Please join Dot Weir, RN, CWON, CWS for this mini on-demand video where she discusses the different types of Lymphedema and the challenges in managing them.
Hello and thank you for joining me. My name is doc We're I'm a wound care nurse of many years. I've been practicing one care for 40 years. I currently am in Saratoga springs associated with the Saratoga Sen for wound healing and hyperbaric medicine. And I think what's important especially from this particular presentation is that I've spent the last 21 years in outpatient wound care. And so that's the perspective that I bring to you today and so today what we're going to discuss is the utilization of compression therapy in the management of lymphedema. This is a busy slide. You can read a little bit of it. But the most important things that I want you to know is that any time you're going to go to start using something or a product that you haven't used before. You definitely want to read up on it and have some instructions. Make sure there's a competency involved. And the other important thing about this particular presentation for me is these are my patients. So the patient pictures that you see and there are actually from my clinic. I am a speaker and happy to be a speaker for three M. Um for Casey I now part of three a.m. So let's take a brief look at lymphedema and I think the disclosure I need to make to you is that I am not a lymphedema specialist and I am not a lymphedema therapist and I think most of us aren't. So I think I bring a perspective of many of you. You work in luke here. You may work in an outpatient center and you happen to see people who have lymphedema and I think it gives us a great opportunity to recognize those patients who have lymphedema and when we have perhaps gotten their wound close we can get them on to someone who can help them and we'll talk a little bit more about that. But just for a brief moment, let's look at the lymphatic system because it's a very intricate system, very delicate system in our body that is designed to have a complete equilibrium when everything is good. So it's a network of vessels and clearing houses if you will organs, like the theme is the spleen, your tonsils for example, and the lymph nodes that help to filter out things in our system, things in our blood that have come out of our bloodstream that need to be moved and filtered out of our body. And so as the fluid shifts as we look at the of course the arterial system brings the blood down our body and then the venus system takes it back up and as the blood is coming back up it goes from the arterial system through the capillary beds and then into the venus system. However, while that is happening, there is a point in time and you can see a little diagram at the bottom where the, as the fluid is moving from the arterial system into the venus system through hydrostatic pressure about fluid moves out and things that like proteins and cellular debris will be in there. So hydrostatic pressure pushes that out and then the venus system will pull it back in through on Codec pressure but there's about 10% that doesn't go in there and that is what contains those proteins and some of that debris. And the lymphatic system picks that up to move it through the filtration system before it goes back into the bloodstream so that it gets filtered out. So as I mentioned is an extremely intricate system and I didn't do it justice, just telling you those little bitty things about it. But it's critically important that it all works in sync and works well so that our fluid system in our body stays normal. So just briefly, let's take a look at the various types of lymphedema and remember I'm not a lymphedema therapist. So this is a very top line approach and look at this. But we have the kind that we probably don't see so much in outpatient clinics. The primary lymphedema is either something someone is born with that shows up within a few months after life uh or they develop either in their teen years at at puberty or into their young adult years. So while we we don't see these so often and certainly don't manage them. Um The lymphedema uh the time we might see them is that they do develop a traumatic injury or something and they can't get the wound heal what we see a lot of our second secondary lymphedema. They may or may not have venus insufficiency coupled with it. But they do have lymphedema as well as the womb. But this is these are patients where the system may or may not be intact but it's not functioning properly. And these are always going to have a similar story. Although this is a pretty long list is not exhaustive actually, but they've had some sort of axillary or groin surgery or radiation therapy. Um, some sort of traumatic injury, pelvic surgery, hip and knee surgery, Obesity plays a role in it. Any kind of radiation, uh tumor, any kind of local trauma. We see a lot of folks who have had motorcycle accidents, for example, as young people and they end up having such a big diversion not only in their lymphatic system, but also when they're being a system, but but they're very telltale people. There's some things that we look for that really clearly tell us that they have lymphedema and one is looking at the toes. There's a couple of things to look out for it. And this may sound not really attractive, but they're actually called sausage toes. And I know that you've seen the kind of tone etcetera, but that top picture. But the other thing is looking for something called a stammer sign a steamer sign is when you try to pinch the surface of their toes and it will not tent up like you might be able to with normal skin and normal subcutaneous tissues. So positive steamer signs mean that they don't tent. And then looking for those sausage toes that are really a telltale sign. Generally. The secondary lymphedema only affects one extremity, although it could affect both depending on the degree of uh surgery or whatever they might have had in their pelvis. Um But I'll give you this example of the gentleman on the right hand side at the bottom. He was a patient who knew he had lymphedema and he also had a venus alter. But what you're looking at at the top there at his thigh was a small wound where they had gone in to do a vascular procedure, vascular procedure. And so is venus altar was not our problem. His one in his thigh was a big problem. But we aren't we aren't set up to wrap somebody's thighs. And so what we did was we put a little portable negative pressure device called a snap on there. And it actually, we only had to change it for times for two weeks time and somehow it just sealed everything off and the drainage stop. He was pouring fluid out of that. So that's really what brought him in the venus also was secondary and we also were able to help him get that close. So those are the kind of folks that we might encounter in the outpatient department. The other thing is that with the management of lymphedema is to know that diuretics are a big no we do not want and this unfortunately happens also with venus patients, a well meaning primary physician or provider will give them diuretics because what do diuretics do they help with swelling? But the important thing about especially lymphedema is that it's a very high protein um fluid. And so if you if you use diuretics and pull all the water out, it becomes even more viscous and actually becomes more pro inflammatory and speeds up the inflammatory process. Then the big treatment for lymphedema is manual lymphedema therapy. These people are so specialized in this. They actually use their fingers to move fluid up the bottom up the body. And what's interesting is that they don't start at the bottom and move up. They start at the top because they have to they have to decongest maybe up into the hip and get that area cleared away to move other fluid up. So they'll start at the top decongest that area, go to the middle of the leg and again move it on up. But they have to displace fluid up the way to upstream basically to make way for the fluid that they're going to shift. And then they use various very specialized wraps, All 100% short stretch. They will maybe recommend that we order pumps for our patients. Uh they teach them good skincare, good nail care. So they are a critical part of our team for taking care of the patients that have lymphedema. So I want to say a word about a very distinctive kind of oedema called lymphedema lymphedema. You see these people out in the community all the time and it's fairly common, fairly common, but it's really underdiagnosed and it's a irregular fat distribution of the legs and the arms. And and mostly though on the lower part of the body And it's about, you know, almost 50% have a positive family history. So you'll have patients say to you, oh I got my mom's big legs or something like that. It's mostly in females. And before it was linked to obesity. And so all these people were dieting like crazy and exercising and not really changing their bodies. Then it was understood that it was a fat distribution problem that they really can't exercise away. Certainly exercise and good health and healthy eating will help by not adding fat on top of that. But it is something that they simply can't do a lot about. But it's often mistaken for lymphedema lymphedema, excuse me. And so what you'll notice and if you look in the pictures here is that you see the extreme size of the legs but the feet are spared, the feet are spared. They have they don't have a positive steamer sign which I'll be talking to you about in just a minute. And usually it's bilateral versus unilateral. So keep an eye out for this. There's not a lot that can be done. A lot of people are some some decongestant therapy might help. But actually liposuction is when a lot of people will turn to in order to re contour their body a little bit. But again, that's also a very extreme surgery. So one of the challenges that we see in the outpatient clinic as we see a significant number of these patients they present with open wounds um and they're not yet appropriate for manual lymphedema drainage. Actually, the many of the lymphedema clinics that I've worked with are just simply not set up to do wound care. And so we do the best we can with them utilizing our good dressings and things and our compression wraps, which we'll talk more about in order to get their wounds healed and then send them on to a lymphedema therapist. But it's really important that we do a good differential diagnosis that we realize that there is a lymphatic component to uh this this this leg or this problem. And as with all patients that we're going to do anything with compression, we have to know what their profusion statuses. So flee bo lymphedema flavor lymphedema, on the other hand is really what we see a lot of because the number one patient that most of us see in outpatient wound care centers are venus insufficiency patients. And so flavor lymphedema is actually the most common form of lymphedema in the Western world, there are some other odd types of lymphedema and other parts of the world. But in the United States, the flavor lymphedema is actually the most common. It's a mixed ideology because you have the venus insufficiency and as a result you have these vibe Roddick scarred up legs. The changes that we see that make the leg look like a turned upside down champagne bottle with a very narrow ankles and the large calves. Just because of all the fi broderick changes that we see. But there are some things that they share. You'll see many times very swollen feet that can be lymph lymphatic. But it also can happen with people who have venus disease. Um The sausage toes, we tend to call these things. Um And the treatment though is is really the same as we begin to take care of these patients. We're going to address the ulcer. We're going to or any break in the scam. We're going to do so with products that absorb an adequate amount because as you know, when we first get these people in and they are draining so much, they tend to need highly absorptive dressings, frequent compression wrap changes because until we get the volume down in their leg that flu is going to take the path of least resistance and cause them a lot of drainage. So then we select the type of compression that we're going to use. And again, if you do this a lot, you know that we have to we have to choose a compression system that the patient can live with, that the patient can live with and borrowing from what the lymphedema folks use. Uh a system that has short stretch is going to be more effective and most of the time more comfortable for the patient than some of the longer stretch. And if you know what I'm talking about, we have our two layer devices like the Kobe in two layer system and then we have R. Three and R four layer and we choose them because of a variety of things. There's not one. And although our purchasing people would love us to carry just one, there's not one that's going to work for all people, we may need to build up the ankle area to more normalize the shape of the leg. They may have a lot of drainage. Um We may need a lot of use a lot of appointments and things on the legs. So we may want the cotton layer that comes with three and four layer bandages. But as we get that volume down, the best thing we can do for a patient and makes our patients very happy is to change them over to a more um a thinner system. The two layer system that allows them a little bit more flexibility with their shoe wear and certainly they find it much more comfortable. Okay, so now I'd like to share with you a patient that really exhibits all of what we've been talking about today. And this was a fellow who had a lot of extra date which created crazy amounts of cost for him because this was all happening during the pandemic. He was a 69 year old man who had was a retired corrections officer. So he was a big burly guy. He had a past medical history was included, obesity and longstanding venus insufficiency. So as a result of the scarring in his legs he had flee bo lymphedema. Now he had been followed by a nurse front clinic and the nurse frank clinic in a town adjacent to ours. But because of the pandemic she had to close her clinic. So the patient was on his own and he was buying 100 A. B. D. Pads a month. He was adamantly opposed to any kind of compression. And so he did his what he thought was the right thing he was purchasing, you know, boots. And he was wrapping them from his his ankle up to his knee which of course we know is not going to be effective. And so when we started discussing with him the concept of needing to have compression, he said no way. He said when he had compression that created 10 out of 10 pain and that he wasn't going to go for it. So we started bargaining with him. We told him that we had a rap that we felt he would find much more comfortable and that we gave him the option that if he if he was uncomfortable, if it started coming down he could remove it or he could come back to the clinic and we would rewrap him. So after a little bit of browbeating and him not being at first very happy with us, he agreed to do that. Okay, so this is how he presented us. The first day that top panel of pictures he came and he was just caked with a zinc based barrier ointment because of all of the drain is that he had and you can see the contour of his leg. I didn't capture his toes unfortunately in this picture, but you can see the contour of his leg, which is so indicative of this liberal lymphedema. You have the very narrow ankle and the larger cast and he did have swelling in his foot. And so the bottom panel is after I got all that zinc paste off. And the two middle ones are actually the ulcers that he had originally. Those are his venus ulcers, the ones that have sort of a yellow extra date sitting on the surface. The back pictures, the two that are on, the ends on the bottom. The back pictures are actually just erosion from his extra date. Nothing else that is pure erosion from his extra date. We had to get that under control. And so we talked him into the co band to layer and three days later he came back and he was remarkably, remarkably improved. And he was admittedly very, very happy with the rap. He said it was comfortable, he was able to sleep. The only thing that happened is as we were taking his dressing off, the jelling fiber stuck at one edge and that caused him a lot of discomfort. And so we switched him over to a silver foam but did continue with the Kobe into later uh wrap. So a week later he comes back and unfortunately the phone did not do a good job of absorbing the extra date. So I just promised him that we wouldn't let it stick again. And we went back to a jelling fiber and a super absorbent. But we continued the same compression By three weeks in all of his wounds related to his extra date were closed. Now, this picture is not three weeks. This picture is at 13 weeks, but by three weeks in his entire posterior caps were closed. So we still had to deal with his ulcer. So we continue to cope and to layer until he was completely closed. And we actually wrapped him about two or three more weeks at his request to make sure his Adina was down and that he didn't get any more ulcers. And then we transitioned him over to 30 to 40 millimeter of mercury compression stockings. But what I want to show you is the remarkable reduction in a demon that he had over that period of time that 13 weeks we went down 2.5 centimeters in his foot, 3.5 centimeters in this ankle and five centimeters in his calf. So again, very, very successful. So just think about that when you're rapping these folks, short stretch means that it's tighter when they're walking, gives them good working pressures when they're walking, but less working pressures when they're lying down and so they're very, very comfortable. But that is really more what real true lymphedema therapists used are the short stretch bandages. So in summary, you know, any edema will eventually impact the lymphatic system. And the, the important thing about this fluid of course is it's high in protein and we want to make sure we can get it diverted and back into the system. Any any form of lymphedema in my opinion, needs to see a lymphedema therapist, even if there is fairly well controlled, they need to have someone in their in their camp that can help them in case things go wrong. So we always recommend and refer them to lymphedema therapy. Once we are finished with getting their ulcer heal, there may be a center in your area of lymphedema clinic that does do wound care but are locally do not. So we get their wounds closed and then send them on. Remember, our goal of care is always to reduce the volume in the leg and as a result, we're going to reduce the extra date and the drainage and make it easier to manage their wound as well as protect their perry wound skin. And just keep in mind that short stretch bandages such as the co band to layer compression bandage is very comfortable and very effective for these patients. So I thank you for your attention and joining me today. I hope you've taken away pearls that will help you in your practice.
