Lung Cancer

Incidence
• Leading cause of cancer death in men and women
• Only 10-15% of people who develop lung cancer survive 5 years after diagnosis
• 40-75 years of age at time of diagnosis

Risk Factors
• Cigarette smoking
– 80-90% of all lung cancers
Related to:
– # smoked in a lifetime
– Earlier age of smoking onset
– Unfiltered cigarettes
– Depth of inhalation

– Cigar and pipe smoking

– Second-hand smoke
– Asbestos
– Radon
– Uranium
– Air pollution

Pathophysiology
• Most cancers arise from epithelium of the bronchus
• Slow-growing
a) Non-small cell lung cancer
a. Most common
b. Squamous cell, large cell, adenocarcinoma
b) Small cell lung cancer
• Common sites of metastasis: liver, brain, bone
• By the time it is detected, the tumor has already metastasized – reason for a bad prognosis

Clinical Manifestations
1. Persistent cough
2. Blood-tinged sputum
3. Chest pain
4. Dyspnea
5. Hoarseness r/t laryngeal nerve involvement
6. Anorexia / weight loss
7. Fatigue

Diagnostic Studies
• Chest X-ray:
• Identify tumor location of the tumor, complication such as pleural effusion
• CT Scan / MRI :
• Done if x-ray result is abnormal
• Sputum specimen for cytology:
• Looking at cell under microscope and look for cancer cell. Diagnostic.
• Bronchoscopy:
• Visualize main stem bronchus.
• Need to wait for gag reflex to return before eating/drinking.
• NPO ½- 2 hrs after bronchoscopy
• Fine needle aspiration (FNA):
• Inserted from outside (the tumor is outside lung), go through the chest wall and remove cell for
biopsy
• Mediastinoscopy:
 • Scope is inserted through incision in the anterior mediastinum.
• Used to take biopsy and determine stage of cancer
Treatment: Surgery

• Determined by type of cancer

• Small cell carcinomas: no surgery
• If the tumor is able to be resected/removed or not wrapped around the vital organ or major
blood vessel, we could remove the surgery. Depending on the location and the type of cancer,
non small carcinoma is more successful with surgery as treatment than the small cell
carcinoma. Surgery is not often done with non small cell carcinoma because usually those are
far advance by the time the cancer is diagnosed. Surgery is not effective
• Squamous cell carcinomas: surgery
• Lobectomy: removal of one or more lobes of the lung where the tumor is
• Wedge Resection:
• Removal of small wedge-shaped area of the lung
• Keep patient on the UNAFFECTED side (to avoid the impaired side or the incision side), semi-
Fowler to expand breathing easily (Seen in patient with respiratory distress or SOB)
• Pneumonectomy: Removal of one entire lung

Post Thoracic Surgical Care

General
• Prevent Pain
• Prevent atelectasis
• Turn, cough, deep breath, use incentive breathing exercise of the spirometer
• Inspect incision for signs of infection
• Monitor vital signs

Respiratory
• Monitor pulse oximetry: 02 saturation > 90%
• Chest tube care
• IBE (incentive breathing exercise) q 1 hour while awake
• Assess sputum:
– Dark red = normal ( that would indicate blood from surgical site)
– Bright red, frothy = bleeding ( bright red color indicates active of bleeding)

Treatment: Radiation
• Increased survival rate when combined with chemotherapy and surgery
• Palliation
• Side effects:

– Esophagitis:
• Radiation therapy to thorax;
• S/S = painful or difficulty swallowing
• TREATMENT: VISCIOUS XYLOCAINE
• Inflammation of the mucosa lining of the upper GI tract. Painful GI tract affect
their nutritional status. Hurts to swallow so it will impact their nutritional status.
• Numb the area, Given ½ before eat/drink anything
• Bland. No temperature extreme (cold/heat)

– Radiation Pneumonitis: occurs 1-3 months after radiation therapy to thorax begins
• Signs/symptoms: SOB , coughing, low grade fever
• Patient thinks their cancer has reoccurred or worse and the treatment has failed
• Can be treated successfully with CORTICOSTEROID, such as
PREDNISONE can be given
Treatment: Chemotherapy
• To treat non-resectable tumors
• As adjuvant therapy to surgery in patients with metastasis

Complication of Chemotherapy: Pleural Effusion

• Irritation of the pleural membrane by cancer cells à fluid production and accumulation in the
pleural space
• Normal fluid in pleural space: 5-15ml = to prevent friction from the two layer rub together
• Pleural effusion: 300 ml +/-
• Effective treatment seen:
a) Monitor output
b) Xray
c) Breathing
Patient who goes to ER develops Pleural effusion have trouble breathing and that’s how they are
diagnosed with lung cancer. This means that the cancer is far more advance and nothing can be done but
they still have to get the fluid remove using the thoracentesis pallatively.

Prior to Thoracentesis: Need Chest xray to find the location of the fluid accumulation.

Signs and symptoms of Pleural Effusion

• Dyspnea
• Pain
• Cough
• Tachycardia
• Tachypnea or absent breath sounds

CHECK FOR: Respiratory rate, pulse oximetry.

Treatment: Thoracentesis
• Get rid of the fluid
• Remove fluid at one time
a) Patient to remain still
b) Local anesthesia = use Xylocaine around site
c) Fluid analysis
d) Monitor VS = patient’s BP drops and HR increases as compensatory mechanism or if
there’s a fluid shift
e) Monitor puncture site = make sure it’s NOT leaking fluid

Treatment: Chest Tube Insertion : Remove draining but the chest tube stays indefinitely

• Pleurodesis – can be introduced into the pleural space through a chest drain.
• The instilled chemicals cause irritation between the parietal and the visceral layers of the pleura
which closes off the space between them and prevents further fluid from accumulating.
• A procedure that causes the membranes around the lung to stick together and prevents the
buildup of fluid in the space between the membranes.
• Is a painful procedure, so patients are often premedicated with a sedative and analgesics.
Chest drainage Collection Device
Chamber 1: Collection (air or fluid collection)
a) Monitor drainage, quality, amount
b) Closed drainage system
c) Measure the I&O at the end of the shift
d) Document the level of the fluid
• If fluid level was 1200 cc at 3pm (when you came on duty) and at 11pm when you left
the fluid was 1400cc, output (on your shift to be documented) at chest tube is 200 cc
Chamber 2: Water Sealà One-way valve to prevent air returning to pleural space
Chamber is filled (partially) with water. When the patient exhales, the air is trap underneath the water .
Water seals the air in so it will not go back to the patient’s lung.
a) Bubbling: Intermittent = air present in pleural space = expected if the patient just had the
chest tube put for pneumothorax
b) Bubbling: Constant/vigorous = air leak = air getting into the system
c) Tidling: water level moves up and down with respirations; Tidling stops when lung is re-
inflated or clotted
Chamber 3: Suction
a) Regulates the amount of negative pressure being exerted on the intrapleural space
b) Determined by the volume (amt) of water in the suction chamber- usually 20cm H20
c) Bubbles only if connected to external suction
d) Specifically ordered by physician

Patient Assessment / Care:

a) Assess respiratory and oxygenation status
b) Encourage deep breathing, coughing
• Help lungs to expand
c) Assess pain
• And medicate if necessary
• If in pain, they don’t want to breath
• ROM (because patient having pain refused to move) to arm/shoulder to avoid atrophy

Chest Tube Assessment / Care:

1. Sterile system
2. Output
3. Air-tight dressing
4. Tape connections
5. Keep below level of chest - to facilitate drainage
6. No dependent loops
7. Clamps at bedside ( do not do unless you have a physician’s order) (can be clamped when the
collection device is full) – must be done quickly to prevent pneumothorax
8. Milking and stripping – to dislodge a clot. Change in pressure in the tubing helps dislodge the clot
– Controversial: increases intrapleural pressure à damage pleural tissue and pneumothorax
– Requires physician order
– Used to encourage clots to pass through the tube
– Causes pain , especially in stripping (rarely done)
Research
• Clinical trials: lung cancer vaccine designed to cause the immune system to attack tumor cells
• Blood screening test: identifying proteins associated with lung cancer

Priority of Care: Chest Tube Dislodgement

• Goal: Prevent air from entering pleural space
• Vaseline gauze to site : prevent air from entering the pleural space
• Call for assistance
• Notify physician (patient may be in respiratory distress)
• Monitor respiratory / oxygenation status

Prevention
• Lung cancer risk drops dramatically 5 years after smoking cessation