Oft-ignored lymphedema can lead to serious chronic wound problems
It makes skin susceptible to infections
In the mid-1980s, when Saskia Thiadens, RN, managed a postoperative care facility, she noticed a patient with a grossly swollen arm. Thinking the swelling was caused by an allergic reaction, perhaps to medication, Thiadens was surprised to learn from the treating physician that the condition resulted from surgery. It was Thiadens’ first encounter with lymphedema.The incident spurred Thiadens to find out more about lymphedema. What she learned surprised her greatly, particularly the fact that the condition was so much more prevalent than she could have imagined, affecting 250 million patients worldwide according to the World Health Organization.
Thiadens’ interest in lymphedema grew to the point that she founded the nonprofit National Lymphedema Network based in San Francisco, of which she is the president. Thiadens is also the clinical director of the Aurora Lymphedema Clinic in San Francisco.
Condition is incurable
Lymphedema is, in brief, a chronic, incurable condition that appears as swelling in the arms and/or legs, and occasionally in other parts of the body. It is caused by the accumulation of lymphatic fluid in the interstitial tissue.
Primary lymphedema can develop when lymphatic vessels are missing or impaired. Secondary lymph-edema, which is more common, occurs when lymph vessels are damaged or removed during surgical procedures. Lymph nodes and vessels are often removed during operations to eradicate various types of cancer. Skin damage after radiation therapy can also lead to lymphedema.
Thiadens estimates that 25-30% of women who undergo breast cancer surgery experience some degree of arm swelling. (For more information on causes and treatments of lymphedema, see story, p. 102.)
What may also surprise many clinicians is that lymphedema and chronic wounds can be closely linked, says John M. Macdonald, MD, a cardiovascular surgeon and director of the Wound Healing and Lymphedema Center in Fort Lauderdale, FL. "A swollen lymph system is a prime site for infection, ulceration, and nonhealing wounds," explains Macdonald.
"Fifty percent of the patients we see in our center have some form of lymphedema that is contributing to the nonhealing of their wounds, whether it’s a coronary bypass patient with lymphedema in the legs after vein harvesting, or a patient with cellulitis who is immobile and has swollen legs."
In addition, patients with severe leg lymphedema are apt to be immobile for long periods of time, thus heightening the risk for wound development.
Slowing the healing process
Macdonald says he quickly learned that if he couldn’t get rid of the edema, he would have great difficulty getting a wound to heal. One prime reason is that the edema is as much a cause of lowered tissue perfusion of oxygen and increased susceptibility to infection as any other factors in wound care physiology.
"When we treat a patient with a chronic wound, we look at the entire patient, systemically and locally, and ask ourselves why isn’t this wound healing?" Macdonald says. "We pick out certain factors, such as malnourishment, inadequate blood supply, or a foreign body in the wound. It seems that very few people have woken up to the fact that edema can be just as bad as insufficient blood supply in lowering the oxygen tension in the area of a wound. You have simply got to address the edema in order to heal the wound."
Lymphedema receives little notice
Macdonald is troubled by the lack of attention that physicians pay to lymphedema, even though effective treatments (though not a cure) are readily available to help lymphedema sufferers lead normal lives and, of course, facilitate the treatment of those who develop chronic wounds.
"Every day I see patients with wide open wounds whose dressings have been applied by dermatologists or surgeons," Macdonald says. "The leg is swollen, edematous, and I ask the patient what their physician is doing for them. Often they tell me they’ve been prescribed diuretics, which are almost contraindicated in these patients. Diuretics just get rid of the water, which makes the lymphedema fluid more viscous and aggravates the situation."
The only way to eliminate lymphedema is by some type of compression therapy, he adds.
To make matters worse, wound care centers operate under several misconceptions regarding lymphedema, Macdonald says, such as:
1. They don’t understand the fundamental fact that the edema must be eliminated for wound healing to occur.
"In many centers, it’s almost like the clinicians don’t even see the condition," he says.
2. They don’t think that they can use compression therapy in the presence of an infection.
"This is nonsense. If the patient is covered systemically with antibiotics, you can use compression." If you don’t, he adds, that wound is either not going to heal or heal up to 70% more slowly than it should, and it’s likely to recur even after primary healing.
3. They think, either correctly or incorrectly, that the patient doesn’t have adequate blood supply for the use of compression.
"This is a real problem," he says. "The determination of whether a patient’s blood supply to the wound area is adequate seems mostly haphazard at best. In a patient with a swollen limb you can’t feel the pulse, so you have to evaluate the patient clinically. The vast majority of these patients can receive judicial compression. And if they have adequate circulation to begin with, then they absolutely need some sort of compression."
Condition should not be ignored
Macdonald predicts that it’s only a matter of time until wound care centers become lymphedema centers as well. "You can’t separate the two," he says.
What frustrates Thiadens is that even though effective treatment for lymphedema is at hand, many physicians choose to ignore the problem, while in Europe the condition is usually treated aggressively.
"We can’t cure it, but we want health care professionals to be aware that if you treat lymphedema in its early stages you can maintain the limb very well," she says. Patients can also be taught to care for the condition at home via techniques such as manual lymphatic drainage, bandaging, and exercise, thus offering them day-to-day independence.
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