Dawn Heal RN, MLD/CDT
MLD Therapist/Lymphoedema Nurse Specialist
The Hampshire Lymphoedema Clinic
Aims
 Anatomy &
Physiology
 Signs & Symptoms
 Preventative
Measures
 Maintenance
What is lymphoedema ?
 Lymphoedema is a chronic swelling/chronic oedema
anywhere in the body but usually affecting an arm or leg. It
occurs when the lymphatic system is overloaded.
 It may begin as a feeling of heaviness and aching in the
affected limb. Mild swelling will initially reduce overnight and
may also be exacerbated by heavy lifting or certain types of
exercise.
 Left untreated the swelling will become worse, firmer and more
rigid, the skin hard and thickened. The limb becomes dry,
heavy and uncomfortable and at risk of cellulitis
Role of Lymphatic System
• To gather fluid from tissue spaces
and return it to circulation
• To gather, transport and absorb
protein and lymph fluid
(containing: water, hormones,
bacteria, enzymes, fats and cell
waste products) and return it to
the circulatory system
• To act as a defence mechanism
against bacteria and mutant cells
Blood and Lymph
Circulatory Systems
• The lymphatic system acts as a one way
drainage system parallel to the venous
system
• The main differences between the blood
circulatory system and the lymphatic
system are:
– the lymphatic system only forms a
semicircle
– has no pump for moving the lymph
• The Lymph transport is maintained by
several alternate transport mechanisms
Normal Flow
Initial Lymphatics - Superficial
 Blind ended tubes
 Single layer of epithelium
 No muscle – passive
 Collapsed when empty
 Attached to surrounding structures
by anchoring filaments
 Opens and takes in fluid in response
to movement of surrounding tissues
 No flow when limb at rest
Lymphatic System Components
 Superficial vessels
– blind end tubes
 Pre-collector vessels
 Collector vessels
 Lymph nodes
 Right lymphatic duct
 Left lymphatic duct
 Cysterna chyli
Anchoring Filaments
Anchoring
filaments
Skin
Muscle
Initial Lymphatics
Lymph Nodes
• Lymph nodes
– where lymphatics drain into
– occur in groups or as node
chains alongside the blood
vessels
• Multiple functions
– biological filter stations
– production of lymphocytes
(especially in an immune
reaction)
– regulates the protein
content of the lymph
Lymphatic System
The Whole Picture
• Superficial lymphatics
• Deeper lymphatics
Understanding the venous system
 The lower limbs contain both deep veins (femoral,
tibial and popliteal) and superficial veins (long and
short saphenous)
 Perforator veins connect them through the fascia
and are reliant on a system of non-return valves
 Therefore when we stand up blood is prevented from
flowing downwards back into the superficial veins.
Non-return valves can be congenitally absent, weakened as in
pregnancy, or traumatized by injury or deep vein thrombosis.
Backflow dilates the superficial veins which then become visible
Venous vs Lymphatics
 Starlings Law Revised !
 Lymph vessels are responsible for taking ALL the interstitial
fluid away
 Venous congestion causes higher capillary filtration
 Venous oedema will turn into chronic oedema if left
untreated!
Lymphoedema
 Lymphoedema (chronic
oedema) is the result of
accumulation of fluid in
the tissue spaces due to an
imbalance between
interstitial fluid production
and transportation.
 Lymph fluid is corrosive to
skin and causes skin
maceration and ulceration
(Lymphorrhea)
Imbalance
Lymphoedema develops when
the balance is disturbed
between:
• Fluid exchange from blood
capillaries and the interstitium
• Fluid transportation via blood
capillaries and the lymphatic
system out of the interstitium
More fluid is entering the
interstitium than the venous
capillaries and lymph vessels
can absorb
Lymphatic Overloading
- Flooding
Factors Causing Oedema
•
Trauma and tissue damage:
•
Malignant disease:
•
Venous disease:
•
Obesity
•
Infection:
•
Inflammation:
•
Endocrine:
•
Immobility / dependency:
–
–
–
–
–
–
–
surgery, radiotherapy, scarring, burns, chemotherapy
metastases, infiltrating tumour, extrinsic pressure, lymphoma
ulceration, chronic venous insufficiency, post thrombotic syndrome, IV drug use
cellulitis, lymphadenitis, filariasis, TB
rheumatoid arthritis, dermatitis, psoriasis
hormonal surges (eg: puberty, pregnancy, menopause)
paralysis, dependency oedema
Influencing Factors in Oedema
Low Protein
• Low Serum Albumin
• Cardiac Insufficiency
• Allergic Reactions
• Renal Insufficiency
• Drugs (NSAID’s, Steroids, Hormonals)
Mixed
• Vena Caval Obstruction
• Venous Insufficiency
• Injuries to bones/tissues
• Inadequate muscle pump
High Protein
• Lymphostatic disorders
Classification of Lymphoedema
 Lymphoedema is classified as primary or secondary
depending on aetiology
 Primary Lymphoedema is a congenital abnormality of the
lymphatic system, often present from birth
 Secondary Lymphoedema results from damage to lymphatic
vessels or nodes or overload to the system ie. Chronic venous
insufficiency or cancer treatments
Primary Lymphoedema
 Congenital
 Missing or malformed
 Lymphatics
Hyperkeratosis
scaly patches caused
by overproliferation of
the keratin layer
Classification of oedema
 Swelling – mild, moderate or severe
 Skin condition – thickened, warty, blistered, lymphorrhea,
ulcerated
 Shape change – abnormal or distorted shape
 Frequency of cellulitis/erysipelas
Classification of Severity
 Mild
<20% excess limb volume
 Moderate
20%-40% excess limb volume
 Severe
>40% excess limb volume
Assessment components
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Medical history
Neurovascular assessment
Oedema history and treatment
Examination of skin, subcutaneous tissues, site, circulation –
Stemmer sign
Degree and distribution of swelling
Functional abilities
Psychological response and motivation
Social situation
ABPI in patients with Chronic
Oedema
 Ankle Brachial Pressure Index in a patient with oedema
may not be possible or advisable. Consider using a larger
cuff and Doppler probe with lower frequency ie 5mHz
rather than 8mHz
 Pulse oximetry is a useful alternative or toe doppler
 Refer for Duplex Ultrasound
 Skin colour and temperature
 Sensation checks
 Capillary Refill
For those ‘at risk’ and those with Lymphoedema
Common Sense General Advice
 Keep nails short - if help required referral
to a podiatrist
 Use an insect repellent in Summer
 Treat pets for fleas
 Treat Athletes foot/fungal nail infections
 Protect skin at all costs
What to Avoid
Things that can lead to infection and
make swelling worse
• Having bloods taken from “at risk” or
swollen arm
• Having infusions (drips) into “at risk” or
swollen arm
• Scratches, cuts and grazes
• Acupuncture
• Blood pressure cuffs to a swollen limb
• Insect bites / flea bites
• Care whilst cleaning or in the garden
• Fungal nail infections
What to Avoid
Constriction of swollen area
 Having blood pressure taken
on “at risk” or swollen limb
 Tight clothing, cuffs, socks
 Tight jewellery, such as rings,
bracelets and watches
Skin Care
Skin Care
 Essential
 natural barrier to infection
 Wash and dry area daily
 water not too hot
 Pay attention to awkward
areas!
 Stretched skin can become
very dry and cracked
 port of entry for bacteria
 Application of emollient
 gentle, with final stroke in
downwards fashion to prevent
folliculitis
Skin Care - Ointment, Cream or Lotion ?
 Lotions – are less moisturising than creams as they have
a higher water to oil ratio.
 Creams – are less greasy than ointments but not as
beneficial to very dry skin. May also cause skin
sensitivities due to preservatives added.
 Ointments – are greasy and rarely cause skin sensitivities.
Will lift dry, scaly patches and intensely moisturize dry
skin.
Skin Observation
• Daily skin care to keep limb supple
• Prevent trauma and injury
• Reduce risk of infection
• Prompt treatment of infection
Address
• Lymphorrhoea
- skin care
- MLLB
• Prevent and treat fungal infections
Lymphorrhoea
•
Lymphorrhoea is the leakage
of lymph through the skin
surface
•
Large beads of fluid appear
on the skin and trickle down
from affected areas
•
It is often cold to the touch
•
Possible source of infection!
Papillomatosis
Dilation of lymphatic vessels and fibrosis
Cellulitis
 Cellulitis is a severe infection requiring urgent
treatment with antibiotics.
 Cellulitis can cause lymphoedema or worsen
existing swelling.
 Following cellulitis lymphoedema is unlikely to
resolve independently, or ever return to normal
 Cellulitis not completely eradicated will remain
chronic and keep returning.
Chronic Cellulitis
Management of Cellulitis
 Acute cellulitis – Treat for at least 14 days or until all signs of
inflammatory episode has gone. Prophylactic antibiotics if
recurrent episodes of infection.
 Amoxicillin 500mg q8h
or Flucloxacillin 500mg q 6hr
If allergic to Penicillin – Clindamycin 300mg
BLS Consensus Document of the Management of Cellulitis
in Lymphoedema – www.lymphoedema.org/lsn
Preventing cellulitis
 Skin Care – frequent bathing and moisturizing of
affected limb
 Treating infections effectively
 Reducing oedema
 Compression therapy (bandaging or hosiery)
Exercise and Lymphoedema
 Promotes lymph drainage
 Improves joint mobility
 Helps maintain weight
 Gentle regular exercise – swimming, yoga, Pilates
 Avoid exercise that puts a heavy strain on the limb
such as lifting weights (includes lifting children),
digging the garden, prolonged ironing or window
cleaning, jogging
Exercise & Movement – improves lymph flow
 Use the limb as normally as
possible
 Avoid strenuous movement
 Rest is as important
 Position and support the limb
 Encourage normal activity
walking, swimming, etc.
 Over-activity can cause
increased swelling
-
Treatment decisions
 Compression Hosiery
 Multi layer lymphoedema bandaging (MLLB)
 Intensive therapy (this includes skin care, exercise and
elevation of the limb) Refer to Specialist
 MLD (manual lymphatic drainage) to decongest
the impaired lymphatic pathways
 MLLB
 Compression hosiery
MLD (manual lymphatic
drainage)
 Aims to reduce swelling by encouraging lymph flow
 Gently massage technique recognised as key component in
DLT
 Bypasses ineffective or obliterated lymph vessels
 MLD must be combined with compression to support and
maintain its effects
MLD – not traditional Massage!
Dependant Oedema
Pre Treatment
3 weeks later with short stretch
bandaging
DVT – Post Thrombotic Syndrome
Before Treatment (unable to work –
leg 100% larger distally)
3 weeks later – leg just 10% larger
– now working full time
What about Obesity?
Morbid obesity can produce
lymphoedema in absence of any
other compromise to lymph system.
When sitting both venous and lymphatic
vessels are obstructed. Obese patients
should avoid sitting at 90 degrees.
Elusive but definite link between
fat, lymphatics and immune
system’
(Rockson 2004)
Metastatic Pelvic Disease
Case Study
 71 year old female
Skin Condition
Discharge Photos
 Total fluid loss in 1st 10 days – 14 litres !
 Each litre weighs 2lb
Maintenance
 Compression Hosiery
 Consider the ‘stiffness factor’
 Interface pressure is the pressure produced by the hosiery
on the skin’s surface. Materials that are less elastic ie flat knit
give sustained pressure levels.
 In the case of shape distortion elastic circular knit hosiery
may cause a tourniquet effect and therefore skin damage.
Flat knit hosiery is the safe option.
 Education and applicators
 Hosiery in the drawer doesn’t help!
What's wrong with this picture?
Compression garments
 What type ?
 Flat knit or Circular knit
 Off the self or made to measure
 Need for a zip ?
 Applicator device ?
Circular knit
 Prevention of oedema
 Varicose veins
 Venous disease
 Leg of Uniform shape
 No folds or rebound swelling
Flat knit garments
• The limb shape is uneven and distorted
• The skin is intact and resilient
• The oedema is long-standing and at risk of
further breakdown
• The oedema is prone to “rebound”
Flat Knit
Circular knit
Mtm flat knit garments
Time for Questions?