The Lymphatic System Flashcards
List the lymphatic organs
Lymph nodes Lymph vessels Thymus gland Spleen Tonsils Peyer's patches
How many lymph nodes in the body
600-700
Lymph nodes - “Filtering stations”, produce WBC, regulate proteins in lymph
processing center, fluid in and lymph processed out, puts fluid overload back into circulation system, it filters through the kidney and then the urine. An increase in urine output is good
Lymph vessels
It is its own system, has intrinsic contractions, 6-10x/minute
With MLD we increase contractility of vessels
Lymph nodes in Breast tissue
Big area but can get it anywhere: (abdominal cancer, obese = in legs, head and neck cancer (neck and tongue)
30-40 lymph nodes in axillary area
200-300 lymph nodes in abdomen
With MLD we want to try to cover as much skin as possible to get the greatest affect
The Lymphatic System: Anatomy
Lymphatic Vessels: Capillaries (smallest)
Pre-collectors
Collectors
Trunks (bigger)
Mechanisms of
Transportation: Intrinsic contraction
Respiration
Arterial/Venous pulsation
Skeletal movement
New lymph (creates pressure)
Direction of Lymphatic Flow
heart pumping blood - arteries - arterioles - capillary bed - venules - veins - back to heart
at the capillary bed exchange occurs with the cell, but some fluid gets lost in the interstitial space (extra cellular space)
fluid that is lost gets picked up by lymphatic capillaries - afferent lymph vessels - lymph node - efferent lymph vessels - lymph trunk - lymphatic duct - veins - back to circulation
2 beds: capillary bed and lymphatic bed
The lymphatic system returns the fluid lost from capillaries during exchange and returns it back to circulation
The lymphatic system is NOT A CLOSED SYSTEM
Drainage fields
aka Watersheds
3/4 of the body (navel and up) drains to the left side thoracic duct and then into the left subclavian vein
Navel and down drains into inguinal nodes
Valves go in one direction but may have to push fluid in opposite direction to another watershed if on has been damaged
Watersheds are on both sides of the body
cubital nodes submandibular nodes parasternal nodes pectoral nodes Cervical Axillary nodes Inguinal nodes Popliteal nodes
Lymph Fluid
consists of:
Proteins (75-100g of proteins are transported by the lymph vessels per day)
Water
Cells (RBC, WBC, lymphocytes)
Waste products and other foreign substances
Fat (intestinal lymph chyle)
The body moves 2-2.5 L of lymph a day
The lymphatic system is picking up dead protein cells in the body - but when it is NOT working the protein gets stuck and can get hard (fibrosis) this creates lots of skin changes b/c it disturbs the ability of the skin to function
Lymphatic System Physiology
Pressure gradient = is the biggest way that things move
Filtration = Resorption + Lymph Flow
Factors: Lymphatic Load (LL) = how much water, proteins,
etc. your body normally needs to move
Lymph Time Volume (LTV) = amplitude and
frequency of intrinsic contractions, body will
just do the minimum
Transport Capacity (TC) = Max LTV (max amount
of ability that your body has to move lymph fluid)
10x LL in intact system
Functional Reserve (FR) = difference between TC
and LL, ability to accommodate
Normal: LL < TC
Dynamic insufficiency: overload lymphatic system
(body creating more fluid than
it can process)
venous insufficiency, cardiac
edema, DVT, etc
Mechanical insufficiency: lymphatic system damaged
(lymph nodes taken out or
radiation over area) TC drops
b/c lymph nodes are gone
but LL is really high
surgery, trauma, radiation
lymphedema always includes
mechanical insufficiency
Combined insufficiency: damaged system and overload
obesity, CVI (chronic venous
insufficiency)
lipedema (fat distributed in an
irregular way)
both problems system damaged
and load is high
Lymphedema
An abnormal collection of protein rich fluid in the interstitium, which causes chronic inflammation and reactive fibrosis of the affected tissues
The lymph load exceeds the total capacity of the system
protein gets stuck and hard
no cure
early detection and management, and patient ability to self-manage yield a good prognosis
if left untreated, or poorly managed will end in elaphantiasis
radiation increases chance of getting lymphedema 15%
More than 90% of cases worldwide are caused by cancer treatment, malignancy, filariasis (parasitic disease caused by an infection with roundworm), and trauma
90% of those that will develop lymphedema develop it in the first 3 years
Risk factors
Axillary, inguinal, etc surgery Radiation Partial or total mastectomy Node dissection Obese or overweight (soft tissue pushing on body = more adipose tissue = less space for lymphatic system Lipedema History of infection in at risk limb Constriction (tourniquet can damage lymph vessels and create damage distal) Tumor causing lymphatic obstruction Scarring lymphatic ducts by either surgery or radiation Intra-pelvic or intra-abdominal tumors CVI Drain complications
Primary Lymphedema
Primary Lymphedema = is genetic in nature
mechanical insufficiency of
the lymphatic system
malformation of lymphatic vessels
congenital or hereditary
Secondary Lymphedema
Secondary Lymphedema = known cause for lymphedema
surgery
radiation
trauma
filariasis
cancer/tumor
infection
obesity
self induced
Early S/S
Limb feels heavy Skin feels tight Limb is achy (not painful) if it is painful it could be DVT, RA Clothing or jewelry is tight Can't see wrinkles in skin
Can get a 30% increase in swelling before it is visible
Staging of Lymphedema
Latency = no visible/palpable edema, subjective complaints possible
Stage 1 = reversible (elevation), pitting edema often present, increased limb girth and heaviness, no fibrosis
Stage 2 = consistent swelling, does not change with elevation, spongy tissue feeling and often fibrotic changes, pitting becomes progressively more difficult
Stage 3 = lymphostatic elephantiasis, non-pitting, fibrosis and sclerosis, skin changes (hyperkeratosis)
Skin Characteristics
Hyperkeratosis = thickening of skins outer layer, this layer is made of keratin which can start to overgrow
Lichenification = leathery and hard, darker in color
Peau d’Orange Texture = may indicate more problems with a cancer (recurrence of cancer) or an infection. Call doctor
Ulcers = may be more common with arterial, neutrotrophic, venous, or traumatic conditions
Vesicles (cysts) = can leak lymphatic fluid
Lymphoria = lymphatic fluid that seeps out from skin b/c there is nowhere else for it to go
Complications
Infection = medical emergency
cellulitis, dermatitis, lymphangitis
skin cut, bug bite, hang nail are portals for
infection and these can spread quickly
Reflux
Weeping = lymphoma
Medical Diagnostics/Management
Medications: no evidence of any meds to treat
Surgeries: no surgeries currently can cure
lymph node transplant
debulking, liposuction (not good, could lead
to amputation)
Tests and Measures:
Lymphoscintigraphy = nuclear imaging method,
tissue injection is transported by lymphatic
system and allows assessment of superficial
and deep lymphatics, no damage to lymph
vessels
Venography and Doppler US: rule out venous
problems (always rule out DVT before treating
for lymphedema
Complete Decongestive Therapy (CDT):
Gold standard for lymphedema management
take advantage of systems to move fluid
Manual Lymph Drainage (MLD)
Compression Therapy
Exercise
Skin Care
Self Care & Risk Reduction/Education
All 5 components of CDT are essential for
best therapeutic outcomes
Diuretics can make it worse
Examination
Clinical Diagnosis
History: reason for swelling, medical conditions, surgeries, how quick did swelling progress or develop, how long, does it decrease at night, what are you doing to help it, pain?
Inspection: (location, skin, lymphoma, wounds, scars)
Palpation: (temp, density, dryness)
Stemmer’s signs: thickening of skin on the dorsal hand/foot; inability to pinch skin in these areas
Measurements: (every 4cm), truncated cone formula to determine volume of limb, not detected clinically until interstitial fluid reaches >30% above normal
Bioimpedance
MMT/ROM/Nerve Mobility/Muscle length/Function
Home assistance/Financial resources
Effects of Complete Decongestive Therapy
Decrease swelling (>50%)
Increase lymph drainage from the congested areas
Improve skin condition
Improve patient’s function, quality of life
Reduce risk of infection
Complete Decongestive Therapy
2 Phases: Reductive Phase
Maintenance Phase
Reductive Phase:
Daily (5x/week) treatments until fluid
reduction has plateaued (when volumes are
equal side by side then compression garment.
Don’t decrease swelling but maintain it. Don’t
put compression garment on until swelling is as
low as you can get it and compression
garments need to be replaced every 4-6 mos
* MLD followed by compression
bandaging, exercise
* 60 min appointments
* bandages stay on until return next appt
Maintenance Phase:
Self-management program
* Self-MLD
* Compression bandaging or bandaging
alter at night
* Compression garments during day
* Skin care
* Exercise
* Pneumatic compression device, sometimes
Periodic monitoring
Replacements of compression garments
even 4-6 mos
CDT includes Diaphragmatic Breathing = allows diaphragm to move and stimulate lymph nodes in abdomen
CDT Precautions/Contraindications
Careful techniques, do not cause genital lymphedema
they may need to wear tight shorts or bras
Do not use long-stretch bandages/ACE wraps (can create more of a tourniquet
Skin irritation
Infection
Cognition/communication (need response with it or could do more damage)
Wounds
Manual Lymphatic Drainage
Increases the movement of lymph/interstitial fluid, including proteins
Improves lymph transport capacity, lymph vessel contractility
Stretching of the skin affects the superficial lymph vessels
* pressure phase promotes fluid movement in a
desired direction
* relaxation phase causes a vacuum due to the
distention of the tissue and leads to refilling of the
lymph vessels
Slow technique, 5-7 repetitions per area
Gentle technique, do not rub or create redness
Side effects = increases urine output
Could spend 1/2 of the time on trunk and less time on legs and get good results
Start with diaphragmatic breathing, then trunk
MLD Sequencing
Clear proximal regions and nodes
Move segmentally
Always stretch from distal to proximal
