1 / 24

The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

TM. The EPEC-O Project Education in Palliative and End-of-life Care - Oncology. The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

addo
Download Presentation

The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3m: Symptoms –Malignant Pleural Effusions

  3. Malignant pleural effusions . . . • Definition: fluid accumulation in the potential space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall

  4. . . . Malignant pleural effusions Symptoms: • Dyspnea • Cough • Chest pain • Decreased mobility and fear

  5. Overview • Scope of the problem • Causes • Pathophysiology • Diagnosis • Prognosis • Management options • Treatment strategies

  6. Impact • More than 25% of newly diagnosed pleural effusions are due to malignancy • 50% of cancer patients will develop a pleural effusion • In US, approximately 100,000 malignant effusions/year occur • Life expectancy 4-12 months

  7. Causes • Breast and lung cancer 50-65% • Lymphoma, GU, GI 25% • Unknown primary 7-15%

  8. Prognosis • Mortality 54% at 1 month, 84% at 6 months • Survival about 10 months where pleural effusion is first evidence of cancer • Known CA, exudate, negative cytology poor prognosis compared with positive cytology • Role of pH, Karnofsky Performance Scale?

  9. Key points • Pathophysiology • Assessment • Management

  10. Pathophysiology • Normally pleural fluid production equals fluidresorption • Effusion: Imbalance between fluid production and resorption • Causes: • Tumor cells blocking lymphatic drainage • Changes in colloid osmotic pressure due to hypoalbuminemia

  11. Assessment • History of dyspnea, chest pain, cough • Physical examination of decreased breath sounds, dullness to percussion

  12. . . . Assessment • Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance • Exam: decreased breath sounds, dullness to auscultation and percussion • Chest X-Ray PA, lateral, and decubitus films • Chest CT or Ultrasound if loculated

  13. Differential diagnosis • Parapneumonic effusion • Empyema • Chylothorax • Transudate

  14. Benign vs. malignant effusions . . . • Light’s criteria for exudates (one or more of following): • Pleural fluid LDH divided by serum LDH is greater than 0.6 • Pleural fluid protein divided by serum protein is greater than 0.5 • Pleural fluid LDH is greater than two-thirds upper limit of normal (ULN) of serum LDH

  15. . . . Benign vs. malignant effusions . . . • Heffner meta-analysis for exudates: • Pleural LDH is greater than 0.45 ULN • Pleural cholesterol is greater than 45 mg per dl • Pleural protein is greater than 2.9 g per dl • Heffner 1997 .

  16. . . . Benign vs.malignant effusions • Cytology: • Positive for cancer in approximately 55 to 65% initially • Yield up to 77% positive on three pleural fluid samples

  17. Management options • Thoracentesis • Tube thoracostomy • Small-bore chest tubes • Pleurodesis • Thoracoscopy • Intrapleural catheters • Pleuroperitoneal shunting • Subcutaneous access ports

  18. Management

  19. Thoracentesis • Diagnostic, therapeutic • Temporary relief • Many contraindications • Risks: • Pneumothorax • Re-expansion pulmonary edema (especially if more than 1500 cc removed)

  20. Treatment recommendations • Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy • Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia • Thoracoscopy: life expectancy greater than 3 months, loculated effusions, biopsies • Intrapleural catheters: outpatient pleurodesis

  21. Thoracoscopy benefits • Direct visualization of lung re-expansion • Identify loculated areas and drain • Administration of dry talc, chest tube placement • Confirm equal distribution of talc • Shorter hospital stay than tube thoracostomy • Diagnostic yield 90%, pleurodesis success rate 90%

  22. Tube thoracostomyand pleurodesis . . . • More definitive than repeated thoracentesis for recurrent effusions • Chest tube 12 to 24 hours or until drainage is less than 250 ml per 24 hr

  23. . . . Tube thoracostomyand pleurodesis • Sclerosing agent: Use after fluid completely drained from pleural space • Talc, bleomycin, doxycycline • Tube clamping controversial • Rotation vs. nonrotation • Failure rate 10 to 40% • Most widely used and cost-effective method

  24. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.

More Related