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unit 11 > Lymphydema > Flashcards

Lymphydema Flashcards

1
Q

What are the causes of ACTIVE hyperemia

A

Anything that causes a greater demand for blood

Inflammation, infection, heat, friction, trauma, exercise

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2
Q

What are the causes of PASSIVE hyperemia

A

Anything that causes obstruction of the venous outflow

DVT, CHF, CVI (chronic venous insufficiency), Tumor

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3
Q

What is the mechanism for both passive and active hyperemia?

A

Vasodilation!

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4
Q

Name the major mechanism difference (and location of mechanism) between active and passive hyperemia

A

Active: due to increased blood flow on the pre-cap arterioles

Passive: due to obstruction on the venous side of the capillary bed

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5
Q

What is the result of both active and passive hyperemia?

A

Ultrafiltration: pressure in blood capillaries forces water to leave blood into the interstitium

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6
Q

What was starlings original equation?

A

Average BCP = COPp

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7
Q

In Starlings original equation (BCP =COPp) what did greater BCP cause?
Greater COPp cause?

A

BCP&raquo_space;> COPp = ultrafiltration

COPp&raquo_space;> BCP = reabsorption

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8
Q

What is the primary source of cellular nutrition?

A

Diffusion

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9
Q

How does diffusion proceed?

A

high to low concentration

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10
Q

How is diffusion measured?

A

L/min of flow

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11
Q

What is osmosis

A

Specialized diffusion through a semi-permeable membrane (capillaries)

Therefore generally water is moving from an area of low substrate concentration to an area of high to dilute it

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12
Q

Osmosis generally has a small contribution to normal nutrition of cells, diffusion mainly takes care of this. However, in what circumstances does osmosis become an important part of cell nutrition?

A

Disease states

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13
Q

How much flow volume is normal / day for osmosis?

A

2-4 L/day

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14
Q

Protein has a strong or high affinity for water

A

high

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15
Q

What is Albumin’s function

A

hold onto fluid volume in the blood

Its the primary protein in the blood

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16
Q

Why does COP develop?

A

Bc protein affinity to bind with water

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17
Q

What is the COP of plasma?

A

7g/% = 25 mmHg

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18
Q

What is ultrafiltration?

A

Hydraulic pressure of the blood capillaries forcing an additional amount of water to leave the blood and enter the interstitial space

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19
Q

When blood enters the capillary bed compare BCP to COPp and what this relationship creates.

A

BCP&raquo_space; COPp

BCP wants to push water out and it wins out, therefore water moves into the interstitium

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20
Q

True or False: pre-capillary arterioles are passive structures?

A

False! they are highly muscularized and innervated by the ANS

Responsible for vasodilation and constriction which we know affects capillary pressure

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21
Q

What is the relationship between arterial BP and BCP

A

Decrease in arterial BP (due to vasodilation) = increase in BPC due to the greater influx of blood

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22
Q

What happens to central blood pressure when vasodilation occurs? BCP?

A

Central blood pressure: drops

BCP: increases

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23
Q

What is the result of both active and passive hyperemia

A

Ultrafiltration

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24
Q

Is BPC hydrostatic or osmotic?

A

Hydrostatic

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25
Q

What did Starling originally propose the extent of lymph function was?

What do we know now and what does that mean the role of the lymphatic system is?

A

takes 10% of the fluid not reabsorbed by the venous side of the capillary

We know now that there is almost no reabsorption of fluid in the capillary beds, therefore excess fluid is almost exclusively the responsibility of the lymphatic system.

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26
Q

How is the majority of capillary filtrate returned to blood circulation?

A

Thoracic duct

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27
Q

What is Glycocalyx?

What is it composed of?

What role does Glycocalyx play in reabsorption?

A

Carb rich layer coating the inner surface of the capillary vessel.

Composed of proteoglycans and glycoproteins therefore….

disrupts oncotic gradient (because its so high in proteins) AND prevents reabsorption of capillary beds due to creating a physical layer acting as a barrier

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28
Q

Compare and contrast the CV system and the lymphatic system

A

CV: closed, circular

Lymphatic: open, one way

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29
Q

This isn’t a question, just general things lymph system does specifically. She outlines four functions later that are less specific.

A

Recognizing, filtering and destroying bacteria, waste and other toxins

Launch immune system via T lymphocytes

Regulate lymph fluid volume

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30
Q

What are afferent lymph vessels?

A

bring unfiltered fluid to the lymph node for filtering

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31
Q

What are efferent lymph vessels?

A

Carry clean fluids away from the lymph nodes to the CV system to help form plasma in the blood

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32
Q

Is the lymphatic system a high or low pressure system?

A

low pressure

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33
Q

Where does lymphatic system pressure exceed CV system pressure?

What is the relevance of this?

A

The venous angle: therefore this is where the lymph gets dumped back into the CV system

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34
Q

Final common pathway of lymph

A

venous angle

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35
Q

At the level of the nodes what happens to excess water?

A

Excess water is given back to the venous side of the blood

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36
Q

3 major lymphatic functions

A

1) recycles proteins
2) immune surveillance: infection, cancer, removal of debris
3) Transportation of digested fat

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37
Q

Why is lymph responsible for filtering macromolecules?

A

They don’t fit through normally places, they generally require active transport, but not in lymph system

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38
Q

What is the significance of terminal ends to the lymphatic system?

A

Because they are tethered into the soft tissue, as tissue swells the anchoring opens and pores form allowing macromolecuels to fall i

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39
Q

Where do lymph capillaries sit?

A

just sub-epidermal;

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40
Q

Do lymph capillaries or lymph collectors have valves?

A

Lymph collectors

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41
Q

What part of the lymph system has anchoring filaments that create pores?

A

Lymph capillaries

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42
Q

Lymphangion is what

What is its pump?

A

“lymph heart”

No central pump! piggy backs on respiration, increased heart rate, MSK pump

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43
Q

Describe lymph collectors

A

Its a transport vessel: Valved
Highly muscular
Innervated by ANS
Resting rate of 6 beats/min

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44
Q

With ANS stimulation what happens to the rate of lymphangion?

A

increased rate

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45
Q

As more fluid is absorbed into the collector, the more the walls stretch and what is the result?

A

the more they end up contracted pulling more fluid towards CV system

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46
Q

What is the relevance of the lymphangion piggy backing on other systems

A

Exercising increases HR and MSK pump therefore increasing flow through the lymphatic system

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47
Q

Where are lymph collectors located?

A

superficial to fascial planes

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48
Q

What is in the lymph?

A

Protein, water, WBC, lymphocytes, CA cells, bacteria, viruses, fat, cellular debris, other debris (tattoo)

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49
Q

What two forces did Starling neglect?

A

COPi

Interstitial pressure

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50
Q

What do COPi and Pi do in terms of ultrafiltration

A

COPi: assists ultrafiltration

Pi: resists ultrafiltration

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51
Q

In a normal situation are COPi & Pi varrying much?

A

no

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52
Q

When does COPi typically come into play

A

when there is lymphatic dysfunction; when this happens proteins accumulate in the soft tissue, proteins attract water, and all this attracted water can’t go into lymphatic channels bc their bound into the soft tissue

53
Q

When does Pi typically come into play

A

old age, planes. Pi is reduced therefore its ability to resist ultrafiltration (its normal function) is slim

54
Q

What is something we do as PT’s to increase Pi?

A

Compression therapy

55
Q

Is lymphydema normally bilateral or unilateal

A

both

56
Q

Is acute DVT generally bilateral or unilateral?

A

Unilateral

57
Q

Is a tumor causing swelling generally going to cause it unilaterally or bilaterally?

A

unilaterally

58
Q

Is arthritis generally going to cause unilateral or bilaterally swelling?

A

unilateral

59
Q

Is post thrombotic going to cause unilateral or bilateral swelling?

A

Unilateral

60
Q

Chronic regional pain syndrome cause unilateral or bilateral swelling?

A

Unilateral

61
Q

name the two diagnoses that can lead to both unilateral and bilateral swelling

A

Lymphydema

Venous insufficiency

62
Q

Does trauma normally cause unilateral or bilateral swelling?

A

Unilateral

63
Q

What is the key take home message for unilateral limb swelling

A

an UNEXPLAINED unilateral limb swelling is a tumor or clot until proven otherwise

64
Q

Name some symptoms of an acute DVT

A

Sudden onset, painful, cyanosis, + homan’s, risk of PE, Wells Rule, dx by doppler US, venous obstruction/passive hyperemia

65
Q

Explain Homan’s sign and what it is testing for

A

Testing for a DVT

PASSIVELY and abruptly dorsiflex the foot and squeeze the calf

Pain = +Homan’s

66
Q

Explain what the Wells Rule is used for

A

placing patients into high, mod or low risk for DVT based on symptoms or characteristics

67
Q

Explain the Wells scoring

A

> or = to 3 is high risk

1-2 is moderate risk

<1 is low risk

68
Q

What is the Gaiter distribution and what is it a sign of?

A

Gaiter distribution: darkening flesh from ankle to the knee

Sign of venous insufficiency

69
Q

What is hemosiderin staining a sign of?

A

CVI

70
Q

Pt presents with decreased hair, and subjectively tells you their legs don’t sweat. You notice brawny skin, and pain above the medial malleolus. This is all consistent with what physiological occurrence?

A

CVI

71
Q

How does arthritis affect hemodynamics?

A

arthritis = chronic inflammation

inflammation –> vasodilation –> increase in BCP –> active hyperemia –> increase in ultrafiltration

72
Q

What medications are associated with edema/fluid retention?

Used for what chronic illness?

A

NSAIDS, steroids

Used for arthritis

73
Q

CA is likely to cause passive or active hyperemia?

A

Passive, tumor causing obstruction

74
Q

Are post-surgical or traumatic edema high or low protein?

Active or passive hyperemia?

A

High

Active leading to increased ultrafiltration

75
Q

Name characteristics of edema stemming form systemic diseases

A

Always bilateral LE

Pitting

Ascites: abdominal swelling + LE’s

Anasarca: full body edema / “third spacing”

76
Q

Explain the mechanism of “third spacing”

A

poor nutrition and falling albumin. Falling albumin = low protein = little ability to carry water. CV system is overloaded an cannot deal with the fluid

77
Q

Low albumin =

High albumin =

A

Low = malnutrition, inflammation, liver disease

High = dehydration

78
Q

When are pts albumin levels tested?

A

Liver disorder
Fatigue or weight loss
Nephrotic syndrome: swelling around eyes, belly or legs
To check nutritional status

79
Q

Is CHF and cardiac edema active or passive hyperemia

A

passive

80
Q

Name some characteristics of cardiac/CHF edema?

A

bilateral, pitting, resolves with elevation, no pain

Dyspnea, orthopena (SOB when lying flat) paroxysmal nocturnal orthopnea, jugular vein distention

81
Q

Explain sufficiency edema

A

Normal lymph system

High protein edema

intermittent, easily solved: trauma or surgery

82
Q

Explain dynamic edema

A

Normal lymph system

Passive hyperemia

Low protein edema

CHF, renal&liver disease, DVT, CVI, tumor

83
Q

Explain mechanical edema

  • primary
  • secondary
A

both have high protein edema

LYMPHYDEMA

Primary: lymph system is abnormal
Secondary: lymph system is damaged

84
Q

Explain combined edema

A

Lymphatics are failing

Mixture of high and low protein edema

  • High: lymph nodes failing
  • Low: veins failing/passive hyperemia
85
Q

BCP net effect in soft tissue

A

Low protein edema

86
Q

COPp net effect in soft tissue

A

Low protein edema

87
Q

What is the most stable of the four hydrostatic pressures?

When does it change?

A

COPp

Changes in severe illness –> increase in ultrafiltration

88
Q

When does Pi decrease?

Increase?

A

Decreases: Planes, aging, long term stretch of tissue

Increase: compression of tissues

89
Q

Net effect of COPi?

A

High protein edema

90
Q

What happens to COPi when the lymphatic system is damaged?

A

COPi increases

Irritating nature of this fluid leads to fibrosis and associated skin changes

91
Q

name some treatments for edmea

A
  • medical management of illness!
  • PRICE for traumatic soft tissue injuries
  • ESTIM: poor evidence
  • Kinesiotaping
  • Compression garments is key for chronic edema!
92
Q

What does PRICE stand for

A 
Protection
Rest
Ice
Compression 
Elevate
93
Q

Lymph system connects interstitial space to what?

A

venous return

94
Q

Are lymphatics located endofascial or epifascial

A

Epifascial: outside of muscle compartments

95
Q

Superficial lymphatics are absorptive in __________ tissue

A

subepidermal

96
Q

Where are regional nodes concentrated

A

Neck, mesentery, and “roots” of limbs

97
Q

Name the main areas these regional nodes drain

Cervical
Axillary
Inguinal

A

Cervical: head, neck above clavicular area

Axillary: arm, breast, trunk

Inguinal: leg, lower trunk, superficial genitals

98
Q

What is the normal transport capacity of lymphatic system for water? for protein? and how much can it increase short fold

A

Water: 2-4 L/day

Protein: 75-100 g/day

Can increase 10 fold in short term

99
Q

Match the primary lymphedema disease to their timing of presentation

Lymphedema Praecox
Milroy’s Disease
Lymphedema Tarda

After age 35
Birth
Adolsecence

A

Milroy’s Disease: birth

Lymphedema Praecox: adolescencemost common

Lymphedema Tarda: after age 35

100
Q

Explain secondary lymphydema and give examples

A

Known trauma to lymphatics: surgery, trauma, radiation therapy, filariasis (#1 cause worldwide - parasite from mosquito), infection, metastisis, iatrogenic

101
Q

General idea of lipedema

A

pathological deposition of fatty tissue below the waist resistant to diet

Normally women: strong hormonal linkage

102
Q

Two co-morbidities that can be related the CVI

A
  • morbid obesity

- post phlebitic syndrome: CVI after DVT

103
Q

Comorbidities associated with lymphedema

A

CVI
Angiodysplasiasis
Lipedema

104
Q

Signs and symptoms of lymphydema

A

Swelling,numbness, tingling, stiffness, pain, aching, heaviness, infection, redness/heat

105
Q

What two conditions normally create pitting edema

A

CHF/cardiac edema and systemic disease

106
Q

Explain the 4 stages of lymphedema

A

O: latency, reduced capacity - no apparent swelling but may have clinical symptoms

I: pits with pressure, spontaneously reversible with elevation

II: non-pitting, does not reverse w/elevation

III: elephantiasis - significant skin changes (severe fibrosis)

107
Q

If edema is bilateral first and foremost are you guessing lymphydema or other medical condition?

A

Medical condition: CHF, systemic disease

108
Q

What is Stemmer sign and what does it tell you?

A

+ if fold of skin lifted at base of toe is thickened or impossible to life

+ = lymphedema: tells you reactive fibrosis of soft tissue

109
Q

Lymphedema Praecox presentation

A
  • adolescent onset
  • insidious onset
  • pain free
  • asymmetric
  • (+) Stemmers sign
110
Q

Is this presentation primary or secondary lymphydema?

Sever trauma from MVA at age 30, recurrent hx of open wounds, + stemmer sign

A

2ndary

111
Q

What does, vascular hyperplasia, hemangiomas, tissue and bone hypertrophy signal

A

Primary lymphedema

112
Q

Does lipedema have + or - stemmers sign

A

-

113
Q

What is this clinical presentation consistent with?

Soft lumpy tissue, painful to palpation, easily bruises, - stemmers sign, symmetrical distribution, orthostasis with dependency

A

Lipedema

114
Q

When is it common for lymphydemas to start after CA tx?

A

1.5 yrs

115
Q

What are things you want to evaluate with lymphedema

A

Circumferential measurements, volumes, AROM, strength, skin condition, tissue texture, FUNCTION!

116
Q

Describe the intensive phase of CDT

A
  • Manual lymphatic drainage
  • multilayer compression bandaging
  • exercise to increase MSK pump
  • meticulous skin care
117
Q

Describe the maintenance phase of CDT

A
  • Garment wear
  • Compression at night
  • Exercise
118
Q

Manual lymphatic drainage effects

A
  • increases absorption of fluid and protein by capillaries
  • increases lymphangion activity
  • diuresis
  • relaxation
  • analgesic
119
Q

Contraindications to compression

Precautions?

A

Contraindications: Acute infection, arterial disease, acute CHF

Precautions: decreased sensation, limb paralysis

120
Q

Compression increases or decreases interstitial pressure?

Ultrafiltration?

A

Increase Pi

Decreases ultrafiltration

121
Q

Are high stretch or low stretch bandages safe to wear 24/7

A

low stretch bc they have low resting pressure

high stretch/ace bandages should be used short term

122
Q

Effects of low stretch bandages

A
  • Increase Pi
  • Reduce ultrafiltration
  • Increase MSK pump
  • reshape irregular limb profile
  • reduce fibrotic changes
123
Q

true or false: the role of elastic garments is to reduce swelling?

A

FALSE: it is to maintain limb reduction or prevent limb from swelling

124
Q

True or false: elastic bandages enhance the MSK pump?

A

False! low stretch bandages do

125
Q

Where do you want the most pressure when wrapping

A

distally

126
Q

Are flat knit or circular knit generally custom?

A

Flat knit

127
Q

Does flat knit or circular knit have better containment?

A

Flat knit

128
Q

What time of day do you wear elastic compression garments?

A

Daytime only!

129
Q

Explain LaPlace law?

A

Pressure inversely proportional to radius

Small limb radius = more pressure

Large limb radius = less pressure

unit 11 (5 decks)

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