【作者】 傅进艺；

【导师】 林棉；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2010， 硕士

【摘要】 慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease,以下简称COPD)是一种全球性患病率、病死率较高的和可预防的慢性呼吸系统疾病。COPD呈慢性进行性发展的过程,又容易在感染等因素的作用下出现慢性阻塞性肺疾病急性发作(Acute Exacerbations of Chronic Obstructive Pulmonary Disease,以下简称AECOPD),出现咳嗽、咳痰、气短和(或)喘息加重,痰量增多,呈脓性或黏脓性,可伴发热等炎症明显加重的表现。目前普遍认为COPD以气道、肺实质和肺血管的慢性炎症为特征。而气道炎症在原有基础上的加重是AECOPD的一个特征。AECOPD的嗜酸粒细胞、中性粒细胞较稳定期增加,释放多种炎症介质,导致TNF-α、IL-6、IL-8等水平升高,从而破坏肺的结构和(或)促进中性粒细胞炎症反应,使肺功能下降。同时,氧化应激也是炎症反应的重要步骤,是COPD患者气道炎症存在的主要原因。COPD可归属于中医“喘证”、“肺胀”范畴。感邪则偏于邪实。AECOPD的证型以“痰热壅肺型”为主。肺与大肠相表里,肺热易移于肠腑,导致肠腑传导失司,而肠腑传导失司也可以加重肺脏病症。因而,肺邪热移于肠腑,热邪耗液,大肠津亏,邪热与燥屎相结而成实,故大便干结。腑实热结上迫于肺,使肺气不降,肺气不降则大肠腑气不通,二者互为因果而成恶性循环。现代医家根据“肺与大肠相表里”的理论,运用“通腑泻热法”治疗AECOPD,取得了一定效果,但研究集中在灌肠方面,也有汤剂口服者,但组方变化复杂,亦未运用肺功能等更客观的指标进行评价,故未能规范、系统评价研究“泻下通腑法”目的：通过规范、系统的症状评分联合肺功能检测,评估“泻下通腑”法在治疗AECOPD中的效果,为合理运用“泻下通腑法”治疗AECOPD提供更多的、科学的临床研究依据。方法：收集年龄在40岁或以上,75岁或以下,住院确诊为AECOPD“肺热腑实型”的患者共60例,将其随机分为治疗组和对照组。两组均予相同的西医基础治疗,治疗组加用“泻下通腑”法的小承气汤治疗。小承气汤治疗,每3日评估,每病例最多治疗9天。患者缓解时观察疗效,用Microsoft Excel建立数据库,用SPSS 11.5进行统计分析,用t检验及卡方检验比较治疗前后患者临床症状、体征、大便、肺功能的差异及两组疗效差异。结果：住院患者以男性居多,发病年龄以71-75岁居多。治疗后,两组的临床症状、体征改善均较显著,两组的临床症状、体征改善均较显著,治疗组达88.76%,对照组达72.87%；而疗效则治疗组平均达90.0±15.54%,对照组亦达75.0±22.63%,两组间临床症状、体征、大便情况、肺功能(FEV1、FEV1%)、疗效、缓解天数(相差2.77天)经卡方及t检验存在统计学差异。结论：AECOPD住院的痰热壅肺型患者多数有大便干结的腑气不通的临床表现。运用中医“泻下通腑法”的小承气汤结合西医基础治疗,提示临床症状、体征、大便、FEV1、FEV1%的均有更好的改善,有更好的疗效,能促进患者更早缓解急性加重期,从而减轻肺功能损害,减少社会经济负担。通过肺功能结合临床症状、体征等评价中医“泻下通腑”法可以为临床提供更客观、更规范的研究依据。更多还原

【Abstract】 Chronic Obstructive Pulmonary Disease is a respiratory disease that h as a higher morbidity and mortality, and can be preventable and treatable. COPD demonstrates a course that develops chronicly and progressively. It c an be exacerbated by infection and develops into Acute Exacerbations of C hronic Obstructive Pulmonary Disease, with the obviously exacerbating imfl ammations of cough, sputum production and worsening dyspnea, more sputum, pu rulent or sticky-purulent, fever, etc. As now, it is thought that COPD is c haracterized with imflammations in the proximal airways, peripheral airway s, lung parenchyma, or pulmonary vasculature. The imfammation exacerbated in the respiratory tract is one of the feature of AECOPD. The steadily incr eased neutrophil and eosinophil cells periodically in AECOPD, releasing mu ltiple inflammatory mediators, will lead to the leveling of TNF-a, IL-6, IL-8 and the destroying of the pumonal structure or the promoting of the im flammation of the neutrophil cells, deteriorating the pumonal functions, Me anwhile, oxidative stress is an important step of the inflammation and th e majoy cause of the exsisting inflammation of the respiratory tract in t he COPD patients. Oxidative stress is further increased in exacerbations. C OPD can be categorized to Panting syndrome or Lung Distension in traditio nal Chinese medicine (TCM).It becomes a state of evil domination when exo genous evil attacks. AECOPD mainly manifests the type of accumulation of s putum-heat in the lung of the differentiation of Syndromes in the traddio nal chinese medicine. As the lung and the large intestine are interior-ext eriorly related, the dry-heat in the lung wil easely move down to the larg e intestine, resulting the disturbance of large intestine intransport whic h may exacerbate the pulmonary disease. Thus, when the dry-heat in the lung moves down to the large intestine, heat evil burns body fluid, lessening f luid in the intestine, and combines dry stool mutually, so dry stool appear. excessive heat of the large intestine viscera transfers up to oppress the lung, so that the Lung-Qi can’t descend, and then the Qi of large intestin e viscera stagnates, the two become cause and effect mutually to develop a vicious circle.The modern TCM doctors treat COPD by using The method of Purging to relax the bowels,based on the theory of the lung and the large intestine being interior-exteriorly related, and have acheived some certa in results. But their researches focus on the clysis, while there is decoct ion-form taken orally, however, the prescripions are various and complex, an d can not be evaluated by more objective indicators like the pulmonary fu nctions.So, the method of Purging to relax the bowels has not been resear ched or evaluated standardizedly and systematically.Objective:The therapeutic effects of the method of Purging to relax the bowels in the treatment of AECOPD are evaluated by combining the sc ores of standardized and systematic symptoms with the examination of pul monary functions, so that provides more and scientific clinic evidence fo r reasonable application of The method of Purging to relax the bowels.Method:Collect 60 inpatients who were diagnosed the heat-lung and t he excess-Fu-organ in accordance with the criterion of AECOPD syndrome, w hose age varies from 40 to 75. They were divided into the therapeutic gro up and the controlled group. The former was treated with Xiaochengqi deco ction of the method of Purging to relax the bowels of TCM, combining with basal treatment of mordern-western medicine, while the latter was just t reated with basal treatment of mordern-western medicine. The course of th e treatment of the Xiaochengqi decoction is three days, which was divided into three part. The therapeutic effect is observed before the disease r elieve, calculating the data with Microsofe Excel 2003 and carrying out s tatistic analysis with SPSS 11.0, using t-test and chi-square test to com pare the differences of the clinic symptom, sign, constipation, pulmonary function and therapeutic effect of the two group between the therapeutic before and aft.Result:The majority of inpatients are man and whose age varies betw een 71 and 75. After treatment, the improvement of clincic symptoms and s igns of both groups are obvious. The improvement rate of the therapeutic group is 88.76%, reaching a average of therapeutic efficiency of 90.0±1 5.54%, while the improvement rate of the controlled group is 72.87%, rea ching a average of therapeutic efficiency of 75.0±22.63%. There are diff erences between the two group of the clincic symptoms, signs, feces, pulmon ary function (FEV1, FEV1%), therapeutic efficiency, days of relief by t-te st and chi-square test.Conclusion:Most inpatients of the type of the accumulation of sputu m-heat in the lung manifest constipation of the excess-Fu-organ.The the rapeutic group applying the therapy of Xiaochengqi decoction of the meth od of Purging to relax the bowels of TCM combined with basal treatment o f mordern-western medicine shows better improvements and therapeutic eff ects than the controlled group,which relieves the inpatients’exacerbat ion earlier,reduce the injury of the pulmonary function and the econom ic burdens of the society.To evaluate the method of Purging to relax the bowels of TCM by combining the clinic symptom and sign with the examina tion of the pulmonary function can provide more objective and standardiz ed researching evidence for the clinic practice.更多还原