Clinical Question 2017 5 27
1 PCOC 1. 12778 ( 55%, 45% NRS. 1 54, 35%. NRS. NRS,,,,,,,, Performance status, Ekstrom, M., et al.2016 J Pain Symptom Manage 51(5):816-23.
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1 85 ADL. 3,,,,. JCS200,, 40 /, 10L SpO2 96% 1,.,,,,,.,,.
2 78 COPD HOT. 2, GOLD IV, D, 5 50%, e-prognosis 1 34%. https://eprognosis.ucsf.edu/calculators/ 5 39.6,,.. 10L SpO2 80, 30 /,,., COPD. CO2,,,,.
Clinical Question,.,.,,,.
A.,, B. C.
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,.,.,,.,,,., PaO2 60Torr. Ⅰ PaO2<60Torr A-aDO2>20Torr PaCO2>45Torr,, Ⅱ PaO2<60Torr A-aDO2 10-20Torr PaCO2 45Torr
Step 1 ( ) Step 2 Step 3
Step1 SpO2,,.,. Time of onset / Duration acute-on-chronic / Frequency Intensity Associated symptoms, EPO NPPV Booth S, et al. Nat Clin Pract Oncol, 5: 90 100, 2008.
. NRS: COPD,. 0 10 11. VAS: COPD. 100mm. mbs:, COPD,. 0 10 12 (+ ).. Cancer Dyspnea Scale (CDS)...
Step2 (PaO2<60Torr) Ⅰ,. (SpO2<90%) VAS Bruera E, et al. Lancet. 1993; 342(8862): 13-4.
NPPV NHF Ⅰ, Ⅱ, (NPPV) (NHF). NPPV, NPPV. (Evidence Ⅱ, C1) COPD NPPV A B C DNI* ARDS *DNI: Do Not Intubate NPPV
NHF NHF (NPPV ), RCT 14, 2507,, NHF,. RCT, 310 ARDSⅠ NHF, NPPV,,,P/F < 200, NHF,. NPPV B,C, NHF. Monro-Aomeville T. et al. Crit Care Med. 2017 Apr;45(4):e449-e456. Frat J-P, et al. NEJM 2015; 372:2185-96. 2016; 26(1): 21-25. NHF, NPPV, NHF NPPV QOL,,, Ⅱ FiO2 21 100% 21 100% 60%(90% PEEP 2 4cmH2O 0 24cmH2O 160 819 65
Step3, Step2, (refractory dyspnoea),,. total dyspnoea.,,,,. TOTAL DYSPNOEA J Palliat Med. 2011 Oct; 14(10): 1167 1172.
1. ( ) ( ) / 2. ( CO2 ) () 3. ( )
1. 2. 3. COPD 4.
,.. COPD, 20mg CO2. Rice KL et al. Br J Dis Chest. 1987 Jul;81(3):287-92. 120mg/ 2 vs 6,. Bengoechea et al.j Palliat Med. 2010;13(9):1079-83.
(2.5-20mg),. NRS,, SpO2 PaCO2 ( / ) 30 90 41.8 ± 4.7 (35.0 50.0) 35.5 ± 4.2 (30.0 40.0) 25.7 ± 4.5 (20.0 32.0). Clemens EK et al. J Palliat Med. 2008;11:204 216. J Pain Symptom Manage. 2007;33:473 481. 35 50 / 20 30 / 83 ( COPD 54%, 29%, 12%). 10mg, 1 10mg/, 30mg. 10 30mg 6 VAS 17.1mm., 7 10mg. Currow et al. J Pain and Sym Manage. 2011;42(3): 388-399.
50% -3- (M3G), 10% -6- (M6G). M6G, M6G., Cr > 2.0mg/dl Ccr < 30 ml/min... 2006;33(4):529-32.. 2005; 16: 52-6. COPD : 10mg/, 10% VAS 2. Int J COPD.2006 Sep; 1(3): 289 304.,., 0.25mg/1A+ 20ml 10 25ml 0.8ml/h 1.25ml/h ( 20-30mg),. 1mg (30mg) Journal of Pain&PalliativeCare Pharmacotherapy 2011; 25: 316-334.
COPD GOLD,, (Evidence C). GOLD 2017 COPD, VAS,,, QOL. Eiser N et al. Our Respire J 1991; 4:926-31. Johnson MA et al.bmj Clin Res Ed 1983; 286: 675-7. COPD. COPD 11 30mg1 4 (20mg) 25mg1 4, 24 1 PaCO2,, PaCO2. Rice KL et al. Br J Dis Chest. 1987 Jul;81(3):287-92.
ACCF/AHA EJC. ACCF/AHA 2017 Oxberry NYHAⅢ-Ⅳ 3320mg/ 10mg/ placebo 4 1 1, 3 placebo. Oxberry SG et al. J Palliat Med. 2013;16(3):250-5. Johnson, NYHA3-4 1020mg/ 4 2 6 VAS 23 mm (P = 0.022). Johnson MJ Eur J Heart Fail. 2002 Dec;4(6):753-6.
. 3-5.. Indian Journal of Palliative Care 2016;22(3) 282-287. Allens 11 2.5mg 15, VAS 100mm 47mm,. Allens S. Palliat Med. 2005 Mar;19(2):128-30.
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, COPD. -.. -, 1. -,. COPD, squeezing ADL. -,. -,. Buckholz GT, et al. Curr Opin Support Palliat Care, 3: 98 102, 2009. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD005623 Galbraith S, et al. J Pain Symptom Manage 2010; 39: 831-8.
, 10mg 30mg, 10mg. NPPV, NHF., COPD,,.,.
1 (CTRX+LVFX)., 40 /,, 0.5mg/h (24mg/ ). 1 35, 1mg/h, 25 28.., 6L., 7.
2 CFPM+CPFX, COPD., NPPV.,,,,.,. 5., Advanced directive,, COPD CO2,,.,,.
. 25,, 6.. QOL Trajectory Farquhar, M., et al. 2017; PLoS One 12(5):e0177081.
,. CASCADE study,. 240 1546 229. 80%, 2.21,,.. J Am Geriatr Soc 2006; 54: 290-5
Take home message.,,.,,,, QOL.