Eng

Protocols

A Guide for Clinicians

This document offers general guidance for clinicians in the selection of treatment parameters. These treatment parameters (pressure, frequency, and duration of treatment) should be selected according to individual patient modalities, including oedema, fibrosis, and wound status, body fluid mass and response to previous treatment sessions during the trial process.

Patient evaluation

Obtain medical history
  • Current & ongoing medical treatments.
  • Surgeries, comorbidities, pain/ sensation levels, functional ability/mobility, oedema, and skin condition including fibrosis, scars and wounds.
  • Obtain baseline (pre-treatment) measurements.
Rule out general contraindications
  • Known or suspected deep vein thrombosis or pulmonary embolism; inflammatory phlebitis process; acute infection of the affected limb; decompensated cardiac failure; severe arteriosclerosis or other ischemic vascular disease; any circumstance where increased venous and lymphatic return is undesirable.
  • Due to movement of fluids in the body when using the device, be careful with patients who have heart disease.
  • High pressure is not recommended for patients with peripheral vascular disease.
  • The abdominal area should not be treated during pregnancy.
Perform a trial to determine response to treatment time and pressure

Follow the guidelines for pressure selection provided in Tables 1-3:

  • Begin with the lower pressure ranges indicated, adjust pressure upward within these recommended ranges according to patient tolerance and response.
  • Gradually increase pressure if no adequate response is seen, noting patients comfort and change in response.
  • The patient should feel comfortable during treatment.
  • If patients are insensate or have fragile skin, begin at conservative levels of compression, and observe skin changes.
  • If using an appliance garment that covers the abdomen, set the pressure in the chambers above the abdomen to a setting of 40 mmHg or lower. This will avoid discomfort and encourage movement of lymph from the extremity.
  • If patient feels discomfort, investigate source. Reducing the compression level may alleviate discomfort.
  • If discomfort persists, stop treatment and determine whether pump treatment should be continued.
  • Assess patient, noting if the patient experiences dizziness, numbness, tingling cramping, coldness, extremity or chest pain, or shortness of breath during or immediately following treatment.
  • After assessment, if treatment is continued, compression levels and/or treatment time should be resumed at a reduced level.
  • After completion of the trial treatment, check for oedema reduction, softening and tissue extensibility changes. Inspect the skin to ensure there are no adverse effects.
Prepare an at home management program
  • Educate patient in elements of a home oedema management program, including an advised usage schedule for the Lympha Press®, positioning during treatment, and limb elevation.
  • Educate patient to recognise signs of infection and development of contraindications to pump use and compression.
  • Educate patient in the correct operation of the pump system, including the correct application and removal of garments.

Knitted compression garments, compression wraps, or bandaging should be worn between pumping sessions to maintain reduction.

Quick reference guide
  • Rule out contraindications.
  • Trial pump on patient, starting with lower pressure and increasing pressure if no adequate response seen.
  • Patient should feel comfortable during treatment – if patient feels discomfort, investigate source.
  • Reducing the compression level may alleviate discomfort.
  • After the initial trial session, inspect for oedema reduction, softening and tissue extensibility changes. Assess the skin for any adverse effects (skin breakdown, irritation, or other).

Venous Ulcer/Venous Stasis

Compression Level Pressure Appropriate for Frequency/Duration
Low compression < 40 mmHg Patients with wounds, insensate, or fragile tissue (can increase with monitoring if no adverse response is seen). 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
Moderate compression 40 – 60 mmHg Most patients. 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
High compression > 60 mmHg Extreme fibrotic changes; lipodermatoscierosis 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.

Venous Ulcer/Venous Stasis

Low compression
Pressure: < 40 mmHg
Appropriate for: Patients with wounds, insensate, or fragile tissue (can increase with monitoring if no adverse response is seen).
Frequency/Duration: 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
Moderate compression
Pressure: 40 - 60 mmHg
Appropriate for: Most patients.
Frequency/Duration: 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
High compression
Pressure: > 60 mmHg
Appropriate for: Extreme fibrotic changes; lipodermatoscierosis
Frequency/Duration: 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.

Lower Extremity Lymphoedema

Compression Level Pressure Appropriate for Frequency/Duration
Low to moderate compression 30 – 60 mmHg Low to normal body mass, Stage 1 or Stage 2 lymphoedema, patients with wounds, insensate or fragile tissue (can increase with monitoring if no adverse response seen). 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
Moderate to high compression > 60 mmHg Stage 3 lymphoedema, heavy fibrosis and/or high body mass. Use < 40 mmHg compression over the abdomen for comfort. 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.

Lower Extremity Lymphoedema

Low to moderate compression
Pressure: 30 - 60 mmHg
Appropriate for: Low to normal body mass, Stage 1 or Stage 2 lymphoedema, patients with wounds, insensate or fragile tissue (can increase with monitoring if no adverse response seen).
Frequency/Duration: 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.
Moderate to high compression
Pressure: > 60 mmHg
Appropriate for: Stage 3 lymphoedema, heavy fibrosis and/or high body mass. Use < 40 mmHg compression over the abdomen for comfort.
Frequency/Duration: 60 minutes once or twice per day. Shorter, more frequent sessions may be helpful for patients who can comply. Evening or afternoon sessions will provide the most response.

Upper Extremity/Post Breast Cancer Lymphoedema

Compression Level Pressure Appropriate for Frequency/Duration
Low to moderate compression 30 – 50 mmHg Low to normal body mass, Stage 1 or Stage 2 lymphoedema, patients with wounds, insensate or fragile tissue (can increase with monitoring if no adverse response seen). 60 minutes once or twice per day.
Moderate to high compression 40 – 60 mmHg Stage 2 or Stage 3 lymphoedema, heavy fibrosis, or high body mass. Use < 40 mmHg compression over torso for comfort. 60 minutes once or twice per day.

Upper Extremity/Post Breast Cancer Lymphoedema

Low to moderate compression
Pressure: 30 - 50 mmHg
Appropriate for: Low to normal body mass, Stage 1 or Stage 2 lymphoedema, patients with wounds, insensate or fragile tissue (can increase with monitoring if no adverse response seen).
Frequency/Duration: 60 minutes once or twice per day.
Moderate to high compression
Pressure: 40 - 60 mmHg
Appropriate for: Stage 2 or Stage 3 lymphoedema, heavy fibrosis, or high body mass. Use < 40 mmHg compression over torso for comfort.
Frequency/Duration: 60 minutes once or twice per day.

Lipoedema

Compression Level Pressure Appropriate for Frequency/Duration
Low compression 20 – 40 mmHg Low to normal body mass, low swelling in feed and ankles, low amounts of fibrosis. 60 minutes once or twice per day.
Moderate compression 40 – 50 mmHg Moderate swelling, fibrosis and/or increased body mass. 60 minutes once or twice per day. Afternoon or evening sessions will provide the most response.
High compression > 50 mmHg Profound swelling, fibrosis and/or high body mass(> 200lbs) 60 minutes once or twice per day. Afternoon or evening sessions will provide the most response.

Lipedoema

Low compression
Pressure: 20 - 40 mmHg
Appropriate for: Low to normal body mass, low swelling in feed and ankles, low amounts of fibrosis.
Frequency/Duration: 60 minutes once or twice per day.
Moderate Compression
Pressure: 40 - 50 mmHg
Appropriate for: Moderate swelling, fibrosis and/or increased body mass.
Frequency/Duration: 60 minutes once or twice per day. Afternoon or evening sessions will provide the most response.
High Compression
Pressure: > 50 mmHg
Appropriate for: Profound swelling, fibrosis and/or high body mass(> 200lbs)
Frequency/Duration: 60 minutes once or twice per day. Afternoon or evening sessions will provide the most response.

Special Considerations

Congestive heart failure

Decompensated cardiac failure (CHF) is a contraindication to pump use. Patients who have had recent hospitalisation for CHF should receive medical clearance from their Cardiac Specialist prior to pump use. Patients with a history of CHF should be monitored for symptoms of shortness of breath, increased rate or laboured breathing, lung crackles, cardiac gallop, and jugular vein distension. Patients with CHF who avoid lying flat due to shortness of breath should initially have close specialist monitoring if they use pneumatic compression.

Monitor symptoms during and after treatment. Start treatment at low pressure (< 35 mmHg) and short (< 30 minute) treatment cycles gradually increasing pressure and time according to tolerance and treatment response. For initial leg treatments in patients with CHF, start by using pump on one leg, and then follow up with the second leg the next day or treatment session.

If after pumping there is no worsening in symptoms, simultaneous bilateral treatment can be applied. If pants-type garments are being used, treat bilaterally at low pressures for short periods of time (30 minutes, < 35 mmHg) and increase time and pressure gradually per treatment session, according to tolerance.

Patients undergoing treatment in hospital can receive IV diuretics prior to treatment. Start treatment after urine output is established. Pulse oximetry can be used to monitor lung function.

Mixed venous and arterial disease

Some patients with venous stasis ulcers may have arterial insufficiency as well as venous insufficiency. Use Lympha Press® with caution (lower pressures, frequent inspection of skin) on patients with ABI from 0.6 to 0.8. Lympha Press® pumps should not be used on patients with ABI < 0.6.

Deep vein thrombosis (DVT)

Patients with a history of DVT should have a Doppler ultrasound to rule out DVT prior to initiating treatment. Treatment of post thrombotic syndrome is at the discretion of the prescribing specialist.

Cellulitis infection

Patients should avoid pneumatic compression treatment during an acute infection; treatment may be resumed 48 -72 hours after beginning antibiotics.

Patient disability

Patients who are unable to operate pump, don, doff, or adjust the appliance garments should have an appropriate family member or other caregiver available to assist throughout the treatment session.