best practice for the management of lymphoedema ... - EWMA

ASSESSMENT
FIGURE 4 Simplified measuring method for patients with palliative care needs
A pretensioned tape measure should be used. No tension should be applied to the tape during measuring.
Upper limbs
With the limb in a supported
position and the arm straight,
measure circumference:
■ around the dorsum of the
hand (if oedematous)
■ around the wrist
■ 10cm below the point of
the elbow (olecranon
process)
■ 10cm above the olecranon
process
Repeat with the other arm
Lymphangiectasia: dilatation of
lymph vessels; may appear as
blister-like protuberances on the
skin
Lymphorrhoea: leakage of lymph
from the skin surface
Papillomatosis: the development
of warty growths on the skin
consisting of dilated lymphatics and
fibrous tissue
Lipodermatosclerosis: thickening
and hardening of the subcutaneous
tissues of the lower leg with brown
discolouration of the skin;
associated with chronic venous
insufficiency; in severe cases
lymphatics become damaged
Assessment of skin condition
The general condition of the patient's skin
and that of the affected area should be
assessed for:
■ dryness
■ pigmentation
■ fragility
■ redness/pallor/cyanosis
■ warmth/coolness
■ dermatitis
■ cellulitis/erysipelas
■ fungal infection
■ hyperkeratosis
■ lymphangiectasia
■ lymphorrhoea
■ papillomatosis
■ scars, wounds and ulcers
■ lipodermatosclerosis
■ orange peel skin (peau d'orange)
■ deepened skin folds
■ Stemmer sign (Figure 5).
Examples of some of the skin changes
seen in lymphoedema can be found on
pages 24-27, along with the indications for
referral of patients to dermatology or other
specialist services.
Vascular assessment
The arterial vascular status of the legs of all
patients with lower limb lymphoedema
should be assessed. The presence of
peripheral arterial occlusive disease may
contraindicate compression therapy or
necessitate a reduction in the level of
compression used.
ASSESSMENT
Lower limbs
With the limb in a relaxed position, measure circumference:
■ of the foot (if oedematous)
■ 2cm above the medial malleolus
■ 10cm above the superior pole of the patella
■ 10cm below the inferior pole of the patella
Repeat with the other leg
Ankle-brachial pressure index (ABPI)
provides an objective measure of the
patency of the large arteries supplying blood
to the foot. It is calculated from the ratio of
the highest ankle systolic pressure for each
limb to the highest systolic pressure in the
arm. There are limitations to the test
particularly in the presence of
lymphoedema. Tissue thickening,
hyperkeratosis or oedema may make it
difficult to detect blood flow using the
standard 8MHz probe. The use of a 4MHz
probe and a larger size blood pressure cuff
may overcome these problems 37 .
An ABPI of 1.0-1.3 is normal; an ABPI of
1.3 also indicates vascular disease.
Measurement of toe-brachial pressure
index (TBPI) may be useful when obtaining
an ABPI is not possible or too painful 38 .
Alternatives for assessing vascular status
include pulse oximetry and pulse
oscillography of the limbs, but may be
subject to false-positive ischaemic results in
the presence of oedema.
If there is any doubt about the patient's
peripheral arterial status, a vascular opinion
should be sought.
Use of these vascular assessment methods
requires appropriate training in
measurement technique and interpretation
of results.
12 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA