武维屏教授治疗慢性咳嗽的学术思想与经验总结

【作者】 赵丹；

【导师】 冯淬灵；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2015， 硕士

【摘要】 咳嗽是指肺失宣降,肺气上逆,发出咳声,或咳吐痰液的一种肺系病症。它既是肺系疾病的一个主要的症状,又是具有独立性的一种疾患。在肺系的诸多疾病中,甚至在日常生活中,咳嗽无论作为症状还是独立的疾病都是很常见,影响着人们的生活和健康,因此开展对咳嗽文献的综合研究,对认识和治疗该疾病、确保生活质量,都具有重要的意义。本论文将通过文献综述及临床研究两个部分进行介绍。第一部分：文献研究综述。中医部分包括研究古代医家对于“久咳”、“久嗽”的认识,着重论述“五脏六腑皆令人咳”的学术观点；现代医家在继承前人“久咳”、“久嗽”的研究基础上各有发挥,包括病名讨论、病因病机、分证及治疗等,通过对各医家对慢性咳嗽的辨病辨证、治疗经验等的认识,体现中医治疗慢性咳嗽的优势。西医部分包括现代西医学对慢性咳嗽的病因及发病机制、诊断标准与治疗方面对慢性咳嗽的认识,目前西医对慢性咳嗽发病的内在因素已有一定认识,可为进一步有效治疗慢性咳嗽提供帮助。第二部分：临床回顾性研究。研究背景：慢性咳嗽通常是指病程时间超过8周的咳嗽。临床上胸部X线片无明显异常的慢性咳嗽很常见,致病原因众多,诊治较困难。临床上中医药对慢性咳嗽的治疗具有独特的效果,而现代名老中医的临床经验代表着当代中医学术发展的最高水平,符合现代中医治疗慢性咳嗽的证治规律,对于名老中医经验的总结与继承显得至关重要。目前临床多数名老中医研究是以临床验案论述研究为主,与数理统计结合不够紧密,未能充分在名老中医经验的总结中利用数理统计工具进行数据挖掘,缺乏科学、系统的论证,对慢性咳嗽的经验性数据调查式研究,从中总结出名老中医对慢性咳嗽的证治经验分布的一般规律、对于指导临床的辩证论治是一项必要的研究。研究目的：归纳总结武维屏教授临床慢性咳嗽治疗的经验,从描述性统计学角度对武维屏教授关于本病的认识进行分析并探讨其辩证思路及方药规律,通过对统计结果的讨论分析,总结武维屏教授论治经验。方法：记录武维屏教授东直门医院特需门诊85例慢性咳嗽病例,详细记录患者首诊时疾病诱因、病史、症状、体征,有条件者录入实验室检查(血气分析或Sp02、肺功能、肺部CT),记录临床治疗理法方药。依据主要症状咳嗽痊愈、好转及未愈的评价标准,复诊病例进行疗效统计。用Epidata建立慢性咳嗽患者数据库,应用统计软件SPSS 20.0对辨证与用药的关联性进行聚类分析。结果：1.85例患者中男性29例,占34.1%；女性56例,占65.9%,病程持续1年以上者47人,对比患者的性别、病程存在差异,(P<0.05)统计学有意义。2.根据统计,咳嗽程度中等患者较多,咳嗽程度较重的患者次之,咳嗽轻者最少。其中咳嗽伴咳痰的占81.18%,干咳无痰占18.82%。3.伴咳痰的患者咯痰粘(57.65%)、色白(51.76%)、量少(57.65%)为主,另外存在咳痰黄(23.52%)及黄白相间(5.88%)、质清稀(14.12%)或泡沫痰(9.41%)、痰量多(30.58%)。大部分患者痰粘难咯出,占63.53%。4.全身伴随症状分别是口干欲饮、眠差、咽痒、气短、胸闷、心烦易怒、乏力、大便干、畏寒、手脚心热。舌脉象以舌胖暗,中有裂,苔黄腻为主,脉象以滑、弦、细者居多。3.临床证型分布：痰湿蕴肺>痰热内蕴>燥邪犯肺>肝火犯肺>气阴两虚>肺气亏虚,存在肺阴亏虚、虚风内伏、风寒犯肺及风邪外束证,因数据量小,统计意义不大。复合证型最常见的(n>5)分别为痰湿内蕴与肝郁气滞证、痰热内蕴合风邪外束证、虚风内伏合风邪外束或燥邪犯肺合肺阴亏虚证组合,单证出现频率低。4.方药：临床统计常用药为柴胡、前胡、杏仁、黄芩、清半夏、防风、赤芍、炒枳壳、桑叶、炙麻黄、川贝、乌梅、甘草、浙贝母、连翘、厚朴、五味子、石膏、钩藤、炒薏苡仁。频率>10%的常用方剂分别是：小柴胡、止嗽散、柴朴二三汤、玉屏风散、清燥救肺汤、桑杏汤、蒌芩止嗽煎。5.根据统计结果分析,痰湿蕴肺证主要用方为二陈汤,兼夹肝郁气滞证、气逆而咳时加厚朴、苏子等药物。痰热内蕴证主要用方为蒌芩止嗽煎,燥邪犯肺偏风温者用桑杏汤,兼气阴两虚主方为清燥救肺汤,肺气亏虚证用玉屏风散,气阴两虚证用生脉饮,肝火犯肺证用泻白散,肺阴亏虚证用沙参麦冬汤滋阴,虚风内伏证主要用过敏煎,风寒犯肺证用三拗汤,风邪外束证用止嗽散。6.最后疗效：复诊病人占85.88%,其中咳嗽症状痊愈者占46.58%,明显好转者占51.35%,未愈者占1.18%。咳嗽治疗疗效最佳的证型为风邪外束证、燥邪犯肺证及风寒犯肺证,其次是肝火犯肺证、痰湿蕴肺、痰热内蕴、肺阴亏虚、虚风内伏及肺气亏虚证及痰浊内阻证,最末为气阴两虚证。结论：武维屏教授认为,慢性咳嗽多反复发作,病势缠绵,临床治疗难以速效,临床治疗,灵活运用治咳四法,即：“从风论治,肝肺同调,祛风为要”,“从痰论治,肺脾同理,运化为本”,“从气论治,肺肝胃同治,和降为先”及“从虚论治,肺脾肾同养,气血阴阳有别”；临床用药平补缓调,根据标本缓急进行施治。除治疗外,需配合生活起居的调适,注意气候季节变化,心情畅达,适当进行锻炼以增强体质,正气存内,邪不可干,使患者在提高机体抗病能力的基础上,达到根治的目的。更多还原

【Abstract】 Cough is refer to the lung of gas upward reversal, with Lung function disorder, occured cough, or a liquid cough spit lung disease. It is not only a major symptom of pulmonary disease, but also a disease of independence.In many diseases of the lung, even in daily life, cough both as a disease Symptoms or independent are very common, affecting people’s life and health, so carry on comprehensive study of cough literature, on the understanding and treatment of the disease, to ensure that quality of life has important significance.This paper will introduce two parts through literature review and clinical research.The first part, literature research were reviewed. Traditional Chinese Medcine part includes the study of ancient physicians for chronic cough or long cough, focuses on "all the organs can cause cough" academic point of view; modern physicians in inherits the predecessor " chronic cough "based on the study of the play, including the name of the disease discussion,etiology and pathogenesis, syndrome and treatment, according to the doctors of chronic cough resolution disease diagnosis and treatment experience of understanding, manifests the Chinese medicine treatment of chronic cough advantage. Some western modern western medicine to chronic cough etiology and pathogenesis, standard of diagnosis and treatment for the understanding of chronic cough, at present western medicine to chronic cough onset of internal factors have certain understanding, can provid more positive effect on further treatment of chronic cough.The second part:clinical retrospective study. Background:chronic cough usually refers to the last of time for more than 8 weeks of cough. There are no obvious significant abnormal chronic cough in clinical chest X ray film, and it is difficult to diagnosis and treatment.C linical medicine of doctor of traditional Chinese medicine on the treatment of chronic cough with unique effect, and the clinical experiences of the famous old doctor of traditional Chinese medicine represents the highest level of contemporary Chinese academic development, conforms to the modern Chinese medicine treatment of chronic cough syndrome rule for inheritance and summarize the experience of the famous old doctor of traditional Chinese medicine is very important. The clinical most name old doctor of traditional Chinese medicine research is in clinical test case and discusses the research, and mathematical statistics with close enough, failed to fully in the summary of the experience of the famous old doctor of traditional Chinese medicine using statistical tools for data mining, lack of scientific and systematic demonstration, of chronic cough experience data of survey research and the summary of famous old doctor of traditional Chinese medicine on chronic cough syndrome and treatment experience distribution rule, to guide the clinical dialectical theory of governance is a necessary research.Objective:the purpose of this study is to summarized Professor Weiping Wu clinical chronic cough treatment experience, from the perspective of descriptive statistics of Professor Weiping Wu knowledge about the disease analysis and to explore the dialectical way of thinking and drug laws, through the analysis and discussion of the statistical results, sum up the different experience of professor Weiping Wu on the treatment.Methods:the records of Weiping Wu, Dongzhimen Hospital VIP Clinic in 85 cases of chronic cough cases, detailed records of patients with first diagnosis of disease inducement, medical history, symptoms, conditions into the laboratory examination (blood gas analysis or SpO2. lung function, lung CT), recorded clinical treatment method of medicine. According to the main symptoms of cough cured, improved and healed evaluation criteria, referral cases curative effect statistics. Using Epidata to establish the database of chronic cough patients,meanwhile,by the application of statistical software SPSS 20 for the dialectical and the relevance of the use of the clustering analysis.Results:1.Account for 85 of the patients,cluding 34.1% men and 65.9% women,in which the lasting of the disease over 1 years about 47, the differences comparing the patient’s gender are statistically meaningful.2 According to the statistics, more patients with moderate cough, cough severity in patients with serious times, at least mild cough. The cough with expectoration and cough without sputum accounted for 81.18%, another for 18.82%.3. With expectoration of most patients with sputum viscosity (57.65%), white (51.76%), less (57.65%), there is another expectoration yellow (23.52%) and yellow and white (5.88%), quality Qingxi (14.12%) and frothy sputum (9.41%), sputum amount more than 30.58%. The majority of patients with sputum difficult to sputum, accounting for 63.53%. Basic body accompanying symptoms are thirsty, poor sleep, pharyngeal itching, shortness of breath, chest tightness, irritability, fatigue, dry stool, chills, hands and feet are heavily heat. Tongue is fat in dark, cracked, yellow greasy moss, pulse string to slip, and fine.3 the clinical syndrome type distribution:phlegm obstructing lung> phlegm heat intrinsic> dryness invading the lung> anger make lung> deficiency of both qi and Yin> lung qi deficiency, lung deficiency of yin deficiency, virtual wind volts, cold make lung and pathogenic wind outside the beam card, because a small amount of data, statistical significance was not. Composite syndromes most common (n>5) respectively for phlegm dampness and stagnation of liver qi stagnation, accumulation of phlegm and heat intrinsic pathogenic wind outside the beam card, virtual wind spathogenic wind beam or dryness invading the lung combined lung yin deficiency syndrome combination, the documents appear low frequency.4. Prescription:clinical statistics commonly used drugs for bupleurum root, Peucedanum root, almond, Radix Scutellariae, Qing pinellia tuber, Radix Saposhnikoviae, radix paeoniae rubra, fried Fructus aurantii. mulberry leaf Ephedra Sinica, Chuanbei, plum, licorice, Bulbus Fritillariae thunbergii. forsythia. Magnolia, Schisandra, gypsum, uncaria, coix lacryma jobI. Frequency than the commonly used formula are:Xiaochaihu, Zhisou scattered, bupleurum and Magnolia 23 soup, Yupingfeng powder, qingzhaojiufei decoction, sang Xingtang, louqinzhisou fried.5. According to the statistical results, tanshiyunfei syndrome mainly with Erchen decoction, and clamping stagnation of liver qi stagnation syndrome, inverse gas and cough with magnolia, Suzi, and other drugs. Phlegm heat intrinsic card is mainly used Weilou Qin stop cough fried, dryness invading lung partial air temperature who sang Xing Tang, deficiency of both qi and Yin and Qingzao save Decoction; pulmonary, lung qi deficiency syndrome with Yupingfeng San, Qi and yin deficiency syndrome with Shengmai Decoction and syndrome of liver fire invading lung with Xiebai San Lung Yin deficiency syndrome with Shashen Maidong Decoction of Nourishing Yin, virtual wind within the card mainly used allergy fried, wind cold invading the lung syndrome using Sanao decoction, external wind evil beam card.Conclusion:In Professor Weiping Wu’s oppion,chronic cough has recurrently attacks,which is a lingering illness, clinical treatment is available.During clinical treatment, flexibility in the use of four methods of treating cough, namely:"from the wind on the treatment, liver and lung homology, expelling wind to"," from phlegm on the treatment, lung and spleen similarly "," treatment based on the gas, lung liver and stomach treatment together, and falling for gas is the first "and" from deficiency on the treatment, lung, spleen and kidney with raises,can not ignord Qi, blood, yin and Yang "; clinical medication nourishing slow tune, according to samples priorities and treatment. In addition to the treatment, with the adjustment of daily life, pay attention to weather changes, mood unobstructed, proper exercise to enhance physical fitness, keep healthy, evil can not be dry, make the patient to the foundation to improve the ability of the body resistance, to effect a radical cure purpose.更多还原