Lymphatic Flashcards
Primary lymphedema
Occurs due to abnormal development of the lymphatic system. May include absent lymph vessels, decrease in number or size of vessels, or increased size of lymph vessel, which makes valves incompetent.
Usually occurs in females and seen in LEs.
Secondary lymphedema
Occurs as a result of some other disease or injury. May include trauma, surgery, radiation, tumor growth, multiparity, chronic venous insufficiency or infection.
In the US, most common cause is breast cancer surgery and treatment.
Dynamic insufficiency
Most common type of insufficiency that leads to lymphedema.
Occurs when there is excess lymph circulating in lymph system.
Results in pitting edema
Associated with venous insufficiency, CHF, and pregnancy.
Mechanical insufficiency
Occurs when transport capacity of system is reduced. Results in more protein rich lymphedema (non-pitting).
Combined insufficiency
Occurs when there is both an increase in lymph fluid and a decrease in transport capacity.
Lymphedema symptoms
Achiness, fullness, and heaviness of affected limb.
In later stages, proteins can degrade, which leads to the development of chronic inflammation and fibrotic changes to surrounding tissues.
Fibrosis leads to local hypoxia, which further causes chronic inflammation and increased risk for infection.
Lymphedema prevention
Avoid injury to skin to reduce infection.
Avoid constriction, of extremity, like tight clothing or BP cuff
Diet and exercise to decrease being overweight
Observe size of limb during exercise and take frequent rest breaks with intense activity.
Avoid extreme hot and cold temperature because they can lead to fluctuations in limb edema
Wear compression garments during periods of strenuous activity, when standing for prolonged periods or when traveling on airplane.
Imaging technique - Direct lymphography
Injection of contrast medium into a lymph vessel that allows for visualization of the entire lymph system through radiography. Not commonly used.
Imaging technique -Indirect lymphography
Injection of a contrast medium (water soluble) just under the skin to allow for visualization of the smaller superficial lymph vessels
Imaging technique - Lymphoscintigraphy
Injection of a radioactive material that allows for visualization of the lymphatic system through nuclear medical imaging. Traced throughout system to determine how effectively lymph is being transported. Fewer complications than direct lymphography
Imaging technique - MRI and CT Scan
Can identify tumors that may be causing lymphedema
Circumferential Limb Measurement
7 circumferences are recommended for UE and LE to deduce that fluid has been removed and not just redistributed.
Opposite limb used for comparison if available. A difference of 2-3 cm between 4 comparative circumferences on bilat UEs is evidence of edema.
Classifications:
Mild - < 3 cm difference between affected and unaffected limb
Moderate - 3-5 cm difference
Severe - > 5 cm difference
Complete Decongestive Therapy
Treatment model that occurs in 2 different phases.
Phase I is intensive acute treatment phase that is typically provided on an outpatient basis for 4-6 weeks.
Phase II is the self-management phase consisting of long-term management of symptoms.
May need to return to phase I of treatment with a significant change in symptoms.
Complete Decongestive Therapy - Manual Lymphatic Drainage
Techniques designed to move lymph around blockages in the lymph system and into desired areas where it can be drained.
Treatment should first be directed at uninvolved areas to prepare for new lymph flow from involved areas.
Important to know location of lymph nodes and if they are functioning.
Complete Decongestive Therapy - Compression Therapy
Helps maintain reduction in edema achieved with MLD. Improves reabsorption ability of the capillaries and reduces filtration of fluid into interstitium. Can also help soften fibrotic tissues.
In phase I of treatment, bandages typically used. Short-stretch bandages used because they have a low resting pressure and therefore do not constrict lymph flow.
In phase II of treatment, a combination of compression garments (during the day) and compression bandages (during the night) are used. Compression garments should only be fitted once edema has plateaued. Bandages and garments should have higher pressure in distal regions (graded compression)
Complete Decongestive Therapy - Exercise
Can help improve lymph flow by increasing lymph vessel contractions, increasing fluid uptake in the initial lymph vessels, improving “muscle pump” to stimulate lymph flow, and increasing deep breathing (which improves lymph flow in thoracic duct).
Program should be gradually progressed b/c can have a negative response to exercise. Low impact, aerobic activities recommended.
Start with trunk exercises, working towards proximal joints to distal joints of extremities. Finish with additional trunk exercises and deep breathing to enhance lymphatic flow.
Compression bandages/garments should be used when exercising.
Complete Decongestive Therapy - Skin Care
Lymphedema impairs immune function, making skin more susceptible to bacterial and fungal growth and infections.
Limbs should be inspected and cleansed thoroughly each day. Lotion should be used often. Soaps and lotions should have low or neutral pH to avoid skin damage.
Contraindications to Complete Decongestive Therapy
Acute infection Cardiac edema Diabetes Hypertension Malignancy Renal insufficiency DVT
Debulking
Surgery to remove excessive skin that forms in later stages of lymphedema
Stage 0 of Lymphedema
Latent or preclinical stage. No visible edema, though the transport capacity of the lymph system has been affected.
Stage 1 of Lymphedema
Reversible stage. Pitting edema present and increases with activity or heat but will diminish with elevation and rest.
Stage 2 of Lymphedema
Spontaneously irreversible stage. Edema is non-pitting and does not change with elevation or rest. Skin begins to demonstrate fibrotic changes and risk for infection increases. Stemmer’s sign is positive (thickened fold of skin at the base of the second toe or second finger that can be gently pinched and lifted, which indicates thickening of skin due to fibrotic changes).
Stage 3 of Lymphedema
Known as lymphostatic elephantiasis stage. Extensive non-pitting edema, significant fibrotic changes to the skin, and presence of papillomas, deep skinfolds, and hyperkeratosis. Infection is common. Stemmer’s sign is positive.
Filariasis
Disease caused by parasitic infection. Most common causes of secondary lymphedema worldwide.
