Series No.67 – On-treatment diary for patients having radiotherapy/proton beam therapy to the chest

Fatigue

Tiredness during and after treatment.

If you're feeling fatigued, there are some things you can do to help you manage your tiredness:

• Physical activity/gentle exercise can help reduce the symptoms of fatigue. Choose an activity or exercise that you enjoy, as you are more likely to keep doing it.
• Eat a balanced diet and keep hydrated (1.5 - 2 litres of water a day). During hot weather, the amount of water you drink should increase. Avoid too much caffeinated fluids such coffee as they make people dehydrated and urinate more.
• Even though your fatigue may make you feel like sleeping all the time, try to keep to a normal sleep routine and only take short naps if needed during the day.
• You may find it harder to complete your daily tasks and you may need help to do so. Please ask your clinical team if you feel that you need a referral to occupational therapy to help you manage tasks such as your personal care, cooking or returning to work.
• Dealing with fatigue can be very difficult. Some people find it can affect their feelings. If you are finding it difficult to cope talk to your clinical team. 

You can have a look at Macmillan’s ‘Coping with Fatigue’ Booklet for more information: Available at radiotherapy reception and their website.

Pain

This can depend on the area being treated.

Increases as treatment progresses.

Can be managed with pain medication.

(All can be prescribed in a liquid/ dissolvable form)

Dependent on your needs and any current medication you are taking, you may require the following:

Cough

Radiotherapy can irritate and inflame your lungs which can produce a cough and/or increase a cough if you had one previously

To help with coughing: 

• Drink plenty of fluids. 
• Sleeping with an extra pillow. 
• Staying inside in very cold weather and covering your mouth with a scarf when you must go outside. 
• Simple cough syrup can give temporary relief 
• If you have a productive cough, (producing phlegm) please let the team know. Steam inhalation or nebulisers can be used to loosen phlegm. 

Clearing phlegm:

It is important to remove sputum from your lungs to help you breathe more easily, prevent chest infections and reduce bouts of coughing. Leaving sputum in your chest can make your condition worse. The Active Cycle of Breathing Techniques (ACBT) is one way to help you to clear sputum from your chest. ACBT is a set of breathing exercises that loosens and moves the sputum from your airways. It is best to be taught ACBT by a physiotherapist. The ACBT exercises are breathing control, deep breathing and huffing which are performed in a cycle until your chest feels clear.     

Leaflet: The Active Cycle of Breathing Techniques 

You can also have a look at this video ‘airway clearance techniques’ to help with secretion clearance: Respiratory outpatient physiotherapy patient videos : University College London Hospitals NHS Foundation Trust (uclh.nhs.uk) 

Sometimes, coughing can lead to pelvic floor weakness. Therefore, it is also important to exercise your pelvic floor:

Pelvic floor exercises for men leaflet

Pelvic floor exercises for women leaflet

Shortness of breath

Radiotherapy can increase shortness of breath from underlying conditions such as COPD and asthma.

Shortness of breath can also occur during radiotherapy especially towards the end. 

• There are three ways in which you might feel short of breath: with moderate exertion e.g., exercise, housework, walking etc 
• With minimal exertion e.g., preparing meals, shopping or,  
• At rest e.g., bathing, dressing, feeding oneself.

If you become short of breath after moderate exertion or with minimal exertion: 

Change environment, maintain calm atmosphere, promote cooler temperatures i.e use a fan, humidify air, avoid smoke/smoking. 

Consider referral for use of a mobility aid: for example, a wheelchair or stick - please ask the team for a referral to physiotherapy or occupational therapy if you think you need any additional equipment at home.

Use relaxation techniques: controlled breathing, visualization. You can focus on ‘rectangular breathing’ – find a rectangle for example a window or door and focus on this. Breathe in on one edge and out on the next. This can help you focus and calm your breathing. 

Positioning: Avoid compression of chest and abdomen when positioning

Positions that allow for optimal lung expansion and gas exchange are:

• Sitting: Sit upright with back against chair, with feet wide apart, leaning forward with arms on bedside table or on knees – allows more space for lung expansion  
• Standing: Lean yourself forwards by wall or windowsill with feet slightly apart and head and shoulders relaxed  
• In Bed: Elevate head of the bed, support and elevate arms with pillows  
• Other: Lean forward on shopping trolley when out shopping. 

You can also take a look at these leaflets which show you pictures of how to perform these positions as outlined above:

How to Cope With Being Short Of Breath – Positions

How To Cope With Being Short of Breath -
Breathing Exercises

If you are short of breath at rest, have chest pain or you have a temperature above 37.5, please call the 24hr number regardless of the time of day.

Skin

Your skin may become red and sore in the treatment area and you may experience some hair loss.

Weight loss

Whilst on treatment you are using more calories than you did before. 

It is important you maintain your weight to be able to ensure the accuracy of the treatment and give you the best recovery.

Difficulty or Pain when swallowing

If we are treating close to your food pipe (oesophagus) you may find it difficult or painful to swallow.

Use the pain medications as advised e.g., before meals to reduce pain on swallowing 

Drink liquids while eating- to help food go down 

Change consistency of food you eat e.g. soft pureed food will go down easier than salad. Make sure food is not too spicy or hot. 

You may be given medication called Antacid and Oxetacaine Oral Suspension to help with swallowing. Oxetacaine is a topical anaesthetic which effectively relieves pain when applied to the lining of the mouth and food pipe. The antacids neutralize stomach acid and prevent further irritation to the food pipe. Take as prescribed. The usual dose is 10mls fifteen minutes before food and at bedtime (4 times a day)

Constipation

The use of strong pain killers and dietary changes can cause this. We can prescribe laxatives to help.

Stay hydrated.  Drink 1.5-2L of fluids daily

Sodium Docusate – to soften stool

Movicol/ Laxido – 1 x day when using co-codamol / morphine. Can increase if needed. 

Senna – to help push bowel movement

Other medications

Stomach protectors 

Anti-Sickness 

Oral Thrush 

Steroids

Lansoprazole/ Omeprazole 

Cyclizine / Domperidone / Metoclopramide/

Ondansetron 

Nystatin 

Dexamethasone/Prednisolone

Smart snacking options

Choose snacks that are high in energy and protein

You may need to change to softer or puree / blended foods if you have increased swallowing difficulties towards the end of treatment.

Puree: Full fat yoghurt, custard, rice pudding, smooth porridge with full fat milk/cream, weetabix soaked in warm milk, thick smooth soup with added cream, ice cream, doogh/ayran, milkshakes/lassi (no lumps) 

Minced & Moist: Hummus, tzatziki, guacamole, scrambled eggs, mashed paneer with sauce, mashed avocado, soft cheese, tuna mayonnaise, egg mayonnaise, mashed banana/mango/plantain, rice pudding, soft sponge with cream, mousse, crème caramel, panna cotta, biscuits dipped in hot drinks, trifle, tiramisu, cheesecake (no crust)

Soft & bite-sized: Room temperature chocolate, mashed avocado, soft puddings, falafel, tinned spaghetti or tinned macaroni cheese  

Normal diet: Cheese, pancakes with jam and cream, crème brulee, ‘melt in mouth’ crisps (e.g. Wotsits), chocolate, nuts, olives, crudités dipped in peanut butter/hummus, dates, nut butter

Eat ‘little and often’

As above

Make every mouthful count

Add cream, cheese, butter, milk, milk powder, oil, ice cream, yoghurt, salad cream, mayonnaise, nut butter, ground nuts/seeds, honey, jam, sugar, milk powder to your meals.

Aim to include some high protein food with every meal and snack.

Meat, poultry, fish, eggs, dairy products, tofu, lentils, beans, pulses, Quorn™ and soya protein products.

Nourishing drinks

Whole/jersey milk, smoothies, flavoured milks, drinkable yoghurts, milkshakes, fruit juice, full sugar fizzy drinks (if tolerated) and ‘fortified milk’, hot chocolate, hot malted drinks, café latte, cup-a-soup with added milk/cream, full fat lassi

Recipe for ‘fortified milk’

Make a paste using 4-5 heaped tablespoons of skimmed milk powder (e.g. Marvel TM, NestleTM, NidoTM) and a little whole milk. Next, add the remaining pint of whole milk gradually to the paste and mix well.

Supplements

Nutritional supplements are often used when you are eating less during treatment, as they contain energy, protein, fats, vitamins and minerals. Your dietitian will guide you on starting supplements if appropriate and how much to take.

There are a wide variety of supplements drinks available including: 

• Juice based e.g. Ensure Plus Juce, Actagain Juce  
• Milk based e.g. Ensure Twocal, Fortisip 
• Fibre containing e.g. Ensure Plus Fibre
• Low volume e.g. Ensure Compact, Altraplen Compact, ProCal shots
• Semi-elemental (for tolerance reasons) e.g. Vital 1.5

Plan ahead

Bring snacks/supplements with you when you are out of the house or coming to treatment