An RT’s role in a healthcare team may not demand primary involvement of the palliation of all of the symptoms experienced by a patient with lung cancer. Yet the more an RT is aware of the patient’s situation, their concerns and symptom palliation needs, the more valuable that RT is to the patient-centered care that becomes the primary goal of the whole team.
RTs must deal with patients with lung cancer in very similar ways as individuals with other lung diseases, depending on the severity or stage of a patient’s lung cancer. A patient with lung cancer, with or without co-morbid tobacco-related disease such as COPD, will often need similar common respiratory services such as aerosol therapy, bronchopulmonary hygiene and hyperinflation therapy related to their lung cancer.
National guidelines, developed by the American Association for Respiratory Care (AARC) and the American Thoracic Society (ATS), define clinical indications and care plans for various modes of respiratory therapy services. However, these guidelines often are lent to modification to apply to patients with advanced cancer.
Symptoms and Comorbidities
The manner of presentation and the anatomic location and stage of the lung cancer can determine the type and severity of respiratory symptoms manifested by patients with lung cancer. Understanding the particular patient’s situation in this regard can help the RT be aware of what signs and symptoms with which a patient with lung cancer may present and therefore some clues as to therapeutic modalities best suited to the patient.
Symptoms from the primary tumor in the chest may include dyspnea, wheezing, cough, hemoptysis and chest pain. More locally advanced tumors in the chest may lead to obstruction of major vessels (superior vena cava syndrome), pleural effusions with consequent symptoms.
SEE ALSO: Lung Cancer Discovery
Respiratory symptoms can also result from complications of lung cancer treatment such as radiation- and chemotherapy-induced lung toxicity, airway stenosis and necrosis, fistula formation, hemoptysis from neovascularization. Comorbid conditions such as COPD, heart failure, pulmonary embolism, prior lung resection, malnutrition can cause or contribute to respiratory symptoms. Constitutional symptoms of depression, fatigue, insomnia, anorexia-cachexia syndrome are common.
Symptoms may be referable to distant extrathoracic metastases to bone, brain, spinal cord and liver pose additional problems that the patient and the health care team need to address.
Therapies and Modalities
Primary modalities/services that the RT will be asked to provide to patients with lung cancer include aerosol therapy, bronchopulmonary hygiene and oxygen and hyperinflation therapy. Patients with lung cancer will have similar needs to other respiratory patients but at times the goals of care in this population may be more palliative than curable. These may lead to a different set of indications and modifications frequently must be made to the therapy itself if the patient is going to be able to tolerate it. Examples of such modifications are discussed below:
Aerosol Therapy Shortness of breath and dyspneic feelings can be clinical indications for aerosol therapy in lung cancer patients. The clinical indications for aerosol therapy in the general population, as described by national guidelines, includes bronchospasm, history of bronchospasm, thick proteinaceous secretions, and airway inflammation. Aerosol therapy for patients in palliative care may be modified to include increased frequency of bronchodilator use. Another modification that has been used with varying clinical validity in multiple studies is the use of aerosolized morphine treatment. Although the value of nebulized morphine in this population is debated, it has been shown to be effective in several small studies of patients with chronic lung disease and cardiac disease.
Bronchopulmonary Hygiene Patients with advanced cancer who have rhonchi or a nonproductive cough may benefit from bronchopulmonary hygiene, which consists of: traditional chest physiotherapy or its modern day equivalent, high frequency airway/chest oscillation therapies, manual/mechanical cough assistance, and suctioning. However, patients may experience pain, discomfort or be intolerant from any of these therapies. In addition, certain situations in lung cancer (spinal or chest wall metastasis) or the presence of a platelet count of less than 50,000 (due to chemo or metastasis), may be relative contraindications to these therapies. Clear cut goals of therapy must be established to ensure proper balance between the risks and benefits.
Oxygen and Hyperinflation Therapy Hyperinflation therapy involves the use of a leak-free seal between the patient and the equipment interface. Both Bilevel Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP) are used to assist the patient with either oxygenation and/or ventilatory impairment as a result of their lung cancer. Although both of these therapies are intended to improve patient comfort and reduce work of breathing, they may have the opposite effect in this patient population requiring flexibility on the part of the caregiver to modify the care plan for the intended effect. Based on the goals of care for a particular patient, family members may also request therapy that is less aggressive than the use of a face mask and positive airway pressure. Modifications that can be made include using high flow oxygen delivery systems utilizing a nasal cannula or loose-fitting mask. In addition, the health care provider may decide to accept lower levels of blood gases (PaO2 and SpO2) than called for by national standards. Rather than target conventional SpO2values of 90% to 100%, the provider may compromise to accept values in the low- to mid-80s.
These kinds of modifications demonstrate a need for protocols and a differing level of understanding for the RT in dealing with patients with lung cancer, particularly when palliation is one of the main goals in the care of these patients. Effective communication between the RT and the rest of the healthcare team is vital for the appropriate delivery of care with modifications as mentioned above.
Monitoring the Patient
Overall the RT should monitor the patient with lung cancer in very similar fashion to any patient with a chronic respiratory condition. Respiratory rate (RR) and pulse oximetry (O2 sat) readings are readily available objective measures that can be monitored. Other clinical signs that the RT should be familiar with would include cyanosis (central or nailbed), increased work of breathing with use of accessory muscles of respiration, and/or the presence of paradoxical breathing.
“RTs should monitor patients with lung cancer in a very similar fashion to any chronic respiratory condition.”
Stability would be observable by the presence of acceptable vital signs and O2 saturation in a patient who is mentating appropriately, not working too hard to maintain the vital signs, and is not distressed by refractory cough or pain. Stability would also mean that the RT’s chest exam is normal or at least stable when compared to clinical notes from previous exams (the presence or absence of wheezing, decreased breath sounds, rales).
Trouble would be indicated by the trending of unacceptable vital signs such as RR (too high or too low) and O2 saturation dropping below 89-90%, altered mental status that may be a sign of hypoxemia or hypercarbia, central or peripheral cyanosis, increased work of breathing, as well as anxiety and distress related to being uncomfortable from pain, dyspnea or cough. Changes in the patient’s exam such as the development of cyanosis, new or worsening wheezing or rales or the loss of breath sounds that may indicate atelectasis from tumor or mucoid plugging or worsening of a pleural effusion may indicate trouble as well.
Dr. Rizzo is the senior medical advisor for the American Lung Association and Section chief, pulmonary/critical care medicine, at Christiana Care Health System, Newark, Del.
Be Part of the Solution
The vital roles of RTs begin well before they are confronted with a patient with lung cancer. As healthcare professionals, RTs are particularly well positioned in the fight against lung cancer by being an advocate for lung health and in particular an advocate for tobacco control measures and the prevention of smoking.
Smoking cessation is the best way to prevent lung cancer. Once a smoker is identified, RTs should be role models and ideally smoke-free themselves. Even if they are smokers (and depending on their setting — office, clinic, hospital, home visits), they should utilize the 5 A’s that help clinicians identify a smoker who is potentially ready to quit:
- Ask if the patient smokes.
- Advise smokers to quit.
- Assess their readiness to quit.
- Assist them in seeking concrete steps (counseling or pharmacotherapy) to quit.
- Arrange referrals/follow up contact for those making the effort to quit.