Episode 295: Cancer Symptom Management Basics: Pulmonary Embolism, Pneumonitis, and Pleural Effusion

"So much of this is just knowing what is their diagnosis, what medications are they on, what could be the root cause of this—where is their disease to begin with? There's really a lot of differential diagnosis and workup that has to be thought about, you know, when you're dealing with shortness of breath and pulmonary toxicities," Beth Sandy, MSN, CRNP, OCN®, thoracic medical oncology nurse practitioner at the Abramson Cancer Center at the University of Pennsylvania in Philadelphia, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a discussion about just a few of the pulmonary toxicities oncology nurses may encounter in patients receiving pharmaceutical cancer treatments. This episode is part of a series on cancer symptom management basics; the rest are linked below. You can earn free NCPD contact hours after listening to this episode and completing the evaluation linked below. Music Credit: " Fireflies and Stardust " by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: The learner will report an increase in knowledge of pulmonary complications from cancer treatment. Episode Notes The NCPD activity for this episode has expired, but you can still earn NCPD through many other ONS Podcast episodes. Find a full list of opportunities . Oncology Nursing Podcast Cancer Symptom Management Basics series ONS Voice articles: Pneumonitis With Immunotherapy Treatment Hematologic Cancers Have Higher Long-Term Risk of Clots and Bleeding Clinical Journal of Oncology Nursing articles: Durvalumab Immunotherapy: Nursing Management of Immune-Related Adverse Events During the Journey of Patients With Stage III Non-Small Cell Lung Cancer Heart and Lung Complications: Assessment and Prevention of Venous Thromboembolism and Cardiovascular Disease in Patients With Multiple Myeloma Chronic Obstructive Pulmonary Disease: Clinical Implications for Patients With Lung Cancer Oncology Nursing Forum article: Multifactorial Model of Dyspnea in Patients With Cancer ONS book: Understanding and Managing Oncologic Emergencies: A Resource for Nurses (third edition) ONS Symptom Interventions and Guidelines™: Dyspnea To discuss the information in this episode with other oncology nurses, visit the ONS Communities . To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library . To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org . Highlights From Today's Episode "Your lungs are what is needed to have the gas exchange within your bloodstream. So, when we inhale, we're inhaling oxygen, and we need that gas exchange to occur in the alveoli, which are the tiny, little bubble-like structures within the periphery of the lungs. And they're communicating with tiny, itty-bitty little blood vessels. And that's where the gas exchange occurs, where you get rid of the carbon dioxide from the blood and you get oxygen to the blood. And what ends up happening is there is, for whatever reason it may be, that gas exchange can't occur, and that can result in so many different forms from different toxicities, whether there's an inflammation causing the alveoli not to work correctly, whether there's an obstruction where there's literally something obstructing the air getting into the lungs, or whether there's compression from an external source like a fusion or something like that that is pressing against the lungs where that gas exchange cannot occur." TS 2:36 "Pulmonary embolism, I'll tell you, is one of the most common things that we see in cancer. As a matter of fact, often patients are diagnosed with cancer because they present with a pulmonary embolism into the E.R. (emergency room) and there's really not a lot of reasons why healthy-otherwise patients develop a PE [pulmonary embolism]. So, we start looking for cancer. So, just having cancer in general puts you in that hypercoagulable state. . . . And then, being on chemotherapy increases that risk." TS 6:38 "I think we need to really make sure that they're compliant. We need to make sure they're not having bleeding. Are you having significant bruising anywhere? Are you having unprovoked nosebleeds? And by that, I mean, I always tell people, 'Were you just sitting watching TV and it started dripping?' versus, 'Oh, I blew my nose and some blood came out.' Okay, well, that is probably pretty common side effect of this and should stop quickly." TS 12:06 "The problem is the majority of these patients have metastatic disease or an incurable cancer. So, we prefer not to stop it [PE medication] in those patients because if you think about it, their risk comes from the cancer. And we're not getting rid of that if they have metastatic disease. I think for those patients with metastatic disease, as long as they're tolerating it, they're not having bleeding events, we will typically tend to just keep them on it." TS 13:09 "The main difference with the targeted therapies is it tends to be worse, and it's not something that you can rechallenge. And I think that's kind of one of the most important things to think about here. In immunotherapy, it's like, okay, it's T-cell mediated; we gave you corticosteroids; it calmed itself down. And a lot of times we can rechallenge, and we don't necessarily see it again. Whereas with targeted therapies, you have to be much more cautious. If you look at the package inserts for the EGFR and ALK inhibitors, most of them are going to tell you this is not something you ever rechallenge. Any kind of symptomatic pneumonitis, you're going to permanently discontinue the drug. Because if you give it again, it's going to recur in a pretty bad way, where corticosteroids may not even be helpful again even if you rechallenge them." TS 17:52 "What can happen in cancer, typically, thoracic cancers—so lung cancer, mesothelioma for sure, thymic cancers like thymomas and thymic carcinomas—often will have pleural effusion or pleural disease as well. But when cancer cells get into that fluid, there's irritation which causes an increase in the amount of fluid there. And then what happens is when that space, that pleural space, is now enlarged with fluid or engorged with fluid, a few things occur here. Patients are short of breath because it's a pressure gradient there. So, you're trying to inhale against this fluid-filled cavity that's making it hard. So, often patients will describe it as it feels like someone's giving you a really tight hug and they won't stop." TS 21:59 "There is another procedure called a talc pleurodesis, where you can have a procedure where you inject some powder in there that will kind of dry it up. The downside of that is that it kind of fuses the pleura to the lung, so there can be some complications there, some pain, and decreased lung function just from doing that, but it can be an easy fix that you certainly don't want to have an indwelling catheter there." TS 25:11 "So, patients need to know, if they are short of breath at all, call us; let us know. The other thing that's important is know with their baseline vital signs are, especially their pulse ox. You know, some people, their pulse oximetry may be in the low 90s or upper 80s at baseline. We need to know that because there's a big difference if a patient has, you know, they're living at 99% versus 91% normally. Because if they come in and they live at 99 and they're 91, that's a huge drop. But if they come in and they were 91 to begin with and they're 90, that's not a big difference. So, we really do need to make sure we know what their baseline is before they're starting any treatments." TS 29:18 "This is not something that you want to downplay. You can't sit there and say, you know, 'Oh, they smoke a lot, so it's probably that.' Or, 'They have this type of cancer, so it's probably that.' I think this is something that you have to take shortness of breath seriously, and you have to work up and understand and know your patient. But for the most part, this is not something you're going to just triage to the next day or to a few days later. You're going to need some kind of urgent intervention or workup to be done pretty quickly." TS 32:54 "I think the biggest misconception is that they can't be treated even if they're severe. Most of these things can be reversed. Part of it is just diagnosing it at first and then going from there and starting the appropriate treatment strategy." TS 33:29