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Lymphedema Click on arrow for next slide Objectives Understand/describe the normal structure and function of the lymphatic system. Identify risk factors affecting the normal drainage of the lymphatic system. Discuss diseases or procedures that could predispose a patient to lymphedema. What is lymphedema? Lymphedema is an abnormal accumulation of high-protein concentrated fluid, usually in the arms and legs. Dell & Doll, 2006 Image reproduced with permission from vascularsociety.org The Lymphatics The lymphatic system filters and collects lymph and large molecules in the interstitial space that come from the intravascular space. Golshan & Smith, 2006 Used with permission from lymphacare.com Normally, the heart pumps so strongly that it causes 20-30 liters of plasma per day to leak from the capillaries. This is the interstitial fluid, which the lymphatic system drains, filters, and returns to the heart. Nazarko, 2006 This interstitial fluid contains proteins, lipids, water, and products from cellular breakdown. Golshan & Smith, 2006 Lymphatic vessels are similar to veins, but with thinner walls to allow larger proteins to permeate through. Holcomb, 2006 National Cancer Institute, 2006 Once this interstitial fluid is absorbed, it moves through the lymphatic vessels, and is considered lymph fluid. As lymph fluid moves through the lymphatic system, it passes through lymph nodes. Lymph nodes filter harmful substances and contain lymphocytes that activate the immune system. National Cancer Institute, 2006 Used with permission from Lymphnotes.com The lymph system carries the lymphocytes throughout the body to respond to antigens and communicate responses to other parts of the body. Lacovara & Yoder, 2006 Lymph then travels through multiple lymphatic channels and nodes before returning to the venous system by the thoracic duct. Golshan and Smith, 2006 Used with permission by med-ars.it Under normal conditions, the entry of fluid and other materials into the interstitial space is balanced by outflow of the lymphatic fluid from the limb, which maintains standard volume. Golshan and Smith, 2006 Used with permission from www.med-ars.it Lymphedema occurs when there is an interruption or obstruction of the lymphatic system that causes an accumulation of fluid in the limb. Golshan & Smith, 2006 Used with permission from lymphacare .com A healthy adult has approximately 600-700 lymph nodes. Lacovara & Yoder, 2006 The main areas are: Supraclavicular Retroperitoneal (deep abdomen and pelvis) Trachea Thoracic (adjacent to the lung) Thiadens, 2005 Abdominal (near the intestine) Axilla The pelvic area Inguinal Also found in tonsils, spleen, intestinal wall, and bone marrow. Thiadens, 2005 Review of the “Flow” Click on the screen Interstitial fluid has diffused from blood capillaries The lymph capillaries absorb this interstitial fluid The capillaries join to form vessels that carry the lymph fluid back to the heart. Thoracic Duct The lymph fluid then enters either the thoracic duct or right lymphatic duct On the trip back, the lymph fluid passes through lymph nodes, where it is cleaned and filtered Mader, 1994 www.lymphacare.com The fluid is then enters the subclavian veins and is returned to the circulatory system. Risk Factor: Surgery Any surgery that dissects or removes lymph nodes increases the risk of lymphedema by impairing the lymph flow. Marrs, 2007; Lacovara & Yoder, 2006 Common cancers that may require surgical alterations of the lymph nodes include breast cancer, melanoma, gynecological cancers, head and neck, prostate, testicular, bladder, or colon cancer. Thiadens, 2005 Risk Factor: Obstruction Tumors themselves may cause lymphedema by obstructing the lymphatic vessels. Dell & Doll, 2006 This is can be seen with many cancers, including cervical cancer, breast and prostate cancer, and head and neck cancers. Nazarko, 2006; Romero, 2007. Risk Factor: Radiation Radiation therapy to the axillary or groin region around the lymph node can cause fibrosis and scarring of the tissue and therefore cause lymphedema to occur. Golshan & Smith, 2006 Risk Factor: Lymphedema and Breast Cancer It is estimated that that anywhere from 25-60% of patients with breast cancer will experience lymphedema. Lacova & Yoder, 2006 The sentinel lymph node is the first lymph node draining from this tumor bed. Tumor Dow, 2002 Sentinel Node Used with permission from www.med-ars.it A technique called Sentinel Node Biopsy can be performed, which the surgeon finds and removes this first node and sends it for a pathologic examination. New evidence suggests that there is no need to remove any more lymph nodes regardless of the pathology-- the SNB pathlogy gives the physician the info needed to design treatment protocol. Thaidens, 2005 Lymph node anatomy Used with permission from Bocaradiology.org Other Risks: Infection and Injury Things such as infections, bug bites, and bee stings may lead to lymphedema in a high-risk patient. Trauma to the extremity at risk may also cause lymphedema. What constitutes trauma? The rationale is lymphatic flow increases to the affected site, however there is an obstruction or defect in the lymphatic system, causing lymph fluid to leak. Dell & Doll, 2006 Other Possible Risks: Other causes that may lead to lymphedema include: Scarring from a vesicant extravasation Local burns Lymph node metastasis Overexercise, including stretching of cord Cording or Axillary webbing Diagnosing Lymphedema Painless swelling of the arms or legs, which may get worse during the day and better at night. Warmth or achiness in the extremity. A feeling of tightness, heaviness, tingling, numbness, or weakness in the affected extremity. Redness of the affected extremity. Bracelets, rings, or shoes may become tight. Lacovara & Yoder, 2006 Diagnosis, Continued… A 2 cm difference between affected extremity and non-affected extremity is a general classification. Bicego, et al, 2006 Infection Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Lacovora & Yoder, 2006 Low prophylactic doses of antibiotics may be used if patients develop cellulitis frequently. Thiadens, 2005 Cellulitis: used with permission from www.med-ars.it Stages of Lymphedema: Stage I Considered reversible There is pitting and the tissue is soft Arm girth may or may not be increased. Treatment = elevation Lacovara & Yodder, 2006 There is > 3 cm difference between extremities Itano & Taoka, 2005 Used with permission from lymphacare.com Stage II Considered irreversible May be non-pitting and fibrotic Elevation does not reduce swelling. Lacovara and Yoder, 2006 There is 3 to 5 cm difference between extremities. Itano & Taoka, 2005 Used with permission from lymphacare.com Stage III Tissues are hard and may have cartilage formation developing. Swelling is severe and may form deep crevices. Lacovara and Yoder, 2006 There is a > 5 cm difference between extremities. Itano & Taoka, 2005 Photo Courtesy of Lymph Notes (www.lymphnotes.com) Prevention No blood draws, IVs, blood pressures, or injections should be taken on the affected extremity. Thiadens, 2005 This includes all needle sticks, such as sub-q/IM injections and finger pricks for blood sugar testing. Cole, 2006 The rationale is if any foreign object, such as a needle, is placed in the affected extremity, it will cause an inflammatory response. This puts the lymphatic system under more stress, which may cause swelling to occur. Cole, 2006 A general recommendation is to avoid having blood pressure taken in that extremity, avoid tight clothes, rings, etc. but recent research suggests that this might not be a risk factor. Normalize body weight Progressive exercise programs Good skin care: Keep the skin clean and dry Apply moisturizer daily Protect skin with sunscreen and insect repellant Use care with razors Wear gloves when gardening, etc to protect the skin Keep cuts clean and dry – monitor closely for S & S of infection Contact physician immediately for rash, redness, pain, increased swelling, etc. Thiadens, 2005 Avoid extreme temperatures, such as hot tubs and saunas. Heat may cause vasodilatation, which causes more fluid to move from the blood vessels into the tissues. Dell & Doll, 2006 Cold may cause rebound swelling or chapped skin, leading to infection. Air travel has been thought to be a risk factor for lymphedema, but recent research does not support this, except for those who have a high number of nodes removed, for e.g. 15+. For these individuals, wearing a compression sleeve MAY prevent lymphedema. If the lower extremity is affected, avoid standing or sitting for long periods of time and do not cross legs. Marrs, 2007 Treatment Used with permission by www.bellisse.com Manual Lymph Drainage (MLD) Performed by specially trained therapist Massaging connective tissue rather that deep muscles Stimulates the lymphatic system and decongests the affected area to encourage formation of new pathways to unimpaired lymph nodes to reduce swelling. May also be taught to patient to perform on self. Thiadens, 2005; Dell & Doll, 2006 Compression Bandaging Bandages may be applied to increase tissue pressure and counteract the elastic insufficiency of the connective tissue. Thiadens, 2005 Used with permission from lymphacare.com Once a manageable size has been achieved from wrapping, a compression stocking may be worn to maintain the size and prevent increased swelling. Thiadens, 2005 Used with permission By knueppels.com There are no medications available at this time to treat lymphedema. Diuretics should not be used to help lymphedema because they draw off excess water in the interstitial spaces, not the excess protein. Once the diuretic is out of the system, it pulls more water into the affected area. Holcomb, 2006 DISABILITY Impaired physical mobility Disturbed body image Risk for infection Risk for impaired skin integrity Itano & Taoka, 2005 References Academy of Lymphatic Studies (2006 ) The source for research based lymphedema management. CD Rom. Sebastian, FL. ACOLS Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R. (2006). Exercise for women with or at risk for breast cancer-related lymphedema. Physical Therapy. 86 (10). pp. 1398-1405. Cole, T. (2006). Risks and benefits of needle use in patients after axillary node surgery. British Journal of Nursing 15(18) pp. 969-979. Dell, D.D. (2005). Spread the word about breast cancer. Nursing2005 35(10). pp56-63 Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema. Nursing2006. 36(6). pp. 49-51. Dow, K.H. (2002). Pocket guide to breast cancer (2nd ed). Sudbury, MA: Jones and Bartlett Publishers. Golshan, M., Smith, B. (2006). Prevention and management of arm lymphedema in the patient with breast cancer. Supportive Oncology 4(8). pp. 381-386 Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Nursing Made Incredibly Easy! 4(2). Pp26-34. Itano, J.K., Taoka, K.N. (2005). Core curriculum for oncology nursing (4th ed) Philadelphia, PA: Elsevier Saunders. Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the cancer patient. MEDSURG Nursing. 15(5). pp. 302-306. Lewis, M.S., Heitkemper, M.M., Dirsken, S.R. (2000). Medical-surgical nursing: assessment and management of clinical problems. St. Louis, MO: Mosby. Mader, S. (1994). Understanding human anatomy and physiology (2nd ed). Dubuque, IA: Wm. C. Brown Publishers. Marrs, J. (2007). Lymphedema and implications for oncology nursing practice. Clinical Journal of Oncology Nursing. 11(1). pp. 19-21. National Cancer Institute (2006). www.cancer.gov. retrieved 4/5/07 Nazarko, L. (2006). Understanding lymphedema in older people. Nursing & Residential Care. 8 (6). Pp.254-258. Porth, C.M. (2005) Pathophysiology: concepts of altered health states (7th ed). Philadelphia, PA: Lippincott Williams & Wilkins. Romero, R. (2007). Bandaging options for head and neck edema. eLymphnotes. Retrieved from www.elymphnotes.org Thiadens, S.R.J., (2005). Lymphedema: an information booklet. (8th ed). Oakland, CA: National Lymphedema Network.