MS2 - lympathic systems

What does the lymphatic system do?

regulates fluid balance

How much fluid/day are removed from the interstitial space via the lymphatic system?

2-4 L

What percentage of liquid is not returned in the circulatory loop?

10-20%

What are some functions of the lymphatic system?

Assists w/ infection

Absorbs lipids (small intestine) → NOT absorbed by blood capillaries

Lymph is fluids made up of

water, proteins, dead/dying cells, cellular components, fatty acids, foreign material and debris

List the main highway from start to finish

lymph capillaries, precollectors, AFF collectors, nodes, EFF collectors, trunks, ducts

What are the backroads called?

collateral pw

What the collateral pw of the lymphatic system?

initial lymphatics

interterritorial anastomoses

vaso vasorum

perforating vessels

What is drained by the purple?

R thoracic duct

Lymphatic territories are divided by

watershed

Lymphagion =

functional unit of the lymphatic system

Movement of Lymph involves all of the following EXCEPT:

Skeletal muscle relaxation

Lymphangiomotoricity is ____ controlled

ANS

Resting lymphangiomotoricity = ________; lymphangiomotoricity with exercise = _____.

3-12x/min

20x/min

Lymphatics

Take up what is not reabsorbed

ultrafiltration

vessels causes fluid to move OUT of blood vessels

reabsorption

vessels causes fluid to move INTO blood vessels

Factors that favor ultrafiltration may lead to /

INC swelling

Factors that favor reabsorption may lead to /

DEC swelling

Factors that favor ultratrqation include all of the following EXCEPT

DEC capillary pressure / interstitial proteins

Factors that favor reabsorption include all of the following EXCEPT

INC in capilary pressure / interstitial protein

Lymphatic Insufficiency can result from changes in

lymphatic components, load, or flow

Dynamic insufficiency =

INC load

Mechanical Insufficiency =

DEC flow/capacity

Combined insufficieny is a combo of

mechanical and dynamic insufficiency.

As with heart rate, the lymph system normally operates

below maximum transport capacity and

can INC transport to match load

If the lymphatic load exceeds the transport capacity of the lymphatic system, ______

edema will occur

Edema is transient if

the functional reserve capacity can compensate for the INC lymphatic load over time

A prolonged increase in lymphatic load, as may occur with

CVI

may lead to chronic edema.

How Is the swelling (increase in fluid) after a knee surgery or ankle sprain, different from lymphedema?

Swelling after knee surgery or ankle sprain is usually temporary and results from inflammation and increased fluid accumulation, while lymphedema is a chronic condition caused by impaired lymphatic drainage.

If there is a decrease in the maximal transport capacity of the lymphatic system, ________ can result

mechanical insufficiency

if the remaining transport capacity continues to exceed the lymphatic load =

no overt signs of lymphedema

If the remaining transport capacity is less than the lymphatic load

lymphedema will occur

This may be seen in patients who have had a

LG # of axillary lymph nodes removed due to breast cancer

Transient Edema = __________ interstitial fluid

water rich

What are the characteristics of transient edema?

Lymphatics and capillary system intact

Swelling goes away and tissue returns to normal

Lymphedema = _______ interstitial fluid

protein rich

What are the characteristics of lymphedema?

Lymphatics not functioning properly

Accumulation of water along with fibrin/proteins (and...) in interstitial space

How do you know a person’s lymph transport capacity?

By measuring the rate of lymph flow and evaluating the response to lymphatic drainage techniques.

What is lymphedema?

the buildup of protein-rich interstitial fluid due to improper functioning of the lymphatic system

Primary lymphedema

congenital malformations or genetic factors affecting lymphatic dev, often appearing at birth or puberty

Secondary lymphedema

dev as a result of damage to the lymphatic sys,

often due to surgery, radiation, infection, or trauma

Which type of lymphedema is more common?

secondary is more common

What is the leading cause of lymphedema in the US?

cancer treatment,

(surgical removal of lymph nodes or radiation therapy damaging lymphatic sys)

What is the standard of care?

Complete (or complex) Decongestive Therapy (CDT) i

There are 4 components of Complete (or complex) Decongestive Therapy (CDT). All of the following are components EXCEPT:

Decompression

Which of the following may not be actual risk factors for lymphedema?

seroma and air travel (w/o compression)

What patient population is at risk for lymphedema?

Those post-surgery/RT and prone to scar tissue formation

All of the following are typical chief complaints for lymphedema EXCEPT

INC pain with ELV

Pruiritus is common in

LE

Why might “itchiness” be particularly problematic?

it can lead to skin breakdown and infection

d/t compromised lymphatic drainage and increased vulnerability.

Examination for lymph should include

BMI, Integument, sensation, vascular, and circumferential measurements

Stemmer sign is a diagnostic test used to assess lymphedema. It involves

pinching the skin on the second toe or finger; if the skin folds easily, lymphedema is unlikely, while difficulty folding suggests lymphedema.

Vascular assessment should be used to rule out

arterial insufficiency (AI/peripheral arterial disease (PAD)

Circumferential measurements can be done at every

3-12 cm (and include an areas of deformity / localized swelling)

Lipolymphedema =

Feet initially spared, ELV - no effect, infections/pitting/fibrosis UNcommon

tends NOT to improve with treatment

Lipedema =

B/L symmetrical INC in adipose tissue deposition in abdomen, buttocks, and legs but NOT feet

severity of < 3 cm | <20%?

mild

severity of 3-5 cm | 20-40%?

moderate

severity of >5cm | 40%?

severe

Stage 0 descriptor

latent

Stage 0 characteristics

No edema

at risk d/t reduced transport

Stage 1 descriptor

reversible

Stage 1 characteristics

Edema, may pit, reduces w/ ELV

No secondary skin changes

Stage 2 descriptor

spontaneously irreversible

Stage 2 characteristics

Edema does NOT pit nor reduce w/ ELV

Skin is fibrotic + may have infections

Stage 3 descriptor

Lymphostatic elephantiasis

Stage 3 characteristics

Extreme INC in limb vol

Deep skin folds + freq skin infections

What must the assessment include?

type, severity, stage

Volume Calculating Software

LVP, lymph calc, programmable calculator, and excel

What does the perometer use to measure limb vol?

infrared light

Pain

Fullness, tightness, heaviness Stretch pain, pain from infection/inflammation

Position

Area of lymphatic damage or obstruction Primary (1%)

Presentation (wound)

Lymphorrhea; possible infection

If wounds: copious drainage, may be slough covered

Lymphorrhea

both

Periwound + surrounding tissue

cellulitis; stemmer sign; lipodermatosclerosis; Papillomatosis

Cellulitis

both

Lipodermatosclerosis

both

Papillomatosis

stage 3

Pulses

Normal (though edema may require US to find)

Temp

Normal or warm (due to edema or infection)

Bacterial:

cellulitis, Streptococcus, Pseudomonas

Fungal:

tinea pedis, Candida

Papilloma:

cauliflower-like projections of epithelium cased by distended superficial lymphatics

Papillomatosis

cobblestone-like appearance of epithelium in stage 3 lymphedema

HEP including

breathing and exercise

Teaching compression wrapping typically requires

3-5 consecutive days

Once wrapped, perform HEP addressing

affected limb and trunk

Once patient/caregiver master compression wrapping, seen less frequently for

MLD

Limb volume changes

quickly initially, especially for stage 1/2. Remeasure regularly

quickly initially, especially for stage 1/2. Remeasure regularly, monitor

every 2-4 weeks until plateau

What is the last step of lymphedema POC?

Obtain garment (then second one once satisfied with first!)

Teach patient self-measurement (friend/family assist prn)