3. Organs of respiratiory system
Upper respiratory tracts
Nose
Pharynx
Larynx
Trachea
Lower respiratory tracts
Two bronchi (one bronchus to each lung) Bronchioles
and smaller air passage
Two lungs and their covering pleura
4. Normal Physiology Of Respiration
Normal respiration begins by inhaling air through the
mouth and nose.
This air flows down into trachea, which divides into
the left and right bronchi, and then to the alveoli.
The alveoli are responsible for oxygenating the blood
for circulation as well as removing carbon dioxide
from the blood.
5. Lung Cancer
Most common cause of cancer death for men
and women.
Tobacco use accounts for 87% of lung cancer.
Lung cancer affect primarily in 5 or 6th decade
of life.
In 70% of lung cancer patient , disease has
spread to distant organs.
6. Definition
Cancer: An abnormal growth of cells which tend to
proliferate in an uncontrolled way and, in some cases,
to metastasize (spread). Cancer is not one disease. It
is a group of more than 100 different and distinctive
diseases.
9. Types of Lung Cancer
Two main Types of Lung Cancer:
Small Cell Lung Cancer (20-25% of all lung cancers)
Non Small Cell Lung Cancer (most common
~80%)
10. Small Cell Lung Cancer
Small Cell Lung Cancer is the most aggressive
form of lung cancer.
It usually starts in the bronchi and then effects the
whole lung.
These cancer cells are small and are considered to
be quite aggressive in nature and they have a large
growth factors.
11. Contd..
Because of these reasons, at the time of
diagnosis, (60% of the time), these tumors have
often metastasize to other parts of the body
(brain, liver, and bone marrow)
SCLC accounts for 20-25% of all lung cancers.
13. Non Small Cell Lung Cancer
NSCLC is any type of epithelial lung cancer
other than small cell lung cancer.
Non-small cell lung Ca usually grows and
spreads more slowly than SCLC.
14. Types of NSCL
Squamous cell carcinomas usually arise centrally in
larger bronchi
Adenocarcinoma : formed from grandular structure in
epithelial tissues (mucus secreting glands) are often found
in the periphery of the lungs
Large cell carcinomas can occur in any part of the lung
and tend to grow and spread faster than the other two
types
15. Squamous Cell Carcinoma
Moderate to poor differentiation
Makes up 30-40% of all lung cancers
More common in males
Most occur centrally in the large bronchi
Uncommon metastasis that is slow effects the liver,
adrenal glands and lymph nodes.
Associated with smoking
Not easily visualized on x-ray.
16. Adenocacinoma
Increasing in frequency. Most common type
of Lung cancer (40-50% of all lung cancers).
Clearly defined peripheral lesions
Glandular appearance under a microscope
Easily seen on a CXR
Can occur in non-smokers
Slow metastatic in nature
Pts present with or develop brain,
Liver, adrenal or bone metastasis
17. Large Cell Carcinomas
Makes up 15-20% of all lung cancers
Poorly differentiated cells
Tends to occur in the outer part (periphery) of lung,
invading sub-segmental bronchi or larger airways
Metastasis is slow BUT
Early metastasis occurs to the kidney, liver organs as
well as the adrenal glands.
18. Causes and risk factors
Gender
Smoking history
Active smoking=85-87%
Passive smoking=3-5%
Older age
Presence of airflow obstruction
Genetic predisposition.
19. Cont...
Pollution and occupational exposure
Industry work due to asbestos(heat resistant fibrous).
Lung Disease like T.B
family History
Diet (low in fruits and vegetables)
20. Patho-physiology
Carcinogens like smoking, occupational and
environmental agents, genetics.
Binds with cell’s DNA and damage the cells.
Cellular changes and abnormal cell growth
occur.
21. Cont...
Malignant transformation of pulmonary epithelial
cells.
Abnormal proliferation of the lung cell. These
cells grow slowly and covers the segmental
bronchi and lobes of the lung.
Non specific inflammatory changes with
hypersecretion of mucus, desquamation of the
cells.
22. Cont...
Lesions formation in the lung’s tissues involving
the bronchi, bronchioles or even alveoli
Bronchogenic carcinoma.
23. Signs and Symptoms
There are two types of signs and symptoms of
lung cancer:
1) Localized – involving the lung.
2) Generalized – involves other areas throughout
the body if the cancer has spread.
24. Localized Signs and Symptoms
Cough and fatigue
Breathing Problems, stridor
blood in phlegm
Lung infection, hemoptysis
Hoarseness, Hiccups
Weight loss
Chest Pain and tightness
Pleural Effusion
25. Generalized Signs and Symptoms
Bone pain
Headaches, mental status changes or neurologic
findings
Abdominal pain, elevated liver function tests,
enlarged liver, gastrointestinal disturbances
(anorexia, cachexia), jaundice, hepatomegaly
Weight loss
26. Early/late Signs and Symptoms Of Lung
Cancer
Early Signs Late signs
Cough/chronic cough Bone pain, spinal cord compression
Dyspnea Chest pain/tightness
Hemoptysis Dysphagia
Chest/shoulder pain Head and neck edema
Recurring temperature Blurred vision, headaches
Recurring respiratory
infections
Weakness, anorexia, weight-loss,
cachexia
Pleural effusion
Liver metastasis/regional spread
28. Laboratory Tests
Blood Tests
*CBC- to check red/white blood cell & platelets
-to check bone marrow and organ function
*Blood Chemistry Test- to assess how organs are
functioning such as liver and kidney
Biopsy-to determine if the tumor is cancer or not
-to determine the type of cancer
-to determine the grade of cancer (slow
or fast)
33. Nursing Management for post endoscopic
procedures
Bronchoscopy Mediastinoscopy VATS
Monitor V/S; NPO
status maintained
until return of gag
reflex.
(Fever up to 1010F
can be expected
afterwards).
Monitor VS;
potential for
bleeding, infection
and dyspnea; NPO
status until return
of gag reflex
Monitor V/S;
potential for
bleeding,
infection and
dyspnea; NPO
status until return
of gag reflex
34. Post-op complications for those
with lung cancer
Airway obstruction, dyspnea, hypoxemia, respiratory failure
Anesthesia side effects (N/V)
Bleeding (hypotension, cardiogenic shock)
Cardiac dysthymias, CHF, fluid overload
Fever, sepsis
Pneumonia
Pneumothorax
Pulmonary embolus
Wound dehiscence
Prolonged hospitalization
Death
35. Cancer Staging Systems
The most common staging system for lung cancer is
the TNM System developed by the International
Union Against Cancer (UICC).
Guides best course of treatment
Estimates prognosis
It is only useful in staging NSCLC, when surgery is
considered.
36. TMN Staging system for Lung Cancer
T= Tumors : tumor size,
(local invasion)
N= Node : node involvement
(size and type)
M= Metastasis : general
involvement in organs and
tissues
37. Tumor size
Tx – The tumor size is unknown, or cancer cells are
only found in sputum.
T0 – The tumor is present only in the cells lining the
airway
T1 – Tumors less than or equal to 3 cm
T2- Tumors size is 4-7 cm.
T3 – Tumors greater than 7 cm
T4 – tumor that invades structures in the chest such
as the heart, major blood vessels near the heart, the
trachea, the esophagus.
38. Nodal involvement
N0 – No nodes are involved.
N1 – The tumor has spread to nearby nodes on the same
side of the body.
N2 – The tumor has spread to nodes farther away, but
on the same side of the chest.
N3 – The tumor has spread to lymph nodes on the other
side of the chest from the original tumor, or has spread
to nodes near the collarbone or neck muscles.
39. Metastasis
M0 - The tumor has not spread to distant regions.
M1:
M1a – The tumor has spread to the opposite
lung, to the lung lining
M1b – The tumor has spread to distant regions
of the body, such as the brain or bones.
40. Staging
Stage 1. Tumor is small and localised to lung, no lymph
node involvement
A-Tumor <3 cm
B-Tumor >3 cm and invading surrounding local area
Stage 2.
A-Tumor <3cm with invasion of lymph nodes.
Tumor >3 cm involving the bronchus and lymph nodes
on the same side of chest and tissue of local organs.
41. Contd..
Stage 3.
A. Tumor spread to the nearby structure and
regional lymph nodes
B. Tumor involving heart, trachea, esophagus,
mediastinum and lymph nodes.
Stage 4- distant metastasis
42. Medical Management
The three main cancer treatments are:
*surgery (lung resections)
*Radiation therapy
*chemotherapy
Other types of treatment that are used to treat certain
cancers are hormonal therapy, biological therapy or
stem cell transplant.
43. Surgical treatment
Lobectomy: a single lobe of lung is removed
Bilobectomy: 2 lobes of the lung are removed (only on R
side)
Sleeve resection: cancerous lobe is removed and segment
of the main bronchus is resected
Pneumonectomy: removal of entire lung
Segmentectomy: a segment of the lung is removed
Wedge resection: removal of a small, pie-shaped area of
the segment
Chest wall resection with removal of cancerous lung
tissue: for cancers that have invaded the chest wall
44. Radiation treatment
Useful in controlling the neoplasm that can not be
surgically removed.
Used to reduce the size of the tumor
May help to remove the symptoms like cough, chest
pain, dyspnea and hemoptysis etc.
45. Chemotherapy
Is used to alter tumor growth and to treat the patient with
metastasis.
Non small cell:
Two drug regimen.
Cis/Carbo platin + 1 other
(Taxol/Taxotere/Gemcitabine)
Small cell:
Cisplatin / Etoposide
47. Side effects of treatments
SURGERY RADIATION CHEMOTHERAPY
Pain fatigue Anemia,
thrombocytopenia
Hemotomas Decreased nutritional
intake
Fatigue
Hemmorhage Radiodermatitis Alopecia
Altered respiratory
function
Decreased
hematopoietic function
Cold, pale skin
Risk for atelectasis,
pneumonia, hypoxia
Risk for Pneumonitis,
esophagitis, cough
Tingling
Risk for DVT Lung fibrosis Irritable
Grief Dizziness, weakness
48. Complimentary Therapies
Includes ACUPUNCTURE and MASSAGE and
pharmacological approaches such as vitamins and
herbal medicine.
These herbal therapies combined with chemotherapy
increases survival in non-small-cell lung cancer by up
to 42%, compared with chemotherapy alone.
50. Complimentary Therapies cont’d
Mind-body: help to reduce anxiety, mood
disturbance, or chronic pain in cancer patients
(audiotapes, videotapes, books, music,
relaxation, yoga, meditation).
Acupuncture
Hypnosis
Massage therapy
51. Prognostic Factors
The best estimate on how a patient will do
based on:
*Type of cancer cells
*Size or location of the tumor
*Stage of the cancer at the time of diagnosis
*Age of the person
*Gender
*Results of blood or other tests
*A persons specific response to treatment
*Overall health and physical condition
52. Prevention: Primary
Avoid the use of tobacco smoke
Know environmental carcinogens that increase risk
Chemoprevention:
Consuming Vit. A, Vit E,, Vit C.
53. Prevention: Secondary
Aim is to early diagnose high risk populations via
screening
Chest X-Ray, MRI, CT scans, sputum cytology
54. Prevention: Tertiary
Targeted at people who survived a cancer disease
Assists them to retain an optimal level of functioning
regardless of their potential debilitating disease
55. Nursing assessment
Subjective data-
Past health history
Exposure to smoke, air born carcinogens, any
respiratory diseases and pollutants
Nutritional habbits
Symptoms like anorexia, nausea , vomiting, cough
and hemoptysis.
57. Nursing Diagnoses
1. Ineffective breathing pattern r/t loss of
adequate ventilation as evidenced by
overexertion of pt. during respiration.
2. Impaired gas exchange r/t excessive or thick
secretions or r/t decreased passage of gases
between alveoli of lungs and vascular system
as evidenced by decreased SPo2 level of pt.
58. 3. Chronic pain related to Stage IV NSCLC diagnosis
as evidenced by client reporting “pain in right chest
and lower ribs”.
4. Risk of infection related to altered immune system
secondary to effects of cytotoxic drugs as evidenced
by side effects of the drug/chemotherapy.
5. Risk for disturbed self concept related to changes in
lifestyle.
59. Nausea related to effects of chemotherapy as
evidenced by
client reporting feeling nauseated.
Risk for deficient fluid volume related to
gastrointestinal fluid loss secondary to vomiting.
Fatigue related to chemotherapy secondary to stage IV
NSCLC as evidenced by client reporting he “ no
longer has the energy to play with his grandchildren or
visit his friends”.
60. Ineffective breathing pattern
Teach patient about deep breathing exercises
Encourage alternating activity with rest periods
Chest physiotherpy
Suctioning
Bronchodilator medication
O2 administration, if required
61. Impaired gas exchange
Instruct the patient to stop smoking
Semi-fowler position
Administered antibiotics as prescribed
Adequate hydration
Deep breathing exercises
Nebulisation
Suctioning, as required
62. Chronic pain
Relaxation techniques
Diversional therapy
Frequant massage
Encourage energy conservation
Comfortable position
Education to avoid concern about pharmacological
and non- pharmacological therapies
Medication , as prescribed.
63. Risk of infection
Monitor the client body temp. routinely
Encourage the patient to do regular ADL like
brushing, bathing, eating, toileting
Provide a high calorie, high protein diet
Hand washing before and after taking food
Antibiotics, as prescribed
64. Risk of disturbed self concept
Provide psychological support
Encourage the family members in caring of the
patient
Encourage the communication with the patient
Diversional therapy
Ask the client to identify personal strenght and
talent.
65. Risk of deficit fluid volume
Encourage the patient to take fluids (2-3 l/day)
Small and frequent diet
I/V fluid administration, if prescribed
Intake- output charting
Administer skin care, apply hydrating lotion
Weight recording
66. References
Brunner and sudderth’s, a textbook of medical- surgical
nursing, smeltzer bare, 10th edition, page no-554-557.
Lewis’s , a text book of medical surgical nursing, chintamani,
7th edition, page no. 585-588.
Potter.perry, a text book of fundamental of nursing, 7th
edition, page no. 1066, 865.
Posther KE, Harpole DH. The surgical management of lung
cancer. Cancer Investigation, 2006;24:56–67.
National Comprehensive Cancer Network. NCCN Clinical
Practice Guidelines in Oncology: . Accessed at
www.nccn.org/professionals/physician_gls/PDF/nscl.pdf on
March 18, 2013.