重症社区获得性肺炎患者病原体与证候关系研究

发布时间：2018-11-25 19:45

【摘要】：目的:1.分析重症社区获得性肺炎患者临床症状的证候分布特点及证候、病机演变特点。2.研究重症社区获得性肺炎病原体种类分布情况,探讨不同病原体与证候、病机演变之间的关系。方法:采用前瞻性研究方法,根据纳入与排除标准收录2016年12月1日至2017年2月28日入住北京中医药大学附属第一临床医学院ICU、中日友好医院呼吸与重症医学科ICU、首都医科大学附属朝阳医院呼吸与重症医学科ICU符合重症社区获得性肺炎中西医诊断标准的患者。记录入院一般情况、实验室检查、主要临床表现等内容;将内容填入调查表,建立原始数据库,运用SAS软件进行分析,归纳重症社区获得性肺炎患者的中医证候;观察不同种类病原体与证候的关系。结果:1.重症社区获得性肺炎证候演变规律:重症社区获得性肺炎入院证候以痰热壅肺证、痰湿阻肺证、热陷心包证为主。第7、14天证候以气阴两虚证、肺脾气虚证为主。痰热壅肺证主要转变为气阴两虚证,热陷心包证易转变为热毒入营证而成危候,或转变成痰热壅肺证转出气分向愈。痰湿阻肺证易转变成痰热壅肺证和肺脾气虚证。气阴两虚证可转变成为肺脾气虚证。2.重症社区获得性肺炎证候与病原体之间的关系:重症社区获得性肺炎以革兰阴性菌为主。常见致病菌为铜绿假单胞菌、鲍曼不动杆菌、肺炎克雷伯菌等。革兰阳性菌以肺炎链球菌、金黄色葡萄球菌为主;病毒、真菌和非典型致病菌也可感染发病。细菌、真菌、病毒、支原体与各观察点(入院第1天、第7天、第14天)SCAP证候分布之间存在相关性,革兰阳性菌和革兰阴性菌在各证候分布上未见明显差异。结论:1.重症社区获得性肺炎入ICU以里热证为主要表现,以邪热流连气分为主,可出现热毒入营血的危重证候。热邪留恋气分耗气伤津而见气阴两虚的表现。可见重症社区获得性肺炎核心病机符合风热毒邪乘体虚侵袭,肺卫受袭,宣降失常,肺卫热邪不解,则痰热瘀毒阻肺,伤气伤阴,甚至内陷营血,热陷心包,进一步阴竭阳脱而成死证。及早应用中药可防止病证进一步进展。2.细菌感染更易出现痰热壅肺气分证,真菌感染易出现痰热壅肺证和痰湿阻肺证,而病毒感染传变较快,易引起热陷心包、热毒入营血分的更危重证候。把握好气分关是预防危重症发生和降低死亡率的关键。
[Abstract]:Objective: 1. To analyze the characteristics of syndromes distribution and pathogenesis of severe community-acquired pneumonia. 2. To study the distribution of pathogens in severe community acquired pneumonia, and to explore the relationship between different pathogens, syndromes and pathogenesis. Methods: according to the criteria of inclusion and exclusion, ICU, was admitted to ICU, the first Clinical College affiliated to Beijing University of traditional Chinese Medicine, from December 1, 2016 to February 28, 2017, according to the criteria of inclusion and exclusion. ICU of Department of Respiratory and intensive Medicine of Chaoyang Hospital affiliated to Capital Medical University meets the diagnostic criteria of TCM and Western medicine for severe community-acquired pneumonia. The general condition of admission, laboratory examination and main clinical manifestations were recorded, the contents were filled in the questionnaire, the original database was established, and the SAS software was used to analyze the TCM syndromes of the patients with severe community-acquired pneumonia. To observe the relationship between different pathogens and syndromes. Results: 1. The syndromes of severe community-acquired pneumonia were characterized by phlegm-heat blockage, phlegm-dampness obstruction and pericardial heat. The 7 th day 14 th syndrome to qi-yin two-deficiency syndrome, lung-qi-deficiency syndrome. The syndrome of phlegm and heat obstructing the lung mainly changed into deficiency of qi and yin, and the syndrome of pericardium of heat trapping easily changed into heat toxin into camp syndrome and became dangerous, or turned into phlegm and heat stagnation of lung syndrome to turn out qi to recover. Phlegm dampness blocking lung syndrome is easy to change into phlegm heat obstruction lung syndrome and lung spleen qi deficiency syndrome. Qi and Yin deficiency syndrome can be transformed into lung and spleen qi deficiency syndrome. 2. The relationship between the syndromes and pathogens of severe community acquired pneumonia: Gram-negative bacteria were the main cause of severe community acquired pneumonia. Common pathogens are Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae and so on. Gram-positive bacteria are mainly Streptococcus pneumoniae and Staphylococcus aureus. Viruses, fungi and atypical pathogens can also be infected. There was a correlation between bacteria, fungi, virus, mycoplasma and the distribution of SCAP syndromes at the observation sites (1st, 7th, 14th day). There was no significant difference between Gram-positive bacteria and Gram-negative bacteria in the distribution of the syndromes. Conclusion: 1. The main manifestations of severe community-acquired pneumonia in ICU were heat syndrome, heat flow combined with qi, and serious syndrome of heat toxin entering camp blood. Heat evil nostalgia Qi points out qi injury and see Qi Yin deficiency performance. It can be seen that the core pathogenesis of severe community-acquired pneumonia is in accordance with the invasion of wind-heat toxin evil and deficiency of body, the attack on lung and Wei, the disorder of propaganda and lowering, the confusion of lung and heat evil, the phlegm and heat stasis toxin obstructing the lung, the injury of qi and the injury of yin, and even the depression of blood and heat in the pericardium. Further Yin exhausted Yang to become a death syndrome. Early application of traditional Chinese medicine can prevent further progress of disease and syndrome. 2. Bacterial infection is more likely to appear phlegm and heat obstruction of lung qi syndrome, fungal infection is prone to phlegm heat blockage lung syndrome and phlegm dampness block lung syndrome, while virus infection becomes faster, easily cause heat into the pericardium, heat into the blood of the more serious syndrome. It is the key to prevent the occurrence of critical illness and reduce the mortality.
【学位授予单位】：北京中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R259

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