Lymphedema Flashcards
What is lymph?
Interstitial fluid once it enters the lymph vessels
What are the only organs that do not secrete lymph?
THe brain and spinal cord
What does lymph contain?
protein, water, fatty acids and cellular components of bacteria, viruses and debris
What is the function of lymph?
Keeps connective tissue in a healthy state
Removes fluid, foreign particles from tissues and fats from intestines and returns to bloodstream
Protects body from infection and disease via immune response (lymphocytes)
What are the components of the lymphatic system?
Lymph vessels Lymph nodes Spleen Thymus gland Tonsils Peyers patches Lymphocytes
What are the two segments of a lymph vessel?
The superficial portion (contains Capillaries and pre-collectors-NO VALVES) Deep portion (contains collectors and Trunks. HAVE VALVES)
What are lymphangions?
Valves that separate collectors into functional segments. Resemble veins but have thinner walls and valves in shorter intervals. FROM ONE VALVE TO ONE VALVE.
What does lymphatic fluid flow rely on?
Intrinsic muscle contractions from the smooth muscle within walls of the vessels (lyphangions)
How often do Lymphangions contract at rest? During exercise, heat or inflammation?
6-10x/min. Increases 10 x with exercise, heat or inflammation
What is a lymphotome/watershed?
Distinct, anatomic areas of lymph drainage that drain to regional lymph nodes.
What is lymph drained through to get across a watershed?
Through anastomoses
What are lymph nodes?
Small kidney shaped vessels arranged in chains.
How many lymph node are there in the body? How big are they?
600-700 lymph nodes. About 2-25mm in diameter
Lymphatics vs. Circulation: direction
lymphatics-one way
circulation-circular
Lymphatics vs. Circulation: Amount
lymphatics-1/2 litres/day
circulation-4-8 L/min
Lymphatics vs. Circulation: Contraction
Lymphatic- intrinsic contractions (can also be aided by skeletal muscle contractions)
Circulation-seperate pump (heart)
Lymphatics vs. Circulation: Obstruction
Lymphatics-Obstruction leads to accumulation of high protein fluid (>1.5 gm/dl) doesn’t move well with gravity changes
Circulation-Obstruction leads to collection of low protein fluid (<1gm/dl) moves better with gravity changes
Lymphatics vs. Circulation: Filtering
lymphatics-fluid filtered by lymph nodes
Circulation-no filtering
What is microcirculation?
The 10% of fluid that leaves the arterial end of a capillary that is not reabsorbed by the venous end is reabsorbed by the lymphatic system and returns to circulation.
What are some clinical implications of microcirculation?
- Accumulation of proteins in interstitum w/ impaierd lymphatic system. Will pull water across cell membrane to maintain osmotic equilibrium.
- Loss of elasticity of skin
What is dynamic insufficiency?
Healthy lymphatic system but LL exceeds TC
Happens during sprained ankle, DVT, cardiac edema
What is mechanical insufficiency?
Diseased lymphatic system, normal LL exceeds impaired TC
Lymph node removal
What is lymphedema?
Abnormal accumulation of protein-rich fluid in the interstitial that occurs when the lymph load exceeds the lymph transport capacity (general but heavily debated)
What are the signs and symptoms of lymphedema?
slow, progressive onset
pt feels limb is heavy, not painful
usually starts distally and is asymmetrical
What is Primary lymphedema?
Hereditary or congenetial
What is secondary lymphedema?
Acquired
Result of damage to soft tissue, lymph vessels or nodes
secondary to radiation, surgery, tumor infection
mosquito bite (Filariasis)
What are the 4 stages of lymphedema?
Sub-clinical stage 0-feeling of heaviness in limb w/o any visible swelling
Stage 1- pits on pressure, high water content, reduces with elevation, reversible
Stage 2-Non-pitting, not reduced by elevation, moderate to severe clinical fibrosis
Stage 3-Elephantiasis-skin changes, lobules
Who experiences primary lymphedema most?
females 87%
What is lymphadema praecox?
primary lymphedema that occurs before 35 (83% of cases)
What is lymphedema tardum?
primary lymphedema that occurs after age 35
Where is primary lymphedema most common? What can trigger it?
Lower extremities. Triggered or exacerbated by infection, trauma or pregnancy
What is aplasia?
Lack of lymphatics incompatible with life
What is hypoplasia?
most common type of lymphatic dysfunction, decrease collectors and capillaries
What is hyperplasia?
Increase in width of lymphatic collectors, insufficient valves
What is inguinal node fibrosis?
Kinmonth syndrome, nodes cannot drain properly
What is inguinal node fibrosis?
Kinmonth syndrome, leg edema ***
What are the 3 watersheds of the body?
Transverse, longitudinal, and superclavicular
What is LL?
Lymphatic load, LL
-Amt of fluid and cells to be removed from the interstitium
What is LTV?
Lymph Time volume, LTV (lymph transported/time)
-Amount of lymph transported per unit of time
What is TC?
Transport capacity TC
-Maximum lymph time volume
What is secondary lymphedema?
Result of an insult to the lymphatic system (often in the treatment of cancer)
What factors have a role in secondary lymphedema?
surgery, radiation, BMI, and cellulitis
When does 2ndary lymphedema usually happen?
Within 4 years but can occur over 10 yrs later
What are some differential diagnosis for lymphedema?
Chronic Venous insufficency Acude DVT CHF Lipedema CRPS Myxedema Malignant Lymphedema
What are some presentations of Acute DVT?
Sudden onset (usually unilateral) May be painful Cyanosis or erythema \+/- Homans's sign Potential for pulmonary embolus Venous doppler ultrasound
What are some presentations of CHF?
Swelling distally Sudden weight gain of greater than 2 lbs overnight Bilateral and symmetrical Pitting swelling decreases w/ elevation painless jugular venous distention
What are some presentations of lipedema?
Usually in women Bilateral from iliac crest to ankles dorsum of feet not involved no pitting no cellulitis pain on palpation w/ bruising
What are some presentations of Malignant Lymphedema?
Pain, paraesthesias, paralysis Proximal swelling Rapid development, continuous progress Lymph node enlargement Ulcers Heatoma-like discoloration
What are the six ways of measuring lymphedema?
Circumferential (high intrarater, low interrupter)
Water displacement
Weight
Optoelectrical: perometer
Tonometry
Bioimpedance (ratio of extracellular to intracellular fluid volumes)
What are the negatives of measuring lymphedema?
none can measure face, hands, feet, breast or trunk
Dont measure differences btwn R and L limbs
do not factor change in noninvolved armo ver time
What is a Stemmers sign?
Can’t quite pinch the skin on the toes and so you bring extra tissue with it. Presence of lymphedema
What is 1+?
visible edema
What is 2+?
5–15 seconds
What is 3+?
15-30 seconds
What is 4+?
> 30 seconds
What are some interventions for Lymphedema?
Nothing Pt education Compression garment, no bandage Bandage then compression carnet Complete decongestive therapy (CDT) compression pump
What is phase one of CDT?
skin care
MLD
Compression bandage up to 24 hrs a day
exercise in bandage
What happens in phase 2 of CDT
Skin care self/partner massage
Compression stockings days, bandage nights
What are general contraindications for CDT?
Acute infection Cardiac edema Malignant disease (relative) Renal Dysfunction Acute DVT
What are some contraindications for bandaging?
Arterial disease
precaution in case of HTN, paralysis, diabetes, bronchial asthma and CHF
What are some contraindications for MLD of abdomen?
pregnancy
Recent abdominal surgery
intestinal problems
Aortic aneurysm
What are some contraindications for MLD of Neck?
Cardiac arrhythmia
Hypo/hyper thyroidism
Hypersensitivity or carotid sinus
Over age 60 (relative)
Education
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What are the effects of MLD?
Increased freq. of lymph vessels contractions
increase volume of lymph transported
increased pressure in collectors
redirects lymph flow towards collateral vessels and across watersheds
What are the characteristics of MLD techniques?
specific light do not cause increased blood flow superficial (dermis, sub-dermis) 2 phase stretch and release slow every six to ten seconds
What type of bandages are used for lymphedema?
Short stretch bandages
How much pressure is exerted by a class 1 compression stocking?
20-30 mmHg
How much pressure is exerted by a class 2 compression stocking?
30-40 mmHg
How much pressure is exerted by a class 3 compression stocking?
40-50 mmHg
How much pressure is exerted by a class 4 compression stocking?
50-60 mmHg
What is exercise thought do do for lymphedema?
activate muscle and joint pumps
