1. Adult Medical-Surgical Nursing Respiratory Module: Lung Cancer

2. Bronchogenic Carcinoma (Lung Cancer): Description Bronchogenic carcinoma is a major cancer killer for both men and women Often by the time of diagnosis malignancy has spread to regional lymphatics Therefore the long-term survival rate for lung cancer even with treatment is low

3. Lung Cancer Lung cancer comprises: Primary bronchial carcinoma Lung metastases secondary to a primary malignancy elsewhere in the body eg the breast

4. Lung Cancer and Smoking 85% of lung cancer is related to cell mutation from carcinogenic chemical inhalation, especially from smoking Primary inhalation (x 10 incidence than in non-smokers) Secondary passive smoking in a smoke- filled room Risk is associated with number of packs smoked daily, years smoking, filtration, tar

5. Lung Cancer: Aetiology/ Risk Factors Smoking Environmental / occupational hazards: Urban areas (↑ pollutants) Industrial carcinogens (asbestos, coal smoke, radiation) Genetic pre-disposition: ↑ risk x 3 whether smoker or not Dietary factors: diet low in fruit and vegetable, especially vitamin A and C

6. Lung Cancer: Classification Non-small Cell Carcinoma (75%): Squamous cell (bronchial epithelium) Adenocarcinoma (peripheral tumours → metastases) Large cell (peripheral, rapid growing) Bronchio-alveolar cell (terminal bronchi) Small Cell Carcinoma (25%): rapid infiltration and metastases

7. Lung Cancer: Pathophysiology A single epithelial or gland cell of the tracheo-bronchial airways is damaged through binding of carcinogenic chemicals to the cell DNA → Cellular changes (mutation) occur and abnormal cell growth → malignant cell Damaged DNA is unstable and passes on changes to daughter cells This is the start of invasive carcinoma

8. Lung Cancer: Progression Insidious progression: The condition is usually well-developed before symptoms appear

9. Lung Cancer: Clinical Manifestations Chronic cough (dry persistent or purulent): *a cough which changes in character should be investigated* Wheezing, chest tightness, hoarseness, dysphagia Haemoptysis Pain: pleuritic, shoulder, rib (metastases) Weakness, fatigue, weight loss, anorexia Fever (if pneumonia develops)

10. Lung Cancer: Diagnosis History and physical assessment Chest Xray CT scan Sputum cytology Bronchoscopy: examination, brushings, washings, biopsy Trans-thoracic fine needle aspiration (fluoroscopic guidance) occasionally

11. Lung Cancer: Other Assessment in Diagnosis Presence of metastases: Bone scan Abdominal scan Liver scan Brain scan (MRI) Assessment of lung impairment and function: PFT, ABG, VQ ratio, treadmill, ECG

12. Lung Cancer: Staging In addition to histology of bronchial carcinoma, staging assists the treatment plan: Carcinoma in situ Localised infiltration Metastases to other organs

13. Lung Cancer: Management Separately or in combination: SurgeryRadiationChemotherapy Determined by: Type of tumour and staging General condition of the patient

14. Surgery

15. Surgery Surgical resection is the preferred treatment if: There is no evidence of metastases Patient’s general condition would tolerate Surgery is used for non-small cell carcinoma with no infiltration (small cell infiltrates through the lymphatics early) Often a patient presents with metastases already and surgery would not be useful

16. Surgery Procedures include: LobectomyPneumonectomy (Both involve Thoracotomy)

17. Surgery: Pre-operative Management and Nursing Care Pre-operative assessment: PFT, ABG, VQ ratio, treadmill, ECG LFT, KFT, RBS, CBC, Group X-match Chest physiotherapy: use of nebulised bronchodilators and postural drainage to encourage expectoration; leg exercises Patient teaching: breathing/ coughing technique, site and extent of wound, chest drains, possible ventilation, relieve anxiety

18. Surgery: Post-operative Management ICU: ventilator if required Humidified O2; nebulised bronchodilators IVI; IV antibiotics/ medications Chest drains ABG; serum electrolytes Chest physio Prophylactic Heparin; anti-embolism stockings

19. Surgery: Post-operative Nursing Care ICU: ventilator if required Position patient semi-sitting once able, pillows to support (thoracotomy wound) Monitor vital signs, especially respirations Care of O2, IVI, wound dressing, chest drains, mouth, pressure areas, urination Adequate pain relief; emotional support Breathing, leg, arm, shoulder exercises

20. Radiotherapy

21. Radiotherapy: Indications Radiation therapy is useful for neoplasms which are: Difficult to resect Small-cell infiltrating Also used pre- or post-surgery →

22. Lung Cancer: Radiotherapy and Surgery Radiation pre- or post-surgery: Radiation inhibits cell growth, reducing the size of a tumour → More accessible for surgery Reduces symptoms of pressure therefore: Relieves dyspnoea, cough, chest pain, haemoptysis, bone pain Improves quality of life

23. Lung Cancer: Radiotherapy Protocol Usually almost daily sessions for 4 weeks Area to be treated is marked and kept dry and cool Careful monitoring of blood count and general well-being throughout the treatment period

24. Radiotherapy: Side Effects Radiotherapy is toxic to good cells May lead to oesophagitis, pneumonitis, fibrosis and impaired VQ ratio Other side effects are related to bone marrow depression: Anaemia, fatigue, bruising, ↓ immune response and infection (including opportunistic infection as candida)

25. Chemotherapy

26. Lung Cancer: Chemotherapy Chemotherapy may be used in combination with the other 2 more major treatments Affects cell growth and multiplication therefore reduces tumour size and relieves symptoms as radiotherapy Side effects as radiotherapy (Chemotherapy and nursing care previously discussed: see Leukaemia 1 lecture, Haematology Module)