【作者】 张智琳；

【导师】 陈镜合；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2012， 博士

【摘要】 [背景]急性肺损伤(Acute Lung Injury, ALI)是一种常见而严重的呼吸急症,是指由各种肺内、外致病因素导致的急性进行性缺氧性呼吸衰竭,1967年被Ashbaugh首次报道。该病具有较高的发病率和病死率。其发病机制仍不十分明确,目前认为其发生和发展是多病因共同作用的结果,其中过度失调的炎性反应被认为是最重要的因素之一。临床上尚无特异治疗方法。中医虽无“急性肺损伤”的病名,但按其临床表现,应属“喘证”、“结胸”“喘脱”、“暴喘”等病的范畴,病位主要在肺和肾。肺失宣降、气机逆乱、毒邪壅滞是发病早期的重要病机,其中的毒邪包括热、毒、痰、瘀等,患者热、毒、痰、喘、瘀、闭的表现突出,宜运用清热解毒、宣肺平喘、豁痰开窍、攻里通下等治法。综合既往研究结果提示,一些以清热解毒或清热化痰为指导原则的中药方剂或中成药经实验验证,对ALI有一定效果。[目的]通过设立常规治疗、常规治疗加乌司他丁、常规治疗加清热化痰法等三组,对比三组疗效,评价清热化痰法对痰热蕴肺型ALI的临床疗效,并结合动物实验研究其可能的作用机制,另外还探讨痰热清注射液在治疗ALI方面是否存在量效关系及其安全性,为今后更深一步的研究打下基础。[方法]临床研究采用随机、单盲研究方法。2010年2月至2012年2月期间,从广州中医药大学第一附属医院重症医学科,以及广州市中医医院急诊科、呼吸科纳入的符合标准的病人共计46例。将病人随机分入常规治疗组(A组)、常规治疗加乌司他丁组(B组)、常规治疗加中药组(C组)等三组,三组的治疗方案分别是常规治疗、常规治疗加乌司他丁、常规治疗加清热化痰法,疗程为14天。观察住院期间患者中、西医症候的变化,以及呼吸机使用时间、血清炎症因子、Murray肺损伤评分等指标。本动物实验以静脉注射脂多糖的方法复制ALI大鼠模型。通过对正常对照组(A组)、急性肺损伤模型组(B组)、乌司他汀对照组(C组)、中药常规剂量组(D组)、中药高剂量组(E组)等各组大鼠分别予生理盐水5ml、生理盐水5ml、乌司他丁(2.1万U/Kg)、常规剂量痰热清(2.1ml/Kg)、高剂量痰热清(4.2ml/Kg),连续给药3天,对照观察各组大鼠的肺组织匀浆中的各项炎症指标、肺湿干重量比、肺病理改变,以及各组死亡率,观察清热化痰法对ALI是否存在治疗作用,并初步探讨其作用机制和安全性。[结果]临床研究发现,A、B、C三组治疗后的心率、氧合指数、胸片、Murray肺损伤评分等各项指标都较治疗前有明显改善(P<0.05)。而B、C两组又较A组改善明显(P<0.05或P值接近0.05)。B、C两组之间未见明显的差异性(P>0.05)。A组治愈3例,好转5例,未愈3例,死亡3例,总有效率57.14%；B组治愈7例,好转5例,未愈2例,死亡2例,总有效率68.75%；C组治愈7例,好转6例,未愈2例,死亡1例,总有效率75%。但三组间资料比较未见有统计学意义的差异(P>0.05)。在呼吸机通气时间,以及TNF-α、IL-6、MMP-9等指标的比较上,B、C两组均较A组的数值明显降低(P<0.05)。而B、C两组之间则未见明显的差异性(P>0.05)。动物实验方面,同日不同组之间的比较,C、D、E三组3天的IL-6、TNF-α、MMP-9等炎症指标,以及W/D、病理切片结果均较B组有显著性的改善(P<0.05)；而此三者之间未见明显差异(P>0.05)。同组不同日之间的比较,C3与C1的W/D比较有明显的下降,C2、D2组的TNF-α水平与C1、D1组比较有明显的下降(P<0.05),E3组与E1组的TNF-α水平也有明显的下降(P<0.05),而IL-6、MMP-9则无上述变化。而W/D、肺部切片等在连续给药3天中均有不同程度的逐日改善。不良事件方面,B组在第1天死亡1只,C组在第3天死亡1只,D组在第2天死亡1只,E组大鼠在第1、2、3天各死亡1只。B、C、D三组的死亡率均为5.6%,E组死亡率为16.7%。另外,E组大鼠有半数出现大便溏、次数多的不良反应。[结论]1、常规治疗、常规治疗加用乌司他丁、常规治疗加用清热化痰法三种治疗方法,均对ALI有一定的治疗效果,体现在患者临床表现、影像学检查和实验室检查等方面的改善。而后二者又比常规治疗效果更佳,体现在后二者使用呼吸机的时间更短,血液中炎症因子含量下降更明显,但后二者之间未见有明显差异。清热化痰法治疗痰热蕴肺型ALI的机制之一是降低患者血清中TNF-α、IL-6、MMP-9等炎症因子的水平。清热化痰法能改善痰热蕴肺型ALI的病情,阻断其向更严重的ARDS发展,缩短呼吸机的使用时间,提高临床疗效。2、从中医角度评价疗效,常规治疗加用清热化痰法对痰热蕴肺型ALI有一定的疗效,但与单纯西医常规治疗,以及常规治疗加用乌司他丁相比未有统计学意义上的差异,需进行更大样本量的临床观察以进一步研究。另外,在研究中我们发现,加用清热化痰法的病例大多大便偏软,甚偏溏,根据肺与大肠相表里的理论,通便既可降肺气,又可清肺热,因此这可能是清热化痰法治疗痰热蕴肺型ALI的机制之一。所以,可以在辨证使用清热化痰的治法基础上,酌加泻下通便的中药,可能会增加疗效。3、乌司他丁、常规剂量痰热清、大剂量痰热清均对ALI大鼠有一定的治疗作用,三者的疗效相当,其作用机制是通过降低肺局部TNF-α、IL-6、MMP-9等炎症因子的水平以减轻肺部炎症反应,改善肺部病理改变,从而对ALI大鼠的肺部起到一定的保护作用。4、与第1天相比,当用药到第2天或第3天时,乌司他丁、常规剂量痰热清、大剂量痰热清三组大鼠的肺匀浆中的TNF-α含量均有明显的下降。TNF-α呈逐日降低的趋势,可能与它是早期主要的前炎症因子之一,是炎性反应中释放最早、最重要的内源性介质有关。5、连续给药到第2天、第3天, ALI大鼠的W/D和肺部病理切片均较第1天有一定改善,提示连续用药较单纯用药1次可获得更好的疗效。6、与常规剂量相比,大剂量的痰热清并未能使ALI大鼠获得更好的疗效,反而令该组大鼠的不良反应发生率和死亡率有增高的趋势。更多还原

【Abstract】 [Background] Acute lung injury (ALI), one of the respiratory system emergency cases, first reported by Ashbaugh in1967, is acute, progressive and hypoxia respiratory failure caused by multiple endo-or ecto-lung etiological factors. ALI has high morbidity and fatality, but its pathogenesis is not fully identified. At present, its genesis and development is regarded as the result of multiple etiological factors. among these, over-imbalance inflammatory reaction is regarded as one of the most important factors. Specific therapy is absent so far.The name "Acute lung injury" was not exist in TCM, but according to clinical manifestation, ALI pertains to "panting patterns","chest bind","panting desertion" and "fulminant panting", of which position of disease is lung and kidney. The vital and pristine pathogenesis is impairment of dispersing and descending function of the lung, disorder of the activities of qi, and also obstruction of poison of lung. The poison factors include heat, toxin, phlegm and stasis, by which the patients’appearance with heat, toxin, phlegm panting, stasis and blocking is significant. To treat these, the method of treatment, including clearing heat and resolving toxin, diffusing the lung and calming panting, sweeping phlegm and opening the orifices, and precipitation, should be used. The results of previous researches revealed that some formula and Chinese pattern medicines directed by either the principle of clearing heat and resolving toxin or clearing heat and transforming phlegm have a certain extent of curative effect.[Objective] To evaluate the curative effect for the phlegm-heat-obstructing-the-lung-type ALI of the management of clearing heat and transforming phlegm, we establish the groups of conventional therapy, conventional therapy adding ulinastatin (UTI) and conventional therapy adding clearing heat and transforming phlegm, and compare them. On the other side, we investigate the mechanism of the management of clearing heat and transforming phlegm according to the animal experiment. In additional, we investigate the dose-effect relationship and safety of Tanreqing injection curing ALI for further study.[Method] We used randomized, single blind methods in clinical research. From February2010to February2012, we collected46patients from the First Affiliated Hospital of Guangzhou TCM University and Guangzhou hospital of TCM, who met the diagnosis criterion of ALI. We randomly divided them into the group of conventional therapy (group A), of conventional therapy adding UTI (group B) and of conventional therapy adding Chinese medicine (group C). The therapeutic regimens of these3groups respectively were conventional therapy, conventional therapy adding UTI and conventional therapy adding clearing heat and transforming phlegm, while their courses of treatment were14days. The patients’symptoms of Chinese medicine and Western medicine, the time of using breathing machine, inflammatory factors in serum and lung injury score (LIS) were observed in the duration of hospital stay.The rat model of ALI was produced with intravenous injecting lipopolysaccharide. After establishing the group of normal control (group A), of ALI model (group B), of UTI (group C), of normal does of Chinese medicine (group D) and of high does of Chinese medicine (group E), we respectively gave them normal sodium5ml, normal sodium5ml, UTI (21, OOOU/kg), Tanreqing(2. lml/kg) and Tanreqing(4.2ml/kg), for3days consecutively, then compared inflammatory factors in the rats’lung homogenate, the wet weight-dry weight ratio(W/D), pathologic change of lung, and the mortality of each group.[Result] The result of clinical study revealed that compared to pretherapy, three groups had significant changes in the aspects of breathing rate, heart rate, saturation of blood oxygen, oxygenation index, sternite and LIS after treatment (P<0.05). Generally speaking, the changes of group B and C were more significant then that of group A, while not obvious between group B and C. According to the viewpoint of Chinese medicine, in group A,3patients were cured,5improved,3not cured,3dead, and total effective rate of this group was57.14%; in group B,7patients were cured,5improved,2not cured,2dead, and total effective rate of this group was68.75%; in group C,7patients were cured,6improved,2not cured,1dead, and total effective rate of this group was75%. But no significant difference was observed. In the aspects of duration of ventilation with breathing machine and the inflammatory factors, such as TNF-α, IL-6and MMP-9, group B and C degraded more significantly than group A(P<0.05), while there was no difference between group B and group C(P>0.05).The result of animal experiment revealed that in the aspect of horizontal comparison of the same day, the indexes, such as TNF-α, IL-6, MMP-9, W/D and pathologic change of lung, of group C, D and E were more significant than those of group B(P<0.05), while no significant difference among group C, D, E(P>0.05). On the other side, in the aspect of longitudinal comparison of the same group, the W/D of C3had more significant decrease than C1,whle significant decrease of TNF-α was present between C2and Cl, D2and D1, E3and El(P<0.05), but no such change of IL-6or MMP-9. During these3days, different extent of improve in W/D and pathologic change of lung was observed day by day. A rat of group B died in the first day, one of group C died in the third day, one of group D died in the second day, while a rat of group E died in everyday. The mortality of group B, C and D was5.6%, while group E was16.7%. Besides, half rats of group E appeared frequent and loose stool.[Conclusion]1. Conventional therapy, conventional therapy adding UTI and conventional therapy adding the management of clearing heat and transforming phlegm are effective for ALI, reflected in the improve of the patients’clinical performance, imageology examination and laboratory examination. The latter two are better than conventional therapy, for the time of using breathing machine was shorter and inflammatory factors in serum were less, while they had no significant difference with each other. One of the mechanisms of the management of clearing heat and transforming phlegm curing the phlegm-heat-obstructing-the-lung-type ALI is decrease the content of TNF-α, IL-6, MMP-9in serum. It can improve the phlegm-heat-obstructing-the-lung-type ALI, arrest its growth to ARDS, shorten the time of using breathing machine and enhance curative effect.2. According to the viewpoint of Chinese medicine, conventional therapy adding the management of clearing heat and transforming phlegm has some curative effect for the phlegm-heat-obstructing-the-lung-type ALI, but shows no significant difference with conventional therapy or conventional therapy adding UTI, thus the research of larger sample size is required. In additional, we find the patiens’stool of conventional therapy adding clearing heat and transforming phlegm is soft, or even sloppy. Basis on the theory of "lung and large intestine are exterior and interior", purgation helping downbear lung-qi and clear lung-heat, it is regarded as one of the mechanisms of the management of clearing heat and transforming phlegm. Therefore, it can enhance curative effect by adding the herb for relieving constipation by purgation on the base of the pattern identification and using he management of clearing heat and transforming phlegm.3. UTI, normal does of Tanreqing and high does of Tanreqing has respectively some curative effect for ALI rats, which has no significant difference with each other. The mechanism is that the content of inflammatory factors such as TNF-a, IL-6and MMP-9in lung is decreased so that the inflammatory reaction is gentler, pathologic change of lung is improved and therefore lung is protected.4. In the second day and the third day, the content of TNF-α in the rats’lung homogenate from the group of UTI, normal does of Tanreqing and high does of Tanreqing was lower than in the first day. TNF-α displays the trend of day-by-day decrease, possibly concerned with that it is the one of the pro-inflammatory factors and the earliest and the most important endogenous transmitter in the inflammatory reaction.5. When successive administration to the second day and the third day, rats’W/D and pathologic change of lung improved compared to the first day, which reveals that the effect of successive administration is better than administration only one time.6. Compared with the normal does of Tanreqing, high does fails to benefit the ALI rats, instead, makes the incidence of adverse effect and the mortality of this group seem higher.更多还原