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Home > St George’s Healthcare Professional Portal > Common Side Effects of Cancer Treatment > Immune related pneumonitis

Immune related pneumonitis

Difficulty breathing, a conscious appreciation of increased work done during breathing, may include symptoms such as wheezing, choking, or a feeling of not getting enough air into the lungs

Questions

  • What chemotherapy is the patient on and when was the last treatment?
  • Does the patient suffer of any chronic respiratory disease (COPD, asthma, bronchitis…?)
  • Does patient have chest tightness/chest pain?
  • When did patient start feeling breathless?
  • Can patient talk in full sentences? Is there any stridor? How many blocks/flights of stairs can the patient walk before needing to stop?
  • Does patient report any cough? Phlegm? Does the patient have any temperature?
  • Can the patient lay flat without feeling breathless? Swollen limbs?
  • Is the patient on any of the following: Everolimus, Taxol, Atezolizumab, Ipilimumab, Nivolumab, Pembrolizumab, Tremelimumab, Bleomycin?

Grade 1 (Green)

No new symptoms

Advice

  • Ensure patient is not neutropenic
  • Enquire regarding signs of sepsis/productive cough (escalate to RED when appropriate)
  • Correct anaemia if necessary
  • If there is a history of underlying respiratory disease (asthma, COPD, chronic bronchitis…):

Advise the patient around usual management of exacerbation and discuss with GP/other healthcare professionals  managing this condition

  • Advise to contact Acute oncology Team if symptoms persist/worsen or if they develop any other symptoms
  • Inform AOS Team to contact patient for follow-up

Grade 2 (Amber)

Dyspnoea on exertion

Advice

  • Ensure patient is not neutropenic
  • Enquire regarding signs of sepsis/productive cough (escalate to RED when appropriate)
  • Correct anaemia if necessary
  • If there is a history of underlying respiratory disease (asthma, COPD, chronic bronchitis…):

Advise the patient around usual management of exacerbation and discuss with GP/other healthcare professionals  managing this condition

  • Advise to contact Acute oncology Team if symptoms persist/worsen or if they develop any other symptoms
  • Inform AOS Team to contact patient for follow-up

Grade 3 (Red)

Dyspnoea at normal levels of activity

Advice

  • Ensure patient is not neutropenic
  • If suspected neutropenic sepsis treat immediately with broad spectrum antibiotics as per protocol
  • Admit patient if evidence of:
    • Infection
    • Desaturation
    • Other chemotherapy toxicities
  • Pneumonitis might be drug or radiotherapy related – discuss with Acute Oncology Team
  • For management of SVCO or pleural effusion see relevant guidelines
  • Manage all other causes in accordance to trust local guidelines depending upon differential diagnosis

Grade 4 (Red)

Dyspnoea at rest or requiring ventolatory support

Advice

  • Ensure patient is not neutropenic
  • If suspected neutropenic sepsis treat immediately with broad spectrum antibiotics as per protocol
  • Admit patient if evidence of:
    • Infection
    • Desaturation
    • Other chemotherapy toxicities
  • Pneumonitis might be drug or radiotherapy related – discuss with Acute Oncology Team
  • For management of SVCO or pleural effusion see relevant guidelines
  • Manage all other causes in accordance to trust local guidelines depending upon differential diagnosis

Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding.

Arrange follow up review as necessary.

Initial assessment – patient seen in AOCU

  • Read specific drug information sheet in addition to general dyspnoea guidance
  • Interrupt SACT/chemotherapy including oral chemotherapy drugs, if applicable, until discussed with the Acute Oncology Service Team

Initial assessment

  • Observation: temperature, Pulse, Saturation of Oxygen, respiration rate. Early Warning Score (nEWS)
  • Investigations: FBC, U&E, CRP, D-dimer, sputum C&S, chest X-Ray, blood cultures if pyrexial.
  • Consider ABGs and troponin if appropriate. Consider CTPA/VQ investigations to rule out pulmonary embolism.

History to include

  • What chemotherapy is the patient on and when was the last treatment?
  • Does the patient suffer of any chronic respiratory disease (COPD, asthma, bronchitis…?)
  • Does patient have chest tightness/chest pain?
  • When did patient start feeling breathless?
  • Can patient talk in full sentences? Is there any stridor? How many blocks/flights of stairs can the patient walk before needing to stop?
  • Does patient report any cough? Phlegm? Does the patient have any temperature?
  • Can the patient lay flat without feeling breathless? Swollen limbs?
  • Is the patient on any of the following: Everolimus, Taxol, Atezolizumab, Ipilimumab, Nivolumab, Pembrolizumab, Tremelimumab, Bleomycin?
  • Full physical examination
  • Check bloods (FBC, U&E, D-Dimer, CRP, blood cultures if suspecting neutropenic sepsis)
  • Chest X-ray

Differential diagnosis

  • Chest Infection
  • Pulmonary embolism (PE),
  • Disease progression (i.e. consolidation/pleural effusion/superior vena cava obstruction (SVCO)
  • Cardiac ischaemia
  • Anaemia

Treatments

  • History of complaint – Include other toxicities associated with the complaint.
  • Full Physical examination
  • Full set of vital signs & calculate EWS.
  • AVPU
  • Full blood count, U&Es, G&S, CRP.
  • Consider blood cultures if any signs of infection