Cancer-related lymphoedema is a long-term condition that can develop following cancer treatment involving the removal or irradiation of lymph nodes. It can also occur when cancer cells invade lymph nodes. The management of lymphoedema involves several treatment strategies, which are best used in combination. Without the inclusion of compression, however, swelling can temporarily improve but remain essentially uncontrolled. Compression is therefore considered the mainstay of lymphoedema management (Longhurst et al, 2018), playing a pivotal role at all stages of the condition (Doherty et al, 2006).
Nurses and other health professionals in many areas of health care will encounter patients wearing compression garments for a variety of reasons. Knowledge of problems that can arise, the ability to identify poorly fitting garments and the advice to give patients concerning the application, removal and care of compression garments is therefore important when delivering best care to this patient group.
Compression therapy
In the management of lymphoedema compression therapy can be in the form of compression bandages, compression garments or adjustable inelastic wraps. Compression bandages are generally used to reduce the volume of the limb over a short, intensive period of treatment, followed by the daily use of compression garments to provide long-term control of the swelling. Adjustable inelastic wraps provide an alternative to compression bandaging for some patients and for others they are used as an addition to compression garments, supporting lifestyle choices as patients become independent in the application and re-adjustment of the device (Mosti et al, 2015; Hunter, 2017).
‘For a compression garment to be applied, worn comfortably, and removed each day, the skin must be in good condition and able to withstand application and removal’
A correctly chosen and fitted compression garment requires a skilled practitioner working closely with the patient to ensure the chosen garment is appropriate, comfortable and suitable for the ability and needs of the patient. Wearing an ill-fitting garment can be uncomfortable and potentially detrimental to the skin and tissues, which can undergo trauma from areas of inappropriate pressure.
Compliance with the use of compression garments can fail for several reasons but, with support from nurses and other health professionals, problems can be highlighted and addressed at an early stage.
Choosing compression garments
Compression garments are medical devices designed with a pressure gradient that decreases from the extremity of the limb (ankle or wrist) to the root of the limb (thigh or axilla). The garments are manufactured in a range of compression classes, sizes, styles and colours and it is essential that the choice of garment is based on a full assessment of the patient completed by an experienced health professional (Bianchi et al, 2012; Cooper, 2013).
A full assessment of the patient will clarify indications for use of the compression garment, the ability of the patient to apply and remove a garment and whether there are any contraindications to the use of a compression garment that need to be considered (Box 1).
Aspects of the assessment include:
Skin condition
For a compression garment to be applied, worn comfortably, and removed each day, the skin must be in good condition and able to withstand the application and removal of the garment without the risk of trauma. If infection (cellulitis) is present in the limb, the patient will experience discomfort with the use of a compression garment. It is therefore advisable for the garment to be discontinued until any infection has been treated and the garment can be worn again in comfort.
If the skin is broken or fragile, compression garments should not be used and alternative approaches to compression will need to be considered until the condition of the skin has improved.
Shape of the limb
All areas of swelling must be contained within the compression garment to avoid swelling increasing in areas that are not being compressed. Many compression garments are manufactured in a ‘ready-to-wear’ style that follows the profile of a normal limb but, if the limb profile has become altered because of swelling, a custom-made garment, made specifically for the patient, may need to be considered.
Skin folds and creases in a swollen limb can make the choosing and fitting of a compression garment a challenge and it is essential that the compression garment does not dig into these areas and pose a risk of trauma to the skin and tissues.
Strength of the garment
The appropriate strength or compression of the garment is chosen to ensure therapeutic benefit. Variation in compression classes can be confusing due to the availability of British, French and German standards. The compression measured at the ankle is used to classify the garment into different compression classes, but these differ according to the different standards, as illustrated in Table 1. Each standard is based on individual testing methods, yarn specification, durability and the compression gradient of the garment (Clark and Krimmel, 2006) and an understanding of these is required when garments are chosen for a patient.
| Compression class | British standard | French standard | German standard |
|---|---|---|---|
| 1 | 14–17 mmHg | 10–15 mmHg | 18–21 mmHg |
| 2 | 15–24 mmHg | 15–20 mmHg | 23–32 mmHg |
| 3 | 25–35 mmHg | 20–36 mmHg | 34–46 mmHg |
| 4 | None | >36 mmHg | >49 mmHg |
Source: adapted from Clark and Krimmel, 2006
Size of the garment
Compression garments are manufactured in a range of sizes, which differ between companies. Traditional small, medium and large sizes are used by some, while other companies use a range of sizes from 1 to 8. Measurement charts are provided to assist in the choice of garment size, but it must be remembered that the best guide is the patient's reported comfort once the garment is in position. The garment should feel firm and supportive but not tight and restrictive. If the garment is too big, no benefit will be gained from wear, and if the garment is too small, skin and tissue damage may occur.
Applying and removing compression garments
Adherence to the use of compression garments can fail if the garment provided is too difficult to apply or remove. The choice of compression garment must therefore include consideration of the patient's ability.
Patient information leaflets are provided with each garment to outline the application and removal process and a range of application aids are available from the different companies. Balcombe et al (2017) advised that the choice of application aid should take into account whether the patient or a carer will be using the aid to apply the garment and that cognitive and physical factors should be considered in the selection of the aid.
A larger sized garment or one with a lower compression can assist with independence in the application and removal of garments and a simple pair of rubber gloves worn during the process will allow patients to grip the garment to help ease it into position. Van Hecke et al (2011) found that when patients had knowledge about the application of their compression garment, they gained independence in its use.
Whichever approach to the application or removal of garments is chosen, the patient's ability and approach to treatment are key factors in ensuring success in their use.
Problems that can arise
Compression garments used in the management of lymphoedema are most effective at controlling the oedema when they are worn daily while the patient is active and then removed at night so that the skin can be cleansed and moisturised.
Table 2 outlines some of the problems that can occur with the fit and comfort of compression garments and offers possible solutions.
| Problems that can arise | Possible solutions |
|---|---|
| The garment is reported as too tight | The size may be too small or the compression too strong and the garment should be reviewed |
| Application is too difficult | Consider an application aid or assistance from family members |
| The garment is too loose in one part of the limb | The shape of the limb may not be suitable for the type of compression garment. An alternative style or a custom-made garment may need to be considered |
| The limb is painful | The garment will need to be removed and the cause of the pain established |
| The skin has become damaged by the garment | The garment will need to be removed until the condition of the skin has improved |
| The garment slips down the limb | The size of the garment will need to be checked and the use of a grip-top style may help with positioning |
Care of compression garments
To maintain their effectiveness, compression garments must be washed regularly, following the guidance provided by the manufacturer. Garments can be machine or hand washed and regular washing ensures that skin particles, perspiration, dirt and the residue of any moisturising cream are removed. The elasticity of the fibres of the material is also regained during washing.
Compression garments should then be dried in a warm environment. Hot tumble dryers and the direct heat of radiators or sun can damage the material and should be avoided. The lifespan of a compression garment depends on the degree of wear and the care of the garment. As a rule, compression garments should last for 4-6 months of daily wear, but they should be replaced if signs of wear and tear are evident earlier or if the garment becomes stretched and ineffective.
Old garments should be discarded once a replacement has been provided to avoid any confusion about which garment should be worn.
Summary
Compression garments are an essential aspect of the management of lymphoedema and must always be chosen carefully to ensure they are appropriate for the patient and comfortable when being worn. Patients should be encouraged to be independent in the application and removal of their garments, but nurses have an important role in the identification and resolution of any problems that may arise.