UPPER AND LOWER AIRWAY ALTERATIONS FROM CANCER

104/19/23

204/19/23

TEACHING CLIENTS ABOUT RISK FACTORS

****Smoking and ETOHair pollution & industrial exposurevocal straining/chronic laryngitis

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ASSESSMENTS

If Client has history of following for 3-4 weeks should suspect laryngeal

cancerHoarsenessLump in mouth, throat, neckMouth sores that don’t heal

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Late ASSESSMENTS

DysphagiaFoul breathChronic cough/HemoptysisDyspneaSore throat/sores in throat/burning

when drinking citrus juices or hot liquidsPersistent, unilateral ear pain

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Signs of Metastasis

METASTASIS occurs to local structures first (mucosa, muscle, bone)

LATER METASTASIS: spread by blood and lymph to lung and liver

ASSESSMENTS INDICATING METASTASIS: Enlarged cervical lymph nodesWeight lossGeneral debility

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ASSESSMENTS: Diagnostics

Panendoscopy under general anesthesia: (laryngoscopy, nasopharyngoscopy, esophagoscopy, bronchoscopy)

MRI/CT/SPECT/PET scansXraysBiopsy: squamous cell

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TREATMENT

Varies depending upon location and metastasis• Radiation (may be used to shrink tumor size)• chemotherapy• surgery

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SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE

SURGERY TYPE• LASER SURGERY: reduce

tumor• CORDECTOMY: partial

removal of one vocal cord• HEMI-LARYNGECTOMY:

removal of one vocal cord or part of a cord; temporary tracheostomy

VOICE QUALITYNormal, hoarse

Normal/hoarseHigh cure rate

Voice is breathy and hoarse

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SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE

SURGERY TYPE• Supraglottic partial

laryngectomy: Hyoid bone, false cords, epiglottis removed; possible neck dissection if nodes involvedhigh risk for aspiration; temporary tracheostomy

VOICE QUALITY• Breathy and hoarse

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SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE

• Total laryngectomy: entire larynx,

• Pre-epiglottic region is removed

• Radical neck dissection if nodes are involved to decrease risk of lymphatic spread

• No natural voice• Permanent

tracheostomy

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POSTOPERATIVELY

• NECK DISSECTION: removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve and surrounding tissue, part of thyroid and parathyroid glands

• Shoulder drop: 11th cranial nerve cut (spinal accessory nerve): need PT

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PRIORITY CONCERNS POSTOP

• ****Respiratory: respiratory distress• ****Hemorrhage• Wound/flap integrity• Nutrition• Pain

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POSTOPERATIVELY: AIRWAY

• Pt has a tracheostomy• Temporary: partial laryngectomy• Permanent: total laryngectomy– Upper airway separated from the pharynx and

esophagus– Trachea is brought out to skin in neck and sutured

in place creating a stoma– Called laryngectromy stoma

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POSTOP: AIRWAY• Ventilator to tracheostomy collar• Oxygen • Humidification: thins mucus, prevents obstruction• Some MD have 5-10 ml of sterile saline into airway q

2 hr (CONTROVERSIAL)• Secretions blood tinged 1-2 days• Suction

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AIRWAY CONTINUED FOR TOTAL LARYNGECTOMY PT

Laryngectomy tube (p 575)• Like a tracheostomy tube, but shorter, fatter, larger

lumen• Prevents scar tissue contracture• Care like tracheostomy tube care (see chapter 31)Laryngectomy button: • Like a laryngectomy tube, but made of Silastic, has

single lumen very short• Comfortable, easily removed for cleaning, custom fit

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AIRWAY CONTINUED

• Coughing and deep breathing clear secretions• Oral secretions: suction by client with

Yankauer

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STOMA CARE FOLLOWING TOTAL LARYNGECTOMY

• Use flashlight to assess• Clean suture line with ½ strength hydrogen peroxide:

prevent secretions from forming crusts and obstructing airway

• Suture line care q 1-2 hours during the first few days after surgery then q 4 hours

• Assess stoma for bright/shiny color (should look like the oral mucosa)

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WOUND/FLAP/RECONSTRUCTIVE CARE

• Use to close wound• Use other muscles to reconstruct head and

neck resection• Assess every hour for 72 hours• Cap refill, color, Doppler activity of major

vessel• Any changes call surgeon

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POSTOP HEMORRHAGE

• Drain in neck for 72 hours postop• Want to drain freely. Do not want

accumulation under flaps (impairs blood flow to and from flap)

• Report sudden stoppage (clot obstructing drain)

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WOUND BREAKDOWN

• Common• Due to poor nutrition, alcohol use, wound

contamination, radiation therapy• Packing• Could have carotid artery rupture:

IMMEDIATE PRESSURE, TO OR IMMEDIATELY for carotid resection– Risk of stroke and death

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POSTOP: PAIN

• Morphine (statex) IV bolus and PCA for several days postop

• Progress to acetaminophen with codeine (Tylenol # ___: #1:7.5mg Codeine, #2:15mg Codeine, #3:30mg Codeine, #4:60mg Codeine)

• Oral medication after pt tolerates oral nutrition• Supplemented with NSAIDS – very effective• Amitriptyline (Elavil): use for nerve root pain

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POSTOP: NUTRITION• All clients receive IV fluidsONE OF THREE OPTIONS AFTER HEAD AND NECK

SURGERY to achieve the following goal: 35-40 kcal/kg of body wgt:

• NGT: most common, used 7-10 days postop; pt must be able to swallow

• Gastrostomy• Or jejunostomyPOSTOP TOTAL LARYNGECTOMY: no aspiration can

occur because airway and esophagus are separated

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POSTOP COMMUNICATION

• POSTOP TOTAL LARYNGECTOMY: pt has no voice

• Communication initially through writing/picture board

• Then artificial larynx, then esophageal speech• Need support from laryngectomee (person

who has had larynx removed and is in support group)

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POSTOP COMMUNICATION

• ESOPHAGEAL SPEECH• Sound produced by burping air swallowed and

shaping words with mouth• Monotone voice, no pitch (vocal cords necessary for

15 consonants, other 10 formed by shaping the mouth)

• Need good hearing• Have intestinal bloating - antacids

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POSTOP COMMUNICATION

• MECHANICAL DEVICES• If cannot do esophageal speech can use

electrolarynges• Battery powered device placed against the

side of the neck or check• Air in mouth and throat is vibrated, move

mouth and lips and tongue as usual

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POSTOP COMMUNICATION

• TRACHEOESOPHAGEAL FISTULA (see p 577-578)

• Fistula created between trachea and esophagus during surgery or after

• Pt covers stoma and opening of the prosthesis; air diverted from lungs

• Lip and tongue movement produces speech

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RISK FOR ASPIRATION• Surgical changes in respiratory tract and altered swallowing

mechanisms increase risk for aspiration• NGT in place increases risk

– HOB up, check placement before feeding, check residual before bolus feeding or q 4-6 hours during continuous feedings

– If residual greater than 100 ml withhold feeding, call MD– Keep suction available

• Altered swallowing due to tracheostomy tube placement• Client who has had subtotal, vertical, or supraglotic

laryngectomy MUST be observed for ASPIRATION• Swallowing study helps determine swallowing ability (see

p579, chart 32-4 on how to swallow)

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PREVENTION OF ASPIRATION

• Once client taking po• Small amounts of food• Avoid liquids/used thickening agent• Cut food into small pieces• Meds in elixir form• Break or crush pills• HOB up 30-45 minutes after feedding

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HOME HEALTH TEACHING• Stoma care: mild soap/H2O, lubricate stoma with nonoilbased

ointment• Tracheostomy/laryngectomy tube care:increase humidity• Avoid swimming, careful showering or shaving• Lean forward cover stoma when coughing/sneezing• Wear stoma guard to cover stoma, filters air while keeping

humidity in airway• Wear MedicAlert bracelet and emergency care card for life

threatening situations (mouth to neck breathing, oxygen to neck opening)

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PSYCHOSOCIAL

• total laryngectomy client cannot produce sounds during laughing and crying

• Mucous secretions may appear suddenly, embarrassing, cover stoma with gauze or handkerchief

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CANCER OF THE LUNG

GENERAL SUMMARY

• Leading cause of death in USA• usually dx late with metastasis already present, Px:

good if tumor can be removed• Metastasizes through blood and lymph going to bone

liver, brain, adrenal• Occurs result of repeated exposure to inhaled

substances that cause chronic tissue irritation or inflammation

• Genetic factors

CIGARETTE SMOKING: BIG BAD WOLF

MAJOR CAUSE OF LUNG CANCER:• Cigarette smoking – major factor (85% of all lung Ca

deaths)• Risk based on # years, # cigarettes smoked/day• Risk decreases when smoking stops, but ex-smokers may

still develop lung ca• non-smokers exposed to passive/secondhand smoke have

increase risk of lung ca SECOND CAUSE: industrial chemical and air pollutants

HEALTH PREVENTION

• Review Healthy People for 2010 objectives (see page 611)

• When do you start teaching?• What can nurses do?

WARNING SIGNALSOF LUNG CANCER

• *Hoarseness• *Cough• Sputum production• Hemoptysis (later finding)• Shortness of breath• Change in endurance• Recurring episodes of pleural effusion,

pneumonia, bronchitis

OTHER S&S SEEN:RESULT OF EFFECT ON OTHER SYSTEMS

• Muffled heart sounds: tumor/fluid around heart (cardiac tamponade)

• Dysrhythmias: from hypoxemia caused by tumor pressure on heart

• Cyanosis/clubbing of fingers: hypoxemia• Bones thin: due to tumor invasion – lead to fx,

bone pain• Superior Vena Cava syndrome: comes from

tumor pressure

SUPERIOR VENA CAVA SYNDROME

• Summarized on p502 under General Interventions for clients with Cancer

• LIFE THREATENING EMERGENCY• Compression leads to blockage of blood flow

in the venous system of the head, neck, upper trunk

SUPERIOR VENA CAVA SYNDROME CONTINUED

EARLY S&S:After sleeping see edema

of face, tightness of shirt or blouse

WORSENING OF S&S: • Edema arms, hands,

dyspnea, erythema of upper body, epistaxis

LATE MANIFESTATION:• Hemorrhage, cyanosis, mental

status changes from lack of blood to brain, decreased cardiac output and hypotension

• LEADS TO DEATH if compression not relieved

OTHER S&S SEEN:RESULT OF EFFECT ON OTHER SYSTEMS

• BRAIN METASTASIS: Lethargy, confusion, somnolence

• METASTASIS TO SPINE AND SPINAL CORD: Bowel/bladder function altered

• GENERAL LATE SYMPTOMS OF LUNG CANCER INCLUDE: fatigue, wgt loss, anorexia, dysphasia, N&V

PSYCHOSOCIAL RESPONSE

• Fear/anxiety• Guilt/shame

DIAGNOSTIC TESTS• Chest xray 1st

• Then CT scan• Fiberoptic bronchoscopy to see tracheobronical tree

and – take specimen– Needle bx done to obtain Ca cells

• Thoracoscopy: video assisted thorascope allows entry to chest cavity, small incisions in chest wall: can see lung tissue

• Mediastinoscopy: to identify metastasis to mediastinal lymph nodes, small chest incision

DIGNOSTIC TESTS CONTINUED

DONE TO SEE SPREAD:• Needle bx of lymph nodes• Direct surgical bx• Thoracentesis with pleural bx• MRI of liver, spleen, brain, bone for met tumors• PFT, ABG: resp status• PET scan is becoming the most THOROUGH test for

mets

THORACENTESISTHORACENTESIS: Aspiration of pleural fluid for dx/tx• Prepare pt for stinging sensation from local anesthetic and feeling of

pressure when needle inserted• Must keep still, no C/DB• P542 position (over the over bed table; hands over head, 45degree HOB

up)• No more than 1000 ml removed• Chest xray done after procedure to r/o pneumothorax• Listen for absent or reduced breath sounds• Observe puncture site for bleeding, and hemoptysisLUNG BIOPSY: position is similar and complications same

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TREATMENT

• Chemotherapy • Radiation• Surgery

• Chemo may be used alone for SCLC• For NSCLC may use chemo alone or in

combination with other therapies

SURGERY

• MAIN TX: for stage 1 and stage 2 NSCLC• GOAL: remove tumor – hope for cure• TYPES OF SURGERY: depends on location of

tumor• TYPES OF INCISIONS: posterolateral,

anterolateral, median sternotomy (see fig 33-13, p617

• ALL INCISIONS: long, large, held open with retractors (lots of postop pain)

TYPES OF PROCEDURES

• SEGMENTECTOMY: lung resection – Includes bronchus, pulmonary artery and vein and tissue

of the involved lung segment

• WEDGE RESECTION: removal of the peripheral portion of small localized areas of disease

• LOBECTOMY: removal entire lobe of lung• PNEUMONECTOMY: removal of entire lung including

all blood vessels, bronchus is severed and sutured

NURSING CARE:p618-622

• Impaired gas exchange– Assessment– Position– Treatments

• Alteration of comfort– Assessment– Pain control methods

• Activity Intolerance– Assess– Interventions

CHEST TUBES AND DRAINAGE

PURPOSE:• Restores intrapleural pressure• Allows re-expansion of the lung• Prevents air and fluid from returning to the

chest

CHEST TUBES CONTINUED

• One two tubes placed – One tube drains fluid– One tube drains air

• Puncture sites covered with air tight dressings• Tubes connected via a Y connector to tubing (6 feet

long)• Tubing connected to collection device (bottle or self-

contained unit)• Must be kept below the chest to allow for gravity

drainage

CHEST TUBES CONTINUED

• Uses a water seal mechanism• One-way valve mechanism• Prevents air or liquid from moving back into

the chest cavity

Chest Tube Placement

Water Seal Drainage3 - Bottle System

Chest Water-Seal Drainage

Water Seal DrainagePleur-evac System

PLEUR-EVAC• Replaces the 3 bottle system with a plastic device• Has 3 chambers: – Chamber for drainage– A water seal– Suction control

• ADVANTAGES:– Self-contained– Less breakage– Less contamination– Increased patient mobility

NURSING CARE OF PT WITH PLEUR-EVAC

• Check patency hourly• Tape tubing connections• Keep occlusive dressing on chest tube insertion site• ***Keep emergency sterile gauze to cover insertion site in

case chest tube comes out• ***Keep padded clamps at bedside in case drainage system is

interrupted• Avoid kinks, Avoid large loops in tubing (blocks drainage)• AVOID VIGOROUS STRIPPING OF CHEST TUBE• Book says to use gentle milking of tube to move blood clots

and prevent obstruction (somewhat controversial)

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC

• PRIORITY: assess respiratory status• Document amount and type of drainage hourly• NOTIFY MD if more than 100ml/hr occurs• AFTER 1st 24 hours: check drainage q 8hr• Don’t empty drainage collection• Mark drainage on collection device with tape

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC

• CHECK WATER SEAL CHAMBER for unexpected or CONTINUOUS BUBBLING indicating an air leak (call MD)water-seal chamber: 2cm sterile water tidaling of

fluid;

• NORMAL: to have bubbling during forceful expiration or coughing (comes from air in chest being expelled)

WHERE IS THE AIR LEAK?

After reporting Bubbling: MD may instruct nurse to apply a padded clamp

on drainage tubing close to occlusive dressing• IF BUBBLING STOPS air leak at CHEST TUBE

insertion site or within the chest• IF BUBBLING DOESN’T STOP indicates air leak

is between clamp and drainage system