Chronic Oedema

Chronic Oedema is defined as long standing oedema of greater than 3 months duration.

Fluid in the tissues can cause a number of skin changes. "Pitting" is one. Pitting is when a finger pressed on the skin leaves an indent (shallow pit). This indent reduces on elevation.

As time progresses the fluid and waste products in the tissues can cause tissue thickening and fibrosis (excessive fibrous tissue). The tissues become hard and non pitting . The swelling does not reduce on limb elevation.

Early recognition of the condition and treatment with Actico inelastic bandaging can reduce the swelling.

Once the leg volume has decreased patients may be suited to ActiLymph hosiery which has the compression levels and stiffness required to manage chronic oedema.

Watch the video on Actico full leg bandaging.

Chronic Oedema is the medical term used when a part of the body has been swollen for over 3 months. Common places for this are swollen ankles and swollen legs.

One reason for swollen legs and ankles is caused by sitting still for long periods of time. The medical term is dependency oedema.

Another cause of swollen limbs is known as lymphovenous disease. This is caused by poor circulation in the veins back to your heart.

A conditon called lymphoedema can cause swelling anywhere in the body. Lymphoedema occurs when the lymphatics system is not working properly.

Swollen, enlarged limbs can make you feel very self conscious and in some cases stop you wanting to go out at all.

You might feel very isolated but you are not alone. Contacting others with the same condition can help many people.

The Lymphoedema Support Network has UK wide groups.

Treatment

If you have not yet sought treatment for your swelling then do so.

The condition may be chronic i.e. can not be fully cured, but most cases respond well to bandaging and the wearing of hosiery or armsleeves.

Bandages

Firstly Compression bandages applied by your nurse can reduce the swelling. The bandages push the excess fluid out of the skin back into the circulatory system.

When the swelling has reduced you may be prescribed compression armsleevesor hosiery. They should stop the swelling coming back and will need to be worn long term.

The garments are comfortable and allow you to carry on your everyday life.

Armsleeves and Hosiery

First and foremost these should be comfortable and fit properly. If not speak to your nurse or GP.

If you look after them and wash them according to the manufacturer's instructions they should last up to 100 washes.

After 3 months' wear they should be replaced with new garments to ensure you are getting the optimum compression.

If you have a problem applying your garments then maybe an ActiGlide applicator could help you.

Tips

• Put armsleeves and hosiery on first thing in the morning and take off last thing at night.

• Wear your armsleeves and hosiery when exercising, even swimming.

• Armsleeves should generally not be worn at night.

• Keep your arm moving and use for light, normal tasks.

• Do not carry heavy items with your affected arm.

• Carry your handbag on the other shoulder or side.

• If possible do not allow injections, blood taking or pressure cuffs on your swollen side.

• Take care when performing household tasks such as gardening, ironing etc.

• Wear protective gloves to prevent burns and cuts etc.

• Wash hosiery and armsleeves regularly to prevent a build up of moisturizers especially on the top bands. The build up of moisturizers can make the garments slip down.

• Dry your skin very carefully especially in between skin folds.

• Fungal infections such as Athletes foot can potentially lead to cellulitis, an infection needing anti-biotics. Always check for Athlete's foot - itchy red skin between the toes, and treat immediately.

• If you notice your skin has become red, feels hot and/or tender contact your nurse or GP immediately.

• Always wear sensible shoes which won't rub or restrict.

• Use sun creams and insect repellent to guard against sunburn and bites.

• Use unscented cream daily to moisturise limb.

• Exercise! Here are a few foot exercises which can be done even in a chair.

Foot exercises

Aetiology of Oedema

The arteries, veins and lymphatic vessels make up the circulatory system of the body, though often lymphatics are overlooked.

Fluids and protein leak out of the blood capillaries into the tissue spaces (interstitial spaces) with the lymphatic system being responsible for removing fluid, plasma proteins and cell waste products and debris from these spaces, thereby maintaining homeostasis (state of equilibrium between these independent variables).

The rate of fluid leaking out of capillaries depends on several factors, including blood pressure in the blood capillaries and the concentration of plasma proteins in the interstitial spaces (due to osmotic pressure, as protein attracts fluid).

Similarly the rate of re-absorption of fluid back into the capillaries and superficial lymphatic vessels depends on various factors. Normal function (homeostasis) is reached when fluid and waste is removed equally as quickly as it is produced.

Oedema is an imbalance when re-absorption does not match production of fluid and waste products, leading to an abnormal collection of fluid in the tissue spaces.

Increased capillary leakage can overwhelm the capacity of the lymphatics and result initially in a low protein oedema. If left untreated, oedemas can result in failure of the lymphatic system resulting in a mixed oedema (both venous and lymphatic origin).

Stemmer's Sign

In the picture the Stemmer’s sign is positive as it shows the difficulty in picking up a skin fold on the 2nd toe in a clearly oedematous set of toes.

Stemmer's Sign

Dependency Oedema

Dependency Oedema

Also known as armchair legs, gravitational or lymphostasis verrucosis. This is a common condition found in the community in patients who are immobile and spend a lot of their day and or nights chair bound.

Because of lack of movement and weight bearing, the calf/foot muscle pumps fail to be effective leading to increased capillary leakage and lower venous and lymphatic return. Oedema results.

If recognised in its early state dependency oedema is a soft low protein oedema that responds well to elevation and pits easily.

There will be a rapid response to elevation and after with the limb dependent swelling can occur distally very fast, leading on some occasions to skin stretching and lymphorrea (leakage of superficial lymphatics due to their being over full of fluid and literally bursting as a result). Literally "wet legs" is the symptom that is sometimes seen in this situation.

Lymphovenous oedema

Lymphovenous Oedema

Lymphovenous Oedema refers to the appearance of lymphoedema on limbs affected for some years by chronic venous hypertension that has been poorly managed (Green and Mason 2006).

Venous hypertension results in ineffective capillary dynamics due to the high pressure in the venules.

This affects the re-absorption of fluid and waste metabolites back into the venous system, and also allows the leakage of larger molecules into the interstitial spaces, resulting in increased pressure within the interstitial spaces.

The lymphatic circulation is responsible for removing about 10/20% of fluid from the interstitial spaces, with the rest being removed via the venous capillaries.

If the venous capillaries are not functioning normally this will result in excess fluid, which will overload the lymphatic system. This increased pressure on the lymphatic system eventually results in failure of the lymphatics, leading to the skin changes associated with chronic oedema

Assessment of a patient with Chronic Oedema

1. Is this Chronic Oedema?

Persistent swelling of more than 3 months that does not resolve completely at night or on elevation is a sign of lymphatic insufficiency, and by definition is lymphoedema. Limb shape distortion is due to fluid accumulation and skin folds may develop at the joints.

2. Is there lymphatic insufficiency?

It is important to explore any history (and family history) of primary lymphatic problems or reasons for secondary lymphoedema, including cancer treatment, injury or infection.

3. What skin and tissue changes are present?

The skin and tissues change in response to the build up of fluid, proteins and other macromolecules. Thickening of the skin and the subcutaneous layer occurs due to excess connective tissue and fibrosis. Tissues become hard and may be 'non-pitting' on finger pressure. Peripheral fibrosis affecting the digits results in a positive Stemmer's sign where the base of the second toe cannot be pinched and is a definitive sign of lymphoedema. Cellulitis is common in lymphoedema and may be recurrent as the immune function of the lymphatic system is compromised. The swollen area also provides an ideal medium for inflammatory processes.

Other tissue changes including hyperkeratosis, lymphangiectasia and papillomatosis are often seen in lower limb lymphoedema. Problems such as lipodermatosclerosis and signs of chronic venous disease may also be present. Lymphorrhoea, leakage of clear lymph from the skin, is common in an untreated chronic oedema, if the skin is stretched or injured. Increased exudate from an ulcer site or a poorly healing wound may be a sign that chronic oedema is not adequately controlled.

4. What other problems/contributing factors are present?

Many factors can combine to cause or exacerbate lymphoedema. Further investigations and treatment may be required to effectively manage the swelling.

The amount of fluid accumulating in the tissue will increase due to alterations in capillary filtration caused by cardiac and renal failure, chronic venous disease, immobility and limb dependency. Hypoproteinaemia, often associated with liver problems, produces a generalised oedema and ascites. Obesity and lipoedema (condition where excess fat is laid down) will impact on lymph drainage.

Medication such as non-steroidal anti-inflammatories and calcium-channel blocking agents can increase oedema. Non-adherence to treatment will compromise the treatment outcome and highlights the need to identify patient goals and capabilities. Compression therapy may need to be modified in patients with diabetes.

5. Is there risk or evidence of arterial disease?

Assessment of arterial status is important prior to application of compression although this may not be practical in a grossly swollen limb. Patients with an ABPI of <0.8 or >1.2 will require referral for specialist assessment. Treatment programmes will be modified in these patients.

6. How extensive is the swelling?

Unilateral lower limb swelling is likely to be due to a peripheral problem in the limb or adjacent trunk such as impaired local lymphatic or venous drainage. Bilateral leg swelling is more likely to have a systemic element such as cardiac failure or hypoproteinaemia. It is important to ascertain if trunk, breast, facial or genital oedema is present as this indicates that manual lymph drainage and other specialist treatment may be required.

Patients should be assessed by a lymphoedema practitioner where necessary.

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This information is not intended as a substitute for the advice of a health care professional. Consumers should rely on the judgement of a health care professional for specific conditions.
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