Educational Webinar: Lymphedema and Wounds

Good afternoon and welcome everyone to the McKesson and webinar series. I'm Patricia Howell on the McKesson Clinical Resource team. Our program today is sponsored by the McKesson Clinical Resource team. And this series has been created to provide an opportunity for education and discussion related to clinical topics affecting the post acute care market. Following the call, the attendees will receive a copy of the presentation and recording via email to ask a question. There's a chat box that you can locate at the bottom of your screen. I'm happy to introduce you today to our featured speaker who is Christy Recy and Christy is the wound care lead nurse adviser in long term care with SD health and hygiene. She maintains the gold standard and wound care certification CWCN and is a member of WOCN. She's also certified and lower extremity edema through NAWCCB. Christy holds a master's degree in complementary and integrative health and the certification as an advanced holistic nurse. So, she's got lots of experience to share with us in this presentation today. And so now Christy, I will turn the program over to you. Ok, great. Thank you, Pat. So I'm just gonna advance through here, this little disclaimer from McKesson eligibility requirements and we'll get started. So, hello, everyone and thank you for attending. As Pat said, we are going to discuss today that relationship between lymphoedema and wounds and how best to care for these conditions when they are co committed. So, let's just look over the agenda a little bit here and here is today's agenda. We will go over risk factors for developing wounds and those with lymphoedema. A brief overview of the lymphatic and venus systems, some general principles surrounding wounds and identifying some particular wounds, choosing appropriate dressings, proper care of the skin and lymphoedema. And of course, the importance of addressing the need for compression. So let's get into that brief overview of these systems. So when we look at these two systems, we can see that the Venus system is a closed system. It has its own pump the heart to move that blood around the body. The lymphatic system though is an open system and relies on movement of the body and the muscles to provide that pump. The main fluid in this system is lymph, which is protein rich and made up of not just proteins but a variety of other working cells in detritus. From this graphic here, you can see how these two systems are very closely aligned and when one system is damaged, it can have an effect on the other one. So let's get some detail into how that lymphatic system works. Your body has hundreds of lymph vessels and knows throughout your entire body from the top of your head all the way down to your feet. Our lymph nodes serve to filter our system to remove debris, bacteria and return it to the center to be pushed around your body. Again, to maintain that cleaning system. You can see this system at work. When your body is fighting a bacteria and your lymph nodes swell, you may feel those little bumps under your ears. You may feel them in your armpits, you may feel them in your groin where we have large pockets of these lymph nodes and glands that are moving around your body. This is your lymph system that works filtering and attacking the bacteria. In some cases. When it is a returning bacteria, even the body can react faster because it creates a sort of placeholder or memory where it's dealt with that bacteria before and, and instead of attacking you, it actually can help filter that system out. So, lymphatic fluid now that we have reviewed that system a little bit and you've got that kind of basic knowledge of how the lymphatic system works. What is that fluid that's inside that system? Basically, it is a clear fluid, but it is filled with proteins, water white blood cells, cellular debris, and possibly even that bacteria that I mentioned before when the lymph system is damaged and this lymph fluid begins to build in the tissue. But remember it's still with all these pieces good and bad, they then leak out into what we call lymph oria we see in late stage patients flowing out of your skin, your skin can only stretch so far, it leads to these skin changes where the skin begins to break down due to that slightly state of the lymph fluid, as well as this fibrotic or thickening skin changes where you see that alligator skin and the condition of that thickening and stiffening of the skin layer is making it harder to move. So you've got your edema that swelling the the tissues being expanded and filled with this lymphatic fluid that can't be moved and then you have the skin changes on top of it. So you can see how these compounding problems can lead to some significant issues for the patient. This malfunction presents itself in a variety of ways genetic. Sometimes you'll talk to a patient, let's say, yeah, my mom always had one swollen leg or my uncle had that maybe an acute injury surgery. Remember those lymph nodes and vessels are all over our body and they're on the very surface of your skin underneath those co couple layers. So if you have surgery, the surgeon has to cut through it in order to perform it and or lymph vessels and node removal or damage due to cancers and things like that. So when the system cannot move this fluid as normal it begins to reroute and me and you our system re routes things. And in some cases though it can accommodate the overload. But in patients that are compromised, patients that have genetic defects, patients that have a lot of removal, they just do not have the ability to reroute to other areas for removal or movement of that lymph fluid. So there we begin to see that accumulation of the excess fluid in the skin swelling that cannot easily be reduced by elevation and those skin changes start to occur, the system continues to be overwhelmed and if not addressed can cause wounds, increased pain, decreased mobility, increased risk of infection due to breakdown of the acid mantle on the surface due to that increased fluid overload. So now, not only is the body working harder to move lymphs, but now has to fight off bacteria that has the system been functioning normally would have been corrected by the lymph system. So, what is lymphoedema? What is that? It's that chronic disease caused by that defect in the lymphatic system or that malfunction of the transport system? And it is not limited to just the extremities. It really can occur anywhere that lymph system has been damaged or is malformed just as you, you have that lymph as you saw in that picture prior where the lymph nodes and vessels are all over our body. You can have a damage to that system anywhere. This is a chronic disease that does not currently have a cure, but it does have a wide variety of treatments from surgeries to manual lymph drainage to complete decongested therapy, including compression and good skin care. Any area that has a damaged lymph system can be affected by this overflow. Show the game same skin changes have mobility issues and those pain issues. As we see in extremities, a great deal of the time when we see lymphoedema, there is usually some damage to the venus system as well. And what happens when that occurs? There are some signs to look for when assessing your patient to see if they have damaged both vascular and lymphatic systems. One of those ways is a study, we can relate back to a study done by Doctor Keys in 2014 that if you see chronic edema beyond three months, you're probably looking at a lymphedema issue when you have that lymph lymphatic edema in the legs and it's untreated. Here's where you can start seeing those changes. This combination of the two damaged systems can be referred to as flee bo lymphedema. You can see one leg is usually larger than the other. There's in duration of the tissue from the edema. We have what we call lipoderma tos sclerosis where we see that thickening of the skin and the changes in the leg shape where it can be an upside down champagne bottle shaped leg scaling of the tissue and persistent inflammation. And you can see here in the pictures we have our venous edema as that first problem we note, but you can see as time moves on and those systems are both affected. Chronic edema is present. You see the chronic inflammation creeping in and then the skin changes start to occur as things progress. As a damaged lymphatic system continues to have lymph fluid build up in the tissues due to that damaged transport system. Remember now that system is not flowing as normal, we begin to see other changes and it can identify this edema with something called a stemmer test. So if you go to the top the dorsal surface or top of the second toe, and you cannot pinch the skin, that's one physical way to assess for a sign of lymphoedema. You will also see this accumulating fluid, create these skin changes where that skin becomes thick and fibrotic persistent inflammation that lack of ankle contour where you can no longer see the malleolus or maybe even a humped foot. As you can see here in the picture, you may begin to see fissures in the skin of those thickened areas. Large loaves of stretched out edematous tissue can be seen on the side of the leg or around the foot and ankle. As the lymphoedema progresses, these skin changes due to that increase in toxins in the skin. The bacteria that's laying in that list system that can't be moved or addressed the decreasing acid mantle create a perfect storm for an increased risk for skin infections and can lead to larger wound formations. Less bacteria toxins are being transported out of the body, which also kicks in the body's immune response. If the patient also has compromised blood flow due to arterial issues, that can also be affecting the nutrient delivery to those areas. So this turn of the backlog and limps that needs to be moved can lead to wounds, delays in healing with wounds that are created by other issues due to that overload and decreased nutrient activity. So you can see how the storm is coming together with Venus issues. Lymphatic issues. Now creating skin issues and how do we get a wound healed and identify it when we have all these things happening at once. So let's talk about how these skin changes and lymphoedema together can ultimately lead to these types of wounds. So first, we gotta talk about the skin changes that are occurring because this is where it leads to those open areas. So when it comes to lymphedema, one of the distinct hallmarks of this chronic condition are the skin changes due to that overload of lymph and this constant saturation of the tissue. With that slightly alkaline fluid, you will see things like this top picture of hyperpigmentation looks very similar to humans that are in staining that you see in venous insufficiency again because a lot of times when one is damaged. So is the other system, you'll see inflammation that does not fade. It's persistent bright red limbs or area where the lymph fed fed system is damaged. Again, there's that lipoderma tos sclerosis where we see the thickening skin and now the shape of the leg becomes more tree trunk, like more solid. You lose that ankle contour. You may see things like HR V blanch, which is a starburst of white tissue that has become damaged because of that persistent overflow of lymph underneath the tissue. And of course, there's stasis dermatitis, which is itchy, painful, oozing can often be confused with cellulitis, but it's that weeping out of the tissue in that persistent redness. And we also call that lymph oria. So speaking of lymph ria, here's a prime example in this picture of that lymph fluid weeping out of the saturated cells as each drop of that slightly alkaline fluid comes out on attack skin. It begins a domino effect. We immediately see the inflammatory effect of that alkaline fluid getting on intact skin, it becomes red, it becomes damaged, it becomes thin and it breaks down and pops open. Another drop comes out and another drop comes out and it creates this domino effect where you have that stasis dermatitis then slowing down this whole leg. And again, it puts that patient at increased risk for a further breakdown wound formation due to other underlying conditions and infection, this increase in fluid in that nice warm space of the leg increases, that stasis dermatitis. The lymph oria increases and it may move to a cellulitis state which is a very serious condition. So, moving to that cellulite, we hope it doesn't get to that point. But because of the damaged limp system, because the patient's system cannot respond to bacteria as it normally would in me. And you in comparison to stasis dermatitis, there is an increased risk of cellulitis in these patients, which is a bacterial infection that must be treated immediately. This occurs when a bacteria enters one of those open weeping areas or any other open area in the skin. It's very serious and must be treated with antibiotics to avoid any complications. It can look very much like stasis with that redness with the swelling. But there are other signs that can differentiate such as a fever in your patient, extra warmth or more warmth at that site, sudden increase in pain. It's more likely only gonna be on one side versus both where your stasis dermatitis usually affects both areas or both limbs and a sudden increase in swelling. You may also see some bullet or those raised fluid filled bubbles on the skin. The patient may also complain of pain versus your stasis dermatitis. Patients who are more of burning and itching sensation and there'll be no crusting of the lesions as you see with the stasis dermatitis. So there are some significant differentiations and it is important to be aware of it. When you're looking at this inflammation because it can look very similar in both cases. So as we begin to talk about these other wounds and wounds that are affected by lymphoedema and how that their formation of the wounds from lymphoedema can also affect the chronicity of these wounds and the reoccurrence. And we'll look at some of these different types of wounds here in a little bit more detail as we move on to the next slide. So, diabetic foot ulcers, they can be some of the hardest to treat patients with these types of wounds usually have a high rate of reoccurrence as well as because this is an autoimmune disorder. It places them at a higher risk for infection, add to that a damaged lymph system and you really again have a perfect storm of a high risk of infections, neuropathies where the patient has little to no sensation in the foot or hands or wherever this may be occurring can add an element of concern when treating with compression and garments as they can't report discomfort. And this can lead to pressure injuries if they cannot report the sensation that there's a wrinkle that the velcro has come to slash that there's an extra layer, it's bunched up in their shoe. This can lead to pressure injuries. So now you have a pressure injury along with your diabetic foot ulcer underneath the compression. So it's important to teach patients and staff and those for those patients with diabetes to teach them to inspect feet daily, to check for any open areas that could lead to a chronic ulcer or cellulitis. Or if they are using compression in, in the use of lymphoedema issues, they're checking those wraps to be sure there isn't any wrinkles or areas of concern. An especially imperative part of dealing with diabetic foot ulcers is ensuring there is adequate moisture management to prevent that maceration, that fluid build up and to prevent fungal issues, all float in the area where they have deformities is also very important. And you can see in that top picture is a little deformity in that foot because it is such a significant issue with diabetics. The diabetic also usually on the ball of the foot for the metatarsal area due to this type of deformities and it affects their gait. So that's something to consider with your lymphoedema patients as this sensation, the gait and how they walk. When you're looking at your diabetic foot, ulcers, venus like ulcers again, going back to where the venous system and the lymph system are closely connected. And when one is damaged, you most likely see damage in the other system. Venous also can be a a common problem in those with lymphoedema. Venous ulcers usually occur in that gator area between the ankle and the knee and are caused by that venous insufficiency when venous disease is coupled with lymphoedema, and again, they're closely intertwined that flee O lymphoedema can lead to recur this recurrent or formation of frequent and many venous ulcers. The hallmarks of a venus also include the location in that gator area that ruddy red wound base. You can see in that top picture, oftentimes they can have that fluffy slimy tissue in the base. They will have moderate to copious drainage. And again, coupling that with lymphoedema that drainage can be excessive at times. So just as with diabetic ulcers, it's paramount when dealing with these kind of ulcers again, is that exudate management, managing that moisture to maintain a moist wound environment. So you can keep it healed. But addressing that excess drainage and using antimicrobials, if you need them to control that bio burden, the more excessive the drainage, the higher the chance of maceration of that intact tissue, which leads to increased risk of further breakdown. And of course infection addressing bio burden with the use of antimicrobials or micro binding dressings can assist in preventing and or treating this excess fluid bio burden in these types of ulcerations. These patients also have a high rate of recurrence when compression is either refused, the patient is unable to have compression due to mixed disease or they're non compliant with routine compression. These are oftentimes chronic and patients will report having them for years and this also leads into losing the reps in compression and making sure you have the right level of compression for the patient. They can still use their footwear because you don't want to have any pressure injuries again, being caused by the use of the wrong level of compression. And then we also have the issue of skin tears. if the patient would receive a skin tear and they have venous insufficiency coupled with lymphoedema or even venous insufficiency on its own. A skin tear can lead to a chronic venous ulcer. So, compression therapy and looking into is the patient able to have. It is really important in the treatment of these kinds of ulcers. Arterial ulcers are caused by the decreased blood flow to a particular area of the body. Whether that be from clots, narrowed, arteries, occluded, arteries and capillaries. The inability to get fresh blood to this area creates necrosis and leads to ulcerations, arterial wounds can have many causes. But a lot of the time cardiovascular disease, diabetes can also be hallmarks that you should look for arterial insufficiencies. Being a causative factor. Usually signs of insufficient arterial blood flow. You can see thin shiny pale skin in the extremity. There are also gonna be a distinct temperature difference between the two limbs if they're there to compare that the arterial insufficient leg or area will be cooler to the touch. The area usually has a punched out appearance and there's usually very little exit date. A great deal of the time they will have necrotic tissue and the patient will report them be very painful. Unlike venous ulcers there usually isn't much pain involved with arterial ulcers. The patient will complain of pain usually will occur at the very end of the extremities such as tips of toes or tips of fingers, the dorsal surface of the toes, the top of the foot, the lateral ankle and the heel. Patients with arterial disease and a very low A B I or TB I can be very challenging when trying to treat lymphoedema. It can be hard at times if the patient has an arterial ulcer on the heel to decide, is it chicken or the egg? Was it the pressure that caused the injury faster? Because there's low blood flow or was there a low blood flow which allowed the pressure injury to occur faster? So, assessing that patient's overall ulterior status, doing a full lower extremity assessment, looking at those things as temperature color and things like that can help lead you to figure out is this an arterial issue and getting dopplers done can help finalize that assessment of their insufficient arterial blood flow. And when you're looking at compression, you've gotta check those A bis or TB is to be sure you're not going to include further any narrowed areas or move a clot. So at times, it can be difficult to distinguish a venous ulcer from an arterial ulcer if the locations are very close to where the other ones would be. So it is important again to do that full, comprehensive lower leg assessment when you have an area on the lower extremities at all, the characteristics I mentioned earlier with the venous and arterial systems. And if both legs are present and we know sometimes that isn't the case, but when they are present, it's best practice to compare the two in regards to temperature. First, is one warmer or cooler than the other edema. Is it present or not? And what is the level of edema? What's the color of the leg? Is it pale or does it have persistent redness, hair growth in arterial patients? You're gonna see very little hair or decreased amount of hair on the legs compared to the other leg. The Venus issues checking the toenails, are they malformed? Are they long and thick or are they thin and cracking? Long and thick may mean you have venous issues, thin and cracking means there's very little blood flow or if they're malformed, there's very little blood flow. And lastly, of course, sensation checking to see what sensation they have a patient does or does not have appropriate sensation in the foot or report reports. Any pain or burning sensation in that foot can lead you to the fact that they may have neuropathies and further assessment should be done. All these questions can help lead you to decide what is the underlying condition causing and contributing to this wound. As you're looking at how it ropes in with this lymphoedema issue. Another vital piece of the assessment is obtaining a Doppler to obtain that A B I or ankle brachial index or in patients with diabetes, it is recommended to have a TB I which is a toe brachial index to avoid those issues with calcification. In those types of patients, assessing this arterial blood flow lets you know how much compression that patient can tolerate. And so you don't put him in a higher level of compression and include those arteries. If a patient has an A B I of 0.8 or greater crush compression is fine, if it's between 0.5 and 0.8 modified compression can be used, but it must be monitored if it's lower than 0.5 they should immediately refer to a physician for consideration that there's areas of ischemia looking at your patients, especially with that arterial ulcer that may lead you. Ok. This is an arterial issue going on. So those A bis are very important before you consider putting your patient in what level and type of compression they can have. So now that we've gone over a few more of the common types of wounds that you may see while you're treating a lymphoedema patient. Another important step in treatment is preparing that wound bed, wound healing requires a moist clean wound environment in order for the healing process to move forward. So identifying the type of wound you have and then the tissue present will assist you in providing the appropriate treatment one way to do this is use of acronyms that can assist you in remembering to address all aspects of that wound for a comprehensive assessment. So, we've got tissue management, inflammation and infection, moisture, balance, epithelial edge regeneration and repair and those social factors. And we're gonna go through each of those next. So, tissue management, it is important to know the various types of tissue that you may see in the wound in order to treat them effectively. Any necr tissue such as ear, which is that black, tan, dry, adherent tissue or sloth that's yellow, maybe tan, stringy, dry or moist must be removed. In most cases, in order for the healing process to occur and if not removed can cause infection or increase that bio burden as any dead tissue is going to harbor bacteria. When assessing the granulation tissue, it should be red and beefy. If you think about when you're going to the grocery store and you're looking at hamburger, I and you wanna look for the hamburger that is nice pink red. You're not gonna go for the hamburger, that's gray. You're not gonna go for the really bloody hamburger. So with granulation tissue, we're looking for that nice mix of pink red beefy tissue that bumpy or cobblestone appearance, maybe even look like a little berries is good healthy granulation tissue. If the tissue is red and flat, that would be non granulating tissue, eithe tissue. That is that shiny new pink tissue that we always wanna see on the wound edges, which contracts to bring that wound to closure with a chronic wound. You should also look for biofilm in the base of that wound in that tissue oftentimes this is recognized by a flat red wound base with little to no progress and maybe shiny, maybe a little slimy on top and have that chronic low level inflammation. The next step is to assess that inflammation and that possible infection. Looking again at biofilm and determining what's going on in that wound base. So you can pick the appropriate treatment. A large number of chronic wounds have some level of bio burden, especially those that have no chronic tissue biofilm can be difficult to treat though biofilm occurs when a group of bacteria basically surrounds itself with a protective barrier that the normal body agents can't fight off to penetrate into that bacteria. There are only a few agents out there on the market that can treat biofilm. So identifying it is important to support healing, sharp debridement of the biofilm is often used to quickly remove that out of the body or of that wound. So you don't have it leading to an infection process or again that stalling of the wound removal of that biofilm will help move that wound forward. So going back to acronyms, we had timers that we're talking about, but you can also use acronyms for assessing for inflammation and infection. So here we have two others that can be used in the assessment process for identifying inflammation and infection nerds and stones. So, nerves is for superficial infection at the wound surface. So you're looking for a non healing wound as the first qualifier for that. Next, you'll be looking at the level of drainage. Has it recently changed or increased? And what is the quality of the wound drainage is the area red and has it started to bleed easily or bleeding has increased as soon as you go to clean that wound, this is what we call friable tissue. That tissue is not growing correctly because there's a bacteria present. So it falls apart the minute it's touched and cause excessive bleeding. I can show you that there's a an infection starting at that surface. Yeah, if there is debris or necrotic tissue that has suddenly increased or has changed in quality from so to escar and of course, then if there's a new odor after cleansing, some bacteria does have a distinct odor like pseudomonas. But in other cases, an odor after cleansing can be a sign that there is a superficial bacteria at work. Then if we talk about stones using stones as an acronym for that deep infection, we know we're going to have to get a systemic antibiotic involved with stones. A sudden or progressive increase in the size of the wound. When other factors have been rolled out is an initial sign, then moving to the temperature of your patient and that wounded surrounding area, if you can probe to bone or bone is exposed, is a quick sign that there's probably a deeper infection happening here. New areas of breakdown in the periwound area and again, that new redness and of course that odor. So when you're using these acronyms, it helps you step through. So you don't miss any of the points of assessing for a superficial or deep infection because any infection at the surface level or deep is going to hold up that healing process. We have wounds that are chronic and non healing. Routine assessment for the positive of infection is absolutely necessary. Sometimes this inflammation and infection can be a subtle slow change of a building infection. And other times it can be sudden when you see those systemic changes in the overall condition of the patient. And not only look at these signs of the of the wound, but also look at the signs in your patient. If a patient suddenly has changes in cognition, they have changes in appetite and that wound may be showing signs of infection. If you have inflammation, peri wound, that area is negatively impacted, making it difficult for the cells involved in the healing process to get to that open area. This can lead to that chronicity of that area. The longer the wound is open, the higher the chance of infection and other complications. So it's important not just to assess the wound and your overall patient. But that peri wound area for any new or worsening, redness, swelling, reports of pain, increased drainage or a change in the quality of your exit date that could be thicker leads that pent drainage. This is a lot of times where the wound stalls because of that persistent inflammation. So, addressing that periwound area, assessing for that infection can be a good way to make sure that wound moves forward. The main goal of wound healing is that moisture balance using dressings that can manage not only the volume but the type of drainage is vital to ensuring the healing process can proceed as expected. Think of goldilocks and the three bears. She tried each porridge, she tried each chair, she tried each bed until she found the right one for her. So think of your wounded goldilocks. We've got to find the right dressing for the right wound and the right drainage level. It is up to you to find that right dressing to match, not just the wound size and location, but that drainage level and type that is best suited to maintain that moist wound environment. So you can prevent an increase in bio burden, monitoring. The type of egg date can also assist you in preventing and treating any bacteria related issues such as looking for that purulent drainage, which is that thick yellow green egged date that was previously thin, but now it's getting thicker or even a decrease in the drainage could mean the wound is too dry, which is just as detrimental as it being too wet. This is where you should be monitoring for healing to occur. We wanna see these epithelial edges, these wound edges coming in from the sides, all wounds, whether they're full or partial thickness will get to a point where they will be re epithelializing. If you do not see these edges moving in and contracting to pull in the size of the wound back together, you should be assessing for other mitigating factors. Hypergranulation tissue can stall the healing process by coming up and over your wound edge edges that become rolled or what we call pally can halt the healing process. Because once those cells on top touch cells on the bottom of the wound, the healing process turns out the body's like, oh I'm done, I'm finished. So sometimes we can use a roughing technique on these edges or cauterizing those edges with a silver nitrate stick to open them up or using sharps to even to reopen that wound edge. So that body knows to restart that healing process. So assessing that edge is another important piece of that puzzle. Regeneration and repair is a stage where you can assess whether any additional support may be needed for the wound to heal. Sometimes patients just can't heal the body on their own. They need help because they have so many chronic conditions. Maybe so many medications that they're taking. If the wound is not responding to the treatments that have been in place and chronicity is still a factor. The use of a additional adjunctive therapies might be warranted. Looking at oxygen therapy, cell based skin grafts, extracellular matrix based dressing such as collagen or even negative pressure wound therapy. When the patient's body does not have the ability to heal on its own due to chronic end stage conditions, these therapies should be considered. And of course, the whole patient looking at everything going on with them. And I'm sure a lot of you maybe heard that assess the whole person, not just the hole in the person. So we wanna support the entire patient looking at all aspects of the patient's condition. It's vital to that best possible outcome. The mental state of the patient looking at their stress levels and anxiety is important, stress and anxiety increase the cortisol in your system. This leads to a negative impact on the healing cascade, slowing it and maybe even halting the process entirely. Patients with inability to understand how to not just care for their wound, but inability to comprehend. Caring for their chronic conditions such as their diet, taking their insulation insulin for their diabetes or taking their medication for their hypertension can lead to exacerbations in their condition. Install that healing process also finances social and family support and ability to understand direction should all be taken into account when you're assessing the patient not just for their wound but in relation to this situation with lymphoedema as well, can they even afford the compression and or garment? Are they able to get to the clinic to have their compression applied? Are they able to care for their wound under the compression? Will they even be compliant with the compression while they're in the wound healing process? So all these things need to be considered not just for that wound, but looking at wounds with lymphoedema as a secondary issue and looking at the whole patient. So now we remember the types of wounds, the basics of the system, basics of lymphoedema that's like a proper wound treatment. So we kind of looked at it touched on that a little bit but returning back to our discussion on bio burden if you have identified that bacteria is a factor in the wound selecting, addressing that either kills or removes that bacteria is necessary to allow healing to move forward. Antimicrobial such as silver iodines, gents, and violet methylene blue. All these attack that wound that wound bed directly in that those bacteria explode in the bacteria. And although they do kill it, they leave fragments behind, but the body has to clean up and then healing process can start it, micro binding dressings um bind that whole bacteria hole and put it in a sleep state and then they're removed with the dressing. So assessing your patient, the wound ex date and location can assist you in choosing which one of these antimicrobials might be best for your patient. And that wound addressing the bacteria in the wound is a vital step in the assessment process. And choosing the treatment option that removes that roadblock and takes the bacteria out of that healing process will make things move forward. Several of the antimicrobial and micro binding dressings have absorbed the properties as well. Tying back into our timer's acronym, choosing a dressing that allows the wound to maintain a moist wound environment aids in supporting the healing process. So aggregate management, several of the antimicrobial and micro binding dressings have absorbed their properties as well. Signing back into that Timers acronym from the beginning, choosing a dressing that allows the womb to maintain a moist wound environment aids in supporting that healing process. Use of foams and super absorbent dressings that are vertical wicking versus horizontal wicking that you can see with regular gauze and a BD pads. Use of those vertical wicking agents is helps to manage that wound drainage. This protects the wound base and edges as well as perry wounds so that the healing cascade is not interrupted. Assessment and treatment of fungal of fungal issues lends back to that assessment of peri wound and wound edge health. If you do not have a viable healthy wound edge or a healthy periwound skin wound cannot heal effectively, it cannot progress on that healing trajectory. And you'll see that stalling or chronic wound starting to form antifungal dressing such as silver impregnated textiles, micro binding fabrics, prescriptive topicals or even internal treatment with medications might be warranted in order to protect that hair wound from these fungal issues in these deep creases, abdominal folds underneath the breast. As you see in the picture here to keep that area clean and dry, relating back once again to our timer's assessment, addressing that help of the peri wound and not just treating negatively affected periwound, but the use of preventative measures such as skin protective films and moisture barrier creams help to prevent that damage to the periwound tissue. Use of ph balance cleansers can maintain moist tissue and create a stronger skin surface to apply dressings without the risk of adhesive related skin injuries. In those patients with especially fragile skin or damaged skin, that use of silicone adhesive or silicone based dressings may be necessary to protect an at risk wound or periwound area. Remembering especially in the very young and very old, these anchors become very fragile and thin. So with moisturizing and protection, we have them become more elastic than fall apart for that protection of periwound skin. In those patients where an adjunctive dressing is necessary. Collagen dressings can provide a scaffold of support for the new and fragile tissue to grow on and address that excess M MP S that may be present in those chronic womb beds. These coins can be from variety of sources such as a cow pig or sheep and could be more financially viable options for patients that are self pay versus gen therapies and skin grafts and things like that. So, looking to support that wound wholly and looking at alternatives when they're necessary for those patients that have lymphoedema and wounds. Again, additional considerations should be made regarding compression in the form of possible using pneumatic compression in those patients that maybe can't have wraps or garments, lymphatic taping. And then of course, referral to a lymphedema therapist is the best place, best place to start when you're talking about the just of therapy. So what is that role of compression? We've gone over so much in in relation to lymphedema and wounds? We've mentioned several times how compression is imperative for not just treatment of lymphoedema but for those patients with wounds and lymphoedema. What is this role of compression? It's that complete decongestant therapy. And here's where a lymphoedema therapist can help you with this process. Complete decongested therapy can be performed by a certified lymphoedema therapist. The two main phases of this therapy, the decongestant phase and the maintenance phase. As you can see both phases have very similar steps in the way of exercise. So there's that going back to mobility again, manually, drainage, skin and wound care. And of course, that compression piece. The first phase aims to return the area back to its original use and size as much as possible that that patient can tolerate and the maintenance phase is where we attempt to maintain that reduction that was achieved during the decongested phase. This is the gold standard for the treatment of lymphoedema. Complete decongested therapy that includes manual lymph drainage and compression does have certain contraindications and precautions that must be considered even though the patient may have a wound and have indications that compression should be used. If the patient has any of these issues. Compression may not be a viable option such as DVT compression and manual lymph drainage can move a clot and cause serious issues, occluded arteries, an A B I or TB I that is below the recommended 0.5 should not have compression used untreated or recent CHF is another condition that precludes a patient from receiving MLD and compression. Another consideration is untreated infection in the infected area. You don't want to proceed with manual lymph drainage and compression and move that infection throughout the body. If it is untreated, there's also some precautions to consider any issues with reduced sensation should be monitored. As patient may have difficulty reporting compression wraps again as that. We're looking at our diabetic patients. They cannot report to you that there's wrinkles, it's too tight, it's too loose, it's falling off in my shoe. So they should be monitored if you adhere to the recommendation of using a holistic comprehensive assessment of not just the patient's wound and their lymphoedema status, but the whole person, you can identify these issues early enough to ensure that you're not putting compression or starting manual lift drainage when a patient has contraindications, and you'll note if they have any of these issues for precautions that we're taking those into account moving forward and they have extra monitoring that is completed. If a patient is able to have compression, the use of multi layer compression wraps can be a good choice for those patients with wounds. They come in a variety of levels of compression, depending on the arterial status, you can add absorbent dressings underneath as well as do the wound treatment. Whichever multi layered system you use, it should consist of short stretch bandages that have a higher working pressure and a lowering rest, lower resting pressure. So that means that the more the patient moves and employs the use of the calf pump muscle, they will see greater results. These layer wraps can be contoured with the use of foams to fit those limbs that may be in late stages and have that lack of ankle contour or tree trunk shape or large lobes where you need to have a solid surface to get those compression wraps on and treat that wound. And they can help to reduce that fibrotic condition of the leg. If a patient requires more than two layer application, there are other multi layer kits that have three and four layers. Four layer multi layer kits usually consist of short and long stretch wraps. That can apply moderate working pressure and have also moderate resting pressure. Most of the multi layer wraps can be worn with patients regular footwear, assisting with the compliance of your patient. Several of the multi layer rep kits also come in latex free, which is important to consider and those patients that have skin sensitivity in addition to compression, ensuring proper application of a protective layer. As the first wrap is important to protect that patient's skin. This is where the assessment of the A B I or TB I becomes vital in weighing out, not just how many layers the patient needs, but also the level of compression that they can tolerate. So you can see here in the little table talking about this A B I level and the levels of compression that the patient can tolerate according to their A B I results. And we definitely should be looking at A bis that are current looking back six months or a year and then they tell you, oh I had an A B I done last year when I was in the hospital. It is not appropriate. You should always be using a updated or most recent A B I or TB I for those patients and those individuals that can remove from multi layer possibly once their wounds are resolved. Assessing the patient for an appropriate garment will aid in the maintenance phase of that complete de inducive therapy just as with the multi layer reps is important to find a garment that will can also allow for wound treatment if that is still an issue. Finding a garment that is easy to use and apply by the patient is vital to compliance. Again, there are also latex free versions for those with skin sensitivity. These garments are usually made of a short stretch material. So again, applying that stiffness factor of the short stretch wraps to move that fluid, that the body can no longer move on its own. And to get that limp, moving out of the limbs. As of now, wraps and garments can only be reimbursed if a patient has a wound with venous insufficiency of the cause. The new lymphoedema Act that will come law as of January 1st 2024 will provide compression wraps and garments for those patients with the lymphoedema diagnosis regardless if they have wounds or not, looking more at a preventative treatment. So we can help these patients prior to them getting wounds and be in that cycle of having recurrent wounds and having recurrent cellulitis and having those skin issues. They can be in preventative garments, garment and wraps will come in a variety of compression levels. So just as with CDT in general, it is important to follow considerations for use. I cannot stress enough to ensure you have a current A B I and TB I and use light versions of reps for those with an A B I of 0.5 to 0.8. And regular version can be used for those with a 0.8 and higher. Ensuring you have completed a full comprehensive lower extremity assessment using um and the use of kits and multi layer wrap kits that have indicator symbols to make certain that there's not too little or too much compression being applied, utilizing short stretch wrap garments and finally using the aid of application devices such as donning and dolfin devices, gloves and sleeves. If a patient is unable to apply or use the compression, they will not be compliant which leads to again increased edema, more chance of wounds, more chance of infections and a decrease in the overall quality of life. So any compression that your patient will be compliant in and that is appropriate for their arterial status is better than no compression at all. If a patient is unwilling or unable to use multi layer wraps or garments, you, there are other means to at least bring some form of compression to your patient. If their A B I can tolerate it, we're in the vein of compression socks, there's tubular compression stuck in it. And of course, going back to that pneumatic compression, there is a sleeve that says zips up over the leg and can be used again. Any compression is better than no compression at all. So edema can cause a myriad of issues for the patient in pain, immobility. Overall quality of life. Inability to perform ad LS and of course wounds and then infection risk when the edema is not reduced, we know that oxygen delivery to the cells is decreased. We know that it is a stressor on the skin as it swells and then those cells bust with the overload of fluid. This leads to a higher risk of infection and skin breakdown. Assessing the overall patients deciding on those positive factors, your arterial status and getting that patient in compression, that's right for them right for them will not only help them be compliant but help them tolerate it. So we've gone through all these things about wounds and lymphedema. But how can we do some preventative steps? And one of the most important preventative steps is that general skin care that you saw in that wheel of con complete decongested therapy, prevention of skin breakdown and fungal issues is really important. So that prevention is key routine cleansing of those ominous areas with a balanced or gentle cleanser or soap that moisturizes the skin and upholds that epidermal barrier and acid mantle on the skin surface. Staying away from soaps and cleansers that have a scent and color as they employ alcohol to maintain that small color. So that dries out the skin following cleansing, use of a ph balanced moisturizing cream that will not just moisturize the top layers of the skin, but soak down through all the skin layers to keep the skin strong and will uphold that, uphold better to swelling. Urea based creams, absorb, quickly, try to stay away from those lotions and potions that bath and body works that have a scent because again, they do contain that alcohol. All patients with lower extremity edema and lymphoedema issues. Proper skin care is imperative, cleansing with agents that are gentle, using gentle and soft linens. Routine, moisturizing with a moisturizing does stretch, that skin allow it to stretch before it breaks open and decreases that chance of infection, especially in the very young and very old. We know that the skin anchors become very fragile and the skin breakdown can occur easier. So that regular routine of cleansing and moisturizing can slow down. That significance can change. Making those anchors more elastic than fragile and breaking open. Moisturizing. The skin allows for that flexibility in the face of edema and hydrated skin also is helpful in protecting that periwound area and promoting that healing process. And I thank you and now we'll open it up to questions. Thank you very much Christy. This was very informative. I'm not sure if you realized we lost your sound for a little while. Oh and no, I did not know that. So we had a little, we have some people who I think jumped off and some have questions and I think we there's something we can do. So the recording will be complete. So when it goes out to everyone out there, um you'll hear the entire session, you won't hear a dead space. So we have technical people who can work magic on that. We do have some questions. If you're not sure how to ask a question, please go down to the bottom of the page and um, there's a chat box there. So the first question asks, do you routinely get Doppler studies prior to starting lymph treatments? So, yes, again, going back to the assessment of arterial status, especially when you're looking at manual lymph drainage, you don't wanna move any clots. So you wanna be sure you're checking your arterial status and then moving to compression, you definitely wanna know your patients A B I or TB I in order to ensure you're not putting them in a compression level that can cause Olu. Ok. Somebody said they missed the part of mild lymphedema with no complications. How maybe you can answer this question if the person's still on, on how to handle everyday use of compression for prevention of future complications. So again, it's finding that compression level that's appropriate for the patient and making it something they can tolerate. So use of everyday compression. Um It sounds like they might be talking about garments in order to have um prevention issues in place. So use of a garment that the patient can apply regularly and be able to remove so that they can wash moisturize and cleanse that skin for those patients who don't have wounds currently. But have mild lymphoedema having a garment that is appropriate for them to and, and have assistive devices. Again, to help them apply, it will ensure that they use it regularly and can help with that prevention piece. Um Another question you may have answered this, but I'll ask it anyway, is edema therapy covered under Medicare. So, again, right now, under Medicare, it's only covered for part B if the patient currently has a wound or, or venous ulcer related to venous insufficiency. Now come next year, that lymphoedema act goes into effect. And if the patient has a diagnosis of lymphoedema on their record preventative treatment for compression. So compression that they don't have to have a wound current will be covered. So garments and wraps to help prevent them from getting skin breakdown will be covered under Medicare. That's something to look forward to. Thank you. Um I think that's the end of our questions. If anybody else has a question, you've got a, a minute or two to answer it. If not. Um We have these monthly webinars every month, the second Wednesday of every month at three o'clock Eastern time. And you can check out our upcoming education on Mms.mckesson.com underneath the clinical tab. And with that, Christy. Do you have any closing remark? No, no. All right. Well, thank you all very much and have a great rest of your day.