Pulmonary Toxicity

1. Pulmonary Toxicity

2. Objective The learner will be able to describe pulmonary toxicity, including its major causes, assessment, and management.

3. Pathophysiology/Types • Pneumonitis: Inflammation of the lung • Pulmonary fibrosis: Destruction of the lung, causing scarring

4. Causes • Chemotherapy • Direct damage • Immunologic • Metabolic • Radiation therapy • Concomitant chemotherapy and radiation therapy

5. Signs and Symptoms Pneumonitis: Can occur up to one year after treatment • Nonproductive cough • Low-grade fever • Tachycardia • Dyspnea, tachypnea • Pleuritic chest pain • Shortness of breath • Blood-tinged sputum • Consolidation specifically in area treated by radiation or throughout • Crackles • Fatigue • Restlessness • Hypoxia

6. Diagnostic Tests • Radiographic • Chest x-ray—Diffuse inflitrate • CT scan—Increased density of the lungs • Pulmonary function testing • Later finding could be decreased lung volumes.

7. Signs and Symptoms Pulmonary fibrosis • Later effect- 612 months after treatment • Symptoms • Can be asymptomatic depending on extent • Signs and symptoms can be the same as pneumonitis. • Can lead to a chronic corpulmonale

8. Assessment • Pulmonary assessment is important before, during, and after treatment, and in follow-up. • Percuss and auscultate lung fields for consolidation, wheezes, and crackles. • Note quality of the breathing (labored, shallow, fast, irregular). • Note symmetry of the chest and use of accessory muscle.

9. Assessment (cont.) • Assess for presence and quality of cough. • Assess skin and mucous membranes for cyanosis. • Obtain pulse oximetry for hypoxia. • Assess any chest or back pain. • Document level of consciousness. • Assess fluid status (edema, ascites). • Assess quality of life, activity, depression, self-care, and psychosocial support.

10. Prevention • Know pretreatment status and who is at higher risk. • Provide continuous monitoring of pulmonary function and nursing assessment. • Educate patients on symptoms to report. • Limit radiation dose to the lungs; chemotherapy dose can be reduced or drugs can be changed, if necessary. • Pretreat with medications to reduce risk.

11. Management Pneumonitis • Corticosteriods: Reduce inflammation, relieve symptoms, and prevent progression to fibrosis. • Symptom management • Bronchodilators • Expectorants, humidifier, hydration, antitussives • Oxygen, elevate head of bed • Rest • Antibiotics may be necessary. • Diuretics • Education for patient and family on what to expect

12. Management Pulmonary fibrosis • Employ the same symptom management as for pneumonitis. • Educate patients and families that this is a chronic condition and not to expect a drastic improvement. • Support patients and families in coping with this sometimes disabling side effect of treatment. • Provide continued follow-up and monitoring of pulmonary status.

13. Ongoing Assessment • Psychosocial support for patient and family • Continued assessment, radiographic testing, and oxygenation monitoring

14. References Shelton, B.K. (2009). Side effects of cancer therapy—Pulmonary toxicity. In M. Polovich, J.M. Whitford, & M. Olsen (Eds.), Chemotherapy and biotherapy guidelines and recommendations for practice (3rd ed., pp. 231255). Pittsburgh, PA: Oncology Nursing Society. Moore-Higgs, G. (2005). Site-specific management—Thoracic. In D.W. Bruner, M.L. Haas, & T.K. Gosselin-Acomb(Eds.), Manual for radiation oncology nursing practice and education (3rd ed., pp. 109111). Pittsburgh, PA: Oncology Nursing Society. Triest-Robertson, S., Vogel, W.H., & Gobel, B.H. (2009). Genitourinary, hepatic, and pulmonary toxicities. In B.H. Gobel, S. Triest-Robertson, & W.H. Vogel (Eds.), Advanced oncology nursing certification review and resource manual (pp. 530538). Pittsburgh, PA: Oncology Nursing Society.