Lymphedema Management

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Douglas Joseph, DO:

Thanks for having me. I'm Dr. Joseph, one of the vascular medicine specialists and part of the multidisciplinary lymphedema management team here at Cleveland Clinic. And today, we'll talk about lymphedema.

When patients present with dwelling, the first step is going to be what is the cause, what is not necessarily lymphedema may be lymphedema even in a patient that's had surgery for cancer.

First step is always going to be good physical exam. You're going to look for other signs of other conditions. You're going to look at their medication list. Is there a medication they're on that could be causing swelling? Do they have a heart condition? Could it be heart failure? I always generally look at things like, do they have liver disease? Do they have low protein state, which can cause swelling in the limbs, so you may want to do some blood work. The venous duplex ultrasound, sometimes they'll can get CT scans or MRIs for imaging.

For lymphatic imaging and assessing for lymphatic function, one of the more common tests is a lympho-scintigraphy test. This is something that's done through nuclear medicine. A tracer is injected into the foot in a couple different sites. There are several images that are taken in series over time and usually over a two-hour period of time. And you can see this tracer move up from the foot through the lymphatic channels and then into the groin and then even into the abdomen if they have really good lymphatic function. If you see a delay of that tracer moving through the limb or you see it maybe not even going through channels but become just diffusely spread throughout, say the calf, that would suggest that there's lymphatic dysfunction as a cause for the swelling and not just some other cause.

There's also what we call ICG lymphography. This is a study that we do using a dye rather than a radiolabeled tracer. It's a dye that fluoresces with using near infrared light, and we can see the channels develop over a few minutes after injection, also injection into the foot. You can see the channels up here and then you should be able to see those channels all the way up thigh, high up into the thigh. And if you don't see those channels, but instead you see maybe a diffuse pattern, that's also consistent with there being lymphatic dysfunction. So those are some of the imaging tests that you can use to help make the diagnosis.

When a patient presents to primary care physician with limb swelling, you can do that initial workup to see is it a medication or is it some other cause? And if you don't have another cause, you suspect it's lymphedema, I think that's the point at which I would suggest referral to the vascular medicine specialist or to a specialist that sees patients with lymphedema. We can review additionally, examine the patient, review the history, especially getting a good family history and evaluating for a history of cancer or surgery or lymph node surgery, history of infections and so forth. We can order imaging that is most appropriate and then we can initiate the therapy. The earlier you do it, the better, the more likely they are to have a good outcome and a good response to treatment.

And then if a patient may be a candidate for surgical intervention, we can make that referral to the surgeons as well and complete that workup and get all the imaging that's needed to make sure that if there is an option for surgery, that may possibly be a cure or close to a cure, that we can make that happen as quickly as possible.

After breast cancer surgeries where they remove the lymph nodes and they may or may not do additional radiation, those patients are often immediately sent to, they actually, sometimes even before the surgery, will refer them to physical therapy for lymphedema evaluation and treatment to begin stimulating the lymphatics even prior to surgery. And then they see them immediately after because the assumption is that there's going to be some degree of lymphatic dysfunction, even if it's not physically visible. So they get initial therapy immediately. I think the surgeons will often refer them for that. If not, it's something that you could do, just request a lymphedema therapy with physical therapy, and they'll set it up for them.

Can a patient that has lymphedema in their arm, can they have their blood pressure checked? Can they have a venipuncture or a patients may ask you, can I have a tattoo? Things like that. And generally, the recommendation is that if it's in a life-threatening situation where you need a blood draw or you need an IV and it's medically urgent or emergent, then the recommendation is, allow that. Patients should not prevent themselves from having life-saving needed treatment or therapies. But if it can be avoided, if you can use the opposite arm for an IV for instance, then it would be suggested to do that because you want to avoid causing any further damage or increasing the risk for an infection in the involved arm. And no tattoos or any unnecessary damage to the limb that's involved would be recommended. For blood pressure cuffs, if you can use a different arm, then that's great. You could use the lower extremities for checking blood pressure, although it's maybe more cumbersome to do that. So ideally, you would avoid repetitive trauma or damage that could potentially make the lymphedema worse. In general, you try to use the opposite limb if it's possible within reason. It's not an absolute thing.

For the treatment of lymphedema, every patient should be referred for therapy. Ideally, they would go through manual emphatic drainage. The therapist will teach patients how to perform the treatments themselves, once they're done with their therapy, they don't go indefinitely. I will sometimes refer patients back to therapy if they sort of regress and start to get worse again. Eventually, they'll be out of therapy. So once they're done with their initial, what we call phase one of treatment where you're decongesting and trying to minimize the amount of swelling, you get to the point where they're in their long-term maintenance garment. The therapist can help with choosing a garment that's best for a patient. It depends on the severity of the swelling. I think most patients do okay with a prescribed, but off-the-shelf, I should say compression garment.

There are varying levels of compression. Class one is 20 to 30 millimeters of mercury. Class two is 30 to 40. That fits most patients are either going to be 20 to 30 or 30 to 40 or somewhere around that range. And most patients don't need necessarily custom garments. Custom garments can be very expensive, and that's always a thing you have to think about with patients is are they able to afford their garments. A lot of insurance companies won't pay for them or only pay for a small percentage of the cost. So, if you can get a patient in an off-the-shelf garment, that would be ideal. Even though it's off the shelf, it is measured. They do get a measurement. They have a stocking fitter, garment fitter, measure them and get them into the correct size garment based on their limb measurements.

If it's for an arm, we always try to include digits in what we call a gauntlet. That's just the part of the hand that's provided with compression. And then wrist to axilla or under the arm, just the upper arm, the forearm, and then the gauntlet and the digits. If it's lower extremity, usually closed toe because the swelling can extend all the way down to the toes. But you can order usually a thigh-high garment. Depends, sometimes the thigh is not really involved so they can get away with a knee-high compression garment. Patients sometimes find it difficult to wear their garments or don their garments or pull them on, so it's important to educate them. There's a lot of help to getting on garments and you always tell them about donning gloves that helps give them grip so that they can grab onto the material and not pinch their skin. Pull this garments up. There's also devices that go over their foot so they can slip the garment on over their foot called an easy slide. That really is very helpful for patients and I even sometimes will include that in my prescription for a garment, say knee-high, 20 to 30, and then I'll add a little comment on the prescription, please assist patient with donning assistance, including donning gloves and an easy slide or something like that. You can add that into your prescription, so when they go to a medical supply store to get a garment, you are instructing the stocking fitter to help them with those things. And that helps provide you some success with patients being able to wear their garments.

And keep in mind, there are a lot of styles of garments and fabrics that you have to choose from. There's garments that are soft, white material. You can get ones that are pink stripes. You can get ones that are argyle-patterned. So there are lots of different styles, especially if you are in that 20 to 30 more mild form of lymphedema. The more severe the edema, the more thicker material or more holding material that they need. So, you might have less options in terms of fabrics and styles, but a lot of patients, it helps them if they have more options.

Thanks very much for listening. We are here to help if you have any questions, any assistance with taking care of your patients, please give us a call.

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