facilitates movement
  • Autonomic System
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9
Q

Lymphangiomotoricity

A

stretch by filling lead to response contraction (Autonomic contraction)

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10
Q

What are lymphagions influenced by?

A
  • Muscle contractions (pumps) of LE and UE (tension on skin)
  • Pulsations of adjacent arteries
  • Changes in abdominal/thoracic pressure
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11
Q

How many time do lymphangions pulsate?

A
  • Pulsate 10-12 times/min (1x every 6 sec)
  • Increase rate with additional lymph formation
  • Can increase up to 60x/min (Safety factors to deal with increased loads)
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12
Q

What are the three regional lymph nodes?

A
  • Head: Cervical Nodes (Neck)
  • UE: Axillary Nodes (Armpit)
  • LE: Inguinal Nodea (Groin)
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13
Q

Lymph Nodes

A
  • Born with 600-700
  • Do NOT regenerate
  • Age related changes (decline in function)
  • Lymph moves slowly here (More afferents than efferents)
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14
Q

What are the functions of the lymph nodes?

A

Immunologic Functions
* Filter
* Defense substances (immune)

Concentrate Lymph (some water removed as it is reabsorbed)

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15
Q

Inguinal Lymph Nodes

A
  • 6-12 Nodes
  • Located in femoral triangle (Inguinal ligament, gracilis, sartorius
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16
Q

What drains into the inguinal nodes?

A

Legs, external genitalis, lower body quadrants (umbilical area to floating ribs and below)

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17
Q

From the inguinal node, where does the lymph fluid travel?

A
  • Inguinal node -> pelvic nodes -> lumbar trunk -> cisterna chyli -> thoracic duct -> L venous angle
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18
Q

How many axillary nodes are there?

A
  • 10-24
  • Located between pectoralis and Lat Dorsi
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19
Q

What drains into the axillary nodes?

A
  • Upper quadrants of the trunk
  • UE
  • 75% mammary gland

Belly buttom to the false ribs and above.

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20
Q

From the axillary node, where does the lymph fluid travel

A
  • Axillary node -> subclavian trunk -> R and L venous angle (entrance of venous system)
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21
Q

How many deep cervical nodes are there?

A

3 chains
* Accessory (drains through supraclavicular before reaching venous angle)
* Jugular
* Supraclavicular

Lateral cervical traingle: SCM, Upper Trap, Clavicle

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22
Q

What are the two lymphatic trunks?

A
  • Thoracic Duct: 10-18 inches long, drains 2000 mL/day -> L venous angle
  • R Lymphatic duct: 1-1.5 cm long, drains 300 mL/day -> R venous angle
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23
Q

R vs L Venous Angle

A
  • R Venous Angle: Drains R head, R UE, R Upper Quadrant (Ant/Post)
  • L Venous Angle: Drains 75% of body, both LE, L UE, both lower quadrants, L upper quadrant, L head
Shaded is R Venous Angle (Much less drainage), Brighter is L Venous Angle
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24
Q

What is the Terminus

A

Junction of the internal jugular and subclavian veins

Cannot palpate; underneath clavicle

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25
Q

What level is the Cisterna Chyli at?

A
  • T11-L2 level
  • Dialated sac at the lower end of the thoracic duct
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26
Q

____ transports lipids absorbed from the intestine to tissues

A

chylomicrons

Long Chain Fatty Acids

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27
Q

Watersheds

A
  • Lines that seperate territories on the body (pictured in yellow)
  • 4 of them: Sagittal (ant & post), Upper Horizontal (ant & post), Lower Horiz (ant & post), Gluteal
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28
Q

Territories

A
  • 4 Quadrants (territories) on trunk
  • Collectors drain to regional nodes
    – Head -> cervical nodes
    – Upper Q -> axillary nodes
    – Lower Q -> inguinal nodes
  • Extremities are called bundles not territories
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29
Q

Collectors - generally ____ watersheds

A

do NOT cross

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30
Q

Anastomoses

A
  • Connections between lymphatic vessels of 2 adjacent territories
  • Typically dormant
  • 7-10 collectors; hand width
  • Use to reroute lymph around impaired or absent nodes/vessels
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31
Q

What are the 5 Anastomoses?

A
  • Anterior axillo-axillary
  • Posterior axillo-axillary
  • Axillo-inguinal (AI or IA; anterior only)
  • Anterior inter-inguinal
  • Posterior inter-inguinal
32
Q

What are the 4 LE Bundles?

A
  • Lateral thigh bundle
  • Medial thigh bundle
  • Ventro-medial bundle (15 collectors)
  • Dorso-lateral (6 Collectors)
33
Q

What does the ventro-medial bundle drain?

A
  • Drains plantar surface of feet
  • Medial malleolus
  • Anterior lower leg
  • Bottle neck near medial femoral condyle
  • Progress toward inguinal nodes
34
Q

What does the dorso-lateral bundle drain?

A

Lateral malleolus
Narrow strip from achilles tendon (calf to popliteal fossa)

35
Q

When considering Lymphedema treatment, what do you need to do before starting?

A

Develop a “map” to move lymph fluid from congested area to noninvolved area

36
Q

Why do some lymphedema patients have hard skin if it is swollen?

Pathophysiology - Lymphedema

A
  • Protein rich fluid accumulates in tissues (swells)
  • Proteins out in the tissues produces an inflammtory response. Macrophages then produce cytokines which stimulates fibroblasts. Fibroblasts create more connective tissue resulting in thick skin.
37
Q

What is a functional reserve?

A
  • Safety Factor
  • Capacity to carry lymph fluid
  • Normally have much more capacity than fluid
38
Q

When is mechanical insufficency?

A
  • Someone has more lymphatic load then transport capacity

Due to:
* Surgery
* Radiation
* Trauma
* Congenital malformation
May cause changes/damage to:
* Vessel walls
* Valves
* Vessl obstruction
* Lymphagion spasm
* Vessel absence
* Vessel disruption

39
Q

What populations do we need to screen for Lymphedema?

A
  • Breast Cancer and Prostate Cancer pts.
40
Q

S & S of Lymphedema

A
  • Swelling
  • Discomfort
  • Numbness/tingling
  • Pressure/tightness of skin
  • Heaviness of limb
  • Increased infections
  • Impaired wound healing
41
Q

Primary causes of Lymphedema

A
  • Congenital or hereditary
  • Aplasia
  • hypoplasia
  • Hyperplasia
42
Q

Aplasia

A

missing structures

43
Q

Hypoplasia

A

Incomplete development of lymph vessels

44
Q

Hyperplasia

A

Diameter too large; valves don’t close

45
Q

Example of Primary Lymphedema

A
  • Milroy’s disease
  • Begins in infancy and causes lymph nodes to form abnormally
46
Q

Secondary Lymphedema

A
  • Acquired damage or disease of the intact lymphatic system
  • Ex: Surgery or trauma (severe burn)
47
Q

Acquired Lymphedema

A
  • Filaria: parasitic threadworm
  • Parasite inside of mosquito bite gets into body. Grows too big and doesn’t allow for movement
48
Q

How to Dx Lymphedema

A

Can be down without special tests
1. Pt Hx
2. Systems Review
3. Tests and measure - inspection and palpation and girth measurements

49
Q

Special tests (X-rays) - Lymphedema

A
  • Lymphangioscintography
  • Infra-Red Florescence imaging (NIR)
50
Q

Lymphangioscintography

A

inject radio-labeled protein into skin – taken up by lymph system

51
Q

NIR

A
  • Indocyanine green injected
  • Real time movement within lymph vessels
  • Radioactive can damage lymphatics and nodes
52
Q

What are the Stages of Lymphedema?

A
  • Stage 0,1,2,3
53
Q

Stage 0

A
  • Subclinical
  • Complain or heaviness or fullness in extremity - swelling is not evident
    – May be due to latency or lymphangiopathy
54
Q

Stage 1

A
  • Reversible lymphedema, no secondary tissue changes
  • Elevation reduces swelling; soft/pitting
55
Q

Stage 2

A
  • Irreversible lymphyedema
  • Fibrosclerotic changes, hardening of skin
  • Infections
  • Minimal pitting or no pitting with moderate swelling (fibroblast formation)
  • (+) stemmer sign: inability to lift skin at base of the 2nd toe
56
Q

Stage 3

A
  • Extreme increase in volume
  • Hardening of dermal tissues
  • Papillomas on skin and deep skin fold
57
Q

____ is not a part of lymphedema staging

A

Size!

58
Q

____ cure for lymphedema

A

No

59
Q

What does Complete Decongestive Therapy (CDT) do?

A
  • Mobilize congested fluid
  • Reduce proliferation of connective tissue & fat deposits
  • Reduction in symptoms
60
Q

What are the phases of CDT? What is important for each phase?

A

Phase 1 - CDT
* Manual lymph drainage (MLD)
* Compressive bandages
* Physical Activity
* Skin Tx and care
* Fitted for compression garment (at end of phase 1)

Phase 2 - Management
* Patient maintanence and optimize the results from Phase 1

61
Q

What is the goal of phase 1?

A

Decongest the involved extremity

62
Q

How often are patients seen in phase 1?

A
  • Daily (30-60 min) if possible
  • May take up to 3-8 weeks for phase 1
63
Q

What is the process of Manual Lymphatic Drainage?

A
  • Treat the healthy quadrants to get the lymphagnlions and anastomoses to be working at a higher rate (upregulate)
  • Start on noninvolved extremity -> When extremity decongests move toward involved areas and decrease work on non-involved areas
64
Q

When trying to create compression, what should you use? Why?

A

Short Stretch Bandages
* High working pressure
* Low resting pressure

High pressure distally, lower proximally

Use foam padding to create cylinder shape

65
Q

What is important about skin care with lymphatic patients?

A
  • At a high risk for fungal infections
  • Low pH moisturizers (5-5.5); Eucerine or Aquaphor
  • Must bathe daily
  • Education: Prevent infections, bug bites, sunburn (All will create more inflammation and swelling)
66
Q

Lymphedema management is a ____ practice

A

lifelong

67
Q

What are the compression classes? Which are used for Lymphedema?

A

Class 1: 20- 30 mmHg
Class 2: 30-40 UE
Class 3: 40-50 LE
Class IV = 60+

68
Q

How is compression therapy helpful?

A

Helps maintain manual lymph drainage benefits

69
Q

How is exercise beneficial with Lymphedema pts?

A

During movement, non-yielding bandages:
* Enhance muscle pumps
* Stimulates Lymphangions and transports lymph

70
Q

Why is a debulking procedure not a great option for lymphedema Tx?

A
  • Remove excess skin & subcutaneous tissues

Major disadvantage:
* lymph vessels are removed with skin, interferes with attempts to treat the lymphedema with conservative treatments

71
Q

Contrindications - General MLD

A
  • Cardiac insufficiency (HF); sick heart can’t take on more fluids
  • Acute infections (cellulitis); Don’t want local going global
  • Acute DVT
  • Radiation fibrosis (Radiation destroys skin and collectors beneath it)
72
Q

Contrindications - Cervical MLD

A
  • Cardiac arrhythmias; stroking carotid can influence rhythm
  • Carotid endarterectomy; don’t want to break of bruits
  • CVA
73
Q

Contraindications - Compression bandages

A
  • Cardiac insufficiency (HF); too much fluid for a sick heart
  • Acute infection; don’t want local to become global
  • Spasticity; can lead to increased tension, increasing spasticity
  • PAD
  • Complex regional syndrome
74
Q

Following Surgery/Tx, when do pts develop lymphedema?

A
  • 50% at 12 months
  • 75% at 36 months
75
Q

What is a way to screen for Lymphedema

A

Bioimpedance Spectroscopy (BIS)
* Measurement of extracellular fluid and impedance to flow of current (Similar to bioelectrical impedence)
* The more fluid the faster the current; Must be unilateral in order to compare

76
Q

What would a positive test for BIS be?

A
  • Normal range is -10 to +10

[+] test is one where there is
* 10 point change from baseline
* >10 value

Cardiopulmonary (21 decks)

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