Pleurisy and

Bronchogenic
Carcinoma

Submitted by:
Noemi P. Garcia
John Ray O. Rivera
Pleurisy
• Pleurisy (pleuritis) refers to inflammation of both layers of the pleurae (parietal and
visceral).
• Pleurisy may develop in conjunction with pneumonia or an upper respiratory tract
infection, TB, or collagen disease; after trauma to the chest, pulmonary infarction, or PE;
in patients with primary or metastatic cancer; and after thoracotomy.
• The parietal pleura has nerve endings, and the visceral pleura does not. When the
inflamed pleural membranes rub together during respiration (intensified on inspiration),
the result is severe, sharp, knifelike pain.

PATHOPHYSIOLOGY
• The visceral pleura does not contain any noci-ceptors or pain receptors.
• The parietal pleura is innervated by somatic nerves that sense pain when the parietal
pleura is inflamed.
• Inflammation that occurs at the periphery of the lung parenchyma can extend into the
pleural space and involve the parietal pleura, thereby activating the somatic pain
receptors and resulting in pleuritic pain.
• Parietal pleurae of the outer rib cage and lateral aspect of each hemidiaphragm are
innervated by intercostal nerves.
• Pain is localized to the cutaneous distribution of those nerves.
 • The phrenic nerve supplies innervations to the central part of each hemidiaphragm; when
these fibers are activated, the sensation of pain is referred to the ipsilateral neck or
shoulder.

Clinical manifestation
• The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking
a deep breath, coughing, or sneezing worsens the pain.
• Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one
side. The pain may become minimal or absent when the breath is held.
• Later, as pleural fluid develops, the pain decreases.

SIGNS AND SYMPTOMS

• Chest pain that worsens when you breathe, cough or sneeze
• Shortness of breath
• A cough
• A fever

>Pain caused by pleurisy also might affect your shoulders or back.

>In some cases of pleurisy, fluid builds up in the small space between the two layers of tissue
(pleural space). This is called pleural effusion. When there is a fair amount of fluid, pleuritic pain
lessens or disappears because the two layers of pleura are no longer in contact. A large amount of
fluid in the pleural space can create pressure, compressing your lung to the point that it partially
or completely collapses. This makes breathing difficult and might cause you to cough. The extra
fluid can also become infected. This is called an empyema. An empyema is often accompanied
by fever.

Assessment and Diagnostic Findings

• In the early period, when little fluid has accumulated, a pleural friction rub can be heard
with the stethoscope, only to disappear later as more fluid accumulates and separates the
inflamed pleural surfaces.

DIAGNOSTIC TESTS
• Chest X-ray. A chest X-ray can show if your lungs are fully inflating or if there is air or
fluid between the lungs and ribs. Your doctor might recommend a special type of chest
X-ray in which you lie on your side (decubitus chest X-ray).
• Sputum Analysis. is a test to detect and identify bacteria or fungi that infect the lungs or
breathing passages
• Thoracentesis. To obtain a specimen of pleural fluid for examination.
• Pleural biopsy. Is a procedure to remove a sample of the tissue lining the lungs and the
inside of the chest wall to check for disease or infection.
RISK FACTORS/CAUSES
• Adverse drug reactions
• Autoimmune inflammatory diseases
• Bacterial, fungal, or parasitic lung infections
• Cancer
• Congestive heart failure
• Gastrointestinal (GI) diseases
• Inhaled toxins
• Lung diseases
• Pulmonary embolism
• Trauma

Medical management
• The objectives of treatment are to discover the underlying condition causing the pleurisy
and to relieve the pain. As the underlying disease (pneumonia, infection) is treated, the
pleuritic inflammation usually resolves.
• At the same time, it is necessary to monitor for signs and symptoms of pleural effusion,
such as shortness of breath, pain, assump- tion of a position that decreases pain, and
decreased chest wall excursion.
• Prescribed analgesic agents and topical applications of heat or cold provide symptomatic
relief.
• Indomethacin (In- docin), a nonsteroidal anti-inflammatory agent, may pro- vide pain
relief while allowing the patient to take deep breaths and cough more effectively.
• If the pain is severe, an intercostal nerve block may be required.

Nursing intervention
• Because the patient has considerable pain on inspiration, the nurse offers suggestions to
enhance comfort, such as turning frequently onto the affected side to splint the chest wall
and reduce the stretching of the pleurae.
• The nurse also teaches the patient to use the hands or a pillow to splint the rib cage while
coughing.
LUNG CANCER
• Lung Cancer is the growth of abnormal tissue characterized by the progressive,
uncontrolled multiplication of cells. This abnormal growth of new cells does not develop
into healthy lung tissue but rather manifest into a tumor or also called a neoplasm.
• As tumors become larger and more numerous, they inhibit the lung’s ability to provide
the blood stream with oxygen.
• Lung Cancer arises from the epithelium of the tracheobronchial tree.
• As a tumor enlarges, the surrounding bronchial airways and alveoli become irritated,
inflamed, and swollen. The adjacent alveoli may fill with fluid or become consolidated
and collapse.

Overall incidence of lung cancer is:

 Higher in men than women

 More men than women die from lung cancer.
 Second highest cancer incidence in both sexes after prostate (males) and breast (females)
cancers.

2 Different types of tumors

Benign Tumors
• Remain in one place and do not appear to spread.
• Do not endanger life unless they interfere with the normal functions of other
organs or affect a vital organ.
• They grow slowly and push aside normal tissue but do not invade it.
• Not invasive or metastatic.
Malignant Tumors
• Composed of embryonic, primitive, or poorly differentiated cells.
• They grow in a disorganized manner and so rapidly that the nutrition of the cells
becomes a problem.
• Invade surrounding tissues and may be metastatic (cancer spreading beyond its
site of origin to other parts of the body).
• Malignant changes may develop in any portion of the lung, they most commonly
originate in the mucosa of the tracheobronchial tree.

Major Pathological changes in lung cancer

 Inflammation, swelling, and destruction of the bronchial airways and alveoli
 Excessive mucous production
 Tracheobronchial mucous accumulation and plugging
 Airway obstruction (either from blood, from mucous accumulation, or from a
tumor projecting into a bronchus)
 Atelectasis (collapse of part or all of the lung)
 Alveolar consolidation (liquid-filled alveolar space)
 Cavity formation
 Pleural effusion (buildup of fluid between the layers of tissue that line the lungs
and chest cavity)
TYPES OF LUNG CANCER:
Non- small- cell lung carcinoma(NSLC)
– is any type of epithelial lung cancer other than small cell lung cancer.
Large cell carcinoma
• 10-20% of lung cancer
• Cavitation common
• Slow metastasis may occur to kidney, liver and adrenals
• May located centrally, mid or peripherally
Squamous cell carcinoma
• 30-35% of lung cancer
• Arises from brochial epithelium
• Cavitation may also occur
• Slow growth, metastasis not common
Adenocarcinoma
• 25-30% of lung cancer
• Arises from bronchiole mucus gland
• Slow growth, rarely cavity
• Strongly linked to cigarette smoking

Small Cell Carcinoma

• It is generally starts in one of the larger breathing tubes, grows fairly rapidly and is likely
to be large by the time of diagnosis
• spreads more quickly and aggresively
• accounts for 15% of cases
• found mostly in heavy smokers
•
PATHOGENESIS
 The pathogenesis of lung cancer is like other cancers, beginning with carcinogen-induced
initiation events, followed by a long period of promotion and progression in a multistep
process. Cigarette smoke both initiates and promotes carcinogenesis. The initiation event
happens early on, as evidenced by similar genetic mutations between current and former
smokers (e.g. 3p deletion, p53 mutations).
 Smoking thus causes a “field effect” on the lung epithelium, providing a large population
of initiated cells and increasing the chance of transformation. Continued smoke exposure
allows additional mutations to accumulate due to promotion by chronic irritation and
promoters in cigarette smoke (e.g. nicotine, phenol, formaldehyde).
 The time delay between smoking onset and cancer onset is typically long, requiring 20-25
years for cancer formation. Cancer risk decreases after smoking cessation, but existing
initiated cells may progress if another carcinogen carries on the process.
 SCLC and NSCLC are treated differently because they (i) originate from different cells,
(ii) undergo different pathogenesis processes, and (iii) accumulate different genetic
mutations. SCLC often harbors mutations in MYC, BCL2, c-KIT, p53, and RB, while
 NSCLC often has mutations in EGFR, KRAS, CD44, and p16. These are all either tumor
suppressor genes or oncogenes. See Cancer genetics and Cancer biology chapters for a
description of how mutations like these can cause cancer.

What are the causes and risks of Lung Cancer?

 SMOKING
 Cigarette smoking is the leading cause of lung cancer, accounting for about 85% of lung
cancers. Risk for lung cancer increases with the duration, intensity and depth of smoke
inhalation.
 Second-hand (passive) smoking also causes lung cancer, but is less strongly associated
compared to active smoking.
 Cigarettes contain multiple carcinogens (more than 60) that have been shown to induce
cancers in laboratory settings.
 Nicotine: causes addiction to cigarette smoking and is also a promoter for carcinogenesis.

 ENVIRONMENTAL EXPOSURE
• A number of environmental risk factors have been identified, most of which relates to
occupational exposures such as asbestos, tar, soot, and a number of metals such as
arsenic, chromium, and nickel.
• Air pollution has also been linked to increased risk of lung cancer.

 GENETICS
• There is an increased risk of lung cancer among first-degree relatives, indicating a genetic
susceptibility.
• Candidate gene studies have identified several enzymes in the cytochrome P-450 system
as risk factors for lung cancer. One such gene is CYP1A1, which codes for aryl
hydrocarbon hydroxylase. Certain alleles of CYP1A1 are thought to increase the risk of
lung cancer through increased metabolic activation of procarcinogens derived from
cigarette smoke.

 PRECURSOR LESIONS
 Precursor lesions are of increasing interest due to implication in lung cancer screening.
 Currently there are 3 types of recognized precursor lesions
 Squamous dysplasia and carcinoma: precursor lesion for squamous-cell carcinoma.
 Adenomatous hyperplasia: precursor lesion for bronchi alveolar carcinoma, a form of
adenocarcinoma.
 Idiopathic pulmonary neuroendocrine cell hyperplasia: precursor for pulmonary
carcinoids.
 Precursor lesion for SCLC is unknown.
Pathophysiology
 The most common cause of lung cancer is inhaled carcino- gens, most often
cigarette smoke (90%); other carcinogens in- clude radon gas and occupational
and environmental agents (American College of Chest Physicians [ACCP], 2007).
Lung cancers arise from a single transformed epithelial cell in the tracheobronchial
airways, in which the carcinogen binds to and damages the cell’s DNA. This
damage results in cellular changes, abnormal cell growth, and eventually a
malignant cell. As the damaged DNA is passed on to daughter cells, the DNA
undergoes further changes and becomes unstable. With the accumulation of
genetic changes, the pulmonary epithe- lium undergoes malignant transformation
from normal ep- ithelium eventually to invasive carcinoma. Carcinoma tends to
arise at sites of previous scarring (TB, fibrosis) in the lung.

Signs and Symptoms of Lung Cancer

• Persistent or intense coughing
• Pain in the chest, shoulder, or back from coughing
• Hoarseness of the voice
• Harsh sounds while breathing (stridor)
• Difficulty breathing and swallowing
• Chronic bronchitis or pneumonia
• Sputum production (mucus coughed up from the lower airways)
• Changes in color of the sputum
• Coughing up blood or blood in the sputum (hemoptysis)
• Increased respiratory rate (tachypnea)
• Increased heart rate and blood pressure (tachycardia)
• Cyanosis (blue or purple coloration of the skin)

Screening and Diagnosis

• Chest X-ray (most common screening test)
• Computed tomography (CT) scan
• Positron emission tomography (PET) scan
• A definitive diagnosis, however, can be made only by viewing a tissue sample (biopsy)
under a microscope. Procedures to obtain a tissue biopsy include:
• Bronchoscopy
• Thoracoscopy
• Mediastinoscopy
• Transbronchial needle (open lung) biopsy
• Sputum cytology
• Thoracentesis
• Videothoracoscopy
Staging of Lung Cancer
Non-Small Cell Lung Carcinoma
Stage 0: The cancer is limited to the lining of the bronchial airways. There is no involvement of
the lung tissue or distant metastasis. Cancer is usually found during bronchoscopy. When found
and treated early, cancers at this stage can often be cured.
Stage I: The tumor is less than 3 cm and is located in lobar or distal airways. There is no lung
tissue involvement or distant metastasis.
Stage IIIA: The tumor is any size. The tumor is in the main bronchus, or the tumor is
accompanied by atelectasis or obstructive pneumonitis (inflammation of lung tissue) of the entire
lung. Local invasion involves chest wall, diaphragm, mediastinum, pleural, or parietal
pericardium.
tage IIIB: The cancer has spread locally to areas such as the mediastinum, heart, great vessels,
trachea, esophagus, vertebral body.
Stage IV: The cancer is of any size, involves any of the lymph node groups, and has spread to
other parts of the body, such as the liver, bones, or brain.
Small Cell Lung Carcinoma (harder to detect early)
Limited: The cancer is confined to only one lung and to its neighboring lymph nodes.
Extensive: The cancer has spread beyond one lung and nearby lymph nodes. It may have
invaded both lungs, more remote lymph nodes, or other organs.

Management
Medical Management
• PHOTODYNAMIC THERAPHY
• THORACENTESIS
• LASER THERAPHY
Pharmacological Management
CHEMOTHERPAHY
Name of Drugs
• Cisplatin
• Carboplatin
• Paclitaxel (taxol)
• Albumin-b
• Docetaxel (taxotere)
• Vinorelbine (navelbine)
• Vinblastine
Surgical Management:
• lobectomy
• Bilobectomy
• Sleeve resection
• Pneumonectomy
• Segmentectomy
• Wedge resection
• Chest wall resection with removal of cancerous lung tissue
Pallative care
Advanced disease may be present at the diagnosis. Given the poor prognosis, the goals of
lung cancer therapy may be switched from curative to palliative. Palliative care aims to improve
the quality of life and reduce suffering for patients rather than to prolong life.

ISSUES ARE ADDRESSED IN PALLATIVE CARE:

>physical
>Emotional and coping
>spiritual

Prognosis
• The 5-year survival rate refers to the percentage of patients who live at least 5 years after
their cancer is diagnosed.
• The numbers to the left are survival rates calculated from the National Cancer Institute’s
Surveillance, Epidemiology, and End Results database, based on people who were
diagnosed with non-small cell lung carcinoma between 1998 and 2000.
• The overall 5-year survival rate for stage 4 non-small cell lung cancer is sadly less than
5%.
• The overall 5-year survival rate for extensive stage small cell lung cancer is 6%. Average
survival is 6 to 12 months with treatment, but only 2 to 4 months without treatment.

Nursing management
• Monitor s/s of respiratory failure
• Administer chemotheraphy and other desired medication
• Educate patient with disease and its progression
• Respiratory assessment
• Laboratory investigation and other diagnostic tests patients knowledge and understanding
of diagnosis and treatment
• Patients anxiety level and support system
• Exposure to carcinogen

Conclusion
• Lung cancer is by far the leading cancer killer in both men and women
• In 1987, it surpassed breast cancer to become the leading cause of cancer deaths in
women.
• This cancer causes more deaths than the next three most common cancers combined
(colon, breast, and prostate).
• One important key to beating this disease is prevention in ways of avoiding or
discontinuing cigarette smoking and passive or second-hand smoking.
• Smoking, a main cause of small cell and non-small cell lung cancer, contributes to 80%
and 90% of lung cancer deaths in women and men, respectively. Men who smoke are 23
 times more likely to develop lung cancer. Women are 13 times more likely, compared to
non-smokers.
• That said, there are reports of people who have survived and done well for many years
who had an early diagnosis and detection of lung cancer and received the necessary
treatment that best suits their particular circumstance.