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Welcome to Speaking of Wounds, a podcast by the Wound Care Learning Network. I'm Dr. Jennifer Spector, the Assistant Editorial Director for WoundSource, and we're happy to have you listening today.

Just as a reminder, this podcast is intended as an informational tool for medical professionals and is not intended to diagnose or treat any medical conditions. I'll let our guests introduce themselves in just a moment, but we're so excited to have both of them with us today to be speaking with us on their expertise surrounding edema.

We'll dive into comorbidities, into compression therapy, and some patient-specific scenarios to consider. Welcome to the podcast. Would you please take a moment to introduce yourselves and tell our listeners a bit about your experience in current work in wound care? 

Hi everybody, my name is Erin Fazzari. I'm a lymphedema therapist with Good Shepherd Penn Partners. in Philadelphia, Pennsylvania area. I work in outpatient. Not only do I treat lymphedema, which I've been doing for the last 15 years, I am also a wound specialist, also, which I've been doing for 20 years. It's my area of passion. And I'm happy to be here with you guys today.

Hi, I'm Runzun Shetye. I am also a physical therapist and a lymphedema therapist. I have been practicing-- I've been a physical therapist for about 20 years, but lymphedema I've only been doing for seven years. I'm also a geriatric clinical specialist, which is a certification from the APTA. And I'm very passionate about lymphedema and the patient population that I serve. I live in the Maryland area and I work for Luminous Health Group. 

What are some key factors that clinicians should consider when assessing for edema? 

What I commonly do when I'm assessing for clinical edema is I look at the entire leg first. So, basically, for example, say you have a wound on the lower extremity and the wound is on the calf region. Not only are you going to just look at the edema around the calf and the foot and the toes, you want to look above the knee, you want to look at the thigh, you want to look even in the abdominal region because if you're going to start doing compression in that region, you might move the fluid up to the upper thigh, to the groin area and create problems. We need to clear lymphatic fluid from the whole limb in order to facilitate reduction and get the best outcomes.

So that's one thing that I do. The other thing, I also look at the tissue texture. So for example, the firmer the tissue, the more containment that you're going to need when you're selecting a bandage or a compression garment, the denser the tissue, the more fibrotic.

You need something stiffer. So, firmness, tissue texture is important. I also want to look at how much reduction I think I'm going to need when I am trying to reduce edema.

If the limb is very edematous, much larger, specifically if you have a unilateral, you can see that if you have bilateral it's a little bit more difficult. It's very difficult. decide what kind of compression strategy I want to use.

If the limb is very large, I'm definitely going to do a compression bandage, typically a lymphedema bandage, it's multi-layered with foam. If the limb is a little bit more pitting and softer in texture, I may decide that a bandage alternative device would be best. Because our goal is to maximally reduce compression or maximally reduce edema prior to measuring for our long-term compression strategy, in order to get the best outcomes, I will also not forget to consider looking at the periwound edema a lot of people overlook that when they are looking at the edema itself I types of dressings will not actually facilitate reduction of periwound edema and they may actually increase periwound edema, such as if you put an ABD pad right over an edematous limb, you can get all kinds of lines and ridges and stuff that doesn't facilitate wound healing.

So our goal is to pick a product that will help us reduce the periwound edema as well when we're assessing the edema of a limb. Those are the things that I can think of on top of my head. So I thought also we have this huge-- with new research, we have this huge database or huge selection of products that we can use now for just investigating and looking at what edema is.

And some of the studies that have been done with ICG, which is indocyanide green, which kind of tells us where the lymphatic is moving. So you can inject it in the distal lymphatics and leave it there and come back in like four to six hours and see or more hours depending on where you want to visualize and see the pathway that the lymph took. So you can actually know.

If the lymphatics are normal or they are blocked in a certain path. So there's different images that are obtained. And there's recent studies that show with lower extremity and genital lymphedema that you cannot exclude looking at genital swelling when you have lower extremity lymphedema or lower extremity lymphedema when you're looking at genital.

So like Erin mentioned, you know, looking at the whole limb or not just at the wound or where the localized swelling is, but looking much higher because you're edema, you might not have much edema in your leg, but then it might be concentrated in the genital area because the lymphatics that were impaired. or the lymph nodes that were impaired were more near the genitalia in this patient. So again, re-emphasizing how technology can also help us kind of assess edema as well.

The other thing is bioimpedance. So now, again, with new technology, we can use just the skin resistance. to tell us if the limb has swelling or not.

So I'm not sure that it is in lower extremity edema, but it's getting very popular in upper extremity lymphedema, especially with breast cancer population. So looking at that, the bioimpedance can give us a lot of information of early lymphedema. So edema that we're not able to see.

But maybe the patient is complaining, I just have a little pain on just this area, or I just feel fullness on a certain area. Or after exercise, I feel fullness on my arm. So that's hard for us to diagnose, because when they come to the clinic, they might not show that edema at all. The limb might not be pitting. It might not have fibrotic changes that you can feel or see.

But if you do a bioimpedance, then you see that there is swelling. And you can actually help it. And the best treatment for lymphedema is early detection and treating it as quickly as you know that it exists.

So bioimpedance is a great tool to detect that adema early. And you know--you know, just start addressing it. In your wound care practice, what are some patient factors and comorbidities that typically coincide with edema? One of the big factors is the socioeconomic status that the patient kind of carries with them all the time, you know, ranging from where they live, how they live, what they eat. How much money they have to kind of afford correct good nutrition, how much money their insurance can pay for the garments, or do they have an insurance or not? So all those factors are very important. Apart from that, arterial status or the venous insufficiency status. So for arterial status, you can do an ABI to check how their arteries are.

Look at the cardiac status because all this fluid that we are saying the leg or in the arm or for that matter in the head and neck region has to go back to the heart so that it's sent back to the kidneys and excreted as you are in. So your heart has to be not weak. So in patients with congestive cardiac failure, we actually have to look at the ejection fraction to see if their heart is strong enough to kind of take up all that fluid.

So that's a big consideration. Again, with kidney function, you also have to make sure that the kidneys are able to process all that fluid that's been thrown at them. And the age of the patient is important in the care of the patient.

The social support they have is important because, you know, a lot of times the dressing maybe needs to change. The garments need to be put on and if the patient is not able to put them on, they need some help to kind of do that, someone to do that for them. Obesity is huge. The muscle pump is important, because if the patient is weak and they're not walking or not doing some kind of exercise, then the muscle pump is weak, which means that the lymphatic flow is weak, which means there is swelling that's not going away. Other than that, for patient factors, we, as clinicians, make the determination what we're going to do for the patient. but we have to be equally respectful of knowing what the patient wants, and we have to kind of incorporate all those goals within our therapy program.

So, you know, a patient might come to you with swelling, but then it's our responsibility to ask them, "How does this swelling impair your function, impair your ability to do what you need to do?" And then patients suddenly open up, and they're like, you know, I just want to be able to take a bath. I just want to get in that tub and take a bath.

So that's a huge patient satisfaction for us. And all our goals are not even valid if you cannot kind of accomplish those patient goals, right? So all our goals are not even valid if you can't kind of accomplish those goals, right? So all our goals are not even valid if you can't kind of accomplish those goals, right? So all our goals are not even valid if you can't kind of accomplish those goals, right? diabetes, congestive heart failure, DVT, deep venous thrombosis, CVR. morbid obesity, chronic renal disease, and then like runs and said, one of the key factors, it's dependency edema.

Our patients do not have a muscle pump, lymph node removal, surgeries, is there anything else we can think of? You've covered a lot of it. I just had a patient the other day who I was stumped because we had been doing the same treatment, and he had been reducing very well. And he came back this week, and I said, "Why is your swelling so much higher today? I have to refer you back to your doctor, see what's happening."

Because he also has some amount of congestive cardiac failure. And we talked more, and we realized that he was on a trip. and he couldn't get in and out of the bed so he slept in his chair for two days and that was dependency, right? So a lot of our patients when they lay down, because the gravity is not acting then, at night the swelling kind of clears up and it's not that much work for the compression to work consistently but because he was dependent, then the swelling didn't clear up. He had more swelling. And so our interview with the patient is so important. Because if I hadn't asked him those questions, I would have referred him back to the doctor, which wouldn't have been so bad.

But again, it's a resource that we're over-utilizing maybe. So communication with the patient is so important. When choosing the right compression bandage for a patient with edema, what should clinicians consider? Would you say there's a difference in adult versus geriatric patients? So of course not all compression is created equal, and that's unfortunately something that a lot of clinicians that I find in my practice are not really as aware of as they should be.

When you are thinking about what you should be doing, what you shouldn't be doing, what that we already mentioned in the previous thing, of course, like the extent of the edema. And one of the things that we discuss in our presentation is about the Stride article,  I think it was, 2019. They basically created an algorithm to help you differentiate how to select the appropriate compression garment. And if you haven't had the opportunity to read that article, it is amazing and very helpful to all the clinicians. But they look at the location of edema, they look at the extent of the edema, they look at the texture of the tissue.

They look at the etiology of edema. patient and there's another one that I'm totally blanking on right now. So basically what the clinician has to do is look at the whole leg, look at the tissue texture.

If it's firmer we want something stiffer. We want to reduce the edema first before we measure for a compression stocking. Never, never, never, never put on a compression stocking before the edema is maximally reduced because compression stocking can only do so much and we want to facilitate lymphatic flow because we're going to get the best wound healing, we're going to reduce the inflammatory process, we're going to get better microvascular circulation, so any of that pulling edema will not facilitate all that when we're doing wound healing.

So, with the geriatric population that we see, you know, management of cancers, of venous insufficiency has changed a lot. So a long time ago, they would just take a bunch of lymph nodes out, but now they can selectively take those lymph nodes out that take up the dye. So it's, you know, it's the, that population presented more complications and way more incidents of lymphedema than we see now, so that's one thing that just they have gone through different surgeries and have different problems, so it's important to recognize that. Geriatric population has more comorbidities such as CHF, renal failure, diabetes, and so on, venous insufficiency.

Their muscle pump is weaker too. There's something called frailty syndrome, which means there are five criteria for that. Decreased walking speed, decreased grip strength, lower extremity strength, being fatigued. So, you know... if a patient is frail, if the individual is frail, they're going to walk less or be less active, which is again going to kind of increase that dependency swelling. So that's important. So we need to get those patients out of the frail state and in like non frail or function or fun state so they can be more in the functional and keep up their activity level for as long as possible. The skin is more fragile in this population too. So when you are picking your garment, it's hard for them to pull the garment up and while they're pulling it up, it might rip their skin.

So you have to be aware of that complication. And the fifth one in the frailty syndrome that I forgot to say was finger strength, like grip strength. So when you're pulling a 30 to 40 millimeters compression garment is not the easiest to pull up. So in geriatric population who already have grip strength decrease, you have to make sure that you either have a grip strength decrease or have a grip strength decrease. give them compression.

Like sometimes I'll do two 20 to 30 millimeters of mercury garments to kind of replace that 40 millimeters of mercury garment, or actually have the patient put the garment in front of you so you can recognize in the process of them putting it on. what are they missing what component is falling apart that they're not able to do it so and then there are a lot of like modifications that or DME that you can what are they called? Donning AIDS. Donning AIDS that you can use to kind of help them out with it because you know you can give them the best treatment you can have everything work right and their volume reduced perfectly.

But if you fall apart on that last item, which is the maintenance part, then you have really failed altogether because then your swelling is only decreased for the six weeks that you were seeing the patient and after that their lifetime, they don't have anything. So, it's really important that with another only with the geriatric population, but more so with them to make sure that they can put it on. And patients don't want to fail.

And sometimes they'll tell you that, yes, I'm able to do it. But I sometimes insist, I want to see it. Can I please see it? And so just to see how they do it, what's the best way.

Because a lot of times, since we do this all day, we can probably tell them easier ways. So even if they can do it, and it takes them 10 minutes, maybe when I see them actually do it, I can reduce it to three minutes, which kind of improves the compliance. Because who wants to spend 10 minutes just putting on their stockings? There's more in life to do, right? 

Also, they may have decreased social support. Well, some geriatric populations have great social support. And they have kids and nieces and their friends that can help them. But some don't. And the ones who don't, we have to find another way of kind of incorporating this in their lifestyle and telling them what concessions they have take versus what concessions they cannot take at all. Often this population is on fixed income. They're only getting Social Security or retirement.

And lymphedema garments are extremely expensive. And the lymphedema bandages are extremely expensive. So it's hard for this population to think about, am I going to pay the rent and buy my groceries or am I going to buy a garment because these garments can be in the order of four hundred dollars to a thousand dollars that's a lot of money for someone who is on fixed income so considering that is very important so that the patient can be compliant especially the geriatric population.

Thank you so much to both of our speakers for taking the time to speak with us today. That wraps up our discussion, but for more information on today's topic, we invite our listeners to explore all the resources available online at the WoundCare Learning Network and at Woundsource.com. Thanks again for joining us on Speaking of Wounds and enjoy the rest of your day.