L9 Lymphedema Flashcards
Lymphedema definition
- chronic and slowly progressive disease that results in swelling in the body
- abnormal or excessive accumulation of protein enriched fluid in the tissue spaces of the body
- Impairment in the reabsorption/transportation of protein molecules within the lymph system
- Leads to fibrosis, abnormal adipose deposition and overgrowth of connective tissue
Purpose of lymphatic system
runs throughout your body
filter toxins and waste
keeps body fluids levels in balance
defends against infection
absorbs fat in digestive system
Lymphatic system is made up of
lymph organs, fluid, vessels, nodes
Lymph nodes
filter bacteria, waste and cellular debris
contain immune cells like lymphoctyes and macrophages
regulate fluid volume
Lymph fluid
derived from interstitial fluid
contains RBCs and WBCs, lymphocytes, fat, water, protein, cellular debris
approx 75-100 g of protein are transported by lymphatic system daily
Lymphatic Vessels
thin-walled tubes that carry lymph fluid
similar to blood vessels, but have valves that prevent backflow of fluid
collect lymph from interstital spaces and transport to lymph nodes
Lymph capillaries
tiny, microscopic vessels that collect excess fluid from interstitium
allow fluid, protein, and cellular debris to enter
drained by vessels and processed by nodes
can be crushed by adiposity
What tissues are lymphatic capillaries not present in?
CNS, bone marrow, avascular tissue
Once fluid enters the lymphatic capillaries it is called
lymphatic fluid
volume = lymphatic load
Lymphatic ducts
lymphatic vessels move into larger ducts that drain the lymph back into the bloodstream
Thoracic duct and right lymphatic duct
Thoracic Duct
largest lymphatic vessel
collects lymph from lower half of body and left side of the body
drains into the left subclavian vein, returns lymph to bloodstream
Right lymphatic duct
collects lymph from the right side of upper body
drains into right subclavian vein, returns lymph to blood stream
Lymphangion
functional unit of lymphatic vessel
segment of lymphatic vessel between two valves that contracts and propels lymph forward during lymphatic pumping mechanism
creates a unidirectional flow of lymph towards nodes
Lymphangion contracts
valves downstream close
prevents backflow of lymph fluid
Lymphangion relaxes
valves upstream open
lymph fluid moves upwards
Transport capacity
the max amount of fluid the lumpahtic system can carry
in healthy intact system, the transport capacity exceeds the lymphatic load almost 10x
When the lymphatic load exceeds the lymphatic transport capacity…
fluid balance is disrupted, protein rich fluid accumulates in the interstitium, and macroscopic swelling or lymphedema occurs
Transport capacity
maximum amount of lymph that can be transported by the body in a given length of time (size of the sink)
Under normal lymphatic circumstances
the lymph system can compensate for increases in lymphatic load (water filling the sink)
things exercising, sunbathing, and hot tubbing can increase load
Lymph time volume
the amount of lymph transported per unit of time
Dynamic Insufficiency
occurs when HEALTHY lymphatic system is overwhelmed
the drain can’t keep up with the faucet, the lymph time volume is maxed out
if dynamic insufficiency is present over time, secondary damage can occur
Mechanical Insufficiency
transport capacity of lymph system is decreased
low volume insufficiency, there is something blocking the drain
caused by surgery, radiation, trauma, infections, chronic venous insufficiencies, congenital malformations
Subjective Exam for Lymphedema
Family history of primary lymphedema
history of cancer treatment like radiation, lymph node dissection
travel to areas with high rates of mosquitos
BMI >50
progressive enlargement of area/limb
infection (increased risk of infection in people with lymphedema)
Edema
accumulation of water in tissues
edema is a SYMPTOM
represents dynamic insufficiency of lymphatic system
Lymphedema vs edema
lymphedema is an abnormal accumulation of protein and water in interstitial spaces (edema is just water)
protein rich swelling
disease process!
Primary Lymphedema
congential
may come on at puberty, with hormonal fluctuations, later in life
lipidema
accumulation of protein rich fluid in intertitium to due to low volume of lymphatic system
Secondary Lymphedema
acquired
due to trauma, surgery, infection
mechanical. insufficiency
Causes of primary lympedema
Lymphangiodysplasia: malformation of lymphatic vessels
Inguinal node fibrosis: involves fibrosis, fibrosclerosis, fatty degeneration and other changes to iliac and inguinal nodes
Hypoplasia
less than normal expected number of lymph collectors in affected region
Hyperplasia
excessively dilated vessels
less fuctional due to valvular dysfunction
Aplasia
absence of lymph collectors or lymph capillaries in an affected area
Causes of Secondary Lymphedema
trauma to the lymphatic system
cancer treatments
plebolymphedema
obesity
filariasis (mosquitos)
accident or trauma like surgery, crush injury
infection (cellulitis)
self induced injury/trauma like repeated drug use
Breast cancer is the
number one cause of lymphedema in the US
Cancer-related lymphedema
can be caused by
1. surgery (lymph node dissection
2. radiation
3. cancer itself (cancer blocking pathways)
Obesity related lymphedema
occurs with a BMI >40
BMI>50 causes impaired lymphatic drainage because capillaries are destroyed
non-reversible even with weight loss
Complete Decongestive Therapy
Includes:
manual lymphatic drainage
compression
skin care
lymphatic drainage exercise
education of independent management
Phases of Compression
Reduction
Maintenance
Reduction phase
multi-layer compression bandaging
short stretch bandages for 4-6 weeks, 23 hours a day
take ff to shower and perform skin check
patient can wait until they are ready to get started with maintenance phase
Maintenance phase
compression garments
off the shelf, ready to wear or custom
compression garment alternatives–> lifetime management, worn during the day but off at night, night garments
Short Stretch COmpression bandages
can either be low resting pressure or high working pressure
inversely related to the size of the limb
have graduated compression, which is pressure gradient is greater distal to proximal. Helps move fluid out of limb
Resting pressure
constant pressure externally applied by the bandage
constant pressure may hinder refill of superficial vessels
highest with elastic bandages
Working pressure
temporary pressure that is generated with muscle contraction
increases efficiency of muscle pump
highest with short stretch or unna boot
Compression garments types
compression sleeves
glvoes or gauntlets
compression bras, tank tops
compression stockings–> knee, thigh, pantyhose, leggings
How compression stockings work
- improves microciculation and cutaenous oxygenation
- reduces risk of thromboembolism
- reduces edema and inflammation
- reduces venous reflux, improves the valve function
- increased volvume and rate of venous blood due to efficiency of skeletal muscle pump
-6. improved lymphatic flow
Lymphatic drainage exercises
daily exercises to activate muscle pump to stimulate lympahtic capillaries to absorb and transport fluid
improve mobility, strength, and endurance
follow lymphatic flow of central, proximal, distal
can and should be done with compression
better to do active vs resistive
monitor for increases in swelling
Weight exercise is safe for lymphedema patients
LOW load
SLOW progression
Skin care
education on proper skin care
inspect skin for cuts, rash, irritation, infection
daily cleansing/washing, including compression garments
drying skin
apply lotion as protective barrier
avoid sunburns and insect bites
