**2. Palliative care for lung cancer patients**

Lung cancer is considered as the main cause of cancer death among both men and women in the world [28]. The survival rate is estimated not more than 5-year [29] and the average survival patients who do not take any anti-neoplastic treatment is about 7 months, according to a meta-analysis of over 5000 patients [30]. The main reasons of death from lung cancer included complications of metastases, tumor burden, infection, thromboembolism, pulmonary hemorrhage, and diffuse alveolar damage. The final common attributor for most of these complications is respiratory failure. Both survivals, quality of life and symptoms are commonly worse for patients with end stage of the disease. Symptoms related to lung cancer can include pain, anorexia/ cachexia, dyspnea, nausea, fatigue, confusion/delirium, and depression [31].

As pain is generally part of the reasons behind the suffering in these patients, beside psychological distress. Opioids are chief support that provides effective analgesia in cancer pain, such as morphine, which considered as is the most used opioid for moderate to severe pain. It can be used rectally or transdermally in patients who cannot take it orally [32]. Low-dose corticosteroids are also recommended for relieving pain from liver metastases, bony metastases, or neuropathic pain [33]. Anticonvulsants such as phenytoin, carbamazepine, and clonazepam are also helpful in treating that pain. Tricyclic antidepressants increase the effects of opioids and have analgesic properties [34].

#### *Palliative Care Therapies DOI: http://dx.doi.org/10.5772/intechopen.105220*

Other symptoms that can develop from locally advanced NSCLC or lung cancer metastases are dyspnea and cough, these symptoms are disease-related complications, such as malignant effusions and airway obstruction. Therapeutic procedures with palliative aide can be helpful, such as pericardiocentesis with a pericardial drain/window, thoracentesis, or placement of pleural drain [35]. Other strategies for resolving airway obstruction include laser therapy, bronchoscopy, stent placement (endobronchial or vascular), or photodynamic therapy [36].

Morphine is usually used drug while recommendation of codeine or dihydrocodeine may be considered in dyspnea with lower intensity [37, 38]. Other opioids, including fentanyl and oxycodone, have been studied in this management, opioid mechanism of action is conveyed via opioid receptors of the cardio-respiratory system [39]. Benzodiazepines are also utilized as an adjunct, or as an alternative, to opioids for treating dyspnea which considered as a second or third choice in cases where morphine and non-pharmacological methods are not enough to control dyspnea [40]. Anticholinergic drugs such as hyoscyamine, scopolamine, atropine, and glycopyrrolate can be described to decrease excessive secretions [41, 42].

In 47–86% of lung cancer patients, cough is one of the most common symptoms of lung cancer. Pharmacotherapy includes administration of antitussive drugs and opioids. Oral corticosteroids that are taken for 14 days may resolve coughing result from direct infiltration of the bronchus by the tumor. As consequences of cough, gastrointestinal reflux may occur; which may resolve with metoclopramide or domperidone. Dihydrocodeine, codeine also can be prescribed as antitussive opioid, codeine is usually in complex preparations with paracetamol. Constipation on the other hand is a complication of systematic administration of opioid, therefore prophylactic administration of laxatives is essential. Morphine or other strong opioids such as methadone are recommended for severe cough with pain in the chest, co-administration of more than one opioid is not appropriate. Mucolytic agents such as bromhexine and acetylcysteine that can be taken orally or by inhalation, but have limited use [43, 44].

Hemoptysis is a symptom that appears in about 20% of lung cancer patients. Pulmonary hemorrhage, which usually leads to death, is noticed in 3% of patients. The reasons behind hemoptysis include bronchiectasis, trauma after bronchoscopy, anticoagulation therapy, pulmonary embolism, fistulas, and others. Tranexamic acid and medications that support hemostasis such as vitamin K and antitussives are drugs that inhibit fibrinolysis that is used in adjunctive therapy at the end stage of disease. Also in the mentioned stage of disease mitigation procedures are used such as an appropriate position to forbid choking, taking anti-anxiety drugs (diazepam, midazolam) and using bed linen in dark colors [37, 43] in case of superior vena cava syndrome. The most seen symptoms include swelling of the face and congestion, upper chest and shoulders, shortness of breath, hoarseness, fainting on standing at the slope, dizziness, headache, and extension veins in the neck and the chest wall, corticosteroids such as dexamethasone are used as palliative treatment. Also, the use of heparin because of risk of thrombosis SVCS in the superior vena cava is reasonable [43, 45, 46].

Nutrition and appetite stimulants advising can be considered for patients with critical appetite and weight loss. Low-dose corticosteroids for appetite stimulation are unclear, but the benefit of it is often related to its antiemetic effect. Medications such as stimulants, antidepressants, steroids, and erythropoietin-stimulating agents have been assessed for treating fatigue but without definite evidence of benefit. The intervention studied for enhancing fatigue is exercise and physical activity [47–49].
