基于寒热虚实辨证对COPD机械通气患者营养状况的探讨

Discussion on nutritional status of patients with chronic obstructive pulmonary disease under mechanical ventilation based on cold-heat/deficiency-excess syndrome differentiation in traditional Chinese medicine

目的 观察不同中医证型慢性阻塞性肺疾病（CODP）机械通气（MV）患者营养不良发生率、营养支持疗效及预后情况,探讨这些指标与中医寒热虚实辨证的关系.方法 选择2015年9月至2017年7月浙江省诸暨市中医医院收治的103例COPD行MV患者,按中医证型分为实热证组（42例）和虚寒证组（61例）,比较两组营养指标及预后的差异.结果 实热证组急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、营养筛查（NRS2002）评分、营养不良发生率均较虚寒证组降低,而体质量指数（BMI）较虚寒证组升高〔APACHEⅡ评分（分）：20.1±5.4比22.0±3.4,NRS2002评分（分）：5.2±0.6比6.2±0.8,营养不良发生率：61.9%（26/42）比80.3%（49/61）,BMI（kg/m2）：22.6±3.8比19.9±4.8,均P〈0.05〕.实热证组白蛋白（Alb）、前白蛋白（PA）、转铁蛋白（TF）水平均较虚寒证组升高,MV 7 d时两组间比较差异有统计学意义〔Alb（g/L）：36.14±2.97比34.40±3.37,PA（mg/L）：237.67±28.01比185.34±30.86,TF（g/L）：2.13±0.38比1.95±0.12,均P〈0.05〕.实热证组撤机成功率较虚寒证组明显升高〔85.7%（36/42）比65.6%（40/61）〕,28 d病死率〔14.3%（6/42）比31.1%（19/61）〕、ICU住院时间（d：9.21±2.96比11.13±3.96）均较虚寒证组明显降低（均P〈0.05）.结论 中医＂寒热虚实＂辨证分析对了解COPD行MV患者的营养状况、预后情况变化规律具有一定参考价值.

Objective To observe the incidence of malnutrition, the therapeutic effect of nutritional support and the prognosis of patients with chronic obstructive pulmonary disease （COPD） under mechanical ventilation （MV） in patients with different traditional Chinese medicine （TCM） syndrome types and discuss the relationships between these indicators and the differentiation of cold-heat/deficiency-excess syndrome. Methods One hundred and three patients with COPD and MV admitted to Zhuji Hospital of TCM from September 2015 and July 2017 were enrolled, according to the different TCM syndromes, they were divided into an excess-heat syndrome group 42 cases and an asthenia-cold syndrome group 61 cases, and the differences in nutrition indexes and prognosis between the two groups were compared. Results The acute physiology and chronic health evaluationⅡ （APACHE Ⅱ） score, nutritional risk screening 2002 （NRS2002） score and the incidence of malnutrition in excess-heat syndrome group were significantly lower than those in the asthenia-cold syndrome group, while the body mass index （BMI） in excess-heat syndrome group was obviously higher than that in the asthenia cold syndrome group [APACHE Ⅱ score： 20.1±5.4 vs. 22.0±3.4,NRS2002 score： 5.2±0.6 vs. 6.2±0.8, incidence of malnutrition： 61.9% （26/42） vs. 80.3% （49/61）, BMI （kg/m2）： 22.6±3.8 vs. 19.9±4.8, all P 〈 0.05]. The levels of albumin （Alb）, prealbumin （PA） and transferrin （TF） of the excess-heat syndrome group were higher than those in the asthenia-cold syndrome group, and the differences between the two groups were statistically significant on the 7th day under MV [Alb （g/L）： 36.14±2.97 vs. 34.40±3.37, PA （mg/L）： 237.67±28.01 vs. 185.34±30.86, TF （g/L）： 2.13±0.38 vs. 1.95±0.12, all P 〈 0.05]. In the excess-heat syndrome group, the percentage of weaning from MV was higher than that of the asthenia-cold syndrome group [85.7% （36/42） vs. 65.6% （40/61）], the 28-day mortality [14.3% （6/42） vs. 31.1% （19/61）] and ICU stay time （days： 9.21±2.96 vs. 11.13±3.96） were lower than those of the asthenia cold syndrome group （all P 〈 0.05）. Conclusion The analysis of TCM differentiation of cold-heat/deficiency-excess syndrome has a certain reference value to realize the changing rules in nutritional status and prognosis of patients with COPD under mechanical ventilation.