Transcript Document

Head and Neck Cancer
Isabel Quinn
Clinical Nurse Specialist in Head and Neck
July 2009
Head and Neck Cancers
• Over 30 specific tumour sites
• Includes cancers of
mouth, throat, nose, ear,
larynx, tongue, floor of mouth
salivary glands, thyroid.
• Each site relatively uncommon, 3 most
common – mouth, larynx and pharynx.
• Generally arise from surface layers upper aero
digestive tract (squamous epithelium)
Incidence
• 8,000 cases and 2,700 deaths per year in
England &Wales
• 6th most common cancer worldwide
• Marked regional variations:
8 per 100,000 Thames & Oxford.
13-15 per 100,000 Wales & North West.
• UHMB cases:
125 on database
73 new since July 08
• Mouth & pharyngeal cancers  20% last 30
years, particularly < 65 yrs
• Laryngeal cancer  very slightly.
• Incidence and mortality higher in
disadvantaged social groups.
• Survival rates much the same as 30 years
ago.
(Nice 2004)
Prognosis
• Early cancers T1, T2 single modality treatment. (7891% survival at 5yrs)
• Advanced cancers T3, T4 multi-modality treatment
(42-67% survival at 5yrs)
• But nodal disease ↓ survival all cancers (46% at 5
yrs)
(Feber 2000)
• 29-35% present at T4
• 48 -51% present with nodal disease.
(LSCC Network)
Risk Factors
• Smoking
• Alcohol consumption
• Deprivation
Treatments
• Surgery – resection +/- reconstruction. Eg
laryngectomy, neck dissection, free forearm
flap grafts
• Radiotherapy +/- chemotherapy
• Combined modality
Laryngectomy
• Larynx removed, trachea brought out onto
neck as end stoma.
• Permanent
• Different from tracheostomy
• Often no tubes
• Speech rehabilitation
• Airway / secretion management
• Humidification issues
Free forearm flap grafts
• To repair defect of tumour excision of
tongue / mouth / pharynx.
• Tissue transferred from forearm – microvascular techniques.
• Flap failure
• Issues of speaking and swallowing
• Extensive rehab
Neck Dissection
• To clear neck of metastatic disease
• Lymph nodes +/- other structures
• Associated morbidity
Effects for patients
• Pain (neuropathic) often difficult to resolve
• Facial / mouth weakness (disfigurement /
poor tongue control – swallowing issues)
• Inabilty to raise arm above head
• Inability to use shoulder effectively (lifting
etc)
Radiotherapy
• For T1 or T2 tumours may be first line
treatment.
• May have post op dependant upon
histology.
• Palliative – short course to control local
symptoms.
• 4 – 6 weeks Monday to Friday
• Planning
Effects for patients
• Cumulative effects – worse when treatment
finished
• Pain – skin reactions / oral mucositis
• Difficulty swallowing – nutritional needs
• Dry mouth
• Fatigue
• Osteonecrosis
3 days post treatment
17 days post treatment
Chemotherapy
• Used as dual modality treatment with
radiotherapy.
• Enhances effects of radiotherapy
• Significantly enhances side effects
• Palliative
• Performance status
Tracheostomy and Laryngectomy
Definitions
• Tracheostomy - artificial opening into trachea
which is kept open with a tracheostomy tube (can
be temporary or permanent.) Connection between
mouth, throat and lungs remains.
• Laryngectomy – Larynx has been removed and
trachea is then brought out to form a stoma at the
front of the neck (this is permanent.) There is now
NO connection between mouth throat and lungs neck breather. Often there will be no tube to keep
stoma open.
Tracheostomy – Nursing Aims
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Maintain patent airway
Prevent aspiration and chest infections
Maintain adequate humidification
Prevent tracheal trauma
Develop alternative communication
strategies
• Help adjust to altered body image
• Educate patient / carers
Maintain patent airway
• Tube obstruction 3rd most common cause of death
in patients with tracheostomies. (El Kilany 1980)
• Feel with hand for good flow of air on expiration.
• Check O2 sats.
• Remove, clean and replace inner tube as required,
but a good rule of thumb is at start of each shift
and then prn.
• Encourage patient to cough and self expectorate.
• Suction as required.
Prevent aspiration and chest
infections
• Check swallow / cough reflex - cuffed tube if
necessary. SALT assessment
• Suction to mouth, pharynx prior to deflating cuff.
• Encourage self expectoration of secretions,
involve physio if required.
• One use equipment / closed humidification units.
• Sterile suction technique.
• Rigorous stoma care - clean tapes / dressings daily,
and as required.
Maintain adequate humidification
• HUMIDIFICATION AT ALL TIMES.
Bibs, Swedish nose.
• Diminished warming, moistening effects,
leading to drying and crusting and potential
blocking of tube.
• If oxygen required it MUST be humidified.
• Nebulise saline or steam inhalation if
secretions are very thick and difficult to
expectorate. N.b note fluid intake.
Develop alternative communication
strategies
• Speaking valve attachments and speaking
tubes. (n.b. not to be used at night and
unable to use with cuffed tubes unless
fenestrated.)
• Call bell, pen and pad, picture boards,
magic slate, Magnadoodle etc.
• Coping strategies - extra time and patience
required to ‘listen.’
• Educate and encourage visitors / carers.
Altered body image
• Encourage continued self care of tube / self
suctioning if possible.
• Encourage patient (carers) to look at / touch
tube.
• Remain professional, don’t show
displeasure / disgust.
Prevent tracheal trauma
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Staff awareness, training and competency.
Selection of appropriate tubes.
Correct suctioning techniques.
Cuff pressure.
Use of fenestrated tubes (suctioning).
Change whole tube regularly as per
manufacturers instructions.
Risk to airway
• Showering / bathing / swimming – use of
aids.
• Inhalation dust / foreign bodies etc – use of
bib / scarf.
• Emergency situations – neck breathers.
• Encourage expectoration of secretions.
• Suction if required
Maintain humidification
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Bib / cravat /scarf
Heat and moisture exchangers
Nebulisers
Steam inhalations
Humidified oxygen therapy
Indications for Laryngectomy
• As curative surgical treatment of carcinoma
of larynx.
• To overcome an incompetent larynx
e.g. after radiotherapy, radio – necrosis.
Post Laryngectomy
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Communication issues.
Risk to airway.
Maintain humidification.
Altered body image.
Usual ‘cancer’ issues
Communication issues
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Unable to speak conventionally
Suitability for surgical voice restoration –
speaking valves.
Care of valves.
Electronic speaking aids.
Oesophageal speech.
Pad and paper
Involvement with SALT.
Risk to airway
• Showering / bathing / swimming – use of
aids.
• Inhalation dust / foreign bodies etc – use of
bib / scarf.
• Emergency situations – neck breathers.
• Encourage expectoration of secretions.
• Suction if required
Maintain humidification
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Bib / cravat /scarf
Heat and moisture exchangers
Nebulisers
Steam inhalations
Humidified oxygen therapy
Valve and stoma care
• Cleaning at least once a day, remove crusting
from around stoma (forceps)
• Regular tube cleaning (if worn) – observe size
of stoma
• Use of valve brush / pipette / cotton buds
• Check valve position.
• Valve replacement ?
Coughing when drinking
Observe test drink
Loss of ‘voice’
Candida
Indications for tracheal
suctioning
• Each patient should be individually assessed
for the need and frequency of suction amount and consistency of secretions.
• Patients ability to cough and clear own
secretions.
• Respiratory rate.
• Oxygen saturation.
• Presence of infection.
Suction catheter selection
• Use appropriate size - no more than half
internal diameter of trachy tube. (see chart)
• Too large - tracheal damage, hypoxia.
• Too small - inadequate clearing of
secretions requiring repeated attempts
which may cause tracheal damage.
• Multi - eyed catheters.
Equipment required
• Functional suction apparatus - suction pressure
100 - 120 mmHg recommended for adults.
• Sterile bowl with water for flushing tube.
• Protective eye wear, mask and plastic apron.
• Appropriately sized suction catheters.
• Sterile plastic gloves.
• Yellow disposal bag.
• Inner tube if fenestrated tube in situ.
• Vacuum breaker (finger tip control)
Nursing Intervention
• Explain procedure to patient.
• Prepare equipment.
• Observe patient throughout (hypoxia, bronchospasm
or vagal stimulation - bradycardia.)
• Switch on suction, connect vacuum breaker and
catheter.
• Gently introduce catheter just beyond end of trachy
tube, apply suction and smoothly withdraw catheter.
Do not suction for more than 15 secs at a time, or
whilst introducing catheter.
• Note tenacity, colour and quantity of
secretions. Infected - ? specimen for c&s.
• Remove glove and catheter and dispose.
• Assess patient - is further suction required.
Repeat with new catheter and glove if
necessary.
• Flush suction tubing. Switch off suction.
• Make patient comfortable.
• Document procedure.
Suction Technique
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Do’s
Insert and withdraw
catheter gently
Use low suction pressure
<120mmHg
Use multi hole suction
catheter.
Use vacuum breaker.
Involve physiotherapists.
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Don'ts
Do not perform suction
routinely - only when
necessary.
Do not instil saline prior
to suctioning.
Do not apply suction for
more than 15 seconds.
Do not apply suction when
inserting catheter.
Changing tapes / dressings
• The tapes and dressings will need to be
changed at least every 24 hours to enable
assessment of the tracheostomy site.
• Change more frequently if soiled to
maintain dry skin and reduce risk of
infection.
• Adjust and fasten tapes if they become
loose.
• Use keyhole tracheostomy dressings.
Care of tubes
• Most tracheostomy tubes have inner tubes which
must be cleaned to prevent blockage.
• Frequency of cleaning varies widely - assess
individually, but a good rule of thumb is to check the
inner tube at the beginning of each shift.
• No evidence for the best solution for cleaning inner
tube - sterile or tap water.
• Mouth care sponges, tracheostomy tube swabs /
cotton buds for plastic tubes.
Care of tubes (cont)
• Silver inner tubes can be cleaned gently with
brushes and under running water.
• Do not leave tubes soaking, dry thoroughly and
replace or store spares in a covered container.
• Do not leave patient without an inner tube, other
than for cleaning and weaning. Absence of an
inner tube results in a build up of secretions and
could lead to blocking of airway.
Suction catheter sizing
Trache tube internal
Recommended suction
diameter (on box and flange) catheter size
4.0 – 5.0
5Fg
5.5 – 6.0
8Fg
6.5 – 7.0
10Fg
7.5 – 8.0
12Fg
8.5 – 9.0
14Fg
Thank you
Any questions