Lymphoedema in advanced disease: how can care be improved? Jeanne EVERETT LYMPHOEDEMA NURSE ST TERESA’S HOSPICE, DARLINGTON
Aims of session Remind ourselves of The goals of treatment in palliative care, Some causes of oedema in advanced disease, The general principles of management, Familiarise ourselves with S ome more specialised treatment options available from Haddenham healthcare. 03/03/2020 2
Reminder … • Lymphoedema: tissue swelling that develops due an interruption in the lymphatic system. • In the Western world the main cause is cancer and its treatment - surgery to remove lymph nodes; radiotherapy to nodes; local metastatic disease. • Or a combination of the above Todd (2009) 03/03/2020 3
Caring for the patient with lymphoedema in advanced disease Requires specific attitudes, modified treatment approaches, and a redefinition of the goals of care. (Towers et al, 2019) 03/03/2020 4
Aims of Management • RELIEVE symptoms • REDUCE risks associated with the oedema • IMPROVE quality of life • RESPECT the patient’s choices & priorities • PROVIDE psychological support to patient & family • ENSURE burden of treatment does not outweigh benefits • (Honnor, 2008) (ILF & CANADIAN LYMPHOEDEMA FRAMEWORK, 2010) 03/03/2020 5
Psycho-social effects of lymphoedema Significant effect on quality of life • fear, anxiety & depression. Physical Problems may include: • pain & discomfort • difficulties with clothing • reduced function & mobility • social isolation 03/03/2020 6
..but in palliative care... • The swollen limb can become a central focus for the whole family • It provides a constant reminder of the disease • It can also represent the marker for advancing disease 03/03/2020 7
Assessment: WHY DO WE NEED TO ASSESS? • To determine the differential diagnosis in order to treat the patient appropriately • To Set realistic goals • To determine what the patient sees as problem
Causes of oedema - general: Cardiac failure Late stage chronic renal failure – nephrotic syndrome Nutritional deficiency - hypoproteinaemia - protein-losing enteropathy - catabolic states Hepatic disease Lymphovenous oedema – immobility/dependency - neurological deficit 03/03/2020 9
Causes of oedema – local: • Due to lymphatic obstruction or damage: • surgery or radiotherapy • metastatic tumour in lymph nodes or skin lymphatics • Infection • Venous obstruction • DVT • SVCO/IVCO • extrinsic tumour compression • thrombophlebitis 03/03/2020 10
Causes of oedema – Medication: • Steroids • Non Steroidal Anti-Inflammatory drugs (NSAIDS) • Calcium antagonists • Pregabalin • Hormones • Biphosphonates • ANTI-CANCER MEDICATION - Taxotere 03/03/2020 11
Consider the following complications: • Altered sensations. • Brachial plexus neuropathy – heavy, dependent limb. • Neuropathic pain – due to radiation fibrosis, infiltrating disease. • Genital swelling. • Ascites. • Facial swelling • Lymphangiosarcoma. 03/03/2020 12
Factors Affecting Outcome: • Advancing, obstructive tumor. • Venous thrombosis. • Reduced mobility & function. • Uncontrolled pain. • Medication • Chronic skin problems & tissue changes: e.g. broken or fragile skin, lymphorrhoea, recurrent infection, fibrosis. (Williams, 2004) 03/03/2020 13
Management 4 CORNERSTONES may need to be modified 5 th cornerstone - REMEMBER Kinesio Taping, In addition, consider: Physio OT drug therapy - diuretics anti-cancer therapy. 03/03/2020 14
Be Innovative!
Evaluation of treatment outcomes Measured by improvements in symptoms, skin condition and quality of life, rather than by limb size. 03/03/2020 16
Remember: • Usual treatment options may not be possible for this patient group • Any intervention should be aimed at symptom relief and comfort • Treatment plan must be discussed with patient, carers and other professionals, in order to agree realistic goals (Landers & Thomas, 2017) 03/03/2020 17
SKIN assessment – skin care is always important SKIN MAY BE - dry, fragile, delicate, damaged. TISSUES MAY BE – Firm, or soft & pitting Remember - increased risk of - infection, fungating wounds, DVT, lymphorrhoea, All the above need prompt, appropriate treatment. 03/03/2020 18
Exercise & positioning: Consider • Functional assessment in relation to particular individual tasks, • Active and passive movements. • Fine finger movements may help to reduce hand & finger swelling, • Positioning – support for a heavy limb, to prevent joint & muscle strain, & to aid drainage, especially in dependency oedema • Care if neurological deficit is present – use of slings • Tripudio • REMEMBER REFERAL TO PHYSIO & OT 03/03/2020 19
Lymphatic drainage Massage • Redirects fluid away from oedematous areas via collateral routes towards healthy lymph nodes. • Useful in managing pain and other symptoms i.e. dyspnoea. Can therefore be particularly useful in palliative care. 03/03/2020 20
Lymphatic drainage massage SLD MLD Can be taught to a carer Indicated for truncal or relative - may help swelling: breast, them to feel more genital, head & neck. “useful” Can significantly improve Treatment is more pain & altered readily available for the sensations caused by patient. skin stretching or limb heaviness. 03/03/2020 21
Compression & Support • Older / larger / “slack” garments (lower class) • M.T.M. for “difficult to treat swelling” • M.T.O. for better fit • Palliative bandaging or wraps if: fragile skin, pain, lymphorrhoea. 03/03/2020 22
Palliative bandaging Fragile skin, firm, or soft-pitting tissues, pain, lymphorrhoea. Soft/pitting tissues – beware of using long stretch bandages, which can cut into “boggy” tissues and may cause damage. Always consider short stretch, applied with reduced compression to offer support W raps may be used in place of bandages in many cases 03/03/2020 23
Upper Limb Lymphoedema Haddenham Venex sleeve Soft stretchy conforming fabric, easy to don & doff, ideal for palliative patients where lighter compression may be required. HAND SWELLING Microfine gloves ……easy to don and doff, giving gentle compression. Can be cut to size 03/03/2020 24
Haddenham venex sleeve ……. • extra wide top available, with 5cm grip top - added comfort for larger upper arms - prevents rolling • large soft elbow insert prevents chaffing & improves comfort in elbow crease 03/03/2020 25
Comfiwave – new gentle comfortable garment for night time wear or for palliative care 03/03/2020 26
Case Study 1 - Mary • 84 year old lady – Breast Cancer 2015; W.L.E. & R.TH • 2019 – Secondary cancer in lungs, Supra-clavicular nodes, with a soft tissue mass extending from the anterior chest wall to left axilla, & Lymphoedema • Presented with oedematous left arm hand & fingers, reduced range of movement & poor grip ability. • 16% LIMB VOLUME DIFFERENCE. • CT scan confirmed tumour compression of the axillary vein & brachial plexus nerve, causing the reduced range of movement & the soft pitting nature of the oedema. 03/03/2020 27
Mary’s Management • Skin care, passive & active movement, positioning • Soft pitting oedema prevented use of a traditional sleeve • Comfiwave combined arm garment was selected • Pertex Light flat knit class 1 glove to soften finger swelling • Arm sling for use when out, to support dependant limb • The Comfiwave was fitted easily by Mary with some assistance from her husband 03/03/2020 28
Outcomes of treatment using Comfiwave. • AFTER 2 WEEKS - marked improvement in Mary’s arm: • size had reduced to an 8% limb volume difference, • shape was better, • slight improvement in her hand function - due to reduction in hand / digit oedema. “my arm feels safe & it is comforting to wear “. MARY CONTINUES TO WEAR THE COMFIWAVE AT HOME & AT NIGHT TIME 03/03/2020 29
Case Study 2: Joan • Admitted to the hospice for symptom control:- • grossly swollen left arm and hand resulting in severe neuropathic pain • Various sleeves, wraps and bandages were tried • All proved intolerable due to the severe neuropathic element to her pain.
Joan: management • MLD privately - results were often small and short lived, due to not being able to apply any appropriate compression following treatment. • Blue-line cotton stockinette - only form of sleeve that Joan could bear, which was comforting, but did not provide compression. • On receipt of the COMFIWAVE, Joan initially required the assistance of 2 to get the garment on, due to both the size of her limb and the severe pain in her hand and arm. • Staff were not confident that she would be able to tolerate it for more than a short period…….
Joan: outcomes • After a few hours - definite change to the softness of Joan’s hand and arm. • This encouraged her to persevere, despite the discomfort that she was in. • After a few days of wearing the Comfiwave - swelling decreased, pain reduced slightly, mobility and function of the limb much improved.
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