The Effect of Acute Inflammatory Episodes (Cellulitis) on the Treatment of Lymphoedema

Abstract

Lymphoedema is a chronic, progressive condition which affects a significant number of patients following treatment for cancer. AcutelnflammatoryEpisodes(AIE),commonlyknown as cellulitis, may be a complication, or causative factor, in the development of lymphoedema, and has a detrimental effect on the management of lymphoedema. This paper reviews the literature regarding the pathophysiology oflymphoedema and its treatment using conservative treatment measures. The prevention and treatment of AlE is addressed, highlighting the importance of identifying those patients at risk of developing lymphoedema, and consequently AlE. The role of the nurse in patient education is discussed. INTRODUCTION The literature cites several factors which play a role in the developmentoflymphoedema. Of particular interest is the role of cellulitis, both in the development, and as a complication, of secondary lymphoedema related to cancer and its treatment This paper focuses on the physical effects of lymphoedema, and reviews the pathophysiology of lymphoedema. The development of AlE and its effect on current conservative lymphoedema treatments will be discussed with reference to the treatment and prophylaxis of AlE. The role of the nurse in the education of the patient will be outlined, with suggestions for future development Prior to commencing this review, two objectives were identified: 1) To achieve greater personal understanding of the patho-physiology of lymphoedema, its treatment and the role of AlE. 2) To provide a theoretical background (through this literature review) for the development of a controlled clinical study into the prophylaxis of AlE related to lymphoedema. For the purpose of this paper, the term 'nurse' will be used to describe those members of the multi-disciplinary team (whether they be nurse, physiotherapist, occupational therapist or surgical appliance officer) who are involved in the provision of care to patients with lymphoedema. PATHOPHYSIOLOGY OF LYMPHOEDEMA Lymphoedema is commonly referred to as a chronic swelling resulting from a failure of the lymph drainage system, with the consequent accumulation of protein-rich interstitial fluid 1•2•3•• 5 • 6 • 7 • 8 • One or more limbs may be affected, and sometimes the adjacent quadrant of the trunk • To achieve an understanding of the problems that may occur whenthelymphaticsystemfails,itisfirstnecessarytounderstand the basic pathophysiology of the lymphatic system. The lymphatic system The lymphatics serve two major purposes: the regulation of tissue homeostasis, and an immunological function • 9•• It comprises a complex network of vessels which provide an accessory one-way drainage route by which fluid can flow from the interstitial spaces, carrying macromolecules (including protein and bacteria) back into the bloodstream. It has also been likened to the route taken by a river from its source (tissues) to the sea (bloodstream) • The blood and lymph systems complement each other, providing a fine balance between filtration and reabsorption 11 • Fluid leaves the capillaries and enters the tissues under the compulsion of hydrostatic pressure, which is greater at the arterial end of the capillary. Proteins act as the vehicles in the blood transport system, carrying oxygen and nutrients to the cells of the tissues. At the venous end of the capillary, osmotic pressure (exerted by the plasma proteins remaining in the bloodstream) draws the fluid back into the capillaries. However, macromolecules such as protein and bacteria are unable to return directly to the bloodstream, and must exit via the lymphatic route • Approximately 90% of the tissue fluid returns via the venous system, and the other 10% enters the lymphatic capillaries to combine with plasma proteins, cell debris, organic matter, foreign bodies and fat (from the intestine) to form lymph. The rate of lymph flow is influenced by three major factors: changes in interstitial fluid pressure; muscular activity; and the continual rhythmic contraction of the lymphatic vessels • •• The development of lymphoedema Lymphoedema can be classified into two types: primary and secondary. Primary lymphoedema arises from a congenital abnormality of the lymphatics (which will not be specifically discussed), whereas secondary lymphoedema results from obstruction or damage to the lymphatic vessels 2•5• The literature describes several factors which reduce the transport capacity of the system (Fig 1), and precipitate the presentation of lymphoedema. Currently there has been no work to suggest the degree of risk attached to each factor. The literature describes several factors which reduce the transport capacity of the system: Axillary or groin dissection .s·••• Axillary radiotherapy 1.s·8•15 Tumour Post-operative wound infection•••.ZO Venous complications Radiodermatitis•