非侵襲性呼吸器在末期病人的運用－緩解痛苦？抑或延長死亡？

Non-invasive Ventilator (NIV) at End-of-life Care -- To relieve suffering? Or to prolong dying?

張彤(Tung Chang) ； 柯獻欽(Shian-Chin Ko)

《安寧療護雜誌》 26卷1期 (2021/12) Pp. 52-64

https://doi.org/10.6537/TJHPC.202112_26(1).04

摘要

呼吸困難是末期病人相當常見的症狀，特別是在慢性肺病與肺部惡性腫瘤的病人，呼吸困難是生活品質不佳的元凶，造成病人與家屬身體和精神上莫大的折磨，緩解呼吸困難與控制疼痛一樣是安寧療護中症狀控制的重要課題。傳統上呼吸困難的治療方法分成藥物與非藥物兩類，藥物包括：嗎啡、鎮靜劑、類固醇與氧氣治療，非藥物方法則有：復健、使用風扇、能量保存方法、呼吸技巧與放鬆策略等。然而在生命的最後階段，即使這些處置都用到了極致，不少病人仍有明顯的呼吸困難症狀。在不做氣管內插管的前提下，非侵襲性呼吸器（noninvasive ventilator, NIV）可提供通氣輔助與高濃度氧氣，促進氣體交換功能，降低呼吸作功，或能緩解頑固的呼吸困難。在拒絕插管與末期病人中，NIV的使用有增加的趨勢，但NIV在緩和醫療的角色仍迭有爭議。雖然無須插管，但NIV仍是呼吸器，屬於維生醫療，亦有延長死亡過程的疑慮。關鍵在於NIV使用前就須確立治療目標，如果NIV旨在延長病人生命，則必須確定病人的呼吸衰竭有可逆的病因存在；如果NIV是用於緩解症狀，則須要其他的方法都已用至極致，NIV當成是緩解呼吸困難的最後手段；如果病人的預後仍不清楚，NIV的使用應視為限時嘗試。無論使用NIV的目的為何，用上NIV之後須持續評估其功效與監測其副作用，並持續與病人／家屬溝通，若未能達到當初設定的目標，仍須考慮撤除NIV。本文藉由NIV在嚴重慢性肺阻塞（chronic obstructive pulmonary disease, COPD）患者的使用，探討NIV在安寧緩和療護的角色。

關鍵字

安寧療護 ； 非侵襲性呼吸器 ； 慢性肺阻塞

並列摘要

Dyspnea is one of the most common symptoms in patients with terminal diseases, especially in chronic lung diseases and pulmonary malignancies. Dyspnea is the major cause of poor quality of life, causing great physical and mental distress to patients and their families. Dyspnea relief and pain control are both important issues in palliative care. Traditionally, the management of dyspnea is divided into two categories: pharmaceutical and non-pharmaceutical measures. Medications include morphine, sedatives, steroids and oxygen therapy. Non- pharmaceutical measures include rehabilitation, use of fans, energy conservation methods, breathing exercises and relaxation strategies. However, at the end of life, even if these treatments are used to the extreme many patients still have obvious dyspnea. Without endotracheal intubation, noninvasive ventilator (NIV) can provide ventilatory assistance and high inspired oxygen fraction. NIV can promote gas exchange, reduce work of breathing, and then relieve stubborn dyspnea. Non-invasive ventilation (NIV) is being used increasingly in patients who have a ＂do not intubate＂ (DNI) order or are at end-of-life. The role of NIV in palliative care remains controversial. Although there is no need for intubation, NIV is still a ventilator and belonging to life-sustaining measures. There are also concerns about prolonging the dying process by NIV. The key is to establish the goal of treatment. If NIV is used to prolong the life of the patient, it must be confirmed that the respiratory failure has a reversible component. If it is used to relieve the patient's dyspnea, it is necessary to make sure that both pharmaceutical and non-pharmaceutical treatments have been used to the extreme, and NIV is a ventilator care ceiling. If the prognosis is unclear, NIV should be used as time-limited trial (TLT). Regardless of the purpose of using NIV, it is necessary to continuously evaluate the efficacy and monitor side effects during treatment. Continuous communication with patients and families to confirm their preferences is of paramount importance. If the preset goal is not accomplished, the NIV should be considered to be withdrawn. In this article, we described a patient with severe COPD and chronic hypercapnic respiratory failure to explore the role of NIV in palliative care.

並列關鍵字

hospice palliative care ； non-invasive ventilator (NIV) ； chronic obstructive pulmonary disease (COPD)

參考文獻

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