韩明向运用温法辨治慢性咳喘的学术思想及经验研究

发布时间：2018-07-04 18:18

本文选题：老中医药专家 + 学术经验　；参考：《南京中医药大学》2016年博士论文

【摘要】：目的：系统总结国家级名老中医韩明向教授运用温法辨治慢性咳喘的临证诊疗经验及学术思想,培养临证辨治能力,融会贯通,继承发扬,丰富慢性咳喘的中医药治疗学内容,探索名医临床经验传承的新方法和新模式。方法：通过跟师侍诊学习,记录并整理导师运用温法治疗慢性咳喘的临证医案。通过对234例慢性咳喘患者病案整理,观察就诊患者性别、年龄分布情况、初诊证型分布规律。应用安徽中医药大学第一附属医院自主研发的名老中医学术经验数字化平台,采集患者辨证施治的相关信息,建立“韩明向名医工作室病例采集数据库”,规范化处理后分析各患者中药使用频次、各证型用药规律,提炼核心处方。临床研究选取60例就诊于安徽中医药大学第一附属医院呼吸科辨证属痰湿蕴肺证慢性阻塞性肺疾病急性加重期患者,采用随机数字表法将患者随机分为治疗组30例,对照组30例。两组均给予抗感染、解痉平喘、必要时机械通气等基础治疗。对照组在基础治疗的同时加用沐舒坦针剂,每次30mg静脉注射或静滴,每日2次；治疗组在基础治疗同时加用韩明向教授经验方四子温肺汤,临证加减。10d为1个疗程。观察患者治疗前后咳嗽、咳痰、气喘等症状总积分的变化,肺功能的变化,血中性粒细胞弹性蛋白酶(NE)、表皮生长因子受体(EGFR)、白介素-17A(IL-17A)、缺氧诱导因子-1 α (HIF-1 α)水平的变化,进行疗效比较。结果：韩明向教授认为慢性咳喘多见于现代医学的支气管哮喘、慢性阻塞性肺疾病等慢性气道炎症性疾病,多病程较长,易反复发作,迁延难愈。痰饮是其形成的病理因素,总属阳虚阴盛,本虚标实之候。肺系咳喘疾病多在冬春寒冷季节感寒易发,是由于肺为娇脏,喜温而恶寒,形寒饮冷多伤肺,且肺开窍于鼻,外合皮毛,外邪常先犯肺。素体阳虚复感外邪,痰饮阻于气道,肺气不降而见咳喘诸症。然饮为阴邪,得温则行,遇寒则凝。韩明向教授尊古而不泥古,在咳喘病治疗时,不仅应用温阳化饮,且根据病证,或以辛温散寒宣肺,或以温阳祛瘀,或以甘温补肺健脾益肾。且韩教授认为支气管哮喘、慢性阻塞性肺疾病等慢性气道炎症性疾病急性发作并非全因感染,与过敏变态反应,寒冷刺激等因素密切相关,临证辨证运用温法疗效尤佳。采用温法辨治慢性咳喘,阳气充足则推动温煦作用复常,痰饮可除,喘咳自平。韩教授指出慢性咳喘患者临证辨治要紧扣寒热、虚实,结合病位,注意咳喘兼症。鉴于痰饮与慢性咳喘发病密切相关,根据其病理特点,疾病发展的不同阶段,肺脾肾病位的演变,基于肺喜温而恶寒的理论,宗病痰饮者当以温药和之,提出以温辨治四法：一为温肺散寒,解表蠲饮。慢性咳喘易反复发作,常因外感诱发,尤以感寒居多,外寒每易引动内饮而见咳喘发作。治疗上既要辛温外散风寒,又要温阳内蠲痰饮。韩教授临证喜用射干麻黄汤、小青龙汤等古方。二为温脾益气,培土生金。“脾为生痰之源,肺为贮痰之器”,痰饮总属阳虚阴盛,重在温化,且脾为湿土,赖阳气以健运；慢性咳喘临证治疗不能单纯从肺论治,须兼顾温脾益气,从而培土生金,以杜生痰之源,常选黄芪建中汤、二陈汤、苓桂术甘汤、六君子汤加减。三为温肾化饮,纳气平喘。肾阳亏虚是导致慢性咳喘的主要病因之一。肺为水之上源,主通调水道,然“肾者主水,受五脏六腑之精而藏之”,久病穷必及肾,肺失宣降,通调失职,必及于肾,气化关门失司,水泛为肿为喘为悸,咳逆倚息不得平卧。治疗上着重温肾化饮,纳气平喘。临证韩教授喜用金匮肾气丸、真武汤、补肺汤化裁。四为温阳行瘀,化痰逐饮。肺朝百脉而主治节,治理调节心血运行,现肺虚,“心主营运”过劳,心气、心阳衰惫,无力推动血脉,则血行瘀滞。初病多痰,久病必瘀,痰瘀俱为阴邪,可进一步损伤气阳。气阳虚弱,痰瘀易生,痰瘀既生,更伤阳气,血得寒则凝,得温则行,气阳虚弱,不能温煦血脉,血运不利,则瘀血内阻,血瘀水停则咳喘难平。治疗上喜用温阳行瘀,化痰逐饮之法治疗,多用阳和汤、桃红四物汤、葶苈大枣泻肺汤等化裁。韩教授认为慢性咳喘病位虽涉及五脏,但主要病位在肺。肺主宣发肃降,主气司呼吸,若肺的升降功能失常,肺气上逆则见咳喘诸症,故临证根据肺的生理功能结合病机特点,提出慢性咳喘的治肺七法：宣肺、肃肺、温肺、清肺、润肺、敛肺、补肺。韩教授提出临证治疗慢性咳喘,从温辨治,要紧扣寒证“冷、淡、清、稀、青、白”的证候特点,综合应用温宣、温散、温补、温化之法。采集234例(男性98例,女性136例)慢性咳喘患者数据经规范化处理,其中0-40岁,77例,占总人数32.46%；41-60,74例,占总人数32.13%；61-75,70例,占总人数29.51%；75岁以上,13例,占总人数5.9%。就诊的慢性咳喘患者中风寒袭肺证、痰湿蕴肺证、肺肾两虚证三种证候所占人数居前三位,风寒袭肺证占27%,痰湿蕴肺证占25%,肺肾两虚证占21%,核心处方为射干、麻黄、杏仁、紫菀、冬花、陈皮、前胡、白前、茯苓、百部、五味子。中药使用频次排名前十分别为：陈皮192、茯苓189、紫菀174、冬花172、杏仁151、甘草144、百部142、麻黄132、五味子129、黄芪119。药物配对频数分布前十位分别为：陈皮,茯苓,相关系数23.60828；冬花,杏仁,相关系数20.36355；紫苑,杏仁,相关系数19.369；紫菀,百部,相关系数18.24397；杏仁,麻黄,相关系数17.92094；冬花,麻黄,相关系数16.94005；冬花,百部,相关系数16.80149；紫菀,麻黄,相关系数16.69092；五味子,射干,相关系数15.4311；白前,百部,相关系数15.4311。治疗总以温肺化痰,降气平喘为要。临床研究观察四子温肺汤加减治疗痰湿蕴肺证慢性阻塞性肺疾病急性加重期患者,结果发现对照组总有效率为76.67%,而治疗组总有效率为93.33%,治疗组优于对照组(P0.05)。两组证候积分治疗前症状无差异(P0.05),两组治疗后症状较治疗前明显改善(P0.01)。治疗组咳嗽、咯痰、喘息较对照组无差异(P0.05),但纳呆、脘腹胀满、气短、口中粘腻好转(P0.05,P0.01)。肺功能治疗前后两组均无差异(P0.05)。治疗组和对照组治疗后血NE、EGFR、IL-17A、HIF-1α的水平均有下降,其中IL-17A、 HIF-1α水平与对照组比较差异有统计学意义(P0.05)。结论：韩明向教授基于肺喜温而恶寒的理论,采用温法辨治慢性咳喘,数据挖掘分析结果符合和体现韩教授从温辨治慢性咳喘的学术思想和临证经验。临床研究发现四子温肺汤和沐舒坦针剂均有助于改善慢性阻塞性肺疾病急性加重期痰湿蕴肺证患者的临床症状,在纳差、腹胀脘痞等症状改善方面四子温肺汤有独到的优势。四子温肺汤通过调节血HE、EGFR、IL-17A、HIF-1α的表达,有效改善慢性阻塞性肺疾病患者的气道炎症和粘液高分泌,从温论治慢性咳喘疗效确切。
[Abstract]:Objective: to systematically summarize the experience of diagnosis and treatment of chronic cough and asthma by Professor Han Ming, a national famous traditional Chinese medicine, to cultivate the clinical experience and academic thoughts of chronic cough and asthma, to cultivate the ability of differentiation and treatment, to inherit and carry forward, to enrich the medical treatment of chronic cough and asthma, and to explore new methods and new models for the inheritance of clinical experience of famous doctors. 234 cases of chronic cough and asthma were arranged to observe the sex, age distribution of the patients and the distribution law of the first diagnosis. The application of the digital platform of the academic experience of famous old Chinese medicine, which was developed by the First Affiliated Hospital of Anhui University of traditional Chinese medicine, was applied. Set up the related information of the patients with syndrome differentiation and treatment, set up "Han Ming's case collection database to the famous medical studio", analyze the frequency of the use of traditional Chinese medicine, and extract the core prescription after standardized treatment, and select 60 cases in the Department of respiration, the First Affiliated Hospital of Anhui University of traditional Chinese medicine, which belong to the chronic syndrome of phlegm damp accumulation syndrome in the Department of respiration. Patients with acute exacerbation of obstructive pulmonary disease were randomly divided into 30 cases in the treatment group and 30 in the control group. The two groups were all given anti infection, antispasmodic and antiasthmatic and necessary mechanical ventilation when necessary. The control group was treated with Mucosolvan injection at the same time as the basic treatment, each time 30mg intravenous injection or intravenous drip, 2 times a day; the treatment group. At the same time, the basic treatment was combined with Han Ming four Zi Wen lung soup, and the treatment and reduction of.10d was 1 courses. The changes of total scores of cough, expectoration, asthma and other symptoms before and after treatment, changes in lung function, blood neutrophilic granulocyte elastase (NE), epidermal growth factor receptor (EGFR), interleukin -17A (IL-17A), hypoxia inducible factor -1 Results: the changes in the level of alpha (HIF-1 alpha) were compared. Results: Professor Han Ming Xiang believed that chronic cough and asthma were mostly seen in the bronchial asthma in modern medicine, chronic obstructive pulmonary disease, chronic obstructive pulmonary disease and other chronic airway inflammatory diseases. Lung system cough and asthma disease mostly in winter and spring cold season, cold and easy to hair, is due to the lungs for the dirty, warm and cold, cold drink cold and many injuries lung, and lung opening on the nose, outside the fur, external evil often first offense lung. Vegetarian body Yang deficiency and exogenous pathogenic, sputum blocking the airway, Lung Qi not to see cough and asthma disease. But drink is Yin evil, Wen Zehang, in cold is a coagulant. Han Ming direction to teach In the treatment of antitoughing and asthma, it is not only used in the treatment of cough and asthma, but also according to the syndrome of warm yang, or the dispersing of the lungs with Xinwen, or by Warming Yang and removing blood stasis, or using the spleen to invigorate the spleen and invigorate the kidney. And Professor Han thinks that the acute attack of chronic airway inflammation, such as bronchial asthma and chronic obstructive pulmonary disease, is not all caused by infection, and allergic reaction to allergy. There is a close correlation between the cold stimulation and other factors. The treatment of chronic cough and asthma is treated with warm method. The Yang Qi is sufficient to promote the warming effect, the phlegm can be removed and asthma is self leveled. The pathogenesis is closely related, according to its pathological characteristics, the different stages of the development of the disease, the evolution of the position of the spleen and kidney of the lung, based on the theory of warm and cold in the lung, the sect of the phlegm and phlegm should be treated with warm medicine and the four methods: one is the cold of the lung and the relieving of the table, and the chronic cough and asthma are prone to relapse. In the treatment of the treatment, we should not only make a cough and asthma attack, but also warm yang in the treatment of asthma. The treatment of chronic cough and asthma can not be treated only from the lung theory, so it is necessary to give consideration to warming the spleen and Invigorating Qi, so as to raise the earth's gold, take the source of Du Sheng's phlegm, choose the decoction of Huangqi Jianzhong, two Chen Tang, Luli Gump soup, Six Gentlemen soup, three is the warm kidney yin, and the kidney yang deficiency is one of the main causes of the chronic cough and asthma. Tao, "the kidney is the main water, the essence of the five viscera and six organs of the essence of the hidden", a long illness and the kidney, lung lost propaganda and loss, the transfer of duty, must be in the kidneys, vaporization shut the door lost, the water is swollen for palpitations, cough and rest can not lie flat. Blood stasis, phlegm to drink. The lung toward 100 pulse and main treatment Festival, regulating heart blood operation, lung deficiency, "heart operation" overwork, heart qi, heart Yang decay, blood stasis, blood stasis stagnation. First disease, phlegm and blood stasis, phlegm and stasis is Yin evil, can further damage Qi Yang. Qi Yang weakness, phlegm and stasis not only birth, but also hurt Yang Qi, blood cold, but also the phlegm and blood stasis, more hurt Yang Qi, blood cold is also Coagulation, Wen Zehang, Qi Yang weakness, can not warm blood, blood transportation is unfavorable, blood stasis, blood stasis water stop, cough and asthma difficult to flat. Treatment to use warm yang, blood stasis, phlegm by drink method treatment, more use Yanghe soup, peach red four matter soup, Yuli zizzao diarrhea lung soup, etc., Professor Han recognized as chronic cough and asthma, although it involved five organs, but the main disease position in lung. Lung main main disease. If the function of the lung is abnormal, the lung qi is abnormal and the lung qi is reversed, we can see the cough and asthma, so the lung, the lung, the lung, the lung, the lung, the lung, and the lung are put forward according to the physiological function of the lung and the characteristics of the pathogenesis of the lung. The syndrome characteristics of light, clear, thin, green, white, comprehensive application of the method of warming, warming up, warming up and warming. The data of 234 cases (male 98 cases, female 136 cases) were normalized, 0-40 years old and 77 cases, accounting for 32.46% of the total number; 41-60,74 cases, accounting for 32.13%; 61-75,70 cases, accounting for 29.51%; more than 75 years old and 13 cases, accounting for total. The number of chronic cough and asthma patients with chronic cough and asthma was 5.9%.. The number of three syndromes in the syndrome of phlegm damp accumulation and two deficiency syndrome of lung and kidney was the top three, the wind cold and the lung syndrome accounted for 27%, the phlegm and the lung syndrome accounted for 25%, the two deficiency of the lung and kidney accounted for 21%, the core prescription was the shoot dry, ephedra, almond, aster, winter flower, Chen peel, front Hu, white before, Fuling, 100, Schisandra. Use of Chinese medicine. The first ten of the frequency ranking were 192, 189, 174, 174, 172, 151, 144, 142, 132, and 129, and 129, respectively: Chen, tuckahoe, coefficient 23.60828; winter flower, almond, correlation coefficient; aster, almond, correlation coefficient; aster, 100 Department, the correlation coefficient 18.24397; almond, ephedra, correlation coefficient 17.92094; winter flower, ephedra, correlation coefficient 16.94005; winter flower, 100, correlation coefficient 16.80149; aster, ephedra, correlation coefficient 16.69092; Schisandra chinensis, shoot dry, correlation coefficient 15.4311; white before, 100, correlation coefficient 15.4311. treatment, asthma and asthmatic antiasthmatic. The total effective rate in the control group was 76.67%, the total effective rate of the control group was 93.33%, the treatment group was 93.33%, and the treatment group was superior to the control group (P0.05). The symptoms of the two groups were no difference before the treatment (P0.05). The two groups after treatment were more obvious than before the treatment. Improvement (P0.01). There was no difference in coughing, phlegm and wheezing in the treatment group compared with the control group (P0.05), but there was no difference between the two groups before and after the treatment of lung function (P0.05). The level of NE, EGFR, IL-17A and HIF-1 alpha in the treatment group and the control group decreased, and IL-17A, HIF-1 alpha level and the control group were decreased. The difference has statistical significance (P0.05). Conclusion: Han Ming is based on the theory of fever and chill of the lung by Professor Han Ming, using the temperature method to distinguish chronic cough and asthma. The result of data mining analysis accords with and embodies Professor Han's academic thought and experience in treating chronic cough and asthma from temperature. The clinical research is helpful to the improvement of four sons of warm lung soup and Mucosolvan. The clinical symptoms of the patients with phlegm dampness syndrome in the acute exacerbation of chronic obstructive pulmonary disease, the four Zi Wen lung soup has a unique advantage in the improvement of the symptoms of NDA, abdominal distention and epigastric ruffia. The expression of the four Zi Wen lung soup can effectively improve the airway inflammation and mucus hypersecretion by regulating the blood HE, EGFR, IL-17A and HIF-1, from the temperature of the patients with chronic obstructive pulmonary disease. The curative effect of treating chronic cough and asthma is definite.
【学位授予单位】：南京中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R259;R249

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