There continues to be significant confusion between the terms chronic oedema and lymphoedema. Chronic oedema is thought of as a condition that can be managed in primary care, while lymphoedema requires specialist intervention. Why is this?

The term chronic oedema has been developed as an umbrella term to describe all swelling that is chronic in nature, regardless of cause (including lymphoedema) and that has been present for longer than 3 months (Moffatt et al, 2003).  It is usually used in reference to the lower limbs.

Lymphoedema is failure of the lymphatic system which in turn leads to swelling, skin and tissue changes and predisposition to infection (BLS, 2020). It can be classed as a form of chronic oedema when swelling is present for more than 3 months, but it is important to note that lymphoedema can be present with very little swelling in its early stages.

Chronic venous insufficiency, immobility, systemic failure, e.g. heart failure, infection, chronic wounds/ skin conditions, inflammatory conditions and post-surgery can also lead to an imbalance between fluid entering the interstitial spaces and being drained by the lymphatics resulting in swelling. Thus all visible and palpable swelling is chronic oedema.
 

Chronic oedema is commonly thought of as rare but over 400 000 people in the UK are struggling with this debilitating and distressing condition (Moffatt et al, 2016); a number greater than those with leg ulcers. The incidence of chronic oedema significantly increases with age and polymorbidity, both of which are set to rise exponentially for the next 10–15 years (Moffatt et al, 2016). With the predicted growth of the older population we are set to see a record number of patients with chronic oedema and this means it will be necessary to upscale the generalist workforce to manage this incurable condition.

To this end, and to simplify and demystify the approach to the assessment and management of chronic oedema, a Best Practice Statement for Chronic Oedema (BPS, 2019) has been developed to support community practitioners. Assessment is guided by the six S’: Story, Self-care, Site, Skin, Size, Shape, while management centres around skin and wound care, exercise and compression therapy. 

Management is based upon reducing the volume of oedema, improving skin conditions and any wounds, improving limb-shape and managing the patient’s expectations and psychosocial issues, followed by long-term maintenance of any improvements.

Management strategies include:

• Skin and wound care to maintain the integrity and hydration of the skin and to reduce the risk of infection
• Exercise, to facilitate lymphatic uptake, is especially important in those patients who are largely immobile. It may take the form of chair-based exercises but every movement counts*.
• Positioning, patients should be encouraged to go to bed at night to elevate their limbs, and if this is not possible, a hospital bed at home should be investigated
• Compression in the form of either compression bandaging with inelastic bandages or compression wraps, which have recently shown to be as a clinically and cost-effective alternative to bandaging (Mosti et al, 2019) and/or compression hosiery.

It is important to remember that each individual requiring compression therapy will have specific needs and requirements. Where possible these wishes should be taken into account but it is essential that all patients with chronic oedema are aware that the need for compression will be lifelong and any choices must be therapeutic and effective.

Recognition of early changes associated with lymphatic disease and timely implementation of appropriate treatment strategies are key to preventing disease progression.

Every healthcare professional should be equipped to manage chronic oedema confidently and not have the attitude that it is the domain of the specialist; everyone has a duty of care to see chronic oedema as their responsibility. It is hoped that the BPS for Chronic Oedema will help to simplify the assessment and management process for everyday practitioners. It is important of course, to work alongside specialist lymphoedema teams, where available, to manage those more complex cases, in order to enable learning and mentorship to take place.

Best Practice for Chronic Oedema - Download 

*The BLS has a new exercise campaign #EveryBodyCan. Visit www.thebls.com for more information and FREE resources