Non-Small Cell Lung Cancer

General Information
Case no.	11.A Non-Small Cell Lung Cancer
Authors	Rachel Pata, PT, DPT, CHSE, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Karen Blood, PT, DPT, Board Certified Clinical Specialist in Geriatrics Physical Therapy Sarah Ferrero, PT, DPT, Board Certified Clinical Specialist in Geriatrics Physical Therapy
Diagnosis	Non–small cell lung cancer (NSCLC), status post (s/p) left upper lobectomy
Setting	Medical Intensive Care Unit, transfer to Medical Oncology Floor
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Describe the patient’s history in progress and discuss physical therapy implications of an acute thoracotomy procedure. Prioritize the acute care evaluation of this patient. Discuss patient monitoring and hemodynamic response. Create a patient-centered discharge plan.

Medical
Chief complaint	Difficulty breathing
History of present illness	The patient is an 82-year-old man with a diagnosis of NSCLC. He initially sought medical attention from his primary care physician 1 month ago secondary to persistent cough and hemoptysis. Chest computed tomography (CT) revealed a mass in the left hilar region. Fiberoptic bronchoscopy was performed and biopsy confirmed non–small cell squamous cell carcinoma. A positron emission tomography (PET) scan revealed no metastatic disease. The patient was referred to an oncologist and the decision was made to proceed with a left upper lobectomy with lymph node dissection via thoracotomy. The cancer was classified as stage IIB (T2b N1 M0).
Past medical history	Osteoarthritis, benign prostatic hypertrophy, diabetes mellitus
Past surgical history	s/p left total hip arthroplasty 6 years ago
Allergies	No known drug allergies
Medications	Flomax, Metformin, Glucosamine sulfate
Precautions/orders	Physical therapy, evaluate and treat Out of bed (OOB) as tolerated Titrate O₂ to maintain saturation > 90% Fall precautions

Social history
Home setup	Lives with his wife in assisted living facility (ALF). One-bedroom apartment is on the second floor. Elevator access to apartment (~1,000 feet from the apartment to the elevator) Congregate meals on the first floor, but can also be delivered to apartments or prepared in unit kitchenettes. Assisted living has transport wheelchairs available.
Occupation	Retired; owned a dry-cleaning business for 50 years
Prior level of function	Independent in all functional mobility and activities of daily living (ADLs) without supplemental O₂; used a cane for community ambulation. Participated in instrumental ADLs (IADLs) with his wife, such as shopping and light meal prep; ate breakfast and dinner in congregate dining room. + Driving
Recreational activities	Participates in weekly bridge club at ALF. Goes to daughter’s home every Thursday with his wife to babysit two grandkids (ages 5 and 7). Participates in group exercise classes thrice a week at ALF.

Vital signs	Hospital day 0
Vital signs	Preoperative	Postoperative
Blood pressure (mmHg)	118/68	108/62
Heart rate (beats/min)	72	80
Respiratory rate (breaths/min)	15	12
Pulse oximetry (SpO₂)	96% on room air	93% Intubated via endotracheal tube, on assist control mode
Temperature (°F)	98.8	98.7

Imaging/diagnostic test	Hospital day 0: surgery/postanesthesia care unit (PACU)	Hospital day 1: intensive care unit (ICU)	Hospital day 2: ICU
Chest CT	Fig. 11.1	1. s/p left upper lobectomy. Chest tube in intrapleural space, small left pleural effusion.	1. s/p left upper lobectomy, pleural effusion improved from previous study.

Medical management	Hospital day 0: surgery/PACU	Hospital day 1: ICU	Hospital day 2: ICU
Procedure/surgery	1. Patient sedated and intubated via endotracheal tube in preparation for surgery. 2. Internal jugular (IJ) central venous line placed. 3. Foley catheter placed. 4. Left thoracotomy and left upper lobectomy performed. 5. Chest tube placed in left intrapleural space.	1. IJ central venous line remains in place. 2. Foley catheter remains in place. 3. Bandage in place with minimal drainage. 4. Chest tube in place.	1. Patient extubated to 6L O₂ by nasal cannula (NC). 2. Central venous line removed. 3. Foley catheter removed. 4. Incision healing well and bandage in place. 5. Chest tube removed.
Additional medication	1. Heparin (subcutaneous) daily 2. Oxycodone 3. Intravenous (IV) fluids	1. Continue per medical orders
Respiratory	1. Intubated on assist control mode, FiO₂ 60%, positive end-expiratory pressure (PEEP) 5 cm H₂O.	1. Weaning from ventilator, on synchronized intermittent mandatory ventilation (SIMV), FiO₂ 40%, PEEP 5 cm H₂O 2. DuoNeb q.i.d.	1. 6 L O₂ by NC 2. Continue DuoNeb q.i.d.

Lab		Reference range	Hospital day 0: post-op	Hospital day 1: ICU	Hospital day 2: ICU
Complete blood count (CBC)	White blood cell (WBC)	5.0–10.0 × 10⁹/L	6.8	8.2	10.1
	Red blood cell (RBC)	4.1–5.3 million/mm³	4.0	3.8	3.6
	Hemoglobin	14–17.4 g/dL	14	11	10
	Hematocrit	42–52%	42%	36%	33%
	Platelets	140,000–400,000/μL	260	245	240
ABG	PaO₂	80–95 mmHg	78	75	82
	PaCO₂	37–43 mmHg	40	38	38
	PH	7.35–7.45	7.4	7.41	7.41
	HCO₃	20–30 mmol/L	24	25	24
Basic metabolic panel (BMP)	Glucose (fast)	70–100 mg/dL	156	164	152
	Hemoglobin A1C	< 5.7%	6.2%	—	—
	Cholesterol	< 200 mg/dL	185	—	—
	Low-density lipoprotein (LDL)	< 70 mg/dL	120	—	—
	High-density lipoprotein (HDL)	> 60 mg/dL	65	—	—
	Blood urea nitrogen (BUN)	6–25 mg/dL	25	26	27
	Creatinine	0.7–1.3 mg/dL	1.2	1.4	1.3
	Potassium	3.7–5.1 mEq/L	4.2	4.0	4.1
	Sodium	134–142 mEq/L	138	140	138
	Chloride	98–108 mEq/L	99	100	102
	Calcium	8.6–10.3 mg/dL	8.7	8.5	8.7
	Magnesium	1.2–1.9 mEq/L	1.4	1.5	1.3

Pause points
Based on the above information, what are: Anticipated patient impairments? Examination priorities? Patient precautions/monitoring strategies? Who is on the interprofessional team and what are the roles of the team members?

Pause points

Based on the above information, what are:

Anticipated patient impairments?
Examination priorities?
Patient precautions/monitoring strategies?

Who is on the interprofessional team and what are the roles of the team members?

Hospital Day 3, Step-Down Unit: Physical Therapy Examination
Subjective
“I just transferred to the Medical Oncology floor this morning. They want to get me up but it is hard to move due to pain 6/10 on my left side.”
Objective
Vital signs	Pre-treatment				During ambulation	Post-treatment
Vital signs	Supine		Sitting	Standing	During ambulation	Sitting
Blood pressure (mmHg)	112/76		110/72	118/78	120/80	126/80
Heart rate (beats/min)	87		92	102	117	110
Fig. 11.2 Electrocardiography during activity
Respiratory rate (breath/min)	16		18	22	26	24
Pulse oximetry on 2 L NC (SpO₂)	94%		95%	95%	92%	96%
Borg rate of perceived exertion (RPE) scale	10/20		11/20	13/20	14/20	11/20
Pain	6/10 Left side of thorax		6/10 Left side of thorax	7/10 Left side of thorax	8/10 Left side of thorax	6/10 Left side of thorax
General	Patient found supine in bed with head of bed (HOB) elevated 45 degrees and arms resting on a pillow in her lap. No apparent distress or difficulty breathing. Bandage in place over left thorax with minimal serosanguineous drainage from incision. Lines/equipment notable for telemetry, right upper extremity (RUE) peripheral IV, 4L O₂ by NC.
Cardiovascular and pulmonary	Inspection: no accessory muscle use, left lateral trunk lean with decreased left thoracic expansion. Palpation: reduced expansion left upper lobe (L UL). 2 + pedal pulses bilateral lower extremity (BLE). Auscultation: diminished breath sounds L UL, no adventitious sounds.
Gastrointestinal	Normal bowel movement this morning
Genitourinary	Voiding independently on bed pan, clear, yellow urine
Musculoskeletal	Range of motion (ROM)	Left shoulder: flexion and abduction (ABD): 120 degrees Left elbow, wrist, and hand: within functional limit (WFL) Right upper extremity (RUE): WFL throughout BLE: WFL throughout
	Strength	Left shoulder flexion and ABD: 3–/5 and limited by pain Left elbow, wrist, and hand: 3 + /5 RUE: 3 + /5 throughout BLE: > 3 + /5 throughout as demonstrated through functional mobility
	Aerobic	Unable to perform standardized assessment at this time. Refer to patient vital signs and signs and symptoms.
	Flexibility	Not assessed at this time
	Other	N/A
Neurological	Balance	Static sitting: good Dynamic sitting: good Supported static standing: fair Supported dynamic standing: fair
	Cognition	Alert and oriented (A&O) × 4
	Coordination	Finger to nose: intact BUE Toe tapping: intact BLE
	Cranial nerves	II–XII: intact
	Reflexes	Not tested at this time
	Sensation	BUE: intact to light touch BLE: intact to light touch
	Tone	BUE: within normal limit (WNL) BLE: WNL
	Other	N/A
Functional status
Bed mobility	Scooting: independent Bridge: independent Right rolling: minimal assistance Supine to/from sit: minimal assistance
Transfers	Sit to/from stand: minimal assistance with rolling walker (RW) Bed to/from chair: minimal assistance with RW
Ambulation	Ambulate × 40 feet with contact guard assistance (CGA) and RW
Stairs	Unable to assess secondary to pain and fatigue.
Posture	Maintaining slight left side bend in all positions.
Other	AM-PAC Basic Mobility Inpatient Short Form: 14/24

Fig. 11.1 Chest CT showing a mass in the left hilar region. (Source: Parker M, Rosado-de-Christenson M, Abbott G. In: Abbott G, Parker M, Rosado-de-Christenson M, ed. Teaching Atlas of Chest Imaging. 1st Edition. New York: Thieme; 2005.)

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I want to take care of myself at home.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.