本文選題：老中醫(yī)藥專家 + 學術經(jīng)驗　； 參考：《南京中醫(yī)藥大學》2016年博士論文

【摘要】：目的：系統(tǒng)總結國家級名老中醫(yī)韓明向教授運用溫法辨治慢性咳喘的臨證診療經(jīng)驗及學術思想,培養(yǎng)臨證辨治能力,融會貫通,繼承發(fā)揚,豐富慢性咳喘的中醫(yī)藥治療學內容,探索名醫(yī)臨床經(jīng)驗傳承的新方法和新模式。方法：通過跟師侍診學習,記錄并整理導師運用溫法治療慢性咳喘的臨證醫(yī)案。通過對234例慢性咳喘患者病案整理,觀察就診患者性別、年齡分布情況、初診證型分布規(guī)律。應用安徽中醫(yī)藥大學第一附屬醫(yī)院自主研發(fā)的名老中醫(yī)學術經(jīng)驗數(shù)字化平臺,采集患者辨證施治的相關信息,建立“韓明向名醫(yī)工作室病例采集數(shù)據(jù)庫”,規(guī)范化處理后分析各患者中藥使用頻次、各證型用藥規(guī)律,提煉核心處方。臨床研究選取60例就診于安徽中醫(yī)藥大學第一附屬醫(yī)院呼吸科辨證屬痰濕蘊肺證慢性阻塞性肺疾病急性加重期患者,采用隨機數(shù)字表法將患者隨機分為治療組30例,對照組30例。兩組均給予抗感染、解痙平喘、必要時機械通氣等基礎治療。對照組在基礎治療的同時加用沐舒坦針劑,每次30mg靜脈注射或靜滴,每日2次；治療組在基礎治療同時加用韓明向教授經(jīng)驗方四子溫肺湯,臨證加減。10d為1個療程。觀察患者治療前后咳嗽、咳痰、氣喘等癥狀總積分的變化,肺功能的變化,血中性粒細胞彈性蛋白酶(NE)、表皮生長因子受體(EGFR)、白介素-17A(IL-17A)、缺氧誘導因子-1 α (HIF-1 α)水平的變化,進行療效比較。結果：韓明向教授認為慢性咳喘多見于現(xiàn)代醫(yī)學的支氣管哮喘、慢性阻塞性肺疾病等慢性氣道炎癥性疾病,多病程較長,易反復發(fā)作,遷延難愈。痰飲是其形成的病理因素,總屬陽虛陰盛,本虛標實之候。肺系咳喘疾病多在冬春寒冷季節(jié)感寒易發(fā),是由于肺為嬌臟,喜溫而惡寒,形寒飲冷多傷肺,且肺開竅于鼻,外合皮毛,外邪常先犯肺。素體陽虛復感外邪,痰飲阻于氣道,肺氣不降而見咳喘諸癥。然飲為陰邪,得溫則行,遇寒則凝。韓明向教授尊古而不泥古,在咳喘病治療時,不僅應用溫陽化飲,且根據(jù)病證,或以辛溫散寒宣肺,或以溫陽祛瘀,或以甘溫補肺健脾益腎。且韓教授認為支氣管哮喘、慢性阻塞性肺疾病等慢性氣道炎癥性疾病急性發(fā)作并非全因感染,與過敏變態(tài)反應,寒冷刺激等因素密切相關,臨證辨證運用溫法療效尤佳。采用溫法辨治慢性咳喘,陽氣充足則推動溫煦作用復常,痰飲可除,喘咳自平。韓教授指出慢性咳喘患者臨證辨治要緊扣寒熱、虛實,結合病位,注意咳喘兼癥。鑒于痰飲與慢性咳喘發(fā)病密切相關,根據(jù)其病理特點,疾病發(fā)展的不同階段,肺脾腎病位的演變,基于肺喜溫而惡寒的理論,宗病痰飲者當以溫藥和之,提出以溫辨治四法：一為溫肺散寒,解表蠲飲。慢性咳喘易反復發(fā)作,常因外感誘發(fā),尤以感寒居多,外寒每易引動內飲而見咳喘發(fā)作。治療上既要辛溫外散風寒,又要溫陽內蠲痰飲。韓教授臨證喜用射干麻黃湯、小青龍湯等古方。二為溫脾益氣,培土生金。“脾為生痰之源,肺為貯痰之器”,痰飲總屬陽虛陰盛,重在溫化,且脾為濕土,賴陽氣以健運；慢性咳喘臨證治療不能單純從肺論治,須兼顧溫脾益氣,從而培土生金,以杜生痰之源,常選黃芪建中湯、二陳湯、苓桂術甘湯、六君子湯加減。三為溫腎化飲,納氣平喘。腎陽虧虛是導致慢性咳喘的主要病因之一。肺為水之上源,主通調水道,然“腎者主水,受五臟六腑之精而藏之”,久病窮必及腎,肺失宣降,通調失職,必及于腎,氣化關門失司,水泛為腫為喘為悸,咳逆倚息不得平臥。治療上著重溫腎化飲,納氣平喘。臨證韓教授喜用金匱腎氣丸、真武湯、補肺湯化裁。四為溫陽行瘀,化痰逐飲。肺朝百脈而主治節(jié),治理調節(jié)心血運行,現(xiàn)肺虛,“心主營運”過勞,心氣、心陽衰憊,無力推動血脈,則血行瘀滯。初病多痰,久病必瘀,痰瘀俱為陰邪,可進一步損傷氣陽。氣陽虛弱,痰瘀易生,痰瘀既生,更傷陽氣,血得寒則凝,得溫則行,氣陽虛弱,不能溫煦血脈,血運不利,則瘀血內阻,血瘀水停則咳喘難平。治療上喜用溫陽行瘀,化痰逐飲之法治療,多用陽和湯、桃紅四物湯、葶藶大棗瀉肺湯等化裁。韓教授認為慢性咳喘病位雖涉及五臟,但主要病位在肺。肺主宣發(fā)肅降,主氣司呼吸,若肺的升降功能失常,肺氣上逆則見咳喘諸癥,故臨證根據(jù)肺的生理功能結合病機特點,提出慢性咳喘的治肺七法：宣肺、肅肺、溫肺、清肺、潤肺、斂肺、補肺。韓教授提出臨證治療慢性咳喘,從溫辨治,要緊扣寒證“冷、淡、清、稀、青、白”的證候特點,綜合應用溫宣、溫散、溫補、溫化之法。采集234例(男性98例,女性136例)慢性咳喘患者數(shù)據(jù)經(jīng)規(guī)范化處理,其中0-40歲,77例,占總人數(shù)32.46%；41-60,74例,占總人數(shù)32.13%；61-75,70例,占總人數(shù)29.51%；75歲以上,13例,占總人數(shù)5.9%。就診的慢性咳喘患者中風寒襲肺證、痰濕蘊肺證、肺腎兩虛證三種證候所占人數(shù)居前三位,風寒襲肺證占27%,痰濕蘊肺證占25%,肺腎兩虛證占21%,核心處方為射干、麻黃、杏仁、紫菀、冬花、陳皮、前胡、白前、茯苓、百部、五味子。中藥使用頻次排名前十分別為：陳皮192、茯苓189、紫菀174、冬花172、杏仁151、甘草144、百部142、麻黃132、五味子129、黃芪119。藥物配對頻數(shù)分布前十位分別為：陳皮,茯苓,相關系數(shù)23.60828；冬花,杏仁,相關系數(shù)20.36355；紫苑,杏仁,相關系數(shù)19.369；紫菀,百部,相關系數(shù)18.24397；杏仁,麻黃,相關系數(shù)17.92094；冬花,麻黃,相關系數(shù)16.94005；冬花,百部,相關系數(shù)16.80149；紫菀,麻黃,相關系數(shù)16.69092；五味子,射干,相關系數(shù)15.4311；白前,百部,相關系數(shù)15.4311。治療總以溫肺化痰,降氣平喘為要。臨床研究觀察四子溫肺湯加減治療痰濕蘊肺證慢性阻塞性肺疾病急性加重期患者,結果發(fā)現(xiàn)對照組總有效率為76.67%,而治療組總有效率為93.33%,治療組優(yōu)于對照組(P0.05)。兩組證候積分治療前癥狀無差異(P0.05),兩組治療后癥狀較治療前明顯改善(P0.01)。治療組咳嗽、咯痰、喘息較對照組無差異(P0.05),但納呆、脘腹脹滿、氣短、口中粘膩好轉(P0.05,P0.01)。肺功能治療前后兩組均無差異(P0.05)。治療組和對照組治療后血NE、EGFR、IL-17A、HIF-1α的水平均有下降,其中IL-17A、 HIF-1α水平與對照組比較差異有統(tǒng)計學意義(P0.05)。結論：韓明向教授基于肺喜溫而惡寒的理論,采用溫法辨治慢性咳喘,數(shù)據(jù)挖掘分析結果符合和體現(xiàn)韓教授從溫辨治慢性咳喘的學術思想和臨證經(jīng)驗。臨床研究發(fā)現(xiàn)四子溫肺湯和沐舒坦針劑均有助于改善慢性阻塞性肺疾病急性加重期痰濕蘊肺證患者的臨床癥狀,在納差、腹脹脘痞等癥狀改善方面四子溫肺湯有獨到的優(yōu)勢。四子溫肺湯通過調節(jié)血HE、EGFR、IL-17A、HIF-1α的表達,有效改善慢性阻塞性肺疾病患者的氣道炎癥和粘液高分泌,從溫論治慢性咳喘療效確切。
[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.
【學位授予單位】：南京中醫(yī)藥大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R259;R249

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