重症肺炎中医证型分布特征及相关因素的临床研究

【作者】 兰玥；

【导师】 齐文升；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2012， 硕士

【摘要】 目的①依据采集到的相关信息分析并寻找重症肺炎患者的中医证候分布特点；②确定重症肺炎常见证型与年龄、性别、既往史、痰培养、白细胞、C反应蛋白、乳酸、B型脑钠肽、降钙素原、鲎试验、APACHE Ⅱ评分、临床肺部感染评分等相关因素的关系,为临床提供依据。方法采用回顾性的调查方法,收集2009年1月至2011年12月中国中医科学院广安门医院ICU病房及急诊病房所有诊断为重症肺炎患者的病例数据,收集一般情况、中医证素、实验室检查、病原学检查、预后转归等内容,将结果填入设计好的调查表中。建立原始临床数据库后,将数据导入SPSS17.0,对证素总体分布情况、证素组合规律以及常见证型总结,分析常见证型之间年龄、性别以及各临床检查结果的差异。结果1重症肺炎的中医证素及常见证型：研究显示,对重症肺炎患者证素进行分析,实证证素为4个(痰、热、毒、瘀),虚证证素为5个(阴虚、阳虚、气虚、血虚、气脱)证素组合形式共有5种,其中以两个证素组合最多。两证素组合中痰证+热证出现的频率最高,三证素组合中以阴虚+阳虚+毒证最多。证素组合结果为6种,包括痰热闭肺证、阴阳两虚蕴毒证、瘀热蕴毒证、热毒内蕴证、气阴两虚证、气虚血瘀痰阻证。最常见的三组证型为：痰热闭肺证、阴阳两虚蕴毒证、瘀热蕴毒证。2三组资料一般情况：三组资料ICU住院天数比较,痰热闭肺证时间最短,病死率最低,阴阳两虚蕴毒证ICU住院时间最长,病死率最高,两组数据比较有显著差异(P<0.01)。3三组资料细菌培养结果：痰培养结果显示以革兰氏阴性菌为主约占64.13%,革兰氏阳性菌约占35.87%。革兰氏阴性菌中铜绿假单胞菌最多,其次为鲍曼不动菌、肺炎克雷伯菌(包括肺克亚型)以及大肠埃希菌；革兰氏阳性菌中金黄色葡萄球菌最多,其次为肠球菌(屎肠球和粪肠球),真菌以白色念珠菌为主。研究发现痰热闭肺证以革兰氏阳性菌为主,其中金黄色葡萄球菌37例,占51.38%；阴阳两虚蕴毒证以革兰氏阴性菌为主,其中铜绿假单胞菌例数占66.67%,鲍曼不动菌例数占28.21%。4三组资料与实验室检查的关系：三组资料白细胞、C反应蛋白值均高于正常值,痰热闭肺证患者白细胞及C反应蛋白值比阴阳两虚蕴毒证及瘀热蕴毒证的值高,均有显著差异(P<0.05)。阴阳两虚蕴毒证的临床肺部感染评分(CPIS)、APACHEⅡ评分、B型脑钠肽、乳酸以及降钙素原分别与其他两组资料相比平均值均偏高,有统计学意义(P<0.01)。三组资料鲎试验比较无统计学意义。5重症肺炎的机械通气使用情况与撤机率、生存率、并发症的关系：有创通气121例,无创通气24例,有创通气成功脱机87例,撤机率为61.71%,无创通气较有创通气低,因部分患者长期携带无创呼吸机生活,有创通气患者生存率较无创通气低。重症肺炎并发症,以感染性休克最多,胃肠功能障碍、低蛋白血症及多脏器功能衰竭等次之。结论1重症肺炎患者证素分布实证证素为4个(痰、热、毒、瘀),虚证证素为5个(阴虚、阳虚、气虚、血虚、气脱)。证素组合中痰证+热证最多,其次为阴虚+阳虚+毒证。重症肺炎中医证型主要为痰热闭肺证、阴阳两虚蕴毒证、瘀热蕴毒证,其中痰热闭肺证患者年龄偏低,提示证型与年龄之间可能存在一定关系。2痰热闭肺证患者白细胞、C反应蛋白均高于其他两组数据,提示此证型炎症反应剧烈,中医认为此证型患者正气旺盛,正邪交争激烈。阴阳两虚蕴毒证患者B型脑钠肽、乳酸、临床肺部感染评分、APACHE Ⅱ评分最高,提示此证型患者病情危重,预后差、病死率高。3阴阳两虚蕴毒证患者ICU住院时间较长,提示此型病程长,病情发展缓慢难愈。更多还原

【Abstract】 Objective①Search for the TCM syndrome distribution character of severe pneumonia patients base on the related information analyzation.②Determine the relationship between common TCM syndromes of severe pneumonia pa-tients and some related factors, such as age, gender, previous medical history, bacterial cultures of sputum, C-reaction protein, APACHEII score, clinical pulmonary infection score.MethodUse the retrospective research method; and collect the case information of all the severe pneumonia patients in ICU of Guang’anmen Hospital from Jan.2009to Dec.2012, including general information, TCM syndrome factors, laboratory results, bacteriology test results, prog-nosis condition, etc. Fulfill the case report form, build up an original clinical information data-base, import the information into SPSS17.0, and then statistic analyze the TCM syndrome fac-tors population distribution condition, TCM syndrome type distribution condition under differ-ent influence factor, find out the differences of age, gender and other clinical test results be-tween the common TCM syndrome types.Results1TCM syndrome factor and common TCM syndrome of severe pneumonia:The research shows that, there are4excess TCM syndrome factors (phlegm syndrome, heat syndrome, toxic-ity syndrome, blood state syndrome),5deficiency TCM syndrome factors (Yin deficiency syn-drome, Yang deficiency syndrome, Qi deficiency syndrome, blood deficiency syndrome, Qi prostration syndrome). There are5combination forms of syndrome factors, and the2-factor-combine form is the most in number. Amount the2-factor-combine forms, the phlegm syndrome combine heat syndrome has the most occurrence frequency. Amount the3-factor-combine forms, the Yin deficiency syndrome, Yang deficiency syndrome and the tox-icity syndrome combination has the most occurrence frequency. The result shows that there are6types of TCM syndrome factor combination, including phlegm and heat obstruct lung syn-drome, Yin and Yang deficiency with accumulated toxin syndrome, blood and heat state with accumulated toxin syndrome, heat and toxin accumulated inside syndrome, Qi and Yin defi-ciency syndrome, Qi deficiency with blood and phlegm state syndrome. The common TCM syndrome type is:phlegm and heat obstruct lung syndrome, Yin and Yang deficiency with ac-cumulated toxin syndrome, blood and heat state with accumulated toxin syndrome.2The general information of3TCM syndrome types:Comparing the in-ICU stay and the mortality, phlegm and heat obstruct lung syndrome has the shortest in-ICU stay and lowest mortality, Yin and Yang deficiency with accumulated toxin syndrome has the longest in-ICU stay and highest mortality; there is a significant difference between2syndrome types (P<0.01).3The bacterial culture result of3TCM syndrome types:The phlegm bacterial culture re-sult shows that Gram-negative bacterium has the major percentage about64.13%, and Gram-positive bacterium is35.87%. Amount the Gram-negative bacterium, the occurrence rate from high to low is:pseudomonas aeruginosa, acinetobacter baumannii, klebsiella pneumonia (include the subtypes), escherichia coli. Amount the Gram-positive bacterium, the occurrence rate from high to low is:staphylococcus aureus, enterococci (enterococcus faecalis and entero-coccus faecium). Amount the fungus mostly is Candida albicans. The research shows that, phlegm and heat obstruct lung syndrome patients’bacterial culture result is mostly Gram-positive bacterium, including37cases of staphylococcus aureus, that’s about51.38%; Yin and Yang deficiency with accumulated toxin syndrome patients’bacterial culture result is mostly Gram-positive bacterium, amount it there is66.67%of pseudomonas aeruginosa,28.21%of acinetobacter baumannii.4The relationship between the3TCM syndrome types and the laboratory results:The WCB and CRP of3TCM syndrome types patients are higher than normal, phlegm and heat ob-struct lung syndrome patients’WBC and CRP are significantly higher than the other2types pa-tients (P<0.05). The phlegm and heat obstruct lung syndrome patients’CPIS is significantly higher than the other2types patients (P<0.01). Comparing the APACHE Ⅱ score, the Yin and Yang deficiency with accumulated toxin syndrome has higher score than the other2types (P<0.01). The BNP of3TCM syndrome types is higher than normal, especially the phlegm and heat obstruct lung syndrome is significantly higher than the other2types (P<0.01). Comparing the PCT, the phlegm and heat obstruct lung syndrome is significantly higher than the Yin and Yang deficiency with accumulated toxin syndrome (P<0.05). The difference of limulus test re-sult of3TCM syndrome types is not statistically significant.5The usage of mechanical ventilation of severe pneumonia:There are121cases of inva-sive mechanical ventilation,24cases of non-invasive mechanical ventilation.87invasive me-chanical ventilation cases successfully weaning, the weaning rate is61.71%. The non-invasive mechanical ventilation patients have a lower weaning rate, it may relate to the long-term life with mechanical ventilation. The survival rate of invasive mechanical ventilation patients is lower than the non-invasive mechanical ventilation patients. The complication of severe pneu-monia mainly is septic shock, after that is gastrointestinal dysfunction, hypoproteinemia, and MODS.Conclusion1There are4excess TCM syndrome factors (phlegm syndrome, heat syndrome, toxicity syndrome, blood state syndrome),5deficiency TCM syndrome factors (Yin deficiency syn-drome, Yang deficiency syndrome, Qi deficiency syndrome, blood deficiency syndrome, Qi prostration syndrome). The syndrome factor combination mainly is the phlegm syndrome com-bine heat syndrome, after that is Yin and Yang deficiency syndrome with accumulated toxin syndrome. The common TCM syndrome type is:phlegm and heat obstruct lung syndrome, Yin and Yang deficiency with accumulated toxin syndrome, blood and heat state with accumulated toxin syndrome. Amount them, the phlegm and heat obstruct lung syndrome patients is younger than the other syndrome types, which means there may be some relationship between TCM syndrome types and age.2The WBC. CRP, PCT, LC and CPIS of phlegm and heat obstruct lung syndrome is high-er than the other2TCM syndrome types, which indicates that this type of syndrome has the most severe inflammatory reaction, the TCM theory believes it is because the patients has enough vital Qi to fiercely fight with the evil Qi. The APACHE Ⅱ score of Yin and Yang defi-ciency with accumulated toxin syndrome is much higher than the other syndrome types, which indicates that this type of syndrome is a critical condition, has a poor prognosis and high mor-tality.3The Yin and Yang deficiency with accumulated toxin syndrome patients has a longer in-ICU stay, which indicates this type of syndrome has a long course of disease, progress slowly and to be refractory.更多还原