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EDEMA CONFUSION
VENOUS INSUFFICIECY?
EDEMA?
PHLEBOLYMPHEDEMA?
Marta Ostler PT, CWS, CLT
objectives
1. Recognize CVI
2. Recognize lymphedema
3. Recognize phlebolympedema and its
relationship to the above
4. Become familiar with treatment options for
the above
WOUNDS
NON/POORHEALING
EDEMA
LYMPHEDEMA
WORLDWIDE
FILARIARL INFECTION
WESTERNWORLD
PHLEBOLYMPHEDEMA
CHRONIC VENOUS ULCERS (CVI)
Venous Ulcer account for 60-90% of leg ulcers
More common in women: 3X
Difficult to heal: 50% > 9 months/20% > 2 years
High rate of reoccurrence: 60%
76% Diagnosed by presentation alone
Advances in Skin & Wound Care: August 2009 - Volume 22 - Issue 8 - p 384
VASCULAR MECHANICS
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DEEP VEINS
SUPERFICIAL VEINS
COMMUNICATING VEINS (PERFORATORS)
VALVES
CALF PUMP
Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4 issue
10-Oct 2010.
WHAT IS NORMAL???
average,
typical,
expected
WHAT IS “NORMAL”
ANATOMY
VENOUS SYSTEM
• DEEP VEINS
• SUPERFICIAL VEINS
• PERFORATORS
Semin Intervent Radiol. Sep 2005; 22(3): 147–156.
HOW MUCH PRESSURE IS NORMAL?
Amount of pressure need to collapse superficial
veins in the ambulatory patient.
Initial pressure to narrow a the vessel:
30-40 mmhg
Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4 issue 10Oct 2010.
How Much Pressure Is Normal??
Directly proportional to persons Height and Distance from
heat to feet
OBESITY: Linear relationship girth and IM pressure
• Resting Pressure/supine: ~8 mmHG
• Standing: + 100 mmHG
• Ambulation: ~25-100 mmHg
Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4 issue 10-Oct 2010
Partsch H, Annuals Vascular Disease 2012
VENOUS PRESSURE = EDEMA
Ambulatory Venous Hypertension:
The elevated pressure in the leg vein during walking
Even with intact vessels:
25 mmhg calf pump - 8 mmhg rest
Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.
WHAT IS ABNORMAL??
•
UNPREDICTABLE
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ATYPICAL
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ILLOGICAL
ANATOMICAL FAILURE
• Venous Wall Physical Properties: Reduced Strength
• Venous Valves
Primary Venous Disease: degenerative damage
Secondary Venous Disease:
DVT
• Calf Pump (….exercise…..)
90% of venous return is through these 3
Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg
ulcers; Wounds International: 2013
LYMPHEDEMA
An abnormal
collection of
excessive tissue
proteins, edema,
chronic
inflammation and
fibrosis in the
interstitial space.
The
International Society of Lymphology
CHRONIC PROBLEM
NO CURE
LYMPHATICS
• “Pre” Lymphedema
• High Protein Edema
• Sub-Acute Edema
• PHLEBOLYMPHEDEMA
MEM: Manual Edema Mobilization
MECHANICAL INSUFFICIENCY
LYMPHATIC SYSTEM IS DAMAGED AND HAS
REDUCED TRANSPORT CAPACITY
TRAUMA
RADIATION
INFECTIONS……..ETC
DYNAMIC INSUFFICIENCY
FLUID LOAD EXCEEDS LYMPHATIC TRANSPORT
CAPACITY
HEART FAILURE
KIDNEY DISEASE
OBESITY…….ETC
PHLEBOLYMPHEDEMA
WHAT?????
Mixed-etiology swelling…….
CVI+ lymphatic insufficiency
=Phlebolymphedema
CAUSED BY……………..
THE INABILITY OF THE LYMPHATIC SYSTEM TO
ADEQUATELY DRAIN THE INTERSTITIAL FLUID
THAT ACCCUMMMULATES IN SEVERE
CHRONIC VENOUS HYPERTENSION.
SYSTEMIC DISEASES
CONGESTIVE HEART FAILURE
CIRRHOSIS
CONTRIBUTE TO
NEUROPATHY
OBESITY
MEDICATIONS
P
H
L
E
B
O
L
Y
M
P
H
E
D
E
M
A
SOOOOOOOOO…….
DEFINITION:
Phlebolymphedema is due to insufficiency of the
venous or/and lymphatic system, in
combination with possible systemic
contributors, leading to accumulation of
interstitial protein-rich fluid in the interstitial
space.
CONSIDERED AN ORPHAN DISEASE, AS IT DOES NOT
FALL INTO ANY MEDICAL SPECIALTY
Wound care?
Internal Medicine?
Physical Therapy?
Massage Therapy?
Nursing?
Chiropractic?
What we get…..
• Hyperemia: Venous Hypertension
• Increased interstitial fluid
• Increased subfascial edema
• Increased compartment pressure
OVERWHELEMED LYMPHATIC SYSTEM
PROINFLAMMATORY STATE
EDEMA AND WOUND HEALING
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Inflammation
Fibrosis
Induration
Elevated Proteases
Ischemia
Elevated MMP-1 in Venous Ulcers
Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression
therapy. Wound Rep Regen 16:642-648, 2008.
Organized Approach to Wound Care
1.
Disease Process Controlled
Patient Centered Pain
2.
3.
Wound Moisture Balance
Advanced Modalities
Edema
Offloading
BioBurden
4.
5.
6.
7.
Debridement
Blood Flow
8.
9.
Is there adequate perfusion and/or
oxygenation?
Is non-viable tissue present?
Are signs/symptoms of infection
and/or inflammation present?
Is offloading or pressure relief
appropriate?
Is edema controlled?
Is tissue growth optimized?
Is the wound microenvironment
conducive to healing?
Is pain controlled?
Are host factors optimized?
WHY IS IT SO HARD TO DO THE
RIGHT THING IN WOUND CARE
• 17% VLU patients received adequate
compression
• Inadequate reimbursement
• Lack of familiarity with Clinical practice
Guidelines
WHAT MUST WE DO ABOUT IT?
COUNTERACT GRAVITY
EXERCISE
COMPRESSION THERAPY
PURPOSE OF COMPRESSION
1. Counteract the force of gravity and promote
the normal flow of venous blood up the leg
2. Acts on the venous and lymphatic systems to
improve venous and lymph return and
reduce edema
3. Causes narrowing of the superficial veins
Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158
BUT…….
A WHIRLWIND OF CELLULAR DYSFUNCTION
LEADING TO LIPODERMATOSCLEROSIS AND
PROTEIN ESCAPING INTO THE INTERSTITIAL
SPACE
COMPRESSION REMOVES MORE WATER DUE TO
OSMOTIC PRESSURE
NEED TO REMOVE PROTEIN!!! MLD/CDT
WHAT DOES ALL THIS LOOK LIKE??
STASIS DERMATITIS:
Inflammatory skin disease occurring on the
lower extremities of patients with CVI.
-caused by venous hypertension
-precursor to ulceration
-sensitive to contact allergens
(bacitracin/neomycin)
LIPODERMATOSCLEROSIS (LDS):
Skin change in the lower legs, a type of
inflammation of the subcutaneous fat.
-dermal fibrosis/hyperpigmentation
-inverted champagne bottle
PHLEBOLYMPHEDEMA SIGNS
KAPOSI-Stemmers sign
SAUSAGE TOES
Lippodermatosclerotic changes
LYMPHEDEMA RUBRA (mimics cellulitis)
TREATMENT
COMPRESSION
MLD: MANUAL LYMPHATIC DRAINAGE
CDT: COMPLETE DECONGESTIVE THERAPY
COMPRESSION THERAPY
WHAT???
• Compression therapy is the application of pressure to
the lower extremities. It is the recognized treatment
of choice for recurrent venous leg ulcers.
• Compression therapy systems include hosiery, tubular
bandages, and bandage systems of two or more
components.
• These systems aim to provide graduated compression
to the lower limb in order to improve venous return
and to reduce edema.
http://wwundsinternational.com/pdf/content_10802.pdfw.wo
HOW DO WE DEFINE THIS IN PRACTICE??????
Types of Compression
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ELASTIC
INELASTIC
STATIC
DYNAMIC
WRAPS
HOSE
HELP!!!!!
TYPES
• COMPRESSION WRAPS
• COMRESSION HOSIERY
• INTERMITTENT PNEUMATIC COMPRESSION
(IPC)
WHAT TO DO BEFORE COMPRESSION
VASCULAR SCREENING
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ABI: ANKLE/BRACHIAL INDEX
Greater than 0.90 = normal
0.71 – 0.90 = mild obstruction
0.41 – 0.70 = moderate obstruction
Less than 0.40 = severe obstruction
FALSELY EEVATED WHEN ARTERIES HEAVLY
CALCIFIED AS IS SEEN IN DIABETES.
PURPOSE OF COMPRESSION
1. Counteract the force of gravity and promote
the normal flow of venous blood up the leg
2. Acts on the venous and lymphatic systems to
improve venous and lymph return and
reduce edema
3. Causes narrowing of the superficial veins
Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158
WHAT IS ADAQUATE COMPRESSION
• Overcomes intravenous pressure
• Exerts a sub-bandage resting pressure that is well
tolerated in a resting position
• Provides a pressure increase when the patient
rises to a standing position: (50-70mmHG)
• Provides external compression improving
venous reflux during walking
Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and
prevention of venous leg ulcers; Wounds International: 2013
Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA
Journal 2006, vol 6 NO2.
STIFFNESS OR EXTENSIBILITY
• The relationship between the resting and working
pressures of a compression device
• Achieved through use of inelastic bandages in
multiple layers
• Measured in SSI (Static Stiffness Index)
-LOW SSI: <10: Knitted Stocking, Elastic Bandages
-MED SSI: Flat Knitted Stocking
-HIGH SSI: >10 Short Stretch, Multicomponent
Bandages, Zinc Paste Wraps, Velcro Wraps
Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface
La Places Law
A formula that defines the pressures exerted on curved
surfaces
Pressure = T x N
C xW
N= number of layers applied
T= bandage tension
C= limb circumference
W= Bandage Width
World Union of Wound Healing societies (WUWHS). Principles of best practice:
Types of Bandages
• Non-Stretch
• Short –Stretch
• Long -Stretch
Non-Stretch
ZINC PASTE BANDAGES
Short Stretch
• Bandages that stretch to less than 100% of
their original length: minimal extensibility
• High Working Pressure/Low Resting Pressure
Long Stretch
• Expands over 100% of its original length
• Low Working Pressure/High Resting Pressure
• Contains Elastomeric Fibers:
fibers that are able to
stretch and return to almost their original size.
World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008
Long Stretch
NOTE
BECAUSE OF ELASTIC MATERIAL’S ABILITY TO SUSTAIN
PRESSURE, SOME CLINICIANS BELIEVE THAT IT MAY BE
MORE EFFECTIVE THAN INELASTIC MATERIALS FOR AN
IMMOBILE PATIENT OR THOSE WITH A FIXED ANKLE AND LESS APPROPRIATE AND MORE UNCOMFORTABLE
FOR A PATIENT WITH IMPAIRED PERIPHERAL PERFUSION.
FURTHER RESEARCH IS REQUIRED TO CONFIRM THIS AND
CLINICIANS SHOULD BE AWARE THAT INELASTIC
MATERIAL CAN PROVIDE PRESSURE PEAKS EVEN DURING
SMALL ANKLE FLEXIONS.
World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008
Hose/Support Stockings
• Made of elasticated textile
• Styles: knee, thigh, pantyhose lengths
• Custom or off-the-shelf
• Can be used as first line treatment in
patients with small ulcers
• 2-component systems
LEVELS OF COMPRESSION
• Class I: 14-18 mmHg: Anti-Embolism hose
Not a therapeutic level of compression
• Class II: 18-24 mmHg: dependent edema,
non-ambulatory, CHF
• Class III: 25-35mmHg: Venous Insufficiency
• Class IV: Lymphedema, need to have active
muscle movement
Other compression devices
Intermittent Pneumatic Compression
Intermittent Pneumatic Compression
EVIDENCE SUGGESTS
A boot composed of air-filled chambers
attached to an electric pump, used in
combination with compression bandaging, may
be more effective that bandaging alone.
Schuler JJ, Maibenco T, Megerman J, Ware M, Montalvo J; Treatment of chronic venous ulcers using sequential gradient
intermittent pneumatic compression; Phlebology / Venous Forum of the Royal Society of Medicine; 1996, vol 11,issue 3.
EXERCISE!!
CALF RAISES
CALF STRETCHES
MARCHES
DAILY WALKING
UP AND DOWN STAIRS
SWIMMING
• 75 % adherence
• 24% improved healing rates
Obrien J, Finlayson K, Kerr G, Edwards H; Evaluating the effectiveness of a self –management exercise intervention on wound healing,
functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomized controlled trial. Int
Wound , 2016 Jan 27.
TAKE HOME PEARLS
• THINK ABOUT THE WHOLE PATIENT…..
• REMEMBER OTHER SPECIALITIES THAT MAY BE
ABLE TO HELP
• EXERCISE/MOBILITY
• LYMPHATIC CARE/EDUCATION
• COMPRESSION TOOLS/TRICKS
THANK YOU FOR COMING TO THIS YEARS SYMPOSIUM!!!!!
BIBLIOGRAPHY
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Brenner E, Putz D.MorigglB: Stemmer (Kaposi-Stemmer-sign-30 years later.
Phlebologie.2007: 36(6):320-324.
Farrow W, Phlebolymphedema-A common Underdiagnosed and Undertreated problem
in the wound Care clinic. Journal fo the Am. College of certified Wound specialists
(2010) 2: 14-23
Valencia IC, Falabella A, Kirsner RS, Eaglstein WH: chronic venous insufficiency and
venous leg ulceration . J am Acad, Dermatol. 2001 44(3):401-421.
Guyton AC: texbook of Medial Physiology. 8th Ed. Philadelphia PA: WB Saunders:
1991.
FoldiE, Foldi M, Chronic venous insufficiency and venous-lymphostatic insufficiency. In:
Foldi’s texbook of lymphlogy . 2nd ed. Munich, Germany; Elsevier, 2006 p. 434-447.
Fugman SL, Clar, RA, Stasis dermatitis. Available at Http://emedicine .
Medscape,com/article/1084813-overview. Accessed april 26, 2010
Goldman MP: Lipodermatosclerosis: review of ases evaluated at the Mayo clinic H Am
Acad Dermatol. 2002:46: 187-192.
Blankfield RP, Finkelhor RS, AlexanderJJ, et al: Etiology and diagnosis of bilateral leg
edema in primary care. Am J Med. 1998: 105: 192-197.