Critical Care Nurse. 2007;27: 53-60
Copyright © 2007 by the American Association of Critical-Care Nurses.
Clinical Article
Caring for Lung Cancer Patients Receiving Photodynamic Therapy
Angela Smith Collins, RN, DSN, APRN BC, CCNS
Marie Garner, RN, MSN, CNOR
Angela Smith Collins has more than 30 years of experience in nursing, the past 13 years as an advanced practice nurse. She is an associate professor of nursing at the Capstone College of Nursing in Tuscaloosa, Ala, where she teaches pharmacology, critical care nursing, and peri-operative nursing. She holds APN certification as a medical-surgical clinical nurse specialist and as a critical care clinical nurse specialist.
Marie Garner has more than 30 years of experience in perioperative nursing, working as a staff nurse, a team leader, a nurse manager, and director of perioperative services. She is currently the education director and safety officer at the Callahan Eye Foundation Hospital in Birmingham, Ala. She has additional expertise in clinical problem solving and in operating room construction, renovation, and relocation, and she is an expert in change theory and productivity measures.
Corresponding author: Angela Smith Collins, Capstone College of Nursing, Box 870358, Tuscaloosa, AL 35487-0358 (e-mail: acollins{at}bama.ua.edu).
Approximately 172 570 new cases of lung cancer are diagnosed every year.1 Most patients are treated with thoracotomy or a combination of surgery, radiation therapy, and chemotherapy. Patients with non–small cell lung cancer (NSCLC) may choose photodynamic therapy. Two groups of patients meet the specified criteria for this procedure. One group consists of patients with bronchoscopic evidence of early stage I NSCLC. The patients in the other group have end-stage obstruction caused by the tumor and receive photodynamic therapy for palliation of signs and symptoms. Photodynamic therapy often is performed on an outpatient basis. However, patients who have this therapy may require short-term management in the critical care unit after the procedure so that they can be vigilantly monitored and assisted in airway management while they are receiving mechanical ventilation. In this article, we describe photodynamic therapy and 2 cases that illustrate the unique nursing care needs of these patients.
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Photodynamic Therapy: A Unique Treatment
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Photodynamic therapy is a unique combination of pharmacology with laser surgery on a specific timeline. Medication dosage, depth of light penetration, length of exposure to laser light, and type of laser used are the variables that must be calculated specifically for each tumor.2 A team consisting of a nurse, a surgeon, an oncologist, and a pharmacist must plan the photodynamic therapy before patients arrive in the acute care environment. The treatment equation can be described as follows: Improved outcome for patient from tumor regression = Photodynamic therapy (Administration of photosensitizing agent + Distribution time + Laser light activation + Vigilant assessment and monitoring).
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Pharmacology
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Photodynamic therapy evolved from the study of the behavior of malignant cells exposed to different wavelengths of light. Experiments on the uptake of photosensitive compounds showed that hematoporphyrins are selectively retained by malignant cells.3 The compounds are lipophilic and therefore bind to the mitochondrial membranes, endoplasmic reticulum, and nuclear membranes. Because these photosensitive molecules can be incorporated into the membranes of malignant cells, the molecules can then be activated by exposure to red light (photoactivation).4 This activation causes apoptosis (ie, programmed cell death) of malignant cells.
Hematoporphyrins are also selectively retained by the reticuloendothelial system. The hypothesis proposed for incorporation of these compounds in the reticuloendothelial system is that similar compounds are needed for the synthesis of red blood cells.5 A medication called porfimer sodium, which produces a cellular sensitivity to light, was developed. Porfimer sodium is administered 24 to 72 hours before interventional bronchoscopy to allow maximal distribution of the photosensitive agent within the malignant cells (see Table 1
for detailed description of this agent). This medication is a unique pharmacological agent considered both a chemotherapy agent and a photosensitizer. The cytotoxic effects of the chemotherapy depend on light and oxygen.
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Tumor Apoptosis
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Laser activation of the medication triggers multiple chemical responses that can result in an apoptotic response in malignant cells. First, the light produces an oxygen singlet molecule that has cytotoxic actions and results in the lysis of tumor cell membranes and mitochondria.3 Second, thromboxane A2 is released from platelets, stimulating vasoconstriction, leukocyte adhesion, and thrombus formation. These events lead to occlusion of the microvascular bed feeding the tumor. Finally, tumor cell lysis produces a release of malignant cell cytokines into the circulation. The cytokines trigger increased activity of macrophages. The macrophages are sensitized to the tumor-specific peptides, thereby increasing the phagocytosis of the tumor cells8 (see Figure).
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Use of a Photodynamic Laser in the Operating Room
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Many types of lasers are used in photodynamic therapy. The laser used must produce a nonthermal but visible light. The most commonly used and studied laser for photodynamic therapy is the argon/dye laser. This system is capable of delivering from 1 to 7 W of continuous wave 630-nm light energy.9 Other lasers used in photodynamic procedures are the potassium titanyl phosphate: yttrium aluminum garnet (KTP:YAG/dye) laser and the diode laser. The KTP:YAG laser generates a pulsatile light rather than a continuous wave, and the light dose is delivered at a high pulse-repetition rate.10 The diode laser is considered easier to operate and more portable than other laser types. Diode lasers have been approved by the Food and Drug Administration for their 630-nm activation of photosensitizing medications. These lasers are semiconductor light sources and are more compact.9
The laser a facility uses depends on the surgeon’s preference and the laser device that will provide maximal activation of the medication used. After the healthcare team chooses the laser type, photodynamic dose, and timeline, the elective procedure is scheduled.11
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Interventional Bronchoscopy: Initial and Secondary
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Patients are taken to the operative or endoscopic suite for an interventional bronchoscopy. The time in the operating room is designed to be at the point of optimal distribution of the medication in the malignant cells. The proximity of the laser to the malignant cells is vital to maximize the outcome of tumor necrosis. The laser dose is given for the planned time interval. After the removal of the laser, deep suctioning of any cellular debris is performed.
The next stop on the timeline is to move the patient to a recovery area to assess for readiness to extubate and monitor for any complications. Often at this point, critical care nurses become vital in the process of care. The patient must be cared for in an environment where a skilled provider is immediately available for a repeat bronchoscopy. Respiratory distress after the procedure can evolve from excessive mucus production and accumulation of cellular debris.
All patients undergo a repeat bronchoscopy 24 to 48 hours after the initial procedure. This second procedure is called the mandatory debridement bronchoscopy. Purposes of this bronchoscopy are to verify the tumor destruction, repeat the photodynamic therapy to increase tumor regression, and manage the volume of secretions after the procedure.12
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Contraindications and Risks
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The risks and benefits vary for each patient because each patient’s manifestations of tumor are variable. The greatest risk is that a tumor may silently be eroding into a pulmonary blood vessel, and tumor destruction during the procedure may initiate a fatal bleeding episode. Any tumor that appears to have entry into a major blood vessel is a contraindication to the use of phototherapy.5 Other contraindications include the presence of a tracheoesophageal fistula, allergy to porphyrins, and preexisting acute intermittent porphyria. The risks of phototherapy are increased in patients who have a history of radiation therapy or coagulation disorders.
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Before the Surgery
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Once a patient has agreed to the procedure, some arrangements must be completed before the procedure. First, the patient will be extremely photosensitive for 30 to 90 days after the administration of porfimer sodium. Therefore, all the windows and portals of entry for sunlight, such as skylights, must be covered so that the patient is not exposed to sunlight. High-wattage indoor lighting must be modified as well. The patient must have sunglasses that allow light transmittance of less than 4%. All skin must be covered; therefore, gloves, a wide-brimmed hat, a long sleeved shirt, and socks should be brought to the hospital.13 The patient should be told that all daily activities, such as driving, should be done at night. In order to reduce exposure to sunlight, the patient must be house-bound from 1 to 3 months. Before resuming normal sun exposure, the patient must gradually increase the time in sunlight. The patient is advised to have only an inch of skin, such as a hole in the gloves, exposed at first to see how much photosensitivity continues to be present. Sunscreen will not prevent or diminish the burns that will occur upon exposure.
The dose of porfimer sodium is 2 mg/kg of body weight and is given as an intravenous bolus. The porfimer sodium is diluted in 5% dextrose in water and administered slowly over 3 to 5 minutes in an out-patient setting. Patency of the intravenous catheter is vital because tissue extravasation can result in extensive tissue destruction.6
Porfimer sodium is classified as a chemotherapy agent, so only a registered nurse who is chemotherapy certified can administer the medication. The nurse and the pharmacist work closely together to prevent the medication from being exposed to light and to dilute it immediately before administration. While the medication is being administered, the patient must be closely monitored for signs and symptoms of an allergic response. In one case, a patient experienced urticaria and bronchospasm.14
The patient is then scheduled for surgery at the optimal hour for the best response of the medication and the laser. The patient leaves the hospital wearing the protective clothing and then returns for surgery 24 to 72 hours later.
Keeping patients in darkened areas in admitting and holding lobbies is not standard hospital procedure. Education is needed to make sure that everyone who admits, escorts, obtains a blood sample, or obtains a radiograph knows why the room is darkened and that patients receiving photodynamic therapy need the protective clothing and sunglasses. Penlights should not be used when assessing these patients.
Nurses serve these patients by being the one who vigilantly educates and protects the patients from isolation and ostracism. Communication is vital between services. For example, we planned the route to the operating room from the holding room so that our patients would not travel by any windows and thereby be exposed to the sunlight through the window. The operating room was darkened before a patient entered. The surgical intensive care unit had a room ready to receive the patient with all the monitoring equipment on the lowest light-emitting setting. Normal room lighting will not harm the patient’s skin. However, many patients experience indoor photophobia with associated ocular discomfort and prefer a darkened environment.
Other accommodations made for these patients are related to assessment tools that require use of light. Case reports describe pulse oximeters making burns on patients because of the red light output.15 We used spot-checking of pulse oximetry values every hour and when dyspnea occurred so that prolonged exposure to the light would not occur. All respiratory assessments depended more on the clinician’s assessment skills than on numerical values. Light is also required for some laboratory tests, so the laboratory physician director and anesthesia laboratory had to be aware of the administration of the medication so that laboratory tests for these patients could be evaluated within this context. The unique needs of patients receiving photodynamic therapy require that interdisciplinary collaboration be seamless (Table 2).
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During Surgery
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Anesthesia Accommodations
The anesthesia prescription for a patient undergoing interventional bronchoscopy requires an individual evaluation of the patient’s risk factors. The potential risk of anesthesia is evaluated on a scale of 1 to 5 as proposed by the American Society of Anesthesia classification.16 The anesthesia provider must also understand the intraoperative variables inherent in laser surgery. These variables are the possibility of an airway fire due to laser malfunction and the importance of minimizing the patient’s movement during the procedure.
The patient’s airway anatomy is evaluated first for preexisting abnormalities or changes associated with tumor growth. Knowledge of the changes in anatomy is vital because the patient is intubated during the procedure. The photodynamic laser does not generate heat, only light, but some anesthesia providers use a laser-resistant endotracheal tube as an additional precaution. In late-stage NSCLC, the patient’s nutritional status may be compromised, making tissue susceptible to trauma. Miller17 states that current anesthesia standards recommend not using any volatile inhalation gases during airway laser surgery. The anesthesia provider may use a combination of opioid analgesics, benzodiazepines, and a short-acting dose of neuromuscular blocking agent. These prescriptions allow the patient to be motionless during the laser light application and be unaware of the instrumentation used.
Intraoperative Team Roles
The operating room nurse acts as the patient’s teacher and advocate. The circulating nurse explains to the patient the reasons for positioning and the protective measures. Because use of a laser requires highly specialized competencies, a laser specialist may also be included on the operating room team. The circulating nurse, anesthesia provider, laser technician specialist, and surgeon verify the laser function, laser setting, total time of laser light application, optimal positioning, information from magnetic resonance imaging or computed tomography, and the correct procedure for each patient before anesthesia is induced. A "time out" is called by the circulating nurse to confirm that everyone is aware of the patient’s identity before draping and of the side on which the tumor is located. This time out demonstrates to the patient that the focus is not on tasks but on the patient’s needs. The patient can derive comfort from the collaboration of the team before the procedure. During the procedure, the circulating nurse ensures the patient’s safety and advocates for the patient, who is anesthetized.
After Surgery
The 5 roles of critical care nurses in providing care after the procedure are vigilant assessment of the respiratory system, education of the patient and his or her caregivers or family, coordination of care, optimization of pain management, and "presence" with the patient.
The decision to allow the patient to remain intubated after the procedure is based on the degree of difficulty encountered when the tube was inserted and the ability of the patient to maintain adequate oxygenation. The intent of the procedure (curative vs palliative) also can be considered in the decision to extubate. A bronchoscopy cart should be in the unit, as should a healthcare provider who can use the equipment in a timely manner. After the procedure, the patient’s secretions are heavy, and as the gag reflex returns, coughing episodes will occur. Atropine should be readily available for any coughing that leads to a vagal response.
Complications after the procedure are summarized in Table 2
. Education should be continuous for the patient and the patient’s family. Constant reinforcement of information may be necessary because of memory impairment by both anxiety and anesthesia. Some patients experience chest pain related to the inflammatory response of the pulmonary tissue to the photodynamic therapy. The coughing can also produce aching of the thoracic muscles. The liberal use of pain medications and pain management adjuncts should be encouraged.
Coordination of care is a broad role that includes making sure all personnel understand the photosensitive precautions and that the patient is the center of all required interventions. Interdisciplinary collaboration with the pharmacy is vital. Before any medication is ordered, its interaction with porfimer sodium should be evaluated. Some medications can synergistically enhance the photosensitive properties of porfimer sodium and should be avoided (see Table 1).
Finally, the patient needs a health-care team that focuses on the patient, not on a subsystem or on laboratory values. Presence, as defined by McCauley,18 is "Nurses know how to overcome barriers to understanding what a patient feels and needs in the moment. We overcome these barriers because of presence that is anchored not only in emotion, but also in knowledge." For a patient receiving photodynamic therapy, presence means being the translator for the patient’s unique needs and never letting the patient feel like an outcast. As the nurse interacts with the patient, individualization for the intervention should occur. For example, is the patient comforted best by a hand clasp in silence or by a comforting word when being repositioned?
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Clinical Illustrations
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Case 1
Ms A was referred to the pulmonary clinic because she had had a persistent cough for the past 6 weeks that had not resolved with antibiotic therapy. A diagnostic bronchoscopy revealed a 0.7-cm lesion of NSCLC in the right lower lobe. Ms A was 60 years old and had recently retired from working as a high school teacher. She had smoked for 12 years but had stopped 30 years ago. After being told of the tumor, she was adamant that she would not have a thoracotomy. Her husband had been a coal miner, and she had experienced with him the chronic nature and diminished quality of life that sometimes accompanies extensive lung damage and then lung cancer. She researched her options and decided that she would consider photodynamic therapy. Her medical team was agreeable as long as her computed tomography scan showed no metastasis. The scan showed no metastases. Her son lived near a center that provided this treatment option, so together they planned to provide a living area within his house that could allow her some short-term support.
Ms A’s positive and take-charge attitude made caring for her an enlightening experience. She liked organizing; thus, we let her choose the timing of the procedure in the surgery schedule. She educated others and had designed a plan for her time in "seclusion" by obtaining a score of books to read.
After the procedure, she did not require continued intubation. The only reason she was placed in the critical care unit was the nurse-to-patient ratio for assessment and the emergency availability of the bronchoscopy equipment and personnel. Ms A loved to talk, and her conversations were ended only by coughing episodes. Because most patients in this critical care unit were intubated, it was an adjustment to have a patient who was talkative and interactive. This situation required some changes in our bedside reports. Her chief complaint was the constant nature of the cough and a sensation of chest soreness that radiated to her back on inspiration. Ms A was allowed as much control as we were able to negotiate. She was returned to the operating room 36 hours later for luminal debridement. We watched her for 12 hours after the procedure, and she was discharged home from the critical care unit.
Case 2
Ms W lived in a rural area in Alabama. She had no access to a healthcare provider within 70 miles of her home. She was brought to the emergency department on Christmas Eve by her sister, to whose home she had traveled for the holiday. Because of Ms W’s remote residence and lack of telephone and car, her sister had not seen her since the past Christmas. Her granddaughter, who was in college in another state, had picked Ms W up on the way to the family holiday. Ms W was 73 years old, 5 ft 9 in. (1.75 m) tall, and weighed 54 kg. Her sister reported that Ms W looked as if she had dramatically lost weight. Ms W had been widowed about 18 months ago, and her only son was deceased. Ms W had smoked since she was 17. When she was admitted to the hospital, she was experiencing shortness of breath, hypokalemia, and dysrhythmias.
NSCLC was diagnosed by means of bronchoscopy; an obstructive lesion was present in the right middle lobe. In order to maintain oxygenation after the bronchoscopy, Ms W remained intubated. The hypokalemia was attributed to the vomiting associated with her persistent, constant cough. The hypokalemia and dysrhythmias resolved with hydration and intravenous potassium supplementation. Ms W and her family were called into conference to discuss treatment options. The plan was to provide palliative care and have Ms W remain with her sister.
In order to wean her off mechanical ventilation, photodynamic therapy was recommended. The desired end point was to place her on a different type of oxygenation support so that she could communicate with her caregivers and have some decrease in dyspnea. She wanted to live long enough for her extended family to say their goodbyes. Ms W stated that her goal was "stopping the hurt with each breath." Her family members were referred to the chaplain because they were experiencing guilt for not checking on "Nana." They were struggling with the fact that she would not be cured.
Ms W had copious secretions that required hourly suctioning and a daily bronchoscopy after the procedure. Her skin was fragile because of her poor nutritional status before the procedure. She required the administration of albumin twice to maintain her blood pressure after the administration of opioids. A slow-release fentanyl patch was added for pain control. Sixteen hours after her debridement bronchoscopy, weaning to nasal prongs at 4 L occurred. Still a fragile and frail little woman, she cherished her time with her granddaughter, her namesake. Her granddaughter purchased her a vibrant purple wide-brimmed hat. Seeing Ms W exit the unit with her oxygen tank, purple hat, sunglasses, extra-large tissue box, and white gloves made a lasting impression. Her toothless smile was beautiful (her dentures no longer fit because of the weight loss).
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Conclusion
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Photodynamic therapy is a treatment option for NSCLC at 2 very different intervals in treatment. For one group of patients, photodynamic therapy is curative; in the other group, it can be palliative. However, both groups of patients need the skilled communication, advocacy, and vigilant monitoring of critical care nurses.
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References
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- National Cancer Institute. Non-small cell lung cancer (PDQ ): treatment. Available at: www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung. Accessed January 5, 2007.
- Lee P, Kupeli E, Mehta A. Therapeutic bronchoscopy in lung cancer: laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy. Clin Chest Med. 2002;23:241–256.[Medline]
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- Drug information guide: Photofrin (porfimer sodium) for injection. Birmingham, Ala: Axcan Scandipharm Inc; 2003.
- Deglin JH, Vallerand AH. Davis’s Drug Guide for Nurses. 9th ed. Philadelphia, Pa: FA Davis Co; 2005.
- Physicians’ Desk Reference. 60th ed. Montvale, NJ: Thomson Healthcare; 2006.
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- Patient guide: Photofrin. Birmingham, Ala: Axcan Scandipharm Inc; 2003.
- Karasic DS. Urticaria and respiratory distress due to porfimer sodium. Ann Pharmacother. 2000;34:1208–1209.[Medline]
- Radu A, Zellweger M, Grosjean P, Monnier P. Pulse oximeter as a cause of skin burn during photodynamic therapy. Endoscopy. 1999;31:831–833.
- Rothrock J, ed. Alexander’s Care of the Patient in Surgery. 12th ed. St. Louis, Mo: Mosby; 2003.
- Miller RD, ed. Miller’s Anesthesia. 6th ed. Philadelphia, Pa: Elsevier Publishing; 2005.
- McCauley K. President’s note. AACN News. June 2005;22:2.
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Photodynamic Therapy: A Unique...
Pharmacology
