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1 흉벽질환에의한급성호흡부전환자의생리적특성과장기적인예후 경북대학교의과대학내과학교실윤석진, 전희정, 김영주, 이승준, 김은진, 차승익, 박재용, 정태훈, 김창호 Long-term Prognosis and Physiologic Status of Patients Requiring Ventilatory Support Secondary to Chest wall Disorders Seok Jin Yoon, M.D., Hee Jung Jun, M.D., Yong Joo Kim, M.D., Seung Jun Lee, M.D., Eun Jin Kim, M.D., Seung Ick Cha, M.D., Jae Yong Park, M.D., Tae Hoon Jung, M.D., Chang Ho Kim, M.D. Departments of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea Background: Chest wall deformities such as kyphoscoliosis, thoracoplasty, and fibrothorax cause ventilatory insufficiency that can lead to chronic respiratory failure, with recurrent fatal acute respiratory failure(arf). This study evaluated the frequency and outcome of ARF, the physiologic status, and the long-term prognosis of these patients. Methods: Twenty-nine patients with chest wall disorders, who experienced the first requirement of ventilatory support from ARF were examined. The mortality and recurrence rate of ARF, the pulmonary functions with arterial blood gas analysis, the efficacy of home oxygen therapy, and the long-term survival rate were investigated. Results: 1) The mortality of the first ARF was 24.1%. ARF recurred more than once in 72.7% of the remaining 22 patients, and overall rate of successful weaning was 73.2%. 2) Twenty-two patients who recovered from the first ARF showed a restrictive ventilatory impairment with a mean FVC and TLC of 37.2% and 62.4 % of predicted value, respectively, and a mean PaCO 2 of 57mmHg. Among the parameters of pulmonaty functions. the FVC(p=0.01) and VC(p=0.02) showed a significant correlation with the PaCO 2 level. 3) There were no significant differences between the patients treated with conservative medical treatment only and those with additional home oxygen therapy due to significant hypoxemia in the patients with recurrent ARF and the mortality. 4) The 1, 3, 5-year survival rates were 75%, 66%, and 57%, respectively, in the 20 patients who had recovered from the first ARF, excluding the two patients managed by non-invasive nocturnal ventilatory support. Conclusion: These results suggest that active ventilatory support should be provided to patients with ARF and chest wall disorders. However, considering recurrent ARF and weak effect of home oxygen therapy, non-invasive domiciliary ventilation is recommended in those patients with these conditions to achieve a better long-term prognosis. (Tuberc Respir Dis 2006; 61: ) Key words: Chest wall disorder, Pulmonary functions, Respiratory failure, Home oxygen therapy. 서 흉벽질환들은흉곽유순도의감소에따른제한성환기장애라는공통된생리적특징을가지며, 여기에는대표적으로척추후측만증 (Kyphoscoliosis), 섬유흉 (Fibrothorax), 흉곽성형술 (Thoracoplasty) 등이포함된다 1. 이들질환에서는호흡근의근력이흉곽유순도 론 Address for correspondence : Chang Ho Kim, M.D. Departments of internal medicine, Kyungpook University Hospital, 50, Samdeok 2-Ga, Jung-Gu, Daegu, Korea, Tel : Fax : kimch@knu.ac.kr Received : Jun Accepted : Aug 의감소에따르는과부하를견디지못할경우고탄산혈증저환기가나타나게되고, 심한흉벽질환말기에는결국환기부전이발생한다 2. 그리고이들만성호흡부전환자들에서흔히합병되는급성호흡부전은이들의주요사망원인이며, 일차발병에서생존하더라도질병의경과중에반복하게된다 3. 최근의비침습적환기보조 (Noninvasive ventilation, 이하 NIV) 는이들환자에서급성호흡부전에일차적으로사용될뿐만아니라, 간헐적환기보조에의해만성적인환기부전을개선시키고생존율향상에기여하고있다 4-7. 결핵의여전히높은유병율에의해비교적흔한섬유흉을포함하여, 국내에서도이러한흉벽질환자들을드물지않게접할수있으나지금까지국내에서이들 265

2 SJ Yoon et al: Long-term prognosis and physiologic status of patients requiring ventilatory support secondary 환자들에서급성호흡부전에따른사망률과이후의생존자에대한특성등을조사한보고는없었다. 따라서저자들은이들흉벽질환자에서급성호흡부전의빈도와결과, 폐기능및동맥혈가스소견의생리적상태, 그리고장기적인예후등의특성들을알아보고자하였다. 대상및방법 1. 대상경북대학교병원에서 2000년 1월부터 2005년 9월사이에급성호흡부전으로첫환기보조를받게된흉벽질환자 29명을대상으로하였다. 이들의평균연령은 56.2세였고, 흡연력은평균 10.3갑년이었다. 성비는남자 16명, 여자 13명이었고, 이전에평균병원입원횟수는 1.6회이었으며, 기저흉벽질환으로는척추후측만증 7명, 흉곽성형술 3명, 그리고섬유흉이 19명이었다 (Table 1). 2. 방법급성환기보조를요하는급성호흡부전은동맥혈이산화탄소분압이 50mmHg 이상이면서 ph가 7.3 미만인경우로정의하였다. 급성호흡부전시의첫환기보조방법으로는우선적으로 NIV를시도하였으며, 의식변화, 호흡부전의진행, 불안정한혈역학적소견, Table 1. Characteristics of subjects Parameter No. of mean ± SD n 29 Age, yr 56.2 ± 12.8 Sex, M/F 16/13 Smoking history, PY 10.3 ± 15.9 Prior admission, frequency 1.6 ± 3.7 Underlying disorder Kyphoscoliosis 7 Thoracoplasty 3 Fibrothorax 19 그리고환자의협조가충분치못했던경우에는침습적환기보조 (Invasive mechanical ventilation, 이하 IMV) 로전환하였다. 환기보조를필요로하는첫급성호흡부전에서의사망률, 유발인자, 그리고생존한환자들에서이후의급성호흡부전재발과각재발에서의인공호흡기이탈성적을알아보았다. 이후의급성호흡부전반복과각각그때의이탈성적을알아보았다. 첫급성호흡부전으로부터회복된환자에서이후안정시시행한폐기능및동맥혈가스검사결과로이들의생리적상태를평가하고, 이들검사지표들간상관관계를조사하였다. 이탈후에시행한폐기능검사값이없는 7예에서는급성호흡부전전 12개월이내의자료를선택하였다. 대상군을첫환기보조후의생리적상태에서치료유형에따라, 보존적약물치료만받은환자군 ( 이하, 보존적치료군 ) 과보존적치료와함께재택산소치료를받은군 ( 이하, 산소치료군 ) 으로나누어이후의급성호흡부전재발환자수와생존율을비교하였다. 재택산소치료의적응증은중증의저산소혈증 (PaO 2 55 mmhg) 이있거나중등증의저산소혈증 (55 mmhg< PaO 2 <60 mmhg) 이면서조직저산소증의소견 ( 폐성심, 적혈구증다증, 인지기능결손 ) 이있는경우로하였으며 8, 일중투여시간은최소 12시간이상사용하도록권고하였다. 또한첫급성호흡부전에서생존한 22명의장기생존율을분석하였다. 3. 통계분석통계분석은 SPSS 프로그램 (version SPSS Release 11.5) 을이용하였다. 각질환군에서폐기능검사의비교는일원배치분산분석법 (One-Way ANOVA) 을이용하였으며, 폐기능검사와동맥혈가스분석검사와의상관관계는선형회귀분석을이용하였다. 보존적치료군과산소치료군의비교는 Student's t-test 및 χ2 test를이용하였으며장기생존율은 Kaplan-Meier 그래프를이용하였다. p값이 0.05 미만인경우통계적으로유의하다고판정하였다. 266

3 Tuberculosis and Respiratory Diseases Vol. 61. No.3, Sep 결 과 1. 급성호흡부전의재발반복빈도와성적 고, 전체적으로 9.9±10.3일 (n=41) 로환기보조의방법에따른환기보조기간의유의한차이는없었다 (p=0.283). 흉벽질환에의한급성호흡부전으로인해첫환기보조를받은 29명가운데 22명이이탈성공하였으며, 7 명이사망하여이들질환에의한첫급성호흡부전시의사망률은 24.1% 였다 (Figure 1). 급성호흡부전의유발인자는호흡기계감염이 27예, 객혈및예정수술 (elective operation) 이각각 1예였다. 발병시점이분명한흉곽성형술 3예에서흉곽수술로부터환기보조를요하는첫급성호흡부전이발생한시점까지의기간은평균 18±14.8년이었다. 사망한환자들의기저흉벽질환은척추후측만증이 1예, 섬유흉이 6예였다. 생존한흉벽질환자 22명가운데급성호흡부전의재발로두번째환기보조를요한환자는 16명 (72.7%) 이었으며, 이들 16명중에 6명이사망하고 10명이생존하였다. 세번째, 네번째, 다섯번째급성호흡부전의재발이각각 4, 4, 3명씩있었고네번째와다섯번째때에각각 1명씩사망하였다. 처음 29명의환자에서부터발생한전체 56번의급성호흡부전가운데총 41회에서 (73.2%) 급성환기보조로부터이탈성공하였다. 이탈성공한환자에서환기보조를시행한기간의평균및표준편차는 NIV만시행한경우 6.6±5.6일 (n=13), NIV 후 IMV로전환한경우 NIV 시점으로부터 13.3±10.2 일 (n=12), IMV만시행한경우 10.1±12.8일 (n=16) 이었 2. 생리적상태 1) 폐기능생존한 22명의각질환군에따른폐기능검사의평균값은 Figure 2에서와같이 FVC, FEV1, FEV1/ FVC, TLC, RV가척추후측만증, 흉벽성형술, 섬유흉질환군서로간에유의한차이없이비슷한유형을보였으며전체적인평균값은 FVC 37.2% pred., FEV1 33.0% pred., FEV1/FVC 70.5%, TLC 62.4% pred., RV 106.8% pred. 로 FVC, FEV1, 그리고 TLC는감소되었으나, FEV1/FVC 와 RV는비교적정상범위를보였다. 2) 동맥혈가스분석 22명의안정시대기상태동맥혈가스검사의평균성적은 ph, PaCO 2 (mmhg), PaO 2 (mmhg), HCO 3 (meq/l) 가척추후측만증에서각각 7.38, 66.2, 51.9, 39.4, 흉곽성형술이 7.41, 58.6, 65.6, 36.6, 섬유흉이 7.44, 53.0, 60.3, 36.5였으며전체적인평균성적은 ph 7.42, PaCO mmhg, PaO mmhg, HCO 3 - KS (n=6) TP (n=3) FT (n=13) Total (n=22) Figure 1. Episodes and outcomes of acute respiratory failure(arf) requiring ventilatory support in 29 patients with chest wall disorders. Figure 2. Pulmonary functions after recovery from the first acute respiratory failure in patients with chest wall disorders. KS=kyphoscoliosis; TP=thoracoplasty; FT=fibrothorax. 267

4 SJ Yoon et al: Long-term prognosis and physiologic status of patients requiring ventilatory support secondary Table 2. Arterial blood gases after recovery from the first acute respiratory failure in patients with chest wall disorders KS (n=6) TP (n=3) FT (n=13) Total (n=22) ph 7.38 ± ± ± ± 0.04 PaCO 2, mmhg 66.2 ± ± ± ± 10.6 PaO 2, mmhg 51.9 ± ± ± ± 9.7 HCO 3, meq/l 39.4 ± ± ± ± 5.4 KS=kyphoscoliosis; TP=thoracoplasty; FT=fibrothorax. Figure 3. Correlations between arterial carbon dioxide tension(paco 2) and pulmonaty functions. A: PaCO 2 vs. vital capacity(vc); B: PaCO 2 vs. forced vital capacity(fvc) meq/l 로 3명을제외하고는만성적과탄산혈증호흡부전소견에부합하였다 (Table 2). 3) 폐기능검사와동맥혈가스검사의상관관계폐기능검사와동맥혈가스검사에서각항목들간의상관관계를조사한결과 PaCO 2 가 VC(p=0.02) 및 FVC(p=0.01) 와의미있는상관관계를나타내었으나, FEV1, FEV1/FVC, RV, 그리고 TLC와는유의한상관관계를보이지않았다. PaO 2, ph, 그리고 HCO 3 -와폐기능검사의항목들간에는유의한상관관계가없었다 (Figure 3). 3. 재택산소치료의효과첫급성호흡부전으로부터생존한 22명가운데재택 NIV를받은 2명을제외하고보존적치료군 10명과산 Table 3. Comparisons between the patients treated with only conservative management and those with additional home-oxygen therapy Conservative Home O2 p-value Age 58.7± ± Physiologic status ph 7.44± ± PaCO 2, mmhg 52.6± ± PaO 2, mmhg 64.5± ± FEV 1, %pred. 41.0± ± FVC, %pred. 46.2± ± TLC, %pred. 67.7± ± No. of patients with recurrent ARF 2nd rd 0 2 Outcome Survivor Non-survivor 5 4 ARF=acute respiratory failure. 268

5 Tuberculosis and Respiratory Diseases Vol. 61. No.3, Sep Figure 4. Survival curve after recovery from the first acute respiratory failure in 20 patients with chest wall disorders. 소치료군 10명의비교를 Table3 에나타내었다. 산소치료군에서보존적치료군보다 PaO 2 가유의하게낮았으며, PaCO 2 및 FEV1 소견도더불량한경향을보였다. 그러나급성호흡부전재이환의환자수에서두군간에유의한차이는없었으며, 보존적치료군에서 5명의사망과함께 1년, 3년, 5년생존율이각각 80%, 60%, 60% 였고산소치료군에서는 4명이사망하여 1 년, 3년, 5년생존율이각각 71%, 71%, 53% 로장기생존율에서도두군간에뚜렷한차이는없었다. 4. 장기생존율 첫급성호흡부전으로부터생존한 22명의경과에서 13명이생존하고 9명이사망하였으며, 사망원인으로는응급실도착당시이미사망한상태였던원인불명의 1명을제외한 8명에서심폐부전이원인이었다. 관찰기간중재택 NIV를받은 2명을제외하고, 산소치료를포함한보존적치료를받은 20명의장기생존율을 Kaplan-Meier 생존곡선으로나타내었을때이들의 1년, 3년, 5년생존율은각각 75%, 66%, 57% 이었다 (Figure 4). 고 흉벽질환자에서발생하는호흡부전의주기전은흉 찰 곽변형에따른흉곽및폐유순도의감소에의한폐포저환기이며, 그외일부환기-관류불균형이관여할수있다 1. 이러한호흡기계의불리한역학상태에서는경미한하기도감염으로도이들환자들은쉽게급성호흡부전에이환됨으로써사망의위험에놓이게되며이와같은과정이재발되는특성을가진다 2,3. 본연구의결과에서사망환자의대부분이급성호흡부전에이은심폐부전으로사망하게되었지만이들흉벽질환자의첫급성호흡부전시사망률은 24% 로비교적낮게나타났다. 이와함께급성호흡부전에대한기계환기의이탈성공률이전체적으로 73% 를보여이러한환자들의급성호흡부전시에기계환기치료를적극적으로시도해볼수있을것으로사료된다. 또한이들의장기적인예후를향상시키기위해서는, 급성호흡부전의대부분이호흡기계감염에의한것이었고, 급성호흡부전에한번이환된환자들의 70% 이상이경과중급성호흡부전재발의위험성을가진다는점을고려할때호흡기계감염의예방및조절이중요할것으로생각된다. 이탈성공한환자에서환기보조방법에따른환기보조기간의유의한차이는없었으나, NIV만시행한경우, IMV가필요했던경우보다환기보조의기간이다소짧았다. 일반적으로 NIV 시행중상태가악화되거나늦어도 4시간이내에임상적호전을보이지않는경우에 IMV로전환하는것을감안할때두가지환기보조를모두사용한환자에서실제로는 IMV에의해소요된시간이대부분이었다. 본연구의목적이환기보조방법에초점을둔것이아니어서이러한것에대한지표분석을하지않았지만 NIV만시행한환자군이상대적으로환기보조기간이짧았던것은의식상태, 호흡부전의정도, 혈역학적상태등이양호한조기에환기보조가이루어졌을가능성때문인것으로생각된다. 척추만곡증에서의폐기능소견은 RV보다 VC의감소에의한 TLC의감소, 흡기량의감소에따라호기의 FVC는감소하지만호기속도는폐용적감소에따른감소만있을뿐인것으로알려져있다 9. 흉곽성형술후상태에서의폐기능소견은동반된결핵성병변등에의해폐쇄성환기장애가공존할수있으나, 제한성환 269

6 SJ Yoon et al: Long-term prognosis and physiologic status of patients requiring ventilatory support secondary 기장애를근간으로하며, 섬유흉또한기류-용적곡선에서호기말에유량이급속하게떨어지는특징을보이나, 폐기능소견은제한성환기장애에해당된다 10,11. 따라서이들흉벽질환에서의폐기능소견은서로유사한것으로알려져있다 1. 본연구에서도, 급성호흡부전에의한첫환기보조로부터이탈성공한 22명의폐기능소견은전체적으로 FEV1/FVC 와 RV는비교적정상을유지하면서 TLC의감소, 특히 FVC가감소하는제한성환기장애유형을보였다. 또한다른보고에서와같이이들세질환군의폐기능검사성적은서로비슷한유형을보였다 1. 본연구대상의동맥혈가스검사소견은평균적으로저산소혈증과과탄산혈증이공존하였으며, 과탄산혈증에대한대사성보상기전에의해혈중 ph는정상범위를유지하고있는만성적인호흡부전상태를나타내었다. 흉벽질환과마찬가지로저환기에의한주기전으로만성호흡부전에이르게되는근육이영양증의폐기능지표와동맥혈가스소견간의상관관계에서 PaCO 2 는 FVC와가장연관성을보인다 12. 본연구에서도 VC 및 FVC가 PaCO 2 와의미있는상관관계를보였다. 이러한상관관계는근육질환에서와같이폐활량측정법으로질환의경과상태를평가할수있을뿐만아니라비교적침습적인동맥혈가스검사의결과를간접적으로추정할수있게함으로써 NIV와같은치료시점의설정에참조될수있을것으로생각된다. 흉벽질환으로인한만성호흡부전환자에서최근의 NIV 치료방법이전에는보존적인방법으로폐성심이동반된환자에서는디곡신및이뇨제의사용과함께저산소혈증의교정을위해만성폐쇄성폐질환등과마찬가지로재택산소치료가시행되었었다 그러나만성폐쇄성폐질환과는달리흉벽질환에서의재택산소치료에대한장기적인효과는의문시되고있으며, 재택산소치료를하는경우에만성폐쇄성폐질환에서와마찬가지로고탄산혈증이악화될수있으므로이에대한주의감시를요하는것으로알려져있다 저자들의결과에서재택산소치료효과는같은생리적상태의대상에서비교한것이아니기때문에직접적인평가가불가능하다. 다만산소치료군이더불량한생리적상태임에도보존적치료군과비슷한예 후를보였다는것에서간접적으로재택산소치료효과의가능성을볼수있을것으로생각된다. 폐포저환기에의한만성적인환기부전환자에서근본적인치료는환기보조이다. 최근의흉벽질환자에서이용되고있는 NIV 치료는삶의질및생존율향상에좋은효과를보이며, 1년및 5년장기생존율이각각 90%, 80% 까지이르는것으로보고되고있다 4-7. 이러한성적은저자들의산소치료를포함한보존적치료를받은환자들이 1년, 5년생존율이 75%, 57% 인것과뚜렷한차이를보인다. 저자들의대상중 NIV 치료를받은 2명도사실 3번의급성호흡부전이후 NIV 를사용하게되었는데, 이후에는급성호흡부전이없었을뿐만아니라주간증상도현저히개선되었었다. 재택산소치료에대한불확실한혹은미미한효과와 NIV 사용에대한여러결과들을고려할때실제저자들의더많은환자에서 NIV가제공되어야했었지만, 현실적으로 NIV 장비구입에대한개인적비용부담실정은이러한치료를쉽지않게하고있다. 본연구는대상이적고후향적조사로이루어졌으며, 첫급성호흡부전이후폐기능성적을모든환자에서얻을수없었던점과이후의경과과정에따른생리적변화를반영하지못하는제한점을가지고있다. 그러나저자들의결과는흉벽질환자의급성호흡부전시에기계환기로부터이탈성공률은높은편이나, 급성호흡부전재이환의가능성이많으며, 또한산소치료를포함한보존적치료만으로도비교적불량하지않은예후를보였지만, 장기적인생존율의향상을위해서는 NIV 필요성을보여준다고생각된다. 요약연구배경 : 척추후측만증, 흉곽성형술, 섬유흉등과같은흉곽변형에따른질환들은비슷한환기장애의형태로서결과적으로만성호흡부전에이를수있으며, 경과중흔히적인급성호흡부전이합병하게되고사망의위험에놓이게된다. 저자들은이러한환자들에서급성호흡부전의빈도와결과, 생리적상태, 그리고장기적예후등의특성을알아보고자하였다. 대상및방법 : 경북대학교병원에서급성호흡부전 270

7 Tuberculosis and Respiratory Diseases Vol. 61. No.3, Sep 으로첫환기보조를받게된 29명의흉벽질환자를대상으로초기사망률, 이후의급성호흡부전의재발빈도, 동맥혈가스검사및폐기능검사, 재택산소치료의효과, 그리고장기생존율을조사하였다. 결과 : 1) 첫급성호흡부전시의사망률은 24.1% 였으며, 생존자중 72.7% 에서급성호흡부전이 1회이상재발하였고전체적인급성호흡부전에대한이탈성공률은 73.2% 였다. 2) 첫급성호흡부전으로부터회복된 22명은평균 FVC 및 TLC가각각추정정상치의 37.2, 62.4% 인제한성환기장애와평균 PaCO 2 가 57mmHg 인만성적과탄산혈증호흡부전소견을보였으며, PaCO 2 와 VC 및 FVC 사이에유의한연관성을보였다. 3) 보존적약물치료만받은군과상대적으로유의한저산소혈증에의해보존적치료와재택산소치료를함께받은군의비교시에, 재급성호흡부전환자수와생존율에서두군간에유의한차이가없었다. 4) 첫급성호흡부전으로부터생존한 22명의경과에서재택 NIV를받은 2명을제외한 20명의 1년, 3년, 5년생존율은각각 75%, 66%, 57% 였으며, 사망자의 88% 가심폐부전으로사망하였다. 결론 : 흉벽질환자의급성호흡부전에대해적극적으로환기보조치료가시도될만하나, 이들만성적호흡부전자에서재택산소치료만으로는그효과가미약하여삶의질및생존율의향상을위해서는재택 NIV가필요할것으로생각된다. 참고문헌 1. Bergofsky EH. Respiratory failure in disorders of the thoracic cage. Am Rev Respir Dis 1979;119: Shneerson JM, Simonds AK. Noninvasive ventilation for chest wall and neuromuscular disorders. Eur Respir J 2002;20: Goldstein RS, McCullough C, Contreras MA. Approaches to rehabilitation of patients with ventilatory insufficiency. Eur Respir J Suppl 1989;7:655S-9S. 4. Todisco T, Baglioni S, Eslami A, Scoscia E, Todisco C, Bruni L, et al. Treatment of acute exacerbations of chronic respiratory failure: integrated use of negative pressure ventilation and noninvasive positive pressure ventilation. Chest 2004;125: Shneerson JM. Respiratory failure in tuberculosis: a modern perspective. Clin Med 2004;4: Leger P, Bedicam JM, Cornette A, Reybet-Degat O, Langevin B, Polu JM, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest 1994;105: Buyse B, Meersseman W, Demedts M. Treatment of chronic respiratory failure in kyphoscoliosis: oxygen or ventilation? Eur Respir J 2003;22: Zielinski J. Indications for long-term oxygen therapy: a reappraisal. Monaldi Arch Chest Dis 1999;54: Kim WS, Kim KY, Han YC, Suk SI. Ventilatory lung functions in scoliosis. Tuberc Respir Dis 1984;31: Bredin CP. Pulmonary function in long-term survivors of thoracoplasty. Chest 1989;95: Bolliger CT, de Kock MA. Influence of a fibrothorax on the flow/volume curve. Respiration 1988;54: Hukins CA, Hillman DR. Daytime predictors of sleep hypoventilation in Duchenne muscular dystrophy. Am J Respir Crit Care Med 2000;161: Miyamoto K, Aida A, Nishimura M, Aiba M, Kira S, Kawakami Y. Gender effect on prognosis of patients receiving long-term home oxygen therapy: the Respiratory Failure Research Group in Japan. Am J Respir Crit Care Med 1995;152: Chailleux E, Fauroux B, Binet F, Dautzenberg B, Polu JM. Predictors of survival in patients receiving domiciliary oxygen therapy or mechanical ventilation: a 10-year analysis of ANTADIR Observatory. Chest 1996;109: Zielinski J, Sliwinski P, Tobiasz M, Gorecka D, Zielinski J. Long-term oxygen therapy in Poland. Monaldi Arch Chest Dis 1993;48: Strom K, Boe J. A national register for long-term oxygen therapy in chronic hypoxia: preliminary results. Eur Respir J 1988;1: Huh JW, Lee JY, Hong SB, Oh YM, Shim TS, Lim CM, et al. Long-term oxygen therapy in patients with chronic respiratory failure in one university hospital. Tuberc Respir Dis 2005;58: Gorecka D, Gorzelak K, Sliwinski P, Tobiasz M, Zielinski J. Effect of long-term oxygen therapy on survival in patients with chronic obstructive pulmonary disease with moderate hypoxaemia. Thorax 1997;52: Crigner GJ. Effects of long-term oxygen therapy on mortality and morbidity. Respir Care 2000;45: Haidl P, Clement C, Wiese C, Dellweg D, Kohler D. Long-term oxygen therapy stops the natural decline of 271

8 SJ Yoon et al: Long-term prognosis and physiologic status of patients requiring ventilatory support secondary endurance in COPD patients with reversible hypercapnia. Respiration 2004;71: Zielinski J. Long-term oxygen therapy in conditions other than chronic obstructive pulmonary disease. Respir Care 2000;45: Strom K. Pehrsson K, Boe J, Nachemson A. Survival of patients with severe thoracic spine deformities receiving domiciliary oxygen therapy. Chest 1992; 102: Goldstein RS. Hypoventilation: neuromuscular and chest wall disorders. Clin Chest Med 1992;13:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar