Grading Toxicity
Pneumonitis
Definition: A disorder characterized by inflammation focally or diffusely affecting the lung parenchyma
- Asymptomatic; clinical or diagnostic observations only; intervention not indicated
- Symptomatic; medical intervention indicated; limiting instrumental ADLs
- Severe symptoms; limiting self-care ADLs; oxygen indicated
- Life-threatening respiratory compromise; urgent intervention indicated (tracheostomy, intubation)
Hypoxia
Definition: A disorder characterized by decrease in the level of oxygen to the body
- N/A
- Decreased oxygen saturation with exercise (e.g., pulse ox < 88%); intermittent supplemental oxygen
- Decreased oxygen saturation at rest (e.g., pulse ox < 88%)
- Life-threatening airway compromise; urgent intervention indicated (tracheostomy, intubation)
Management
Overall Strategy:
- Assess for other etiologies such as infection, pulmonary embolism, progressive lung metastases, or lung disease
- Early intervention to maintain or improve physical function and impact on QOL
- Assess pulse oximetry (resting & on exertion) at baseline and at each visit to assist in identifying a decrease at early onset.
- No known interventions
- Anticipate immunotherapy to continue
- Continue to monitor via radiology testing (q 2-4 weeks, as needed)
- Review symptoms to watch for with patient and family, and remember to assess at every subsequent visit
- Immunotherapy to be withheld for Grade 2 events (resume when Grade 0/1)
- Immunotherapy to be discontinued for recurrent (pembrolizumab, nivolumab) or persistent Grade 2 events (ipilimumab, pembrolizumab, nivolumab)
- Anticipate treatment with:
- Corticosteroids (e.g., prednisone 1-2 mg/kg/day or equivalent) until symptoms improve to baseline, and then slow taper over at least 1 month
- If symptoms do not improve within 48-72 hours, corticosteroid dose will be escalated. IV corticosteroids may be considered
- Additional supportive care medications may also be initiated
- Anticipatory guidance on proper administration
- Anticipate the use of empiric antibiotics until infection is excluded
- Anticipate that bronchoscopy may be ordered by provider
- Assess patient & family understanding of recommendations and rationale
- Identify barriers to adherence
- Discontinue immunotherapy for Grade 3/4 events
- Patient will likely need to be admitted to the hospital for further management and supportive care
- Anticipate the use of high-dose IV corticosteroids (e.g., methylprednisolone 2-4 mg/kg/day or equivalent)
- Once symptoms have resolved to baseline or Grade 1, convert to equivalent oral corticosteroid dose and then taper slowly over at least 1 month
- Anticipate the use of empiric antibiotics until infection is excluded
- Anticipate the use of additional immunosuppressive agents if symptoms do not improve in 48-72 hours (e.g., infliximab, mycophenolate, cyclophosphamide)
- Assess patient & family understanding of toxicity and rationale for treatment discontinuation
- Identify barriers to adherence, specifically compliance with medication, physical activity.
Nursing Implementation:
- Identify high-risk individuals (e.g., asthma, COPD) and those with cardiopulmonary symptoms prior to initiating immunotherapy. Establish a thorough baseline
- Educate patients that new pulmonary symptoms should be reported immediately
- Anticipate that the steroid requirements to manage pneumonitis are high (1-4 mg/kg/day) and patient will be on corticosteroid therapy for at least 1 month
- Educate patients and family about the rationale for discontinuation of immunotherapy in patients who do develop moderate or severe pneumonitis
RED FLAGS:
- Risk of acute onset
- Risk of mortality if pneumonitis treatment is delayed
- Risk of pneumonitis is greater in patients receiving combination immunotherapy regimens
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