In a newly released best practice summary, Maclellan and Greene (2022) discuss a relatively common condition—lymphoedema. They describe the swelling of the body tissue to consist of a protein-rich fluid mostly caused by developmental disruption of the lymphatic system, known as primary lymphoedema, or acquired disruption to the lymphatic system, known as secondary oedema.
A chronic condition that causes swelling in the tissue of any part of the body, lymphoedema worsens over time—unless managed well. Given Maclellan and Greene's (2022) new summary, this month's analysis will recap clinical knowledge and management of lymphoedema and serve as a guide regarding advice that can be given to the patient.
About lymphoedema
In lymphoedema, it is usually the extremities that are most affected (such as the feet, related to acquired vascular problems, or hands/arms related to breast cancer), followed by the genitalia. Maclellan and Greene (2022) describe most cases to be secondary to nematode infection, a condition known as filariasis, or to malignancy or cancer treatment. For example, in a breast cancer patient, the lymph node of the affected side is often removed, therefore disrupting the lymphatic drainage in that part of the body, resulting in swelling of the arm. Usually, there is one-sided limb swelling in lymphoedema. This would be painless in most patients. In the early stages of the disease, there would be pitting oedema, and in advanced disease, non-pitting oedema is usually present. Maclellan and Greene (2022) write in the British Medical Journal that a diagnosis would be made on clinical grounds but also confirmed using a scan of the lymphatic system known as a lymphoscintigraphy.
It is very common to come across a patient with lymphoedema as it can be secondary to various conditions in surgical or medical units. It is therefore important to know how to approach the patient's condition, and to check that the patient has a specialist and has been reviewed. Tissue viability nurses should also be aware of the patient, and it should be determined whether the patient or the nurse needs to apply compression garments, and on what day the patient receives their bandaging changes and by whom, if required. It is important to know that a patient goes home with the right garments and items, and to ensure they are under a community nursing team, so they do not end up back in hospital due to a lack of appropriate follow-up and treatment.
Use of compression
The first-line treatment for the patient involves using compression of some kind. This may consist of compression hosiery (which the patient should be appropriately measured for), complex massage (a drainage technique performed by a specialist such as a tissue viability nurse), compression bandaging and pneumatic compression devices (Maclellan and Greene, 2022). Surgery would only usually be performed in patients with significant morbidity, as an option where conservative measures are not taking effect. This is rare, and therefore, will not be covered within the scope of this short article.
Lymphoedema is not considered curable and is to be managed over the course of the patient's lifetime using a collaborative approach between the patient and caregivers, whether in a hospital admission or the community setting. There should be a seamless flow of care to prevent further complications with the condition such as injury caused by inappropriate compression or lack of supplies, or an infected leg ulcer left unattended for too long under compression bandaging.
Nadal et al (2021) reviewed the use of compression garments in a conventional lymphoedema prevention programme for breast cancer patients who had recently undergone lymph node dissection and were therefore at risk of secondary lymphoedema. The authors note that to prevent the secondary occurrence of this condition in such a patient, there would usually be a lymphoedema prevention programme in place that provides the patient with education on the subject and exercises to carry out. The authors carried out a randomised controlled trial which has a small sample size of 70 patients—35 making up the control group and receiving the normal prevention programme and the other 35 receiving the compression garment in addition to this prevention.
The education was for 1 hour and exercises were over a 12-week period. The patients in the group wearing the garment wore it for 8 hours a day for the first 3 months post-surgery and 2 hours a day thereafter. They concluded that after the 2 years, there was a significant difference between the two groups, with lymphoedema having occurred less often in the group applying the garment. The authors concluded there should be more research in this area of prevention, and that exercise and education were key factors. However, some efficacy was shown in the use of compression, not only as it is used currently (in the treatment of lymphoedema) but also for the prevention of lymphoedema (in this case, for breast cancer patients having undergone lymph node dissection).
Moseley et al (2007) describe compression to benefit the patient's presentation by reducing the buildup of interstitial fluid, and preventing lymphatic reflux, while also helping the muscle beneath the fluid buildup by providing an ‘inelastic’ barrier.
Special considerations
Macmillan, well known for helping cancer patients, provides a useful section on lymphoedema, which can be applied to most patients with the condition whether it has been caused by cancer or not. Macmillan (2021a) discuss a range of compression garments such as sleeves for swollen arms, stockings for swollen legs, specialist garments for fingers or toes, a compression bra or vest and specialist garments for the genital area. The tissue viability nurse can give further advice on what is required and how these can be applied. The specialist can train a nurse to apply the garments for the specific patient being reviewed as managing this condition requires a multidisciplinary team effort. If the condition is not managed well, the patient may feel despondent and develop issues with anxiety or depression, caused by issues such as chronic pain, mobility and appearance issues associated with lymphoedema—not to mention their worry about the management itself. Patients must be given the right contacts and information, and the assurance they are receiving an optimal team effort. Any deterioration in mental health can present in various ways or be very subtle.
An offer for mental health support through the relevant service may be a good idea, and should of course reflect the sensitive nature of the patient's presentation and the context of the care setting, while also considering patient privacy.
Macmillan (2021a) highlights that in some situations, compression garments should not be used. For example, where there is a chance of a wound developing (these are very difficult to heal in oedematous tissue), where the skin is fragile – or where the skin is already damaged, compression should be avoided. The same avoidance may be required in a patient with pitted, folded or leaking lymph fluid, or where cellulitis (infection of the tissue) is present (Macmillan, 2021a). Complications can occur such as the compression material forming a tight band across the skin which may cause the skin to break.
It is important to advise the patient and other members of staff or caregivers that sometimes compression garments can be too tight, so signs should be noted and reported to the specialist and removed as soon as possible to prevent any further complications. The signs of a garment being too tight include numbness, pins and needles, pain or a change of colour such as in the fingers or toes (Macmillan, 2021a). This emphasises the importance of correct fitting.
Drainage, deep breathing and massage
The patient may also receive lymphatic drainage in conjunction with other care and treatment. This is a specialist type of medical massage which can push the lymph fluid to drain through the lymph vessels and as a result, reduce or manage any swelling. Someone with lymphoedema may be receiving either manual lymphatic drainage (MLD) or simple lymphatic drainage (SLD). Manual drainage consists of a short course of treatment but must be given by a trained lymphatic drainage therapist, and SLD can be taught to the patient so they can perform this on the affect area over the long term (Macmillan, 2021b). It is important to ensure the patient is advised not to have any other types of massage on the affected area.
With MLD, deep breathing exercises can aid drainage so these perform a simple yet important part of the process. The MLD would be given in conjunction with compression garments or bandaging and is noted by Macmillan (2021b) to be of good use for areas where compression therapy cannot be used.
A deep breathing exercise to help lymphatic drainage before and after MLD and SLD massages is recommended by Macmillan (2021b) with the following advice for patients:
- Sit upright in a comfortable chair, or lie on your bed with your knees slightly bent
- Rest your hands on your ribs
- Take slow, deep breaths to relax
- As you breathe in, move the air down to your tummy (abdomen). You will feel your tummy rising under your hands
- Breathe out slowly by sighing the air out. While breathing out, let your abdomen relax inwards again
- Carry out the deep breathing exercise five times
- Have a short rest before getting up, to avoid feeling dizzy.
SLD is a simplified version of MLD. The specialist should teach the patient first despite it appearing to be simple, as there is a technique to ensure the areas without swelling are massaged, so that the fluid in the swollen areas can take up some space in the non-swollen areas. It is commonly misunderstood that the swollen area would be massaged to push fluid out, but the whole idea of SLD is to not massage the swollen areas at all, instead focusing on simply allowing more space in the non-swollen parts, for the fluid to drain into.
A useful tool in the conservative management of lymphoedema is a handheld massager. These would normally be used by someone who has problems with their manual dexterity and grip/strength in their hands and the patient should be advised of the importance of speaking to their specialist first before considering the use of this tool. Macmillan (2021b) notes that a tool used in place of a handheld massager that is often used by patients is a soft-bristled baby's brush.
Conclusion
Overall, lymphoedema can be acute or secondary, and results from various causes. It is a chronic condition requiring careful conservative management through a team effort, using compression techniques including bandaging or aids such as hosiery, although in some patients this may not be appropriate. SLD and MLD may be added. In some cases, the condition may be prevented through the use of educational tools, exercises and compression although research in this area continues.