2012 年 12 月 271 第 22 回日本呼吸ケア リハビリテーション学会学術集会 ( 福井 ) 奨励賞 受賞報告 特発性肺線維症における呼吸困難感, 運動 耐容能,QOL を含む多面的評価の重要性 要旨 IPF QOL IPF modified MRC modified MRC 6 SpO 2 modified MRC IPF IPF 6 QOL IPF QOL は じ め に 24 11 22 QOL 1 2 スコアは 患者の 予後を予測する 1 modified MRC IPF 2000 4 2005 7 IPF retrospective IPF 2000 ATS/ERS 2 93 18 19.4 75 80.6 HRCT 93 81 12 FVC 2.370.73 L FVC 75.0 20.1 Dl CO 9.193.92 ml/min/mmhg Dl CO 56.3 20.6 81.011.9 mmhg 1 40.625.8 49 52.7 18 19.4 IPF 13 14.0 5 5.4
272 日本呼吸ケア リハビリテーション学会誌第 22 巻第 3 号 5 5.4 4 4.3 4 4.3 表 1 Variables Value Age, yr 66.3 8.1 Sex Male 81 Female 12 Height, cm 160.8 8.0 Body weight, kg 60.4 11.6 BMI 23.3 3.5 Smoking status Current 15 Former 59 Never 19 Baseline pulmonary function testing FVC, L 2.37 0.73 FVC, pred. 75.0 20.1 FEV 1, L 1.93 0.57 FEV 1, pred. 85.4 22.1 Dl CO, ml min mmhg 9.19 3.92 Dl CO, pred. 56.3 20.6 Baseline arterial blood gas values, mmhg 81.0 11.9 PaCO 2, mmhg 39.8 5.3 ph 7.42 0.03 MMRC score 0 11 1 41 2 38 3 3 4 0 Six min walk test at baseline Walk distance, m 516 96.8, 82.7 9.5 Borg 4.0 2.1 n 93 except for Dl CO,, PaCO 2, ph n 90, respec tively and 6 min walk test variables 92. Continuous vari ables are expressed as mean values standard deviations. BMI: body mass index; FVC: forced vital capacity; FEV 1 : forced expiratory volume in 1 second; Dl CO : diffusion ca pacity of carbon monoxide; : partial pressure of oxy gen; PaCO 2 : partial pressure of carbon dioxide; MMRC: modified MRC; SpO 2 : arterial oxygen saturation measured by pulse oximetry. 1 2 FVC Dl CO modified MRC 6 SpO 2 Borg stepwise modified MRC 6 SpO 2 3 表 2 Univariate cox proportional hazard model Variables Hazard ratio p value Age 1.027 0.987 1.069 0.1915 Smoking status Current 0.818 0.338 1.984 0.6573 Former 0.959 0.475 1.936 0.9069 BMI 0.977 0.891 1.071 0.6233 FVC, pred. 0.965 0.948 0.982 0.0001 Dl CO, pred. 0.978 0.963 0.993 0.0041, mmhg 0.963 0.938 0.989 0.0060 MMRC 2.402 1.495 3.858 0.0003 Walk distance, m 0.995 0.992 0.998 0.0020, 0.944 0.918 0.972 0.0001 Borg 1.285 1.091 1.514 0.0027 n 93 except for Dl CO and n 90, respectively. Hazard ratios in smoking status are to never smokers. The walk dis tance, lowest SpO 2, and Borg are variables of 6 min walk test. BMI: body mass index; FVC: forced vital capacity; Dl CO : diffu sion capacity of carbon monoxide; : partial pressure of ox ygen; MMRC: modified MRC: SpO 2 : arterial oxygen saturation measured by pulse oximetry; CI: confidence interval 1 表 3 Stepwise multivariate cox proportional-hazard model の結果 Variables Hazard ratio p value MMRC 2.181 1.333 3.568 0.0019, 0.952 0.924 0.981 0.0014 n 87, because patients for whom all data were available were included in the analysis. Forty six of these 87 patients 52.9 died during the observation period. Variables that were signifi cant in univariate analysis were included in the analysis. Vari ables eliminated were FVC predicted, Dl CO predicted,, and walk distance and the Borg scale at 6 min walk test. is a 6 min walk test variable. MMRC: modified MRC; SpO 2 : arterial oxygen saturation mea sured by pulse oximetry; CI: confidence interval 1 modified MRC 6 SpO 2 IPF 1 modified MRC Kaplan-Meier survival curves modified MRC COPD 5 IPF University of California San Diego Shortness of Breath Questionnaire SOBQ modified MRC
2012 年 12 月 273 1.8 (ml/min) 2000 Probability of Survival.6.4.2 0 MMRC 3 MMRC 2 MMRC 0, 1 0 20 40 60 80 100 120 Months 図 1 IPF modified MRC Kaplan Meier 1 VO 2 max. 1 1000 0 r=0.62, p< 0.0001 0 50 100 150 200 (Nm) 大腿四頭筋筋力 患者では大腿四頭筋筋力が低下しており 運動耐容能低下の重要な説明因子である 3 41 IPF cardiopulmonary exercise test: CPX Cybex II 35 6 VC 2.5 0.7 L VC 76.616.8 DLco 10.63.9 ml/min/ mmhg DLco 58.920.4 CPX V 4 O 2 max 892314 ml/min V 4 O 2 max 46.013.1 AT 710210 ml/min AT 58.214.7 quadriceps force: QF handgrip force: HF HF 3219 N HF 9457 QF 8728 Nm QF 6515 V 4 O 2 max VC TLC DLco PEmax QF VE/V 4 CO 2 slope stepwise VC QF VE/V 4 CO 2 slope QF IPF AT VC DLco QF QF QF V 4 O 2 max 2 COPD IPF IPF 図 2 IPF 3 に対する呼吸リハビリテーションは 有効である 4 IPF 30 10 28 13 15 12 1 FVC 2.10.4 L FVC 66.113.2 Dl CO 59.416.7 79.811.5 mmhg 9 6 FVC 2.00.8 L FVC 68.719.5 Dl CO 48.616.7 83.012.3 mmhg 6 46.3 m St. George s Respiratory Questionnaire SGRQ QOL total -6.1 BDI 4 3 6
274 日本呼吸ケア リハビリテーション学会誌第 22 巻第 3 号 (m) P<0.05 (m) NS 700 700 600 600 6 分間歩行距離 400 300 385 116 427 84 400 300 476 128 472 130 200 200 100 baseline after the program 100 baseline after the program 図 3 IPF 6 4 表 4 Difference between groups in change from baseline FVC L 0.03 0.13 0.19 N.S. FEV 1 L 0.04 0.17 0.08 N.S. Dl CO 0.04 0.17 0.08 N.S. mmhg 0.03 0.18 0.24 N.S. PaCO 2 mmhg 1.0 5.0 16.0 N.S. 6MWD m 46.3 8.3 84.4 0.01 BDI score 0.4 0.6 1.4 N.S. SGRQ score Symptoms 5.7 18.7 7.2 N.S. Activity 5.8 14.7 3.1 N.S. Impacts 6.2 12.8 0.3 N.S. Total 6.1 11.7 0.5 0.05 FVC: forced vital capacity; FEV 1 : forced expiratory volume in 1 second; Dl CO : diffusion capacity of carbon monoxide; : partial pressure of oxygen; PaCO 2 : partial pressure of carbon di oxide; 6MWD: 6 min walk distance; BDI: baseline dyspnea in dex; SGRQ: St. George s Respiratory Questionnaire 4 p まとめ IPF QOL IPF COPD IPF 5 weak yes 385116 m 42784 m IPF 6 QOL 受賞にあたっての感想とこれからの抱負 IPF QOL COPD IPF
2012 年 12 月 275 Multidisciplinary evaluation including dyspnea, exercise capacity, and health-related quality of life in idiopathic pulmonary fibrosis Osamu Nishiyama Department of Respiratory Medicine and Allergology, Kinki University Faculty of Medicine 文献 1 Nishiyama, O., Taniguchi, H., Kondoh, Y., et al: A simple assessment of dyspnea as a prognostic indicator in idiopathbic pulmonary fibrosis. Eur Respir J, 36: 1067 1072, 2010. 2 American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. Am J Respir Crit Care Med, 161: 646 664, 2000. 3 Nishiyama, O., Taniguchi, H., Kondoh, Y., et al: Quadriceps weakness is related to exercise capacity in idiopathic pulmonary fibrosis. Chest, 127: 2028 2033, 2005. 4 Nishiyama, O., Kondoh, Y., Kimura, T., et al: The effects of pulmonary rehabilitation in patients with idiopathic pulmonary fibrosis. Respirology, 13: 394 399, 2008. 5 Raghu, G., Collard, H.R., Egan, J.J., et al: An official ATS/ERS/ JRS/ALAT statement: idiopathic pulmonary fibrosis: evidencebased guidelines for diagnosis and management. Am J Respir Crit Care Med, 183: 788 824, 2011.