Lower Extremity Venous Disease (LEVD): Management, Patient Education, and Lymphedema

Speaker A: 00:00:10

Okay, so we talked about venous leg ulcers. Kind of big picture. To summarize, we said venous leg ulcers are the most common type of leg ulcer.

The basic pathology is you've got failure of that one way system due to valve damage. So now you've got venous insufficiency, backflow of blood into the superficial system, back pressure on the capillary beds.

You've got venous hypertension, high pressures from the deep system transmitted to the superficial system, causing all kinds of vessel damage, risk factors, anything that causes an obstruction to venous return, pregnancy, morbid obesity, sedentary lifestyle, anything that causes damage to the valves and anything that compromises the calf muscle pump.

Clinical presentation, venous insufficiency, you're going to see edema, you're going to see hemocytosis, you're going to see aching pain that's typically relieved by elevation. Probably see varicosities, might see atrophy, blanche might see venous dermatitis.

Venous ulcers, location between the ankle and the knee, usually a red yellow base. Highly exudative management is all about improving venous return.

So the two consistent elements of management are going to be compression and elevation. Medications sometimes help. Surgery sometimes helps.

So in this part, we're going to talk about specific guidelines for compression wraps, compression stockings, garments and orthotics. Compression pumps, medication options, surgical options, topical therapy, patient education, and lymphedema.

So when you have a patient with a venous ulcer and you've done the workup and let's say their ABI is normal, now you have to pick the best type of compression therapy. So things to think about, what's the size and shape of the leg and how bad is the edema.

So if a patient has severe edema, you're going to start out typically with some kind of wrap device so that you can essentially modify the application once or twice a week, you're trying to continually compensate for reduction in calf circumference. You have to pay a lot of attention to patient tolerance, preference and mobility. So if the patient's like, I can't stand this, I can't keep this on.

It's too tight. I know you say it's not too tight. It is too tight. I'm going to cut it off. We better listen because they're going to cut it off.

And as one of my friends says, I'd rather have 20 mercury compression on your leg than 40 mercury compression in your drawer. So, yes, I have to pay attention to the severity of the edema.

I have to pay a lot of attention to what the patient says, what they can tolerate, what they can get on, and I have to think about economic issues. That's a major concern for a lot of patients. Are they going to be able to afford this? Where can they get it?

But as we just said, any compression is better than no compression. And many times we find that we need to start low and go slow.

Pay attention to your patient, work with them, find what they can tolerate, start there, and then gradually bring it up.

Now, WCN actually has developed a venous leg ulcer algorithm that helps you select the best compression therapy option for a patient, and that gives you the URL that's accessible to everyone, so it's publicly available. Now, let's go back to selecting compression therapy. We said there's two major categories.

There's the static, that's your wraps, stockings and orthotics, and dynamic, which are your pumps. Static devices are standard therapy. And typically we use wraps initially until we get the edema and the exudate under control.

Because think about, I come in with three plus edema, high volume exudate. If you put me in stockings, then in a week that pair of stockings won't fit. They'll be too big. They'll have to constantly buy new stockings.

Well, that's. I'm not going to do that. That's not reasonable.

So it's much better to do a wrap until you get the edema and the exudate under control, and then you can cross me over two stockings. Now, the nice thing about wraps, they're applied by a professional every three to seven days.

That frequency of change, as we've said, accommodates rapid changes in leg dimensions and also provides effective management of exudate. So typically, we're bringing people into the outpatient clinic during the early weeks of therapy.

We're bringing them in once or twice a week, taking off the old wrap, assessing the wound, redressing the wound, applying a new wrap. But once edema is under control, exudate is under control. My wound is almost healed. We're starting to look at long term therapy.

We've got to look at something that I can do. So now we're looking at stockings or orthotics for long term management. Now I'm briefly going to go over the different types of wraps.

We'll talk a little bit more about this when you come on site for bridge week. And you'll actually practice four layer and two layer wraps. So your four layer wraps the most commonly used are pro four and four flex.

This wrap was developed in the UK with a very systematic approach to measuring sub bandage pressure. They did a great job. They used little manometers so that they could put them underneath the bandage.

They could determine the compression force, they could monitor the compression force when the wrap was first applied. 48 hours later, 72 hours, 96 hours, five days a week.

And so what we know is that if you apply a four layer wrap according to manufacturer's guidelines, you're going to get five to seven days of sustained therapeutic level compression. Another really good thing about the four layer wraps is they're appropriate for both active and sedentary patients.

So they do provide therapeutic, sustained level compression because of the elastic components in the system, and they do not, they are not dependent on the calf muscle pump, so they will support the calf muscle pump. But if you have a patient who's just sitting in their recliner most of the day, the four layer wrap will still be affected.

What if you have a patient who has an ABI between 0.5 and 0.8 and you need to do modified compression? Then you can omit layer three and you will have compressive force between 23 and 30 mercury.

So here's the basic guidelines, and again, we will practice this. So you're going to clean and moisturize the leg.

The base layer of this wrap is very drying, so you want to be sure you moisturize the leg and you're going to dress the wound based on the wound characteristics.

Now, layers one and two are designed to paddle, protect and absorb, and the goal is to pad bony prominences, to create a graduate cylinder contoured to the leg and to be able to manage exudates. So layer one and two are applied. Layer one is applied with no tension. Layer two is applied with just enough tension to keep the wrap smooth.

But neither one of those provides active compression. Layer three provides active compression, and there are three things you need to try to do.

So, obviously, you're going to always start at the base of the toes and go to one inch below the knee.

But the three aspects, the three considerations that are critical to therapeutic effects, you want to apply it at 50% stretch, you want to apply it at 50% overlap. So the bottom edge of the bandage follows the yellow line or the red line from the previous wrap around. We'll show you that.

And you figure eight from the ankle to the knee. It's a lot, but we'll show you how to put it all together. We'll show you how to test to be sure you have the right amount of compression.

So layer three, a critical layer. It's your first active therapy layer, and then layer four is your second active therapy layer, is your coban layer.

You apply it at 50% stretch, 50% overlap, and you spiral. We'll practice the three layer system is another active compression system, so it's okay for both active and sedentary patients.

This one is not used as widely, but it is considered to be therapeutic and appropriate. So if you're using the Dynaflex or another three layer system, again, you just want to make sure you're following manufacturer's guidelines.

So, again, clean and moisturize the leg, dress the wound. Layer one, padding and protection. So you just spiral wrap. Your goal, create a graduate cylinder contour to the leg.

Layer two is active stretch, and there's little visual indicators to tell you when you get to the right amount of stretch. And then layer three is the self adhesive coband type, and it's applied at 50% stretch and 50% overlap. And then the newest is the two layer wrap.

There's one from three m, there's one from Medline.

Now, when they developed the two layer wrap, they were not trying to improve on therapeutic outcomes, because we already had very good data that if the four layer or the three layer wraps were applied according to manufacturers guidelines, more than 90% of wounds would heal.

So when they came out with the two layer wrap, they were trying to maintain the established level of therapeutic effectiveness, but they wanted to improve patient comfort, because patients complain about three layer and four layers. They're like, they're heavy, they're hot, I can't wear my shoes.

And they wanted to improve nurse confidence, because nurses are like, how do I know I got it right? Did I get the right amount of stretch? So they came up with a two layer wrap, and here are the guidelines for that.

So you're going to, again, clean and moisturize the leg, dress the wound. Layer one. Layer one is for padding and protection. You always start at the base of the fifth toe, headed toward the great toe.

You come around the foot only once and go to the base of the knee and Spotify spiral face of the leg and spiral up the leg. You leave the heel out. This is one of the things that makes it low profile. So start at the base of the fifth toe, head toward the great toe.

Come around, go to the base of the leg, spiral up the leg. Then layer two is your active therapy layer. It is applied at full stretch. You figure eight around the heel, and ankle and then spiral up the leg.

So bottom line, because there will be new products coming out all the time, if you get a new product, you want to have the rep come and give an in service and you want to follow manufacturer's guidelines so that you get optimal effects. Now what about Oona's boot? Oona's boot was the gold standard for compression therapy for a long time. It is no longer the gold standard.

So I'm going to explain how it works and why it's no longer the gold standard. So if you look at the slide on top, you see them applying the base layer of the oonis boot.

And the base layer is just plain gauze impregnated with gelatin and zinc oxide. No stretch, no compression. So you wrap that from the base of the toes to an inch below the knee.

You have to constantly either forward pleat it, reverse pleat it, fan fold it, or cut through and smooth it out so that you get a very smooth, conformable boot. That boot will support calf muscle pump. And that's what doctor Una designed it to do, to support the calf muscle pump.

So when you walk, if you engage the calf muscle, that stiff wrap will push against the calf muscle, push it in toward the deep veins and help melt the deep veins, help propel blood back to the heart. But there's no active compression. So when I'm just sitting here, I'm getting nothing from layer one except treatment of any dermatitis.

The outer layer is Coban. So you know when you apply Coban, if you apply it correctly, you do get active compression.

And at the time you apply it, you have therapeutic level compression. But here's the problem. Once you lock Coban down, it can't tighten up, it loses all elasticity.

So once there's any reduction in the circumference of the calf, you drop out of therapeutic range into subtherapeutic range. So let's say you put it on and at the time you applied it, my calf was 36 cm in circumference.

But a few hours later, you've pushed some of the interstitial fluid out of the tissue back into the bloodstream. And now my calf is 34 cm diameter and my wrap is no longer therapeutic.

So Oona's boot is considered appropriate only for patients who are actively ambulating. It can be beneficial for venous dermatitis.

But if you have a sedentary patient, it is not going to manage the venous hypertension or venous insufficiency. It is not going to promote healing of the there are also reusable stretch bandages. These are also called short stretch bandages.

They have very limited elasticity. They usually have little indicators that let you know when you have stretched them to desired therapeutic level of stretch.

So you'll have little rectangles that turn into squares. But because they have limited elasticity, they cannot compensate for changes in calf circumference.

Also, they tend to slide down because they don't conform as well. So can they be used effectively? Yes, but they're not going to be as effective as layered compression reps.

And that's exactly what we said when we summarized the Cochrane findings. So they're not used as much. Now, whichever wrap you use, critical to educate your patients. So you want them to know why we're using compression.

What's going on? Number one, we're trying to reduce swelling.

Number two, we're trying to help blood get back to the heart, because the underlying problem here is your veins are struggling to get blood back to the heart. We want to talk about the importance of elevation.

If you use elevation, if you lie down with your legs higher than your heart for 30 minutes to an hour, you reduce a lot of the edema because you're using gravity to promote venous return. So if you can use a combination of compression and gravity elevation, you can go a long way toward reversing or controlling venous insufficiency.

You definitely want them to know the signs and symptoms of circulatory compromise. So if the toes become discolored and painful, then what should you do? You should notify whoever put the wrap on.

If you don't get a chance to talk to them, just go in and take it off. If you do not respond to elevation, what about stockings?

Once we get extradite under control, a deem under control, usually we cross you over to stockings. Now, we have to actively involve you in decision making here. I have to make absolutely sure that we pick out a stocking that you can and will get on.

So here's what we know is stockings work as long as they're correctly fitted and they give the right amount of compressive force. They have to be worn consistently, so you have to put them on when you get up and take them off when you go to bed.

They need to be replaced every four to six months. So about the time they're getting easy to put on, they're not really working so well and you need to replace them.

In the UK, they did some studies about adherence to compression therapy, and the findings I thought were surprising. I expected them to say different things.

I expected them to say that compliance was dependent in large part on if they were easy to get on, hard to get on, whatever. What they found was that patients were very compliant with compression therapy as long as two criteria were methadone.

Number one, the patient understood why it mattered, what they were trying to accomplish. And number two, once they got it on, it was comfortable.

So I think that's very important for us to remember how important it is for patients to understand how important for us to make sure they can get them on and that they're comfortable once they get them on. There are a lot of dining aids, so if you look at this slide on the bottom, that's also known as a stocking butler.

So if you have good hand strength but limited ability to pull that up over your leg, you can stretch the stocking over the butler, push your leg and foot down, and then pull the butler up, and it pulls the stocking with it. Other things that help, silk footies, rubber gloves, sometimes people will take, especially if they are using compression stockings with open toe.

You can always put the leg down into a kitchen garbage bag, which has a very slick surface, pull the stocking up, and then hold onto the stocking and pull the garbage back out. The other thing is, if you look at the slide on top, they make stockings that have a liner and then stockings with a zipper.

So you slide on the silky liner, then you pull on the stocking, then you zip it up.

So a lot of things out there to make it easier for patients to get stockings on, we need to focus on making sure they understand why stockings matter, how important long term use is.

We want to make sure they're comfortable once they get them on, and then we can work with them with different devices to see which is easiest for them to use. To get the stockings on, there are some compression orthotics, the ferro wraps and the circae.

These aren't widely used because they're costly and not always covered or usually not covered by third party payers. But they can be much easier for patients with limited dexterity because they just slide them on and use velcro straps to close them.

So just be aware that those exist. What about Ace bandages? So patients frequently will revert to Ace bandages. Are they a good option? No, they are not a good choice for compression.

They're way too stretchy. So that means there's way too much give in them.

So when the calf muscle contracts and you want to push in against the calf muscle, an ace bandage tends to give way. So they do not provide effective support.

Think about times when you've wrapped somebody with an ace bandage, and maybe it looks pretty good when you get done and you're kind of proud. But then the patient walks down the hall and back, and when they come back, it's falling down around their knees because it's way too stretchy.

Also, it's totally user dependent and frequently applied incorrectly. So we discourage use of ace bandages. They're probably better than nothing, but I can't say for sure. Well, what would be an alternative?

Many of you have probably seen the elastic sleeves like tube grip, and so you can size those sleeves to match those circumference of the calf. And if you do, one layer of tubigrip will give you 10 mercury support, two layers will give you 20, which is not bad.

It's very easy to apply, easy to remove, easy to wash. So think about if you have a patient who just can't tolerate anything at baseline.

Think about trying tube a grip to work them up to therapeutic level compression. Also think about tube grip as a possible alternative to stockings if they just can't get stockings on. Now, remember, there are pumps.

They work just like sed, so the sleeves are replaced over the legs, the pump's attached, and then you get sick, leak, contraction, relaxation that milks the calf muscle and propels blood back to the heart. So they're considered one good option for refractory venous ulcers.

They're the best option if you have a patient with mixed arterial and venous disease, because it augments both venous function and arterial function. Some of them are sequential, so they milk the blood up the leg, and others just contract, relax, contract, relax. Either seems to work.

What can we do with medications? A little bit right now, not a lot. The primary option in the United States is pentoxify, also known as trentol.

So it is sometimes used for management of refractory venous ulcers. It's typically not first line therapy. What does it do? Well, it improves venous tone, which improves venous blood flow.

It also keeps white blood cells from lining up along the vessel wall. Once they line up along the vessel wall, they start to migrate out into the tissues.

So it kind of keeps those red blood cells and white blood cells moving along and has some positive impact on venous blood flow. It's not stand alone therapy. It would be used in conjunction with compression, primarily for wounds that fail to respond to compression alone.

There is an herbal laser agent known as HCSE, horse chestnut seed extract. So it's obviously an extract of horse chestnut seeds. And interestingly, it actually causes venal constriction.

So it narrows the diameter of the veins and reduces the permeability.

So it improves venous return, reduces the volume of fluid and red blood cells and white blood cells, proteins that migrate out of the venous system into the surrounding tissues. So it helps to reduce pain. It makes the patient less prone to that venous dermatitis. So they have less itching. It reduces edema. A lot of good things.

So it's an herbal agent. It may or may not be recommended to patients, but you want to be aware of it. In Europe, they have a product known as daphlon.

It's micronized, purified flavonoid fraction. I have to look at it every time.

It has been shown to improve ulcer healing compared to standard therapy, but it's not currently available in the US, so don't focus on it. Know about trintal, know about horse chestnut seed extract. What about surgical interventions?

I was talking to one of my friends yesterday who has refractory venous disease. He'll get his wound healed, then he'll come back. So he's like, my vascular doctor is talking to me about surgery. What do you think?

So what do we know about surgical intervention?

Well, we know that surgical, either open surgery or endoscopic obliteration of the incompetent veins, either incompetent perforators or incompetent saphenous veins can promote healing and can help to prevent recurrence. So, yes, especially for a patient with refractory disease, it makes really good sense.

The trend now is to use minimally invasive approaches, so to do endovenous approaches rather than open surgery. So either the endovenous laser ablation of the saphenous or the subfascial endoscopic perforator surgery. Here's the disappointing thing to patients.

So they think, oh, I'll get this surgery, I won't have to wear those stockings, I won't have to worry about. Elevation does not replace those elements. So even if they've had the surgery, they still need to use support stockings to help prevent recurrence.

Now, topical therapy, everything's going to go back to everything we talked about previously under principles of topical therapy. What are we trying to do? Mean ejectionate, which is heavy when we have venous wounds, reduce bacterial loads and protect the periwound skin.

Because, as you can see here, maceration is very common with venous ulcers. So you always protect the periwound skin, either with the liquid skin barrier or with a moisture barrier product.

You're going to select dressings that are absorptive. So you might think about alginates. You might think about foams.

In general, porous foams are better than adhesive bordered foams because you want any excess etudate to pass through for absorption. Bye, secondary dressings. So alginates, foams are typically the agents of choice.

If you have evidence of critical colonization or biofilm formation, you want an absorptive dressing that also has antimicrobial properties. And don't forget about dermatitis management. Dermatitis is miserable for the patient.

So I remember when I was first getting into this, and I had a patient, he came in, he had classic dermatitis, but he also had an open ulcer and like, two plus edema. So he was telling me, you gotta do something about the itching that's driving me crazy.

So I put on what I thought would be a soothing topical agent, and then I put him in a compression wrap. Well, textbook wise, maybe that was a good idea, but I did not hear what he was telling me.

He was telling me that this itching was the number one thing for him. So he called me later that day to say, I just wanted you to know I cut that wrap off so I could scratch.

That tells you how important it is to manage venous dermatitis. So typically, it's going to require topical steroids applied at each dressing change, but no more than twice daily for about four to eight weeks.

It takes a while to get venous dermatitis under control, so you're using low dose steroid creams, typically.

Now, the other thing you should know is that for some reason, probably because venous dermatitis kind of reflects an arousal of the whole immune system. So what have you got? Activated white blood cells triggering an inflammatory response.

Once you've activated a lot of white blood cells, you get skin that is very sensitive and that is likely to react to other agents. And what we know is that venous ulcers are associated with a high incidence of allergic reactions to topical products.

And so we need to simplify our care protocols and minimize use of products that are known to potentially cause allergic reactions. So one of the best moisture barriers is just plain vaseline, just plain petrolatum.

So you might use steroids to get the dermatitis under control and then cross over to petrolatum as a moisture barrier to keep the drainage off the skin and to prevent recurrence of the dermatitis. Patient education. I can't overemphasize how important this is.

If we're going to be effective in managing any chronic wound, we have to partner with the patient. They have to understand what's going on and what has to be accomplished to promote healing.

So they have to know that the problem is blood's getting out to the tissues but not back to the heart. They have to know that everything we do from a therapy perspective is about pushing blood back to the heart and helping the wound to heal.

They have to know that even after the ulcer heals, they still have the underlying problem with getting blood back to the heart. So they're still going to need to wear stockings, do their leg exercises, those kinds of things. They need to know.

It's important to avoid tobacco because it negatively impacts on healing, negatively impacts on blood flow to the wound bed. They need to know the benefits of weight management and proper nutrition. Weight management to reduce the resistance to venous return.

Proper nutrition to promote healing. They need to know their legs are more vulnerable, so they have to be careful, avoid trauma.

Obviously, a lot of education comes down to the importance of leg elevation at night and ideally once or twice during the day. That routine walking exercise, calf muscle pump exercise is very beneficial.

I know one pt who taught her patients, every time a commercial comes on tv, write the Alphabet with your foot. So try it. You'll see it's much more engaging than just doing ten ankle pumps. Write the Alphabet with your foot.

So now they probably are streaming their tv program, so there's no commercials. So now you have to tell them, set an alarm on your computer and every time the alarm goes off, write the Alphabet with your foot.

And then obviously the importance of compression, long term management, it goes back primarily to preventing recurrence, and that goes back to patient education.

A lot of practitioners will bring patients in every three months to reinforce to them the importance of their support stockings, to see how they're doing, to answer any questions, to find out if they're having any problems with application, donning their support stockings, any of those things. It reminds the patient, you're not through with this, it's ongoing. How can we help?

If you have a non healing venous ulcer, you go right back to some of the things we talked about under refractory wounds. Make sure that you're getting adequate compression, make sure that you have managed bacterial loads of.

If you don't know why it's not healing, do a biopsy, make sure it hasn't undergone malignant deterioration, and then you're going to consider dressings to reduce your pro inflammatory cytokine levels, your MMP levels. You can also consider your human skin equivalents.

If you get the exudate under control, the edema under control, so the leg looks good, the wound looks good. No longer evidence of high bacterial counts. The wound's now pretty superficial. It's just not epithelializing effectively.

Then you might think of your bilayered human skin equivalent, apligraph, that acts as a non surgical skin graft. Okay.

And then in the last five minutes, I want to differentiate between lymphedema and venous edema and talk about your responsibilities in regards to the patient with lymphedema. So when we talk about the circulatory system, we typically think arterial and venous. And if you look at this slide, that's probably what you notice.

Arterial in red, venous in blue, but look at what's in light blue. That's the lymphatic system.

The lymphatic system is the third component of the circulatory system, and it plays a very important role because it helps transport protein rich fluid that leaks out of the capillary bed. It transports it back into the bloodstream. Proteins are fat molecules, and they usually cannot get through the capillary wall.

So it's very hard for them to get back into the bloodstream. And if they're sitting out in the tissues, they attract a lot of fluid and they trigger inflammatory reactions.

But the lymphatic system has open ended channels that make it easy for the proteins to get into the lymphatic channels. And then, as you can see there, eventually the lymphatic channels dumped and back into the venous system.

So proteins and fluid leak out into the tissues, and there's the lymphatic system to pick them up and take them back.

So as long as your lymphatic system is working, even at 50% capacity, you're usually in good shape because you have a lot of redundancy in the lymphatic system. But once the amount of fluid leaking out is greater than that, that the lymphatics can pick up in return, you begin to develop lymphedema.

Sometimes it's a congenital issue. So there's not enough lymphatic channels at birth that's going to affect typically much younger patients. Many times it's radical surgery.

So you think about reading surgical reports for patients with advanced malignancy, and they frequently do lymph node dissections. Well, that's going to remove huge components of the lymphatic system.

As you see on this slide, lymphatic channels pick up proteins and other materials from the soft tissues. That fluid runs through the lymph nodes.

The lymph nodes destroy any malignant cells, we hope eradicate bacteria, fungal organisms, viral organisms, and then take the fluid back to the venous system. So if we strip out a lot of lymph nodes, what do we do? We're taking out pieces of the lymphatic system.

Now, you have highways that are no longer connected and no longer functional. Chronic venous disease, because longstanding venous disease causes scar tissue to form out in the tissue.

That scar tissue wraps around the lymphatics and essentially shuts them down. And then you get a secondary lymphedema.

Worldwide, the most common reason for lymphedema is filariasis, which is a parasite infection that shuts down the lymphatic system. Now, here's the pathology. There are multiple stages of lymphedema, major stages. The first one is the reversible stage.

At this point, you have accumulation of fluid. It responds at least partly to elevation and compression. So things may not go back to normal, but they're a lot better than before.

You wrap the leg in the compression wrap, or you taught the patient to do elevation. What are the indicators that this patient with swelling has lymphedema and not venous edema? First of all, and it doesn't say it on this.

Well, it does say it on the slide. Lymphedema is toes to groin. So you have definite foot and toe involvement.

Usually the toes become kind of rectangular, and the tissue on the toes is very stiff. You can't pinch the tissue up. So stage one, you have pitting edema extends typically toes to groin.

At this point, there's no significant fibrosis in the soft tissues. So the big difference is the anatomical area involved. Venous edema is ankles to knees. Lymphedema is toes to groin.

Stage two, lymphedema, at this point, it's spontaneously irreversible. Now, you move from pitting edema to non pitting edema. You get a positive stimmer sign.

Now, that means that if you try to pinch the skin at the base of the second toe on the dorsal surface, so you try to pinch the skin, you can no longer do that. There's too much fluid, too many proteins, too many changes in the soft tissue, so it's too thick, too congested to pinch.

That's a positive stimmer sign. But you see, when you look at this slide, you see all those little overgrowths that make the tissue have almost a cobblestone appearance.

Those are known as papillomas, that conditions papillomatosis, and it occurs because of progressive breakdown of the elastic components of the skin and soft tissues. So that's what you see clinically. You start to see a lot of skin and soft tissue changes.

You have the positive stimulus sign, and the edema is now non pitting. At this point, elevation is ineffective. Compression might help a little, but not long term.

Stage three, you probably know, is lymphastatic elephantiasis. So usually we've seen this, we've seen slides of this condition in patients who have that parasite infection. So now you have severe papillomatosis.

You've got that cobblestone effect. You may very well have open wounds. You have very severe non pitying edema. And the leg or the extremity just looks totally abnormal.

What can you do at this point, elevation won't work. Compression won't work. If you're the nurse trying to take care of this patient, it probably looks overwhelming to you.

And that's because as wound care nurses, we're not prepared to deal with lymphedema. We should be referring them to a lymphedema treatment center. In that lymphedema treatment center, they will typically do manual lymphatic drainage.

So they go to school for a number of weeks to learn the technique for lymphatic massage and manual lymphatic drainage. And what they typically have to do, they start proximal. So you remember the entire leg is going to be affected.

So typically they start with doing light massage in the lower abdomen and the upper thigh to activate the lymphatic channels and get them draining. And then they go mid thigh and start to mobilize that lymphatic fluid.

And then they do knee to mid thigh and then mid calf to knee, and then ankle to mid calf and then toes to ankle. So they're gradually mobilizing the lymphatic fluid, moving as much as possible out of the leg.

Once they reduce the size of the leg, they're going to put them in very high level compression, typically 40 to 50 mercury plus exercises to help continue to mobilize the lymphatic fluid. And they teach the patient meticulous skin care because high protein fluid is a great medium for bacterial growth.

So think what we teach people post mastectomy. We teach them to be exceedingly cautious with their skin, avoid venipunctures, avoid blood pressure checks, avoid any kind of compression.

If they get any kind of break in the skin, manage it promptly, all of those kinds of things. That's equally applicable to the patient with lymphedema involving the lower extremities. So, summarizing, Venus edema versus lymphedema.

We're not really qualified to do primary management of lymphedema. So our major goal is to accurately identify lymphedema pretty promptly.

We can do skin care, we can do wound care, but in order to turn that process around, we usually need to involve a lymphedema special. So remember, edema with venous disease is ankles to knee.

It's water and sodium based, so you get great response in general to elevation and compression. Lymphedema is toes to groin, that positive stenosign. It's protein based.

It's much harder to get all of the proteins mobilized out of the tissue back into the bloodstream, especially when large sections of the lymphatic system are non operational. In general, lymphedema responds very poorly to elevation and compression.

So again, you need to get them involved with the lymphedema treatment center. So here's what they recommend in terms of prevention and early treatment. High level inelastic compression.

So if you have good evidence that your patient has lymphedema, they're awaiting workup at a lymphedema treatment center. You might very well put them in a high level compression wrap.

And if you can get the edema under control, you could move them into a high level compression stocking. Like we've said, once they have stage two or three disease, it needs to be be a lymphedema treatment center.

That's where they're going to do the complex decongestive therapy, manual lymphatic drainage to eliminate the retained fluid, inelastic wraps, exercises, and skincare. So in summarizing, part two of management of venous ulcers and lymphedema, you want to know about your wraps.

You know want to know the key differences. But bottom line, you want to know that wraps is where we usually start until we get edema and exudate under control.

You want to educate your patient about compression wraps, and especially about signs and symptoms of ischemia that mandate wrap removal. Once we get edema and exudate under control, we want to move the patient to stockings or orthotics.

You want to know which pharmacologic agents may be used so specifically pentoxify horse chestnut seed extract. In the US, surgical intervention is usually to do ablation of incompetent perforators or incompetent surface veins.

Topical therapy is all about exudate control, protecting the periwounds, controlling bacterial loads. And finally, you've got to be able to differentiate between venous edema and lymphedema.

So you refer patients with lymphedema to a lymphedema treatment center and that is it for venous disease and lymphedema. Thank you.