Dyspnoea/shortness of breath pathway¹

(Reproduced with kind permission of UKONS¹)

Always make sure that the Acute oncology Team are informed of the patient's assessment and/or admission as soon as possible.

Immediate advice is available from the Acute Oncology Service or the 24-hour Oncology on call rota.

Withhold SACT, including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.

Wide differential diagnosis: disease progression, infection (including SARS-Cov-2), lymphangitis, pulmonary oedema, pulmonary emboli, sarcoidosis.

Immune-related pneumonitis pathway¹

1. Abridged from: NHS Lothian Immunotherapy toxicity management guidelines v7.0. S Clive & C Barrie. Last reviewed: 22.11.2021.

The following content is abridged from: Edinburgh Cancer Centre. Tyrosine kinase inhibitor-related pneumonitis for solid tumours and haematology (S\Tox\20) v1.0. 

Assessment and immediate management

Please ensure that SARS-CoV-2 (Covid-19) has been ruled out.  

General medicine physicians who encounter these patients eg as acute admissions are encouraged to discuss their management with oncology or haematology teams.

Grade 1

• Asymptomatic – radiological changes only 
• Bloods, observations including pulse oximetry, pulmonary function tests.

Grade 2

• Mild to moderate new onset of symptoms limiting instrumental activities of daily living (ADL) (e.g. shortness of breath, cough, fever, chest pain).   
• Bloods, observations including pulse oximetry, pulmonary function tests. High Resolution CT chest.   
• Consider hospital admission. Investigations to exclude pulmonary infection (especially COVID-19). 
• Seek specialist respiratory advice ( Dr Gareth Stewart WGH or Dr Nik Hirani, remote advice)

 Grade 3

• Severe new onset of symptoms limiting self care, or hypoxia or acute respiratory distress syndrome 
• Urgent hospital admission 
• Seek specialist respiratory advice (Dr Gareth Stewart, WGH or Dr Nik Hirani, remote advice) 

Ongoing management and TKI management

Grade 1

• Continue therapy.   
• Monthly clinical review and pulmonary function tests.   
• 2-monthly cross sectional imaging of the chest.

Grade 2

• Withhold TKI.   
• If infection excluded commence high dose steroid (e.g. prednisolone 50mg OD with PPI cover).  
• Seek specialist respiratory advice as above.   
• Taper steroid dose as symptoms improve.   
• If symptoms settle to grade 1 on steroids within 3 weeks and no alternative treatment option available for the patient, discuss risk-benefits of re-introducing TKI at same dose.   
• Steroids need to continue for the duration of TKI therapy. 
• Monthly clinical review and pulmonary function tests.  2-monthly cross sectional imaging of the chest. 

Grade 3

• Permanently discontinue TKI therapy. 
• Manage with high dose steroids, e.g. prednisolone 50mg daily with PPI cover.  
• Seek specialist respiratory advice as above.  
• Taper dose as symptoms improve.   
• Repeat PFTs and cross sectional imaging of the chest to monitor improvement. 

1. UKONS Oncology Nursing Society. Acute oncology initial management guidelines. v.4.0. Publication date: 13.02.2023. Available from: https://ukons.org/news-events/acute-oncology-initial-management-guidelines-latest-version/