Non-small cell lung cancer

Prepared by:Chan Lai Jie, A136321

Year 4,Semester 1,UKM

Non-small cell lung cancer

Definition: A group of lung cancers that are named for the kinds of cells

found in the cancer and how the cells look under a microscope. The three main types of non-small cell lung cancer are squamous cell carcinoma, large cell carcinoma, and adenocarcinoma. Non-small cell lung cancer is the most common kind of lung cancer.

Pathophysiology: Both exposure (environmental or occupational) to particular

agents and an individual’s susceptibility to these agents are thought to contribute to one’s risk of developing lung cancer. In the United States, active smoking is responsible for approximately 90% of lung cancer cases. Occupational exposures to carcinogens account for approximately 9-15% of lung cancer cases.

The types of non-small cell lung cancer are named for the kinds of cells found in the cancer and how the cells look under a microscope: Squamous cell carcinoma: Cancer that begins in squamous cells,

which are thin, flat cells that look like fish scales. This is also called epidermoid carcinoma.

Large cell carcinoma: Cancer that may begin in several types of large cells.

Adenocarcinoma: Cancer that begins in the cells that line the alveoli and make substances such as mucus.

Signs and symptoms NSCLC is often insidious, producing no symptoms until the disease is well

advanced. Early recognition of symptoms may be beneficial to outcome. At initial diagnosis, 20% of patients have localized disease, 25% of

patients have regional metastasis, and 55% of patients have distant spread of disease. Symptoms depend on the location of cancer (Spiro SG et al. 2007)

The most common signs and symptoms of lung cancer include the following: Cough Chest pain Shortness of breath Coughing up blood Wheezing Hoarseness Recurring infections such as bronchitis and pneumonia Weight loss and loss of appetite Fatigue

Metastatic signs and symptoms may include the following: Bone pain Spinal cord impingement Neurologic problems such as headache, weakness or

numbness of limbs, dizziness, and seizures

Diagnosis Testing After physical examination and CBC, chest x-ray is often the

first test performed. Chest radiographs may show the following:

Pulmonary nodule, mass, or infiltrate Mediastinal widening Atelectasis Hilar enlargement Pleural effusion

There are several methods of confirming diagnosis, with the choice determined partly by lesion location. These methods include the following:

Bronchoscopy Sputum cytology Mediastinoscopy Thoracentesis Thoracoscopy Transthoracic needle biopsy (CT- or fluoroscopy-guided)

Staging A chest CT scan is the standard for staging lung cancer. The

TNM (tumor-node-metastasis) staging system from the American Joint Committee for Cancer Staging and End Results Reporting is used for all lung carcinomas except small-cell lung cancer. The TNM takes into account the following key pieces of information:

T describes the size of the primary tumor N describes the spread of cancer to regional lymph nodes M indicates whether the cancer has metastasized

Medical Management

- Surgery : Lobectomy – removing a section of the lungPneumonectomy – removing the entire lungWedge resection – removing part of a lobe

- Chemotherapy

- Radiation

Physiotherapy Managementa) Gravity-assisted drainageb) Chest wall vibrationsc) Manual lung hyperinflation

(King D, Morrell A 1992)(a) to (c): assist in the reexpansion of atelectatic lung (Stiller K et al., 1996) Provide short-term improvement in total lung-thorax compliance

(Jones AY, Hutchinson RC, Oh TE, 1992) and expiratory flow rate (MacLean D et al., 1989)

Positioning to optimize gas exchange and subsequently increase lung volume Moderate unilateral effusion: side ly. with affected lung uppermost

because greater perfusion and ventilation in the lower lung. V/Q is usually mismatched if the affected lung is dependant.

(Gillespie and Rehder, 1987) However, if patients present with large effusion, side ly. with the

unaffected lung uppermost showed to increased PaO2 d/t decreased compression. (Chang et al. 1989)

Deep breathing exercise / Thoracic expansion exercise lungs cannot be expanded under pressure of fluid. Is performed after the effusion has been drained.

(Dechman, 1993) Benefits:

Increases lung volume (Jones et al., 1997) Increases ventilation and decreases airway resistance (Menkes and

Britt, 1980) Increases diffusion (Prabhu et al., 1994) Increases oxygen saturation (Ruggier et al., 1994; Dallimore et al.,

1998) With slow breathing, improves basal ventilation (Reid and Loveridge,

1983)

Can be performed together sustained maximal hold (SMI) for 3 sec To ensure transpulmonary pressure are sufficiently generated and

maintain for an appropriate length of time to expand the atelectatic alveoli.

(Bakow, 1977)

CASE STUDYSubjective Name : Mrs C RN : 141P09001353 Age : 56 Gender : Female Date of Admitted: 22/9/2014 Date of Assessment: 30/9/2014 Dr. Diagnosis: Non-small cell lung cancer

stage IV metastatic to brain

Dr Mx: Conservative Refer chest physio

Present problem: Pt c/o SOB during exertion and bilateral leg weakness

Current Hx: 22/09/14 – admitted d/t breathlessness 23/9/14 – sudden cardiac arrest in ward , resuscitated &

intubated with SIMV mode 24/09/14 – extubated and put on biPAP 25/09/14 – patient not tolerable , intubated with SIMV mode

Past Hx: History of admission to PHKL since 2011. Dec of 2011

- admitted d/t unproductive cough for 3/12 and SOB on exertion for 1/12 - Dr’s management : pleural biopsy, bronchoscopy & insertion of Lt. chest tube- Final Diagnosis : metastatic adenocarcinoma lung

PMHx: Nil

Past Surgical Hx: Nil

Medication: Potassium chloride in IVD 1pieNACL 12hourly Xanax 0.5mg Paracetamol 500mg 8hourly Dexamethasone 1mg daily

Investigation: CXR done on 29/9/2014, AP view

Interpretation: Consolidation in Lt. upper lobe has increased Dense consolidation with loss of volume seen in Lt. lower lobe Opacities in the Rt. Lung appears more

ABG analysis on 29/09/2014pH : 7.471PCO2: 41.5 mmHgPO2 : 181.2 mmHgHCO3 : 29.6 mmol/L

Interpretation: Acute Metabolc alkalosis

Family Hx: Father died at 89 (past hx of pulmonary tuberculosis)

Social Hx:- Married with 3 children - non-smoker - no alcohol consumption- no allergies

Home environment: Stay together with husband and daughter

Occupation: Housewife

Hobby: No specific hobby

Changes in daily activities 3 months ago, sudden onset of lower limbs weakness but still able

to walking independently and cooking.

Premorbid Status: Able to ambulate independently at home.

Patient’s Goal: Hope not to get breathlessness easily in daily life

Objective Assessment General Observation:

Pt is a moderate-sized, middle-aged Chinese lady, ly. on the bed with prop up at about 30 ̊.

Pt is conscious, alert, able to follow commands.

Local Observation: Pt is on P/SIMV, FiO2=0.6 PEEP=5 Ppeak=15 Pt has CBD and ETT attached Pt has artline at Rt. cubital fossa. Pt has central venous line with Triple lumen in jugular vein Pt has non-pitting edema on Rt. hand ̊redness, ̊ cyanosis

Breathing level: Diaphragmatic Breathing pattern: Rapid & Shallow Chest deformity: Nil Cough reflex:

Present but poor

Palpation: Auscultation

Transmitted sound scattered around the lung Fine crackles over bilateral lower lobes Decreased air-entry on bibasal lower lobes

Fermitus : Yes (Rt. > Lt.)

Percussion note: Stoney dull at Lt Upper and lower lobes Resonance sound at Right lungs

Chest expansion: Manubriosternal jt : Poor Xiphisternal jt : Poor 10th rib : Poor

ROM Generally,

Joint Rt. Lt.Shoulder

Elbow AFROM

AFROM

Wrist Hand Hip Knee

PFROM PFROM

Ankle

Muscle power (MRC) :

Muscle Rt. Lt.Sh. FlexorsSh. ExtensorsSh. AbductorsSh. Adductors Elb. Flexors 3/5 3/5Elb. ExtensorsWrist Flexors Wrist ExtensorsGrip

Muscle Rt LtHip FlexorsHip ExtensorsHip AbductorsHip AdductorsKn. Flexor 1/5 1/5Kn. ExtensorAnkle dorsiflexorAnkle Plantarflexor

Vital Signs: HR: 69 bpm Temp : 37.0 ̊C BP: 105/54 mmHg PR: 69 bpm RR: 20 breath/min SpO2: 100% on P/SIMVInterpretation: Pt on mild tachypnea

Bed mobility: Rolling : Pt able to do rolling by herself under supervision

Analysis

• Reduce air entry on bibasal lower lobes d/t secretion retention.

• Retention of secretion due to sedative effect and reduced cough reflex

• Decrease chest expansion d/t reduce in thoracic mobility

• Rapid & shallow breathing pattern d/t incorrect breathing technique

• Reduce muscle power d/t prolonged immobilization

Short Term Goals

Improve airway clearance within 2 days.

Improve the breathing pattern within 3 days.

Improve chest expansion within 3 days.

Improve muscle power within one week

Long Term Goals

To regain optimal cardiovascular and respiratory function within one month

To maintain airway clearance. To maintain joint range and

muscle power

Plan

Airways clearance techniques Breathing exercise Thoracic mobility exercise Active free exercise/Active-assisted exercise Ankle circulatory exercise Positioning Pt education

Intervention Half ly.; deep breathing exercise; 5 reps;

3sets Half ly.; thoracic mobility exercise: bilateral

arms elevation during inspiration and lowering during expiration; 5 reps; 3sets

Half ly.; active free exercise for both upper limbs; 5 reps

Sup. ly. with bilateral leg elevation; bilateral ankle dorsiflexion and plantarflexion; 30 reps

Lt side ly.; gentle vibration over Rt lateral and posterior basal (Jennifer A Pryor, 2003)

Rt side ly.; gentle vibration over Lt lateral and posterior basal (Jennifer A Pryor, 2003)

Supine ly.; suction done by S/N via ETT and oral

Position pt in Rt. Side ly. : prop up to 30 ̊ Patient education:

Encourage side ly. on Rt side (Gillespie and Rehder, 1987) Ask pt to do the breathing exs and ankle circulatory exs taught

hourly.

Evaluation

Pt is cooperate and able to perform all the exercises taught.

Sputum: Colour: whittish Amount: large Consistency: loose

Airflow: Airflow increase from 0.2 L to 0.3 L during perform

deep breathing exercise

Vital Signs: HR: 80 bpm BP: 146/60 mmHg PR: 72 bpm RR: 28 breath/min SpO2: 100% on P/SIMVInterpretation: Pt’s on tachypnea

Auscultation: Crackles disappears Air entry improve for bibasal lower lobes Transmitted sound remain

Review

Reassess auscultation, chest expansion, breathing level, breathing pattern

Review intervention

Follow Up(08/10/2014)

Subjective

Dr Mx: Ventilator mode change to CPAP

Present problem: Pt c/o SOB during turning by S/N

Investigation: CXR done on 08/10/2014, AP view

Analysis: Opacities in the right lung reduce Consolidation in Lt. upper lobe has reduced Volume loss in left lower lobe

Objective General Observation:

Pt is a moderate-sized, middle-aged Chinese lady, ly. on the bed with prop up at about 30 ̊.

Pt is conscious, alert, able to follow commands but look lethargic.

Local Observation: Pt is on CPAP, FiO2=0.35 PEEP=5 Ppeak=15 Pt has CBD and ETT attached Pt has artline at Rt. cubital fossa. Pt has central venous line with Triple lumen in jugular vein Pt has non-pitting edema on Rt. hand ̊redness, ̊ cyanosis

Breathing level: Diaphragmatic Breathing pattern: Rapid & Shallow Chest deformity: Nil Cough reflex:

Present but poor

Palpation: Auscultation

Transmitted sound scattered around the lung Fine crackles over bilateral lower lobes Decreased air-entry on bibasal lower lobes

Fermitus : Yes (Rt. > Lt.)

Percussion note: Stoney dull at Lt Upper and lower lobes Resonance sound at Right lungs

Chest expansion: Manubriosternal jt : Poor Xiphisternal jt : Poor 10th rib : Poor

ROM Generally,

Joint Rt. Lt.Shoulder

Elbow AFROM

AFROM

Wrist Hand Hip Knee

PFROM PFROM

Ankle

Muscle power (MRC) :

Muscle Rt. Lt.Sh. FlexorsSh. ExtensorsSh. AbductorsSh. Adductors Elb. Flexors 4/5 4/5Elb. ExtensorsWrist Flexors Wrist ExtensorsGrip

Muscle Rt LtHip FlexorsHip ExtensorsHip AbductorsHip AdductorsKn. Flexor 2/5 2/5Kn. ExtensorAnkle dorsiflexorAnkle Plantarflexor

Vital Signs: HR: 101 bpm BP: 114/91 mmHg PR: 101 bpm RR: 38 breath/min SpO2: 97% Interpretation: Pt. on tachycardia and tachypnea

Bed mobility: Rolling : Pt able to do rolling by herself under supervision

Analysis

• Reduce air entry on bibasal lower lobes d/t secretion retention.

• Retention of secretion due to sedative effect and reduced cough reflex

• Decrease chest expansion d/t reduce in thoracic mobility

• Rapid & shallow breathing pattern d/t incorrect breathing technique

• Reduce muscle power d/t prolonged immobilization

Plan

Airways clearance techniques Breathing exercise Thoracic mobility exercise Active free exercise/Active-assisted exercise Ankle circulatory exercise Positioning Pt education

Intervention Half ly.; deep breathing exercise; 5 reps;

3sets Half ly.; thoracic expansion exercise:

breath against hands on lateral chest wall; 5 reps; 3sets

Half ly.; active assisted exercise for both lower limbs; knee bending and straightening exercise; 5 reps; 3 sets

Lt side ly.; gentle vibration over Rt lateral and posterior basal (Jennifer A Pryor, 2003)

Rt side ly.; gentle vibration over Lt lateral and posterior basal (Jennifer A Pryor, 2003)

Supine ly.; suction done by S/N via ETT and oral

Position pt in Rt. Side ly. : prop up to 30 ̊ Patient education:

Encourage side ly. on Rt side (Gillespie and Rehder, 1987) Ask pt to do the breathing exs and ankle circulatory exs taught

hourly.

Evaluation Pt appears paradoxical breathing pattern

after performing breathing exercise, so let pt to rest.

Vital Signs: HR: 111 bpm BP: 169/152 mmHg PR: 111 bpm RR: 39 breath/min SpO2: 97%Interpretation: Pt. on tachycardia, tachypnea and hypertension.

Sputum: Colour: whittish Amount: large Consistency: loose

Auscultation: Crackles disappears Air entry improve for bibasal lower lobes Transmitted sound remain

Airflow: Airflow increase from 0.2 L to 0.3 L during perform deep

breathing exercise

Review

Reassess auscultation, chest expansion, breathing level, breathing pattern, coughing effort

Review intervention KIV sitting up patient after pt tolerate with CPAP

References Russell T. Attridge. Pharmacotherapy Conference November 20, 2009 Jennifer A Pryor. Physiotherapy for Respiratory and Cardiac Problems

Adults and Peadiatrics. 3rd Edition. 2004 Alexandra Hough. Physiotherapy in Respiratory Care: An evidence-based

approach to respiratory and cardiac management. 3rd Edition. 2001. Richard W. Light. Management of parapneumonic effusions.Egyptian

Journal of Bronchology. 2008. Vol 2, No 1. John G. Bartlett. Practice Guidelines for the Management of Community-

Acquired Pneumonia in Adults. Clinical Infectious Diseases 2000;31:347–82

G. Ntoumenopoulos. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med (2002) 28:850–856

Beatrice Tucker and Sue Jenkins. The effect of breathing exercises with body positioning on regional lung ventilation. Australian Physiotherapy.1996. Vol 42,No 3.

Bakow, E. Sustained maximal inspiration-a rationale for its. Respiratory care. 1977. Vol 22 No 4.