12.2 Respiratory and Lymphatic Effects

TCO IV.A.2 and IV.A.14 test respiratory and lymphatic treatment effects: what the drug, the beam, the transplant, the node dissection, or the thoracic duct did to gas exchange and lymph flow. This is not the emergency chapter for acute chest syndrome, mediastinal airway compression, or the full transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) algorithms. Those are signposted. Here the CPHON nurse watches pulse oximetry, work of breathing, and a child's ability to play, then decides whether the next move is holding bleomycin, starting an infection workup, teaching the household to stay home with influenza, or elevating a swollen limb.

A 16-year-old with Hodgkin lymphoma who develops a dry cough on bleomycin, a 3-year-old on delayed intensification with a winter runny-nose exposure, and an 8-year-old after thoracic neuroblastoma resection with milky chest-tube output are the pictures.

Bleomycin and radiation lung injury

Bleomycin is used on some Hodgkin and germ-cell pathways. Pulmonary toxicity may appear during therapy or months later. The child has a dry cough, dyspnea, crackles, fever, or a falling saturation. Pulmonary function tests (PFTs), especially diffusing capacity of the lung for carbon monoxide (DLCO), trend before and during treatment on many protocols. A declining DLCO plus new symptoms is a hold, not a "push through this cycle" moment. Use the lowest fraction of inspired oxygen (FiO2) that meets ordered saturation goals; unnecessary high FiO2 can potentiate bleomycin lung injury. Corticosteroids are used for pneumonitis as ordered. Late fibrosis is a chronic restrictive disease: activity limits follow pulmonology, not a coach's pep talk.

Radiation pneumonitis typically declares about one to three months after chest radiation—Hodgkin involved-site fields, whole-lung treatment for metastases (Wilms tumor, Ewing sarcoma, rhabdomyosarcoma), or total body irradiation (TBI) before transplant. Fever, dry cough, dyspnea, and an infiltrate that respects the radiation field are the clues. Radiation fibrosis follows months to years later as a restrictive defect and, in severe cases, chronic oxygen need. Symptomatic pneumonitis is treated with corticosteroids as ordered after infection is addressed. Do not invent a single gray threshold as an ONCC number; teach field, timing, and the workup.

Infection, pneumonitis, and why the workup is the nursing plan

Pneumonitis versus infection is a differential, not a guess. Bleomycin injury, radiation pneumonitis, Pneumocystis jirovecii pneumonia (PJP), respiratory viruses, and fungi can share fever, hypoxia, and interstitial markings. The CPHON action is a workup: pulse oximetry, chest imaging as ordered, respiratory viral testing, and a low threshold to involve the infectious-disease and pulmonary teams—not a solo decision that "this is just radiation."

Immunocompromised children—ALL delayed intensification, infants, hematopoietic stem cell transplant (HSCT) recipients—are at high risk for respiratory syncytial virus (RSV), influenza, and PJP. Trimethoprim-sulfamethoxazole prophylaxis on ALL and HSCT pathways exists because PJP is preventable; missed doses are a nursing failure, not a trivia fact. Breakthrough PJP presents with subacute dyspnea, hypoxia, and fever. RSV in a 2-year-old after transplant can progress from a "cold" to respiratory failure; isolate, support oxygen, and treat the infant's work of breathing as real. Influenza is a household problem: inactivated influenza vaccine for contacts, and for the child when the oncology team clears counts. Live attenuated nasal influenza vaccine is not the default for the immunosuppressed patient. Teach stay-home-if-ill rules for siblings and visitors. School influenza clinics do not vaccinate the oncology patient without oncology clearance—the same principle as in transition-of-care teaching.

Bronchiolitis obliterans, transfusion lung injury, and daily pulmonary nursing

After allogeneic HSCT, chronic graft-versus-host disease (GVHD) can produce bronchiolitis obliterans: new obstructive PFTs, air trapping, wheeze or dyspnea that does not behave like ordinary reversible asthma. Surveillance PFTs belong on the post-transplant calendar. Infection prevention, pulmonary rehabilitation as ordered, and HSCT-team immunosuppression changes are the disease-modifying path. Do not endlessly escalate albuterol at home without telling the transplant clinic.

TACO (hydrostatic overload, often hypertensive, may improve with diuresis) and TRALI (inflammatory acute lung injury during or after transfusion) are signposted. Stop the product, support oxygen, notify the blood bank and the team, and do not finish the unit to "see if the cough settles." Full emergency titration lives later. Acute chest syndrome in sickle cell disease is likewise a later cardiopulmonary-emergency section; a new infiltrate plus respiratory symptoms in a child with hemoglobin SS is not bleomycin toxicity.

Daily tools are simple and pediatric: continuous or frequent pulse oximetry when hypoxic or at risk, play-based incentive spirometry (bubbles, pinwheels, party blowers for toddlers; a spirometer for school-age children), pulmonary hygiene, oxygen as ordered, and activity as tolerated to prevent atelectasis. A 5-year-old after chest radiation who will not "do spirometry" will often blow bubbles with a parent. That is still the intervention.

Lymphatic effects: lymphedema and chyle

Lymphedema follows lymph-node dissection (groin or axillary beds in extremity sarcoma, selected other solid tumors) and nodal radiation. The limb swells, skin breaks down, and cellulitis becomes an emergency for that extremity. Teach elevation, skin care, and referral to physical therapy or a lymphedema clinic. Avoid blood-pressure cuffs, venipuncture, and intravenous lines on the affected limb when another site is available. Compression garments are used as ordered, not improvised with an elastic bandage at home.

Chylous effusion follows thoracic-duct injury during chest or mediastinal surgery—thoracic neuroblastoma, mediastinal germ-cell or lymphoma resection, selected central-line or thoracotomy complications. Output is milky and triglyceride-rich. Respiratory compromise is treated first: oxygen, positioning, chest-tube care. Nutrition is a low-long-chain-fat or medium-chain-triglyceride plan, parenteral nutrition, and sometimes octreotide as ordered; surgical ligation is a team decision if leak persists. Do not call milky output "ordinary serous drainage" and strip the tube harder.

The CPHON product is a child whose cough is worked up, whose bleomycin is held when the lung is the organ failing, whose household is vaccinated and stays home when sick, and whose swollen arm or milky chest tube is treated as lymphatic injury rather than ignored edema.