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Symptom Management

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    Complementary therapies such as acupuncture and acupressure have been demonstrated to be beneficial for relieving dyspnea, although controlled trials are lacking.[55] Antibiotics may provide relief from infectious sources of dyspnea; however, the use of these agents should be consistent with the patient's goals of care. If the patient experiences bronchospasm in conjunction with dyspnea, glucocorticoids or bronchodilators can provide relief. Bronchodilators should be used with caution because they can increase anxiety, leading to a worsened sense of dyspnea. In rare situations, dyspnea may be refractory to all of the treatments described above. In such cases, palliative sedation may be indicated, using benzodiazepines, barbiturates, or neuroleptics.

    Fatigue

    Fatigue at the end of life is multidimensional, and its underlying pathophysiology is poorly understood.[56] Factors that may contribute to fatigue include physical changes, psychological dynamics, and adverse effects associated with the treatment of the disease or associated symptoms. Stimulant medications, along with energy conservation, may be warranted. (Refer to the PDQ summary on Fatigue for more information.)

    Cough

    In some patients, chronic coughing at the end of life may contribute to suffering.[57] Chronic cough can cause pain, interfere with sleep, aggravate dyspnea, and worsen fatigue. At the end of life, aggressive therapies are not warranted and are more likely to cause increased burden or even harm. Symptom control rather than treatment of the underlying source of the cough is warranted at this time of life. Opioids are strong antitussive agents and are frequently used to suppress cough in this setting. Corticosteroids may shrink swelling associated with lymphangitis. Antibiotics may be used to treat infection and reduce secretions leading to cough. Patients with cancer may have comorbid nonmalignant conditions that can lead to cough. For example, bronchodilators are useful in the management of wheezing and cough associated with chronic obstructive pulmonary disease, and diuretics may be effective in relieving cough due to cardiac failure. Additionally, a review of medications is warranted because some drugs (e.g., ACE inhibitors) can cause cough.

    Anecdotal evidence suggests a role for inhaled local anesthetics, which should be utilized judiciously and sparingly; they taste unpleasant and suppress the gag reflex, and anaphylactic reactions to preservatives in these solutions have been documented. In cases of increased sputum production, expectorants and mucolytics have been employed, but the effects have not been well evaluated. Inhaled sodium cromoglycate has shown promise as a safe method of controlling chronic coughing related to lung cancer.[58]

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