DYSPNEA In Advanced Lung Cancer Patients

By: Cindy Stegman RN BSNAlverno College MSN 621

Spring 2010stegmacm@alverno.edu

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QUESTION slide.

Hover over the underlined text for an explanation/definition

To educate RNs and LPNs on the pathophysiology of advanced lung cancer

associated with dyspnea

At the end of the tutorial the learner will be able to:

• Identify pathophysiology of advanced lung cancer associated with dyspnea • Discuss key assessment components of the advanced lung cancer patients experiencing dyspnea

• Describe evidence-based interventions for the advanced lung cancer patients experiencing dyspnea

PURPOSE & OUTCOMES

Clip art, 2010

Pathophysiology of advanced lung cancer

Anatomy of normal lung function

Causes of dyspnea

Mechanisms of dyspneaGenetic relationship

Evidence-Based Nursing Interventions

Stress & Immune/Inflammatory response

Nursing assessment

Case Study Nursing-Sensitive Outcomes

Content of TutorialAt any time during tutorial you may click to come to this screen and select next topic.

Let’s get started… taking a DEEP breath and relax!

Anatomy ofNormal Lung Function

Click each circle in the diagram to recognize the

anatomy of the lungs 1

2

3

5

4

Trachea: Is the tube that runs from your larynx to just above

your lungs. The trachea divides into TWO large

branches called the bronchi.Bronchi: Entering the lung, the bronchi divide into the left and right side of lung. They continue to branch & divide

into smaller bronchi. Bronchioles: Smallest

conducting airways at the terminal end of the bronchi.

At the most distal end gas exchange takes place.

Pleura: A thin serous membrane that lines the

thoracic cavity & cushions the lungs.

Alveolar sacs: Cup-shaped structures which are the

smallest functional unit of the lungs.Porth, 2005

Physiology of Normal Breathing:-Automatic, quiet

- Movement that control ventilation are integrated by neurons located in:

- Medulla & Pons (Respiratory Center)

GOAL of Breathing: Oxygenation of the blood and removal of Carbon dioxide.

Scroll across each picture

Porth, 2005)

What Stimulates your respiratory

system to increase breathing?

ReceptorsClick on star to

receive answer

1)Chemoreceptors - Peripheral chemoreceptors: Located in the

carotid and aortic bodies

- Central chemoreceptors: Located in the Respiratory center in the Medulla & pons

2) Lung & Chest wall Receptors

- Stretch (smooth muscle)

- Irritant (Airway of epithelial cells)

- Juxtacapillary or J receptors (alveolar wall)

Jantarakupt, P. & Porock, D. (2005).

A nurse walks into a room and observes a patient breathing rapid and shallow. Respiratory rateis 32 breaths/min and pulse ox at 80% on room

air. What receptors alerted the respiratory center to turn ON ?

Incorrect.These receptors are located in the medulla & pons and stimulate the resp. center when there are high levels

of carbon dioxide in the blood.

Central Chemoreceptors

Incorrect.These receptors are

located in smooth muscle and do not stimulate the respiratory center when there is LOW oxygen in

the blood.

IncorrectIn this situation because

this scenario did not mention crackles in the

lungs that would suggest pulmonary edema.

Correct!!These receptors alert the respiratory center when there is LOW oxygen in

the blood

J Receptors

Stretch Receptors

Peripheral Chemoreceptors

What Causes Lung Cancer?Repeated

EXPOSURE to

Carcinogens

Transforms: Normal cell into

Malignant

Clip Art, 2010Hoffman, A. & Gift, A. (2007)

Cells in the respiratory membrane that line the

bronchi become THICK &HARDEN

Cilia become

Stiff (Unable to sweep debris away)

Genetic Damage

Lung Cancer Cell Dividing

- Lung cancer cells are highly invasive & may extend into the mediastinum or pleural cavity- Lung network is highly vascular and metastasis occurs early- Distant metastasis may occur in the brain, liver, bones, or kidneys Hoffman, A., & Gift, A. (2007)

Permission from http://images.wellcome.ac.uk/

What we know increases risk for

development of Lung Cancer• Active tobacco exposure

• Passive smoke exposure (Second hand)• Shared environment

• Asbestos (school, home, work, person-person)

• Environmental exposure (Radon & heavy metals)• Nickel, arsenic

National Cancer Institute, 2010

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Research in the works…Study produced by:

• National Cancer Institute• National Human Genome Research Institute• National Institutes of health

Study that was printed in 2004 in the American Journal of Human Genetics

Study involved: -52 families with a minimum of Three 1st-degree family members affected by either lung, throat, or laryngeal cancer

-Used 392 known genetic markers & compared the alleles of each affected and non-affected family member

National Cancer Institute, 2010

Research in the works Cont…Discovered:

A region on Chromosome 6 (susceptibility to Lung caner)

WORK is needed to:Look closer in this

REGION to find the exact GENE that causesthis susceptibility National Cancer Institute, 2010

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Mechanisms of Dyspnea

•Divided into 3 pathologies:

• Chemical Stimulation

• Neural Stimulation

• Emotional Stimulation Clip Art, 2007

Chemical Stimulation

Central respiratory

chemoreceptor

s

Peripheral respiratory

chemoreceptors

PaCO2

PaO2

Eliminate Carbon Dioxide

American Thoracic Society. (1998).

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Jantarakupt, P. & Porock, D. (2005)

Neural StimulationNeural Pathways for breathing receive signals from receptors in:

- Lungs- Skin- Muscles- Joints

These receptors are called “Mechanoreceptors”

- Stretch receptors in (trachea, bronchi) are stimulated with lung expansion

- Irritant receptors (epithelium of airways) stimulated by smoke, pollens, fungi, cold air, & mold

- Movement of lower and upper extremities stimulate receptors in muscles & joints

- Painful stimuli will elicit mechanoreceptors within the skinJantarakupt, P. & Porock, D. (2005)

Once mechanoreceptors are stimulated they

will cause an individual to

breathe faster

Emotional Stimulation• Emotional distress

• Anxiety• Anger• Depression

THE CAUSE & EFFECT relationship is unclear but…

Emotional changes CAN stimulate the respiratory center, which in turn AFFECTS the

Individual’s breathing pattern

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Jantarakupt, P. & Porock, D. (2005).

Dyspnea is a distressing and debilitating symptom that

cancer patients may experience.

- It is SUBJECTIVE (what the patient says)- An uncomfortable, frightening experience

(

Clip art, 2007Dyspnea is estimated to occur in 15-55% at the time of diagnosis

and up to 18-79% during the last week of life

Oncology Nursing Society. (2010).

Stress and Dyspnea: What’s the CONNECTION?

Stress response or General Adaptation Syndrome (GAS)

is meant to protect an individual

during ACUTE episodes stress. If the GAS is

continually stimulated by chronic stressors,

this can be a threat to an individual’s homeostasis.

Porth, C., (2005)

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Stress and DYSPNEA Cont…

Dyspnea: Acute or Chronic

Advanced Lung CancerPATIENT

Physical & Psychological Stress

ALERT: STRESS

RESPONSE

Stress and Dyspnea Cont…Results: In release of catecholamines (such as epinephrine and norepinephrine) and cortisol, which:

- Increases heart rate- Dilates the bronchioles

Stress causes Vasoconstriction to…

- Skin: which becomes Pallor and cold- GI tract: which causes nausea, No bowel sounds, & digestion stops- Kidneys: which decreases urinary output

Porth, C., (2005))

Inflammatory and Immune response stops!

PhysicalBehavior

al

ADAPT to

ACUTE STRESS

WHAT factors AFFECT our ability to ADAPT

to STRESS??

Endocrine-Neurotransmitter pathway… PRODUCE

CHANGES

Click on each circle

Severe emotional distress often

disrupts physiological

function and limits an individuals ability to make

appropriate choices related to adaptive needs. If a dyspnea

is present, this is causing emotional

distress and affecting their ability to enjoy

daily activities due to the stress of not

being able to breathe.

Sleep-Wake Cycles

Hardiness

Mental Health Status

NutritionSleep is the

most restorative function in

which tissues are

regenerated. If an

individual cannot sleep at night, due to dyspnea,

this is affecting

their ability to restore

their energy.

Malnutrition is one of the most

common causes of immunodeficiency.

Most advanced lung cancer

patients have major issues with nutrition due to

loss of appetite & weight loss from treatment &/or disease process

itself.

A personality characteristic

which includes: A sense of

purpose in life and to view

stressors as a challenge rather than a threat. If

dyspnea is affecting their hardiness, the individual will

see this stressor as a threat and slowly become susceptible to

sadness.

Porth, C. (2005)

What happens if DYSPNEA continues to stimulate

our Stress Response??

Exhaustion OCCURS!Coping mechanisms

are depleted.

WEAR & TEAR on the System

Chronic stress will occur & LEAD to:

Loss of AppetiteSleep disturbance

Depression

What does this mean for an advanced lung cancer patient if this

cycle continues ?Porth, C., 2005

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Immune & Inflammatory responses diminish

which means:

The advanced lung cancer patient is at an increased risk for infections

The AGING advancedlung cancer patient hasless ability to adapt to

environmental stressors

Decreases their immune

responsiveness &

abilityto heal wounds

Porth, C., 2005

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Aging can be viewed as a low-grade chronic inflammatory state which is termed as “

inflammaging”

Porth, C. 2005 & Franceschi, C. & Bonafe, M. 2003

If the GAS is constantly stimulated, what does this mean for the

aged advanced lung cancer patient?

Due to the thymus decreasing in size as we age , this affects

T-Cell function within the body.

Ultimately, compromises the immune system

responsiveness to heal wounds.

Due to inflammaging, this can cause

chronic activation of inflammatory responses.

Eventually, leads to the infiltration of

macrophages, lymphocytes, &

fibroblasts, which causes persistent swelling and scar

formation to occur.

Click on ARROW twice

Cancer-Related Causes of DYSPNEA:

1)Direct cause of the cancer

2)Indirect result of the cancer

3)Result of cancer treatment

4) Other

DIRECT -Primary or metastatic cancer to lung

- Pleural tumor

- Pericardial effusion

- Ascites

Permission from http://images.wellcome.ac.uk/

Tyson, L. (2006)

INDIRECT-Anemia

-Pneumonia

- Pulmonary emboli

- Cachexia

Dyspnea from Treatment 1) Surgery

2) Radiation (which can cause)- - Pulmonary Pneumonitis - - Pulmonary fibrosis

Polovich, M., Whitford, J., & Olsen, M. (2009).

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3) Chemotherapy agents that can either cause:

- Pulmonary EdemaCytoxan, Gemzar, Methotrexate, Mitomycin

- Pulmonary Pneumonitis/FibrosisCytoxan (later development), Gemzar (later sign of fibrosis), Bleomycin (Pneumonitis), Methotrexate, Carmustine

- Obesity- Age - Asthma- CHF or COPD

Co-Morbidities that cause

Dysnpea

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Other: - Anxiety

DiSalvo, W., at el., (2008)

Oncology Nursing Society (ONS)

In 2003, ONS developed their own definition of oncology nursing-sensitive

patient outcomes(NSPO’s), which focused around:

Oncology Nursing Society, 2003

-Patient’s problems are significantly affected by nursing interventions.

-Interventions developed within the scope of nursing practice; are sensitive to nursing care and represent the consequences or effects of nursing interventions

-Result in changes in patients' symptom experience, functional status, safety, psychological distress, and/or cost

NSPO’s forDyspnea:

1)Symptom Management- Decrease in patient’s perception of breathlessness- Patient maintains activity level within capabilities- Respiratory rate remains at comfortable level- Patient is able to manage episodes of dyspnea

2) Psychosocial Distress- Promoting relaxation and stress reduction- Education and support to patients and their families

Crowley. (2005) & ONS PEP, (2008)

ASSESSMENT

1)SUBJECTIVE (Pt’s own description, feeling, of breathlessness)

- At rest- With activity- Assess dyspnea with a Visual Analog scale

- Number Scale (1-10)- Mild-Moderate-Severe

2) VITAL SIGNS- Respiratory rate (Rate, Irregular, Depth)- Weight

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Assessment Cont…3) CARDIOPULMONARY:

- Accessory Muscle use- Edema - Tachycardia

- Underlying cause (fever, etc.)

- Auscultation -Wheezes, crackles, cough

- Secretions (amount, consistency)

4) INTEGUMENTARY:- Pallor (Anemia)

- Cyanosis (Low oxygen, hypoxia) Itano, J. & Taoka, K. (2005)

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Assessment Cont…5) MENTAL STATUS

- Restlessness- Confusion- Memory Difficulties

6) PSYCHOSOCIAL Distress:- Depression- Anxiety- Fear

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G. S. is a 65 year-old man diagnosed with Stage IV Lung cancer in October 2009

- His presenting symptom at the time of diagnosis is rib pain.- During the next few weeks, G.S has received several radiation treatments to his ribs.- After his radiation treatment, G.S has also received system chemotherapy.

(Up to this point, G.S. has tolerated this treatment fairly well)

December of 2009 (post radiation/chemotherapy tx) G.S had a PET scan that showing worsening enlargement of primary tumor.

January 2010 G.S. was switched to salvage Taxotere chemotherapy regimen

Over the next few weeks to months G.S. is seen in the clinic with increased weakness, hypotension, nausea, and dehydration.

Continued

Today March 2010, G.S is seen in the clinic:

- G.S. is looking frail & ashen in color- Knees down bilateral has +3 pitting edema- Oxygen saturation measuring at 87% on room air- No appetite- Lost of five pounds since February - Denies any pain- C/o of shortness of breath with activity- Uses a walker to assist with ambulation- C/O of insomnia, due to trouble breathing at night- On auscultation: fine wheezes heard throughout bases of lungs

HOME MEDICATION:

- MS Contin 30 mg BID- Fluconazole 200 mg- Ativan 0.5-1 mg every 8 hrs PRN- Oxycodone 5 mg (1-3) every 2 hrs PRN

These are all possible Nursing Interventions to help relieve G.S’s DYSPNEA.

Click on all the buttons at the bottom to understand WHY?A) Suggest to G.S to get a prescription of Morphine Sulfate in an immediate release

capsules to help relieve his dyspnea

B) On assessment, heard audible wheezes in upper lung fields. Suggest an albuterol inhaler treatment

C) Suggest to G.S to take his Ativan before strenuous activities & before sleep to help relieve his anxiety

D) G.S. oxygen saturation on room air was 87%. Supplement oxygen to help relieve his dyspnea.

E) Due to the edema (swelling) in his legs, ask his physician for an order of lasix

F) Suggest to his wife to place a fan on G.S’s face and nose, as this might help relieve his dyspnea or use breathing techniques to slow down his breathing during periods of dyspnea.

G) Educate G.S on relaxation techniques & encourage G.S to sleep in his recliner to keep upper body at least at 45-90 degree angel to help with sleep.

A B C D E F G

Opioids on Cancer-RelatedDyspnea

• Immediate-release oral agents

• Parenteral

RECOMMENDED for Practice:

• Morphine (most common)• Hydromorphone (Dilaudid)

WHEN OXYGEN OR REST DO NOTRELIEVE DYSPNEA

NCCN, 2010, DiSalvo, W., Joyce, M., Tyson, L., Culkin, A., & Mackay, K., 2008, & Oncology Nursing Society, 2008.

Theory of OPIATES

Act at central/periphe

ral opioid receptors sites

& central nervous

system (Respiratory

center)

Respiratory

drive at rest and activity

Block respiratory responses to hypoxia

& hypercapni

a

Wickham, R. (2002) & Gift, A. & Hoffman, A. (2007)

MORPHINE

Opioids have a depressant effect on the central nervous system, which alleviate dyspnea by blocking the neural signals to hypoxia &

hypercapnia.

Recommendations:Treating COUGH/DYSPNEA/ or AIR HUNGER

- 2-10 mg Morphine orally every 4 hr prn- 1-4 mg Morphine IV every 4 hr prn

1) RE-ASSESS patient

2) SIDE EFFECTS: dysphoria, dizziness, drowsiness, urinary retention, constipation.

Re-assure patient: Opiates will help them rest without the feeling of “suffocation”

REMEMBER!!

Naïve Vs

Tolerant

LOWER dose of

Morphine used to treat

Dyspnea, BUT

Action of Morphine

for dyspnea is shorter

than its analgesic effects!

Jantarakupt, P. & Porock, D. (2005), NCCN, 2010, & Wickham, R. (2002).

NCCN, 2010

Patient/Family MYTHS & FEARS about OPIOIDs

1)ADDICTION- Reassure patient they are taking opioids to relieve their

cancer-related dyspnea. Dyspnea can change from day to daydepending on the progression of their disease state. As nurse providers, reassure patient that the dosage may increase in the future due to repeated administration of that opioid dose. The body will eventually build up a tolerance for that dose of opioids and the individual will not be receiving the desired effect.

2) Over SEDATION- Reassure patient we will be monitoring them while receiving opioids- This is for palliative treatment of dyspnea, so titrating the opioid dosage may be necessary to get the desired effect.- As the individual transitions from palliative care to hospice…

Retain increased amounts of carbon dioxide

Causes

Sleep & a comatose state to

occur with the dying patient regardless if opioids are

administered or not

DYING patient’s

breathing is now more rapid & shallow

Wickham, R. (2002) & Johnston, M. (2007).

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QUIZ1)Are extended-release opioids just as

effective as immediate-release?CORRECT!

Immediate-release opioids have been shown to be

effective in practice when treating dyspnea.

Sorry Extended-Release opioids

have NOT been established to show

effectiveness towards treating dyspnea

FALSETRUE

In the case of G.S, immediate-release opioids are an appropriate intervention, because he has already has been exposed to opioids. REMEMBER… he is opioid

tolerant, so G.S. might need to repeat the dose more frequently to treat the DYSPNEA. As nurse providers, we need to console & support G.S. if he has any

fears of using opiods, because sedation & addiction can be a fear patients have with opioid usage. KEEP the patient’s GOAL in mind & reassure G.S. that this intervention

will be able to get him through tough periods of dyspnea to be able to endure certain activities.

Bronchodilators•Inhaled or Nebulized

-B2 –adrengergic agonist

• Albuterol

decreases

WORKLOAD of the lungs

Nebulized Opioids??Believed to “TARGET” stretch and

irritant receptors in

the lungs

SYSTEMIC TOXICITY

Jantarakupt, P. & Porock, D. (2005) & Kallet, R., (2007)

NOT Recommend for Practice

Due to:Insufficient Evidence

Bronchodilators relaxes smooth muscles within

the bronchioles

CORRECT On assessment you heard wheezing throughout lung

fields to suggest vasoconstriction within

bronchioles. An albuterol treatment would be an

appropriate intervention for G.S’s dyspnea.

Sorry Short-Acting bronchodilators are more effective for patient’s who have either air flow obstruction

such as COPD, asthma, or patient’s with lung cancer & is

presenting with wheezing throughout lung fields to suggest

vasoconstriction.

Quiz1) Which option is correct to suggest an albuterol

inhaler to treat G.S’s dyspnea?

G.S complained of shortness of breath

while walking to the bathroom?

On auscultation, you heard wheezes throughout G.S.’s

lung fields

Wickham, R. 2005

Benzodiazepines•Lorazepam

• Diazepam

Recommended Dosages: Ativan: 0.5-1 mg orally or IV q 4 hrs prn

Diazepam: 2 mg po/SQ/IV q 12 hours (NCCN, 2010)

Sedative action ANXIETY that stimulates dyspnea!!

DO NOT WORK

DIRECTLY ON THE LUNGS

Jantarakupt, P., & Porock, D., (2005) & NCCN, (2010). & Wickham, R., (2002)

Sorry Benzodiazepines do not directly

work on the lungs to relieve dyspnea. Benzodiazepines are used for their

sedative use to decrease anxiety that is commonly associated with

dyspnea.

QuizTrue or False:

Do benzodiazepines work directly on the lungs to relieve Dyspnea?

TRUE

YES Benzodiazepines

treat anxiety associated with dyspnea and do

not directly treat dyspnea. In G.S’s case, this can help his anxiety & let him be able to

sleep at night with out the fear of

suffocation.

FALSE

OXYGEN- Increase oxygen saturation (SaO2)

- Hypoxia is present

DYSPNEA• Lowers respiratory RATE• Lowers respiratory EFFORT

Non-hypoxic Patients?

FEAR and AnxietyJantaarakupt, P. & Porock, D. (2005)

Patient’s with advanced lung cancer have less ability to remove carbon dioxide or

transport oxygen to other parts of the body due to the physical changes cancer makes

within lung tissue. Patient’s with a history of COPD will be at higher risk of retaining

CO2.

CAUTION!! CO2 Retainers

Click on box

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QuizTrue or False

Oxygen therapy is ONLY for patient’s who are truly hypoxic?

IncorrectOxygen therapy is primarily used for

hypoxic patients, but in cases of advanced lung cancer patient’s who are experiencing dyspnea, oxygen has been proven to help relieve the feeling of shortness of breath.

True

Correct Oxygen therapy can be used for hypoxic & non-hypoxic advanced lung

cancer patient’s experiencing dyspnea. CAUTION should be used when titrating

oxygen if patient is a CO2 retainer. In the case of G.S. he is truly hypoxic

when his oxygen saturation was at 87% on room air. Oxygen therapy would be an appropriate intervention to treat his

dyspnea.

False

OTHER Treatments:Steroids & NSAIDS

Side effects of steroids: Gastric toxicity, fluid retention, hyperglycemiaLasixGiven when a patient is experiencing:

1) Pulmonary congestion2) Lower extremity edema

INFLAMMATION in the LUNGS to

relieve dyspnea

Gift A. & Hoffman, A. (2007).

More effective for patient’s with pre-existing conditions such as COPD

LASIX is given for fluid overload to

Decrease the demand on the

heartJantarakupt, P. & Porock, D., 2005 & Wickham, R. 2005

What is the relationship betweenG.S’s lower extremity edema and

him experiencing DYSPNEA?

In G.S.’s situation, there could be multiple factors causing his lower leg edema, such as malnutrition, medications, and/or worsening of his lung cancer involvement . The edema

is causing his heart to pump harder to compensate for the extra fluid, which is

causing G.S. to have dyspnea at rest &/or with activities. Lasix would be an appropriate short term fix to help with the edema in lower

extremities & relieve dyspnea.

CLICK ON

Hoffman, A. & Gift, A. (2007)

1)Breathing Techniques - Pursed-lip and diaphragmatic breathing

(Shown to optimize lung function, decrease stress, & relaxthe breathing for that patient)

2) Increase airflow (generated by a FAN)

- Face- Nose

(Gives the perception of more airflow to the individual, which may reduce the feeling of dyspnea)

3) Providing COOLER temperatures- Decrease the feeling of dyspneaDiSalvo, W., Joyce, M., & Belansky, H. (2009)

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4) Positioning

- Sitting up (expansion of lungs)

5) Promoting Relaxation Stress Reduction

- Massage- Reducing external noise

(Decrease anxiety & stress associated with dyspnea)

6) Emotional & Psychosocial Support

(Coaching and support have been shown to decrease the feeling and anxiety associated with

dyspnea)

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Andry, J. (2008) & Tyson, L (2006)

Key Points to REMEMBER:

-Dyspnea is a SUBJECTIVE feeling & a debilitating symptom that patients experience.

- Key ASSESSMENT skills are crucial to help understand the underline cause of the dyspnea and/or the treatment options.

-Be consciously aware of evidence-based interventions that are already incorporated into nursing practice, whether the dyspnea is oncology related or not.

-Dyspnea is a symptom that can CHANGE from day to day. Reassure the patient of this and the multiple interventions we can help to relieve dyspnea.

-Lastly, keep the patient’s GOAL in mind. Are the interventions appropriate and will the patient be able to enjoy certain activities with some of the side effects that may occur. Just remember to communicate & educate patients on theseinterventions and just maybe, we can give them a little relief from their dyspnea!

KEY POINTS TO

REMEMBER

REFERENCES:

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DiSalvo, W., Joyce, M., Tyson, L., Culkin, A., & Mackay, K. (2008). Putting Evidence Into Practice: Evidence-Based Interventions for Cancer-Related Dyspnea. Clinical Journal of Oncology Nursing. 12(2) pp. 341-352.

Jantarakupt, P. & Porock, D. (2005). Dyspnea Management in Lung Cancer: Applying the Evidence From Chronic

Obstructive Pulmonary Disease. Oncology Nursing Forum. 32(4), pp. 785-795.

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Wickham, R. (2002). Dyspnea: Recognizing and managing an invisible problem. Oncology Nursing Forum, 29, 925-933.

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