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79 Cards in this Set
- Front
- Back
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What is included under the term "lymphatic load"?
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- proteins
- water - cells - fat |
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Where do deep collectors travel?
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along arteries and veins (while superficial/initial and intermediate vessels are much more finite)
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what structures represent the beginning of the lymphatic system?
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initial lymph vessels
- the lymph system is an open system |
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What do the anchoring filaments do?
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enable the lymph capillaries to stay open even under high tissue pressure
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What happens when interstitial fluid accumulates and the tissue pressure increases (think of the open capillaries)?
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the stretched anchoring filaments will cause a pull on the endothelial cells resulting in an open junction between the cells
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how does lymph fluid absorbed into the initial lymph vessel system reach the lymph collectors?
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via the precollectors
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The anatomical structure of the bigger lymph collectors is similar to that of _______?
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blood vessels
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Which lymph nodes receive lymph fluid from the upper extremities?
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- axillary lymph nodes and the skin of the thorax (anterior AND posterior)
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What drains into the the inguinal lymph nodes?
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abdominal, lumbar, and gluteal areas as well as exterior genitalia and lower extremity
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The RUQ drains through the _______.
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R lymphatic duct
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The LUQ and b/l legs drain into the _______.
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thoracic duct
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What portion of the body drains into the R lymphatic duct?
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RUQ
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What portion of the body drains into the thoracic duct?
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LUQ and b/l legs
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__________ gland drains for the most part into axillary lymph nodes.
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mammary glands drain into the axillary lymph nodes
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Name 3 drainage areas in the trunk for lymph fluid.
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1. axillary lymph nodes
2. parasternal 3. supraclavicular |
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Metastases in which lymph nodes can affect the brachial plexus? What sorts of symptoms might occur?
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- metastases (OR RADIATION) in the axillary or supraclavicular lymph nodes can affect the brachial plexus
- result in paresthesias, pareses or paralysis in the UEs |
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What do anastamoses do for the lymph drainage?
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they redirect fluid in different areas along these watershed "areas"
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What is secondary lymphedema caused by?
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caused by CA (radiation, chemo to the tissue) which affects the lymph nodes
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Which lymph nodes do we not want to stimulate after cancer or radiation?
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do not stimulate injured lymph nodes or massage them which will direct all the fluids to one place
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What is the most common cause of lymphedema in the lower extremity than dissection or radiation (which are secondary causes)?
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congenital malformations of the lymphatic system which results in primary lymphedema
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What are the 4 components to complete decongestive therapy?
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1. MLD (manual lymph drainage)
2. compression bandages 3. decongestive exercises 4. skin care |
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What are the two phases of treatment for lymphedema?
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- re-education
- maintanence |
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What is the goal of phase I of lymphedema treatment (intensive phase)?
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mobilize accumulated protein-rich fluid
reduction of fibrosclerotic tissue (if present) |
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What is the goal of phase II of lymphedema treatment?
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preserve and improve success achieved in phase 1
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What is the overall goal of lymphedema therapy?
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bring lymphedema back to a stage of latency
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What does a problem with a lymph node present as?
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the ipislateral trunk as well as the UE is affected
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How does primary vs. secondary lymphedema present in the LE?
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primary: swelling begins distally
secondary: swelling starts at the injury site, gravity takes hold and eventually the whole arm swells if action is not taken |
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What is phlebolymphedema/
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d/t chronic venous insufficiency
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What are common problems with patients who have lymphedema vs. other forms of swelling?
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1. how it feels (tissue gets hard with lymphedema vs. CHF or acute ankle sprain)
2. + stemmer sign (indication of lymphedema -- skin stays up when pinched) |
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What would we do if we find our patient is having a significant cellulitis attack (very red)?
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not treat her, refer her to MD
- no MLD with infection, need 7 days of anti-biotics |
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Why are any signs of cellulitis a significant concern?
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the patient could go septic quickly
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Is surgery a common practice to help treat lymphedema?
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no, it has adverse side effects and does not look appealing
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What are pneumatic compression pumps?
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multi-chambered sequential compression pumps known to have negative effects on lymphedema (causing extreme fibrosis/scarring, cysts, fistulas, and genital swelling)
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What is complete decompressive therapy?
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non-invasive, highly effective lymphedema treatment
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When can elastic support garments be used?
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after complete decompression
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Are medications effective for treating lymphedema?
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dieuretics are NOT effective for treating lymphedema d/t the increased proteins, the meds will take up the water and leave the proteins
- the tissue will be even more fibrotic after the water is reabsorbed |
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What are the 5 common lymphedema treatments in the US?
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1. pneumatic compression pumps
2. surgery 3. complete decompressive therapy (CDT) 4. elastic support garments 5. medications |
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What are advantages to using a pneumatic compression pump?
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can be used at home
fast application |
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What are disadvantages to using a pneumatic compression pump?
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- genital swelling
- disregards ipsilateral trunk - does not work on CT and scar tisssue (phase 2, 3) - machine can traumatize functioning lymph vessels |
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What amount of pressure does it take to shut down the lymph system?
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40-60 mmHg
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What is the Flexitouch?
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addresses the proximal trunk 1st, clearing pathway, then moves distally on to the extremity and finally proximally again (always directing fluid proximally)
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What are the components of CDT (complete decongestive therapy) and MLD (manual lymph drainage)?
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1. skin/nail care
2. MLD 3. compressive therapy 4. decongestive exercises |
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What are the effects of compression therapy (bandaging/stockings)?
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1. reduction of ultrafiltration rate
2. improvement of efficiency of the muscle and joint pump 3. prevents the reaccumulation of evacuated fluid BANDAGES ONLY: breaks up deposits of accumulated scar and connective tissue |
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Should we use long stretch or short stretch bandages and why?
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short stretch: have a high working pressure and low resting pressure
long stretch (Ace): low working pressure and high resting pressure **short stretch won't give as much when exercising where Ace bandages do |
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What are risk factors to developing lymphedema?
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- infection
- traumatic injury - surgical removal of a lymph node and adjacent lymph nodes - radiation therapy - obesity - age, integrity of lymphatic system |
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What are precautions for a patient who's at risk for developing lymphedema?
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1. avoid trauma/strain to affected extremity
2. avoid BP measurements, needle sticks, sunburn, insect bites, abrasions, or rigorous use 3. pressure changes (airplanes) |
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What is the prognosis for a patient with lymphedema?
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very good with treatment and maintenence
very poor for uncontrolled lymphedema |
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What is the only thing proven to decrease swelling?
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bandages are the only thing shown to decrease swelling while compression garments only maintain what we've worked for
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What are the 6 goals of lymphedema treatment?
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1. utilize remaining and intact lymph vessels
2. decongest swollen body part 3. eliminate fibrotic tissue 4. avoid re-accumulation of lymph fluid 5. prevent/eliminate infections (skin care) 6. maintain a normal/near normal size of limb |
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What is LTV (lymph time volume)?
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amount of lymphatic loads transported by the lymphatic system in a period of time
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What is the transport capacity?
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= to the maximum lymph time volume (the amount of lymph a healthy lymphatic system is able to transport utilizing its max frequency and amplitue)
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What is a lymphatic safety factor?
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if the lymphatic system reacts to an increased lymphatic load with an increase in lymph time volume (transport capacity of lymphatic load is much higher than the actual lymphatic load)
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Do we usually treat dynamic insufficiency/high volume insufficiency?
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no, this occurs when the lymphatic load exceeds the transport capacity of the lymphatic system
fluid accumulates in the interstitial tissue causing edema |
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What sort of conditions cause dynamic insufficiency/high volume insufficiency?
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caused by insufficience venous return (CHF, standing too long, pregnancy)
- MLD and CDT is not indicated because with acute CHF, lymphedema treatment pushes the edema back to the heart, we could put this patient in CARDIAC ARREST!!! - treat with elevation and exericises, possibly a compression garment |
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What is mecchanical insufficiency (low volume insufficiency)?
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lymph system is diseased and has a reduced transport capacity
not able to cope with normal amount of lymphatic load |
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What causes mechanical insufficiency (low voume insufficiency)?
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- surgery, trauma, radiation, infection, valvular/mural insufficiencies, and malformations of the lymphatic system
- causes lymphedema |
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What happens with safety valve insufficiency?
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lymphatic water or protein and water is increased at the same time as the transport capacity is decreased
- causes serious swelling - lymphedema patient develops an infection in the lymphedemous area (increased lymphatic loads) |
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What can cause primary lymphedema?
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- congenital malformations
- aplasia (hypo, hyperplasia) - fibrosis or agenesis of lymph nodes |
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If under 35 y/o and you have primary lymphedema, what is it called? over 35 y/o?
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<35: lymphedema precox
>35: lymphedema tardum |
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What causes secondary lymphedema?
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- dissection/radiation of lymph nodes
- trauma - chronic inflammation of lymph vessels/nodes (bacterial, viral, fungal, parasites, RA) - tumors can block pathways - self-induced with too many rubber bands |
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How many stages are there for lymphedema?
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4
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What are the characteristics of the latency stage?
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- no swelling
- reduced transport capacity - "normal" consistency |
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What is an example of someone who'd be donsidered in the latency stage?
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post breast surgery, know they have reduced transport capacity d/t transport system
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What are characteristics of stage I (reversible)?
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- edema is soft (pitting)
- no secondary tissue changes - elevation reduces swelling |
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What are characteristics of the stage 2 (spontaneously irreversible)?
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- fibroscelrotic changes
- hardening of the tissue - frequent infections |
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What are characteristics of stage 3 (lymphosatic elephantiasis)?
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- extreme increase in volume and texture with typical skin changes (papillomas, deep skin folds)
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Should MLD/CDT be done in the case of someone with malignant lymphedema?q
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it may be applied for palliatve care, but this is a decision to be made with me, Dr. and patient
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What are some signs of malignant lymphedema?
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- sudden onset
- rapid progression - pain - paresthesia - paresis or paralysis - skin changes - dilated superficial veins |
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What are some typical characteristics of benign lymphedema?
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- unilateral (if b/l, the swelling is usually asymmetrical)
- slow progression - normal skin color - dorsum of hands and feet are involved (deep natural skin folds) |
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What are the papillomaswe might see during the stage 3 (lymphostatic elephantiasis)/
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decreased immune function, decreased blood flow, decreased nutrient exchange (look like a mushroom head)
HUGE risk for cellulitis** |
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What is the duration of stage 1 treatment?
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2- 3 weeks
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What is phase 1 (decongestion) include for stage 1 lymphedema?
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- MLD (1-2x/day)
- short stretch bandages - skin care - remedial exercises - patient instruction |
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What does phase 2 (preserve andmaintain) involve for stage 1?
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- MLD if necessary
- compression garments - skin care - remedial exercises |
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What does phase 1 (decongestion) invlove for a patient in stage 2 of lymphedema)?
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- MLD 2x/day
- short stretch bandages - skin care - remedial exercises - patient instruction |
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How long does stage 2 treatment last?
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3-4 weeks
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What is phase 2 (preserve and maintain) for stage 2 lymphedema?
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- MLD as neede (1-2x/week)
- compression garments - bandaging at night - skin care - remedial exercises - repeat phase 1 (1-2x) |
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how long des reatment last for stage 3?
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4-6 weeks
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What does phase 1 (decongestion) include with a patient who has stage 3 lymphedema?
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- MLD 2-3x/day
- short stretch bandages - skin care - remedial exercises - patient instruction |
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What does phase 2 (preserve and maintain) involve for a patient who has stage 3 lymphedema?
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- MLD 1-2x/week
- compression garments - bandages at night - skin care - remedial exercises - repeat phase I 3/4x - if indicated, plastic surgery |
