李贵教授学术经验及温肺化瘀定喘法治疗小儿毛细支气管炎的临床研究

【作者】 林海；

【导师】 李贵；

【作者基本信息】 北京中医药大学 ， 中医儿科学， 2011， 硕士

【摘要】 李贵老师从事中西医结合临床与科研工作50年,他融汇中西医学两法,在儿科领域有着丰富的临床经验,临证注重益气健脾以扶正,清热解毒以祛邪的治则运用,尤其重视中医血瘀理论与活血化瘀治则在儿科临床的运用。李贵老师善于运用中西医结合疗法治疗儿科各种常见病及多发病,特别是对小儿呼吸道疾病、肾脏疾病、过敏性紫癜及其并发症等,在临床上取得了很好的疗效。李贵老师在进行临床诊治的同时,针对临床所见血瘀证开展了微循环方面的中西医结合研究,取得了一系列的研究成果。本课题尝试追溯李贵老师中西医结合治疗儿科疾病的学术渊源,发现李贵老师从中医古代文献中受益良多。如唐末宋初儿科专著《颅囟经》的“纯阳”观点,金元时期医家刘完素《宣明论方·小儿科论》对“纯阳”的发挥,清代温病大家吴瑭《温病条辨·解儿难》中提出的稚阳稚阴的生理特点,易于感触、易于传变的病理特点等,以及清代王清任《医林改错》对血瘀证的论述等。本课题对李贵老师诊治儿科疾病的学术特色进行了总结,从生理特点、病理表现、治疗法则等方面进行了阐述。对益气健脾、清热解毒、活血化瘀等治则和用药进行了较为具体的分析,尤其对李贵老师血瘀证治的规范化研究进行了深入学习和总结。李贵老师从中西医相结合的角度出发,探讨了小儿血瘀证理论,提出“血瘀证是儿科常见病的重要发病机制”；他对血瘀证治进行了规范化研究,明确了血瘀证的概念、从中西医学角度总结了血瘀证的致病因素及临床表现；继而根据临床辨证、病因和病机的不同而分别应用不同的活血化瘀法,从而丰富了活血化瘀治则；在选方用药上,提出应根据中医的血药,特别是活血化瘀药的作用机理和作用强度的不同而区别运用；并根据气血相关理论将气药、血药灵活共用,以更加合理有效的治疗儿科临床诸症。最后,本课题对李贵老师诊治小儿毛细支气管炎的多年临床经验进行了临床研究。研究结果表明,温肺化瘀定喘方用于治疗小儿急性毛细支气管炎证属风寒束肺型兼血瘀证的患儿,在总体疗效上与西药对照组并无显著性差异,但对一些症状(如咳嗽)的改善却明显优于西药对照组,据此说明以辨证治疗为基础的活血化瘀疗法对具有血瘀证的小儿呼吸道支气管炎患者是有效的,从而显示了中医药对小儿毛细支气管炎的治疗优势。呼吸道感染是小儿常见病,临床常反复发作。李贵老师认为小儿呼吸道感染多兼血瘀,临床所见舌色紫暗或有瘀点、扁桃体肿大、肺部炎症斑片等皆为血瘀之象,当予活血化瘀之法；尤其在对小儿肺炎具体治疗上,根据不同病情与病程,适量选用具有不同针对性的活血化瘀药物。在肺炎初起,症状较轻,发热较低或不发热,咳嗽咳痰不甚剧烈,肺部听诊仅闻散在罗音水泡音,于清热化痰宣肺药中加入当归、川芎以活血化瘀,以促进炎症的消散和吸收；若病程稍长,症状较重,热重咳重,胸片见大量的斑片影,肺部听诊闻及大量明显的罗音水泡音,则用桃仁、红花加强活血破瘀的力量；若病情进一步加重,炎症长时间不能吸收,则以三棱、莪术破瘀散结。故此,通过合理恰当的运用活血化瘀的药物治疗小儿呼吸道感染,于传统治疗思路中另辟蹊径,取得较好的治疗效果。1.中医活血化瘀法在儿科呼吸道感染治疗中的应用中医活血化瘀法是两千多年来人们在与疾病斗争中逐渐形成和发展起来的,并经历代医家发展、创新,广泛运用于临床各科,其中对于儿科诸病,特别是久病、难治性和易于反复的病证,只要病机相符,即可大胆应用,多获佳效。2.温肺化瘀定喘法治疗小儿毛细支气管炎的临床研究笔者在总结与继承李贵老师学术经验的基础上,进行了“温肺化瘀定喘法治疗小儿毛细支气管炎的临床研究”。目的：观察温肺化瘀定喘法治疗小儿毛细支气管炎的临床疗效,旨在通过本研究,验证活血化瘀法在儿科应用的安全性及有效性,找到更好的治疗小儿毛细支气管炎的中西医结合的方法,更好的解除病人痛苦,为预防婴幼儿哮喘的发生提供新的方法。方法：随机平行对照临床研究,初筛入选病例随机分为试验组30例和对照组27例,基础治疗为沐舒坦、布地奈德混悬液、复方异丙托溴铵气雾剂。实验组在基础治疗用药上,口服温肺化瘀定喘汤；对照组对照药物选用利巴韦林注射液、盐酸丙卡特罗口服液。结果：研究结果显示,实验组与对照组从主要症状体征(发热、咳嗽、气促、痰阻)及主症积分的变化来看,两组比较均未见统计学差异,说明中药治疗效果与西药组并无显著性差异；而从咳嗽的变化来看,两组比较有极显著性差异,中药实验组明显优于西药对照组。结论：本实验证实,温肺化瘀定喘方用于治疗小儿急性毛细支气管炎证属风寒束肺型,在总体疗效上与西药对照组并无显著性差异,但从一些症状(如咳嗽)的改善却明显优于西药对照组,据此说明以活血化瘀为主治疗小儿呼吸道支气管炎是有效的,从而显示了中医药治疗优势。小儿急性毛细支气管炎是由多种病原引起的一组急性下呼吸道疾病。常见的病原有病毒(呼吸道合胞病毒、副流感病毒、腺病毒等)、细菌、肺炎支原体等。西医治疗本病无特异疗法,主要是用肾上腺皮质激素(吸入或全身),支气管平滑肌解痉药,祛痰止咳药等,疗效并不十分理想。温肺化瘀定喘方是李贵老师通过合理运用中西理论制定的、并历经长期临床实践检验而证实有效的方剂,主要用于小儿外感风寒所致毛细支气管炎、喘息性支气管炎、支气管肺炎,表现为发热恶寒、咳嗽、喘息气促、痰壅等症。方中生麻黄辛温发散,配桂枝以散寒解表,合杏仁以宣肺平喘；细辛、半夏、瓜蒌温肺祛痰化饮,五味子敛降肺气而平喘；黄芩清肺热,以祛风寒痰饮郁结之热,桃仁、红花、地龙活血化瘀,宣通肺络以助涤痰,炙甘草调中以和诸药；全方共奏温肺化饮、祛瘀化痰、止咳平喘之功。李贵老师在临床治疗中反对抗生素的滥用。他依据中西医结合理论,运用中医辨证论治治疗儿科疾病,不仅解决了很多临床中单纯西医治疗解决不了的问题,弥补西医抗感染治疗的不足。在感染初期阶段针对表证初起,热毒炽盛之证,多单纯采用中药,以清热解毒之法为主治疗,不仅给大量没有明确抗生素适应证的患儿提供了一种合理有效的治疗方法,并且还可减少抗生素的用量并缩短抗生素使用时间。对小儿外感病所经常出现的纳呆食少、口臭、便秘等消化系统问题,以及病程迁延或反复发病,西医临床尚无很好的对症治疗方法等问题,李贵老师运用益气健脾、扶正祛邪的方法,以中药治疗,取得很好的疗效,解决了临床问题。李贵老师在小儿呼吸道感染中灵活运用活血化瘀治则,不同于传统中医的认识,此为李贵老师多年临床经验积累所得。运用活血化瘀治则治疗儿科疾病是对中医传统治则治法的发展,临床应用证实能显著提高疗效,尤其是对病变较为局限的病例,可以加快感染病灶的消散。李贵老师同时强调,在实际临床工作中,要根据病人的病情、年龄及合并症情况适当调整用药。更多还原

【Abstract】 1. Application of activating blood and resolving stasis to respiratory tract infections in the pediatric areaMethod of activating blood and resolving stasis had gradually formed and grown during the time the human being struggled with the disease for two thousand years, had developed and been innovated by experienced physicians in dynasties, and now had been widely used in different departments in clinic. To various pediatric diseases, especially to chronic, refractory and easily repeated diseases, the method could be applied boldly as long as the pathogenesis matched.2. Clinical study on treating pediatric bronchiolitis with method of warming lung, resolving stasis and relieving dyspneaThe author engaged in clinical study on treating pediatric bronchiolitis with method of warming lung, resolving stasis and relieving dyspnea on the basis of inheriting and concluding professor Li’s academic experience.Objective: To observe clinical effect of treating pediatric bronchiolitis with method of warming lung, to verify the safety and effectivity of Promoting Blood Circulation and Removing Blood Stasis in pediatrics, resolving stasis and relieving dyspnea, so as to find a better way to treat pediatric bronchiolitis by integration of Chinese and Western medicine to relieve the suffering of patients, and to prevent the incidence of asthma in infants and young children.Method: according to randomized parallel-group clinical study, selected patients were randomly divided into experimental group of 30 patients and a control group of 27 patients, with basic treatment of ambroxol, budesonide suspension, and compound aerosol ipratropium bromide. Experimental group, on the basis of basic treatment, took decoction of warming lung, resolving stasis and relieving dyspnea. Ribavirin injection and procaterol hydrochloride oral solution were used as comparison to the control group.Results:The results showed that there was no significant difference between experimental group and control group from the main symptoms and signs such as fever, cough, shortness of breath, phlegm, and cumulative scores change of main symptoms, indicating that there was no significant difference in therapeutic effect between Chinese medicine and Western medicine; while when it came to the change of cough, there was a significant difference between the two groups and the experimental group of Chinese medicine was significantly better than the control group of Western medicine.Conclusion: It was proved by the experiment that the therapeutic effect on acute pediatric bronchiolitis of the formula had almost no significant difference from western medicine generally, but as to improve some of the symptoms (such as cough), group of Chinese medicine was significantly better than the control group of western medicine. Thus we could say that the treatment of activating blood and resolving stasis mainly was effective to treat pediatric respiratory tract bronchitis, and showed the advantages of Chinese medicine.Acute pediatric bronchiolitis was a group of acute lower respiratory tract diseases, which was caused by a variety of pathogens. Common pathogens were viruses (respiratory syncytial virus, parainfluenza virus, adenovirus, etc.), bacteria, mycoplasma pneumoniae, etc. For these viruses, there had been no reliable, specific antiviral medicines available by now, so there was no specific treatment to this disease. Western medicine focuses on use of adrenal corticosteroids (inhaled or systemic), bronchial smooth muscle spasmolytic and expectorant cough medicine, while the therapeutic effect is not very satisfactory.WenFei Hua Yu Ding Chu an Fang (Formula of Warming Lung, Resolving Stasis and Relieving Dyspnea) was made by professor Li by reasonable use of theories of Chinese and Western medicine and was proven to be an effective prescription after long-term clinical practice, which was mainly for children with bronchiolitis, asthmatic bronchitis and bronchial pneumonia caused by exogenous wind and cold, and accompanied with signs such as fever, aversion to cold, cough, dyspnea, shortness of breath, and phlegm stagnation. In the formula, ma huang (Herba Ephedrae, ephedra herb) was pungent-warm with dispersing effect so as to dissipate cold and release exterior combining with gu i zh I (Ramulus Cinnamomi, cassia twig), and to ventilate lung and relieve dyspnea combining with xing ren (Semen Armeniacae Amarum, almond). Xixin (Radix et Rhizoma Asari, Manchurian wild ginger), ban xi a (Rhizoma Pinelliae, pinellia rhizome) and gua lou (Fructus Trichosanthis, snakegourd fruit) were used to warm lung, dispel phlegm and resolve fluid retention, w□w e i z□(Fructus Schisandrae Chinensis, Chinese magnolivine fruit) was used to relieve dyspnea by astringing and descending lung qi, hu a ng qin (Radix Scutellariae, scutellaria root) and qing d a i (Indigo Naturalis, natural indigo), with function of clearing lung heat, were used to clear stagnation heat due to wind, cold, phlegm and fluid retention, taoren (Semen Per sicae, peach seed) and hong hu a (Flos Carthami, Safflower) were used to activate blood and resolve stasis, and aid to clear up phlegm by dredging lung collaterals, zhi gan c□o (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle, prepared liquorice root) was used to moderates the actions of other herbs. All the medicines together had function of warming lung, resolving fluid retention, dispelling stasis, resolving phlegm, and relieving cough and dyspnea.Moreover, professor Li was against the overuse of antibiotics in the clinic. Based on theories of Chinese medicine and Western medicine, syndrome differentiation and treatment of TCM was applied. It not only solved a lot of clinical problems which couldn’ t be solved by Western medicine alone, but also was a good complementary to anti-infective therapy by Western medicine.In the early stages of infection, Chinese medicine, mainly for clearing heat and removing toxin, could be used merely to treat intense heat toxin syndrome at the beginning of exterior syndrome. It not only provided a reasonable and effective treatment to a large number of child patients with no clear indication of antibiotics, but reduced the use of antibiotics and shortened the period of treatment. When it came to the digestive problems such as poor appetite, anorexia, fetid mouth odor, constipation and so on commonly seen during external contraction disease in children, and to persistent or recurrent diseases, western medicine had no good method to treat, while Chinese medicine, those could replenish qi, invigorate spleen, reinforce healthy qi and eliminate pathogen, were used by professor Li and got good effect in order to solve clinical problems.The flexible application of activating blood and resolving stasis to pediatric respiratory tract infections was different from the traditional thought of TCM. It came from years of clinical experience of professor Li’s and was a development of traditional therapeutic principles and methods, which could significantly improve the clinical effect, especially to cases of more limited infection it could accelerate the dissipation of the lesion. Of course, in actual clinical work, medicines should be appropriately adjusted according to the patient’s condition, age and complications.更多还原