基于“脾胃论”内外合治辅助慢性阻塞性肺疾病患者机械通气撤离对患者预后的影响研究
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摘要
背景根据中医五行"虚则补其母"的理论基础,运用"补脾益肺"的方法治疗慢性阻塞性肺疾病(COPD)已被临床广泛应用,并证实具有较高的实用价值。目的探讨基于"脾胃论"内外合治辅助COPD患者机械通气撤离对患者预后的改善作用。方法采用前瞻性随机对照研究的设计方法,选取2015年11月—2017年10月收住诸暨市中医医院暨阳院区和浣东院区ICU的COPD急性发作需行有创正压通气(IPPV)的患者160例作为研究对象,采用随机数字表法,将随机数为4的倍数患者纳入对照组(n=42),其余患者根据中医辨证分型分为肺脾气虚证36例(肺脾气虚组),脾肺虚寒证45例(脾肺虚寒组),脾胃阴虚证37例(脾胃阴虚组)。对照组给予50 ml温开水鼻饲,2次/d;肺脾气虚组予"参苓白术散"加减,脾肺虚寒组予"黄芪建中汤"加减,脾胃阴虚组予"麦门冬汤"加减,同时3组取穴"足三里、丰隆"予"经皮穴位电刺激",疗程14 d。记录插管前(T1)及IPPV第1天(T2)、第5天(T3),进入撤机阶段时(T4)4个时间点的呼吸浅快指数(f/VT)、内源性呼气末正压(PEEPi)、肺顺应性、气道阻力;记录治疗前后C反应蛋白(CRP)、降钙素原(PCT)、白细胞计数(WBC)、清蛋白(ALB)、前清蛋白(PA)、总蛋白(TP);记录所有患者IPPV总时间、自主呼吸试验次数(SBT)次数、拔管后无创正压通气(NPPV)使用率、48 h后再次气管插管率、院内病死率、住ICU时间、住院时间。结果治疗方法与实践在f/VT、PEEPi、肺顺应性、气道阻力上存在交互作用(P<0.05);治疗方法在f/VT、PEEPi、肺顺应性、气道阻力上主效应显著(P<0.05);时间在f/VT、PEEPi、肺顺应性、气道阻力上主效应显著(P<0.05)。T3、T4时间点肺脾气虚组、脾肺虚寒组、脾胃阴虚组的f/VT低于对照组(P<0.05);T4时间点肺脾气虚组f/VT低于脾胃阴虚组(P<0.05)。T3时间点脾肺虚寒组PEEPi低于对照组(P<0.05);在T4时间点肺脾气虚组、脾肺虚寒组、脾胃阴虚组PEEPi低于对照组(P<0.05)。T3时间点肺脾气虚组、脾肺虚寒组肺顺应性高于对照组(P<0.05);T4时间点肺脾气虚组、脾肺虚寒组、脾胃阴虚组肺顺应性高于对照组(P<0.05)。T4时间点肺脾气虚组、脾胃阴虚组气道阻力低于对照组(P<0.05)。治疗后肺脾气虚组、脾肺虚寒组、脾胃阴虚组CRP低于对照组(P<0.05);治疗后脾胃阴虚组PCT低于对照组(P<0.05);治疗后肺脾气虚和脾胃阴虚组ALB低于对照组(P<0.05);治疗后肺脾气虚组、脾肺虚寒组、脾胃阴虚组PA、TP低于对照组(P<0.05)。肺脾气虚组、脾肺虚寒组、脾胃阴虚组IPPV总时间、住ICU时间、住院时间短于对照组,SBT次数少于对照组(P<0.05)。结论基于"脾胃论"内外合治可改善COPD机械通气患者的呼吸力学指标、生化指标,辅助有创呼吸机的撤离,改善整体预后。
Background According to the theoretical basis of "deficiency nourishes the mother" of the five elements of traditional Chinese medicine,the method of "nourishing the spleen and benefiting the lungs" in the treatment of chronic obstructive pulmonary disease(COPD) had been widely used in clinical practice,and had been proved to be of high practical value.Objective To investigate the effect of weaning from mechanical ventilation in patients with COPD assisted by internal and external combination of "Treatise on Spleen and Stomach".Methods We enrolled 160 patients with acute COPD who required invasive positive pressure ventilation(IPPV) in the Intensive Care Unit(ICU) of Jiyang branch and Huandong branch of Traditional Chinese Medical Hospital of Zhuji from November 2015 to October 2017 in this prospective randomized controlled trial.Forty-two patients were assigned to the control group by using the random number table method.The remaining patients were divided into lung-spleen qi deficiency group(n=36),spleen-lung deficiency-cold group(n=45) and spleen-stomach yin deficiency group(n=37).The patients in the control group were treated with 50 ml warm water nasal feeding twice a day.Lungspleen qi deficiency group were treated with Shenling Atractylodes,spleen-lung deficiency-cold group with Huangqijianzhong decoction,and spleen-stomach yin deficiency group with Ophiopogon decoction.At the same time,the three groups were treated with transcutaneous electrical acupoint stimulation therapy on zusanli and fenglong for 14 days.Respiratory index(f/VT),endogenous positive end-expiratory pressure(PEEPi),lung compliance,and airway resistance at four time points:before intubation(T1),day 1 of invasive positive pressure ventilation(IPPV)(T2),day 5 of IPPV(T3),and before intubation(T4) were recorded.Levels of C-reactive protein(CRP),procalcitonin(PCT),white blood cell count(WBC),albumin(ALB),prealbumin(PA),total protein(TP)were recorded before and after treatment.The primary outcome of all patients were IPPV total time,spontaneous breathing test(SBT),non-invasive positive pressure ventilation,NPPV,utilization rate,tracheal intubation rate after 48 hours,hospital mortality,ICU stay,and hospital stay.Results There were interactions between treatment methods and practices in f/VT,PEEPi,lung compliance,and airway resistance(P<0.05).The main effects of treatment methods and time on f/VT,PEEPi,lung compliance and airway resistance were significant(P<0.05).Lung compliance increased successively at T1,T2,T3 and T4(P<0.05).At T3 and T4,f/VT of lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was lower than that of the control group(P<0.05).At T4,f/VT of the lung-spleen qi deficiency group was lower than that of the lung-stomach yin deficiency group(P<0.05).At T3,PEEPi of spleen-lung deficiency-cold group was lower than that of control group(P<0.05).At T4,PEEPi of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and long stomach yin deficiency group was lower than that of the control group(P<0.05).At T3,lung compliance of lung-spleen qi deficiency group and spleen-lung deficiency-cold group was higher than that of control group(P<0.05).At T4,lung compliance of lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was higer than that of the control group(P<0.05).At T4,airway resistance of the lung-spleen qi deficiency group and spleen-lung stomach yin deficiency group was lower than that of the control group(P<0.05).After treatment,CRP of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was lower than that of the control group(P<0.05);PCT of the lung and stomach yin deficiency group was lower than that of the control group(P<0.05);ALB in the lung-spleen qi deficiency group and lung-stomach yin deficiency group was lower than that in the control group(P<0.05);PA and TP of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group,splee-stomach yin deficiency group were lower than those of the control group(P<0.05).The total IPPV time,SBT times,ICU stay and hospitalization time in the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and splee-stomach yin deficiency group were less than those in the control group(P<0.05).Conclusion "Treatise on Spleen and Stomach" internal and external combined treatment can improve the respiratory mechanical index and nutritional index of COPD patients,weaning from mechanical ventilation,and overall prognosis.
Background According to the theoretical basis of "deficiency nourishes the mother" of the five elements of traditional Chinese medicine,the method of "nourishing the spleen and benefiting the lungs" in the treatment of chronic obstructive pulmonary disease(COPD) had been widely used in clinical practice,and had been proved to be of high practical value.Objective To investigate the effect of weaning from mechanical ventilation in patients with COPD assisted by internal and external combination of "Treatise on Spleen and Stomach".Methods We enrolled 160 patients with acute COPD who required invasive positive pressure ventilation(IPPV) in the Intensive Care Unit(ICU) of Jiyang branch and Huandong branch of Traditional Chinese Medical Hospital of Zhuji from November 2015 to October 2017 in this prospective randomized controlled trial.Forty-two patients were assigned to the control group by using the random number table method.The remaining patients were divided into lung-spleen qi deficiency group(n=36),spleen-lung deficiency-cold group(n=45) and spleen-stomach yin deficiency group(n=37).The patients in the control group were treated with 50 ml warm water nasal feeding twice a day.Lungspleen qi deficiency group were treated with Shenling Atractylodes,spleen-lung deficiency-cold group with Huangqijianzhong decoction,and spleen-stomach yin deficiency group with Ophiopogon decoction.At the same time,the three groups were treated with transcutaneous electrical acupoint stimulation therapy on zusanli and fenglong for 14 days.Respiratory index(f/VT),endogenous positive end-expiratory pressure(PEEPi),lung compliance,and airway resistance at four time points:before intubation(T1),day 1 of invasive positive pressure ventilation(IPPV)(T2),day 5 of IPPV(T3),and before intubation(T4) were recorded.Levels of C-reactive protein(CRP),procalcitonin(PCT),white blood cell count(WBC),albumin(ALB),prealbumin(PA),total protein(TP)were recorded before and after treatment.The primary outcome of all patients were IPPV total time,spontaneous breathing test(SBT),non-invasive positive pressure ventilation,NPPV,utilization rate,tracheal intubation rate after 48 hours,hospital mortality,ICU stay,and hospital stay.Results There were interactions between treatment methods and practices in f/VT,PEEPi,lung compliance,and airway resistance(P<0.05).The main effects of treatment methods and time on f/VT,PEEPi,lung compliance and airway resistance were significant(P<0.05).Lung compliance increased successively at T1,T2,T3 and T4(P<0.05).At T3 and T4,f/VT of lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was lower than that of the control group(P<0.05).At T4,f/VT of the lung-spleen qi deficiency group was lower than that of the lung-stomach yin deficiency group(P<0.05).At T3,PEEPi of spleen-lung deficiency-cold group was lower than that of control group(P<0.05).At T4,PEEPi of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and long stomach yin deficiency group was lower than that of the control group(P<0.05).At T3,lung compliance of lung-spleen qi deficiency group and spleen-lung deficiency-cold group was higher than that of control group(P<0.05).At T4,lung compliance of lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was higer than that of the control group(P<0.05).At T4,airway resistance of the lung-spleen qi deficiency group and spleen-lung stomach yin deficiency group was lower than that of the control group(P<0.05).After treatment,CRP of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and spleen-stomach yin deficiency group was lower than that of the control group(P<0.05);PCT of the lung and stomach yin deficiency group was lower than that of the control group(P<0.05);ALB in the lung-spleen qi deficiency group and lung-stomach yin deficiency group was lower than that in the control group(P<0.05);PA and TP of the lung-spleen qi deficiency group,spleen-lung deficiency-cold group,splee-stomach yin deficiency group were lower than those of the control group(P<0.05).The total IPPV time,SBT times,ICU stay and hospitalization time in the lung-spleen qi deficiency group,spleen-lung deficiency-cold group and splee-stomach yin deficiency group were less than those in the control group(P<0.05).Conclusion "Treatise on Spleen and Stomach" internal and external combined treatment can improve the respiratory mechanical index and nutritional index of COPD patients,weaning from mechanical ventilation,and overall prognosis.
引文
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[2]秦北宁,宋永辉,刘新颖,等.慢性阻塞性肺疾病患者呼吸衰竭有创机械通气治疗研究[J].中华医院感染学杂志,2015,25(4):849-850,859.DOI:10.11816/cn.ni.2015-144602.QIN B N,SONG Y H,LIU X X,et al.Invasive mechanical ventilation treatment of respiratory failure in patients with chronic obstructive pulmonary disease[J].Chinese Journal of Nosocomiology,2015,25(4):849-850,859.DOI:10.11816/cn.ni.2015-144602.
[3]中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南(2013年修订版)[J].中华结核和呼吸杂志,2013,36(4):255-264.DOI:10.3760/cma.j.issn.1001-0939.2013.04.007.Chronic Obstructive Pulmonary Disease Group,Respiratory Medicine Branch,Chinese Medical Association.Guide for diagnosis and treatment of chronic obstructive pulmonary disease(2013 revised edition)[J].Chinese Journal of Tuberculosis and Respiratory Diseases,2013,36(4):255-264.DOI:10.3760/cma.j.issn.1001-0939.2013.04.007.
[4]朱文锋.中医诊断学[M].北京:人民卫生出版社,2013:1-2.ZHU W F.Diagnosis of traditional Chinese medicine[M].Beijing:People's Health Press,2013:1-2.
[5]VESTBO J,HURD S S,AGUSTI A G,et al.Global strategy for the diagnosis,management,and prevention of chronic obstructive pulmonary disease:GOLD executive summary[J].Am JRespir Crit Care Med,2013,187(4):347-365.DOI:10.1164/rccm.201204-0596PP.
[6]ZHANG G,ZOU J.Clinical application of enteral immune nutrition for chronic obstructive pulmonary disease patients[J].Zhonghua Yi Xue Za Zhi,2015,95(19):1501-1504.
[7]欧雅丽,许坚.培土生金法治疗COPD临床研究的系统评价[J].世界科学技术-中医药现代化,2015,17(12):2632-2639.OU Y L,XU J.Systematic review on clinical researches of strengthening earth to generate metal method in COPDtreatment[J].Modernization of Traditional Chinese Medicine and Materia Medica-World Science and Technology,2015,17(12):2632-2639.
[8]王洪图.内经选读[M].上海:上海科学技术出版社,1997:158-159.WANG H T.Selected readings in Canon[M].Shanghai:Shanghai Science and Technology Press,1997:158-159.
[9]徐升,魏姗姗,张念志,等.培土生金法对慢性阻塞性肺疾病线粒体膜电位影响的实验研究[J].安徽医学,2013,34(8):1059-1062.XU S,WEI S S,ZHANG N Z,et al.Experimental study on effect of method of strengthening earth to generate metal on mechanism of action in stabilization period of chronic obstructive pulmonary disease[J].Anhui Medical Journal,2013,34(8):1059-1062.
[10]寿依群,葛慧青,戴泽宁,等.肺俞穴经皮电神经刺激对慢性阻塞性肺疾病患者肺功能及诱导痰肿瘤坏死因子-α浓度的影响[J].中华物理医学与康复杂志,2014,36(9):705-708.DOI:10.3760/cma.j.issn.0254-1424.2014.09.014.SHOU Y Q,GE H Q,DAI Z N,et al.The effects of transcutaneous electrical nerve stimulation on pulmonary function,airflow,dyspnea,exercise capacity and TNF-αlevels in patients with pulmonary obstruction[J].Chinese Journal of Physical Medicine and Rehabilitation,2014,36(9):705-708.DOI:10.3760/cma.j.issn.0254-1424.2014.09.014.
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