节点文献
肺系疾病中胸痞常见证与血气分析的相关性研究
【作者】 宗晓宇；
【导师】 孙霈；
【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2014， 博士
【摘要】 现代中医学认为胸痞是属于痞满之下的一个二级诊断病名,如《中医内科学》：“痞满……按部位分有胸痞、心下痞等。”因其极少单独发病而常被临床所忽略。但是在临床实践中,遇到病人有胸闷不舒的症状时,又不能不考虑其中医诊断与治疗。并且反观所有并发胸痞的疾病,都可以看到这样的疾病有不伴胸痞者。这也就说明虽然胸痞多与其他疾病合并发病,但它有属于自己独立的病机特点。故而在临床上应当将其作为一种独立的疾病来对待。只有充分认识到胸痞是一种独立的疾病,深刻认清胸痞的病因病机,才能在临床潜方用药时更有针对性。中医的精髓在于辨证论治,对于证候的准确把握则是取得临床疗效的前提,因此本次研究通过文献研究探讨胸痞的定义、诊断、病机及治法,明确胸痞作为一个独立的内科疾病的地位。并以临床回顾性研究结合现代统计学方法探讨胸痞的证与证素分布规律,及其与现代理化检查结果之间的相关性。综述部分通过对34篇古代文献中涉及到“痞”的相关内容进行整理探讨研究后,结合临床实际情况得出胸痞的定义为：“胸痞是由于外邪内侵,酒食不洁,情志失调,嗜好及职业环境不良,禀赋不足,劳逸失度,上中二焦素有痼疾或失治误治等因,以致正气不足,阴阳气血失调,上中焦气机壅滞,寒、燥、火、湿、浊、痰、瘀血等邪内阻内扰,胸中阴阳之气遏郁,升降失常所引起的以胸部闷窒不爽,吐纳不快,外无膨胀之形,内有塞阻之感,痞而不痛为主症的病证。”并整理出胸痞的病因、病机、治法、方药等。再通过对胸痞的主要临床症状“胸闷”的分析研究,明确了胸痞与肺系疾病的关系最为密切,与血气分析结果有内在关联,从而确定了本次研究的基本方向。科研部分目的：通过对117例患者四诊资料的分析,探讨研究胸痞的证与证素的分布规律,并进一步探讨胸痞常见证与血气分析结果之间的相关性。方法：根据临床流行病学横断面调查的方法,在北京中医药大学东直门医院呼吸科病房对符合纳入标准的胸痞患者的四诊信息进行采集,应用Epidata3.0软件建立数据库,应用SPSS24.0软件进行统计分析。临床一般资料采用描述性统计分析以频次、百分率形式表示；中医四诊信息应用主成分分析因子提取结合聚类分析、粗糙集理论聚峰试验进行分析研究。证和血气分析结果以Logistic回归分析。结果：1.证素分布：通过因子提取结合聚类分析,得出公因子20个,经20次代迭旋转后各载荷系数收敛至可解读水平。经整理后共得出有效公因子13个,经电脑判定结合人工判定后,可以认定胸痞的相关证素主要有病位证素6个,分别是：肺、心、肝、脾、肾、胃；病性证素7个,分别是：气虚、阳虚、阴虚、气滞、火、痰、湿。2.证型分布：通过对以上13个有效公因子及其对应的72个证候进行聚峰试验。先以简单约简按照风险决策值最小的原则确定聚峰目标个数为4个。后将数据代入Nelson模型检验公式尝试聚峰,共得出3个常见证,分别是：“肺脾气虚痰湿内阻证”、“肝胃气滞证”、“脾胃阳虚湿郁化火证”。另有单独一例聚峰失败。所得出的3个常见证并没有明显违反中医理论的地方,故判定为相对可信。3.常见证与血气分析结果的相关性的研究：在得出以上3个常见证型后,以这3个常见证为标准重新筛选117例病例,共筛选出病例43例,其中符合肺脾气虚痰湿内阻证病例18例,符合肝胃气滞证病例11例,符合脾胃阳虚湿郁化火证病例14例。对这43例病例的血气分析结果进行初步处理,从血气分析的角度来观察证。以胸痞中医辨证的三个证为因变量,pH、PO2、PCO2分别为自变量,进行多重线性Logistic回归、有序多分类Logistic回归分析,根据得出的回归方程,推断出在血气分析的结果中以氧分压偏移为主的病例的证偏向于肺脾气虚痰湿内阻的可能性更大。在血气分析的结果中以酸碱度偏移为主的病例的证偏向于肝胃气滞可能性更大；为在血气分析的结果中以二氧化碳分压偏移为主的病例的证偏向于脾胃阳虚痰郁化火的可能性更大。
【Abstract】 Modern medicine considers XiongPi as the Secondary diagnosis of PiMan, Textbooks like "Chinese Medicine Textbook of internal medicine" all carrying the same point of view. Because of its rarely came to be a separated disease, XiongPi often ignored by clinical diagnosis. But in clinical practice, patient encounters the chest discomfort symptoms, doctors will have to taking account into its treatment. And all the diseases associated with symptom of chest fullness, can also be the same disease without chest fullness. This phenomenon also shows that although XiongPi often associated with other diseases, but it has its own independent pathogenesis. Therefore, in clinical practice,XiongPi should be put as an independent disease to treat. Only by fully understanding Xiongpi as an independent disease, etiology and pathogenesis profoundly understand, can we be better in clinical practice.TCM’s essence lies in syndrome differentiation and treatment, to accurately understand the syndrome is a prerequisite to obtain clinical curative effect, so this study is in order to findout XiongPi’s definition, diagnosis, pathogenesis and therapeutic methods by literature study, clear XiongPi as an independent diagnosis of internal medicine diseases. And by retrospective clinical study combined with modern statistical methods to explore the elements of syndromes and syndromes of XiongPi distribution rule, and the correlation between physicochemical examination results and syndromes of XiongPi.According to34ancient literatures,we manage to determine the definition of XiongPi:XiongPi is composed of the evil invasion, excessive drinking, eating unclean food, emotional disorders; hobby and the job environment is not good, maladjustment of work and rest, chronic disease, and treatment failure or mistreatment and other factors, resulting in the deficiency of vital qi, Yin and Yang Qi and blood disorders, stranded in chest air congestion, cold, wet, dry, fire, phlegm, blood stasis, turbidity and other bad factors resistance disturbance, chest Qi of yin and Yang choke, abnormal movements caused by blocked uncomfortable tightness in the chest, breathing is not smooth, there was no thoracic shape change, there was a block in the feeling, but no pain. Make further efforts,we also try to find out the etiology, pathogenesis, treatment, prescription of XiongPi.Analysis of the main clinical symptoms "the chest fullness" of XiongPi, we discover the close relationship between XiongPi and lung disease, and blood gas analysis, determines the basic direction of the research.Research part: Purpose: Through the analysis of117cases of diagnostic data, to explore the distribution of syndrome elements and syndrome of XiongPi, and further to explore the correlation between common syndromes of XiongPi and blood-gas analysis results.Method: According to the method of clinical epidemiology cross-sectional study, we collected the four diagnostic information from patients meet the acquisition of XiongPi of Dongzhimen Hospital Department department of respiration,using the application of Epidata3.0software to establish a database, using SPSS24.0software for statistical analysis. The general clinical data using descriptive statistical analysis on frequency, percentage representation; Chinese medical information application of principal component analysis factor extraction combined with clustering analysis, theoretical peak test are analyzed based on rough set. Type of syndrome and blood-gas analysis results by Logistic regression analysis.Results:1.Distribution of syndrome elements:with clustering analysis by factor extraction, there are20common factors.Consulting manually identify, that XiongPi related syndrome elements mainly include6position syndrome elements, respectively is:the lung, heart, liver, spleen, kidney, stomach;7quality syndrome elements, respectively is:deficiency of Qi, Yang and Yin, qi stagnation, phlegm, dampness, fire.2. Distribution of syndromes:Firstly by a simple reduction in accordance with the principle of minimum risk decision value to determine the number of target poly peak is4. After the data into the Nelson model checking formula to poly Feng, altogether obtains3common types, respectively is:"the lung spleen qi deficiency and phlegm dampness syndrome","liver qi stagnation syndrome","Yang deficiency of the spleen and stomach damp depression transforming into fire".3.Study on relationship between the common syndromes and blood-gas analysis results:make standard of the above3common types, rescreening all117cases,43cases were selected, which conforms to the lung and spleen deficiency phlegm syndrome18cases,11cases with liver and stomach qi stagnation,14cases with Yang deficiency of the spleen and stomach, wet fire retarding syndrome. Studying the blood-gas analysis results of the43cases, in order to observe syndromes from the perspective of the blood-gas analysis. Consider the three types of XiongPi syndrome differentiation of traditional Chinese medicine as the dependent variable, pH, P02, PCO2were the independent variables, using multiple linear Logistic regression, ordinal Logistic regression analysis, according to the regression equation, deduce syndrome cases in blood-gas analysis results in oxygen partial pressure offset based bias in the lung spleen deficiency phlegm dampness and greater possibility. Syndromes mainly pH shift in blood-gas analysis results in the case of bias in the liver qi stagnation syndrome is more likely; possibility for blood-gas analysis results in the partial pressure of carbon dioxide offset based case bias in the spleen and stomach Yang deficiency and phlegm stagnation of fire more.