针灸联合肺康复训练对卒中性...功能及外周血炎症因子的影响_张彩艳.pdf

海南医学2023年7月第34卷第13期Hainan Med J,Jul.2023,Vol.34,No.13马妍,张玉勤,张春琰.早期预警评分联合Braden评分对急诊老年危重症病人预后的评估效果J.实用老年医学,2022,36(5):483-486.10 Mnatzaganian G,Bish M,Fletcher J,et al.Application of acceleratedtime models to compare performance of two comorbidity-adjustingmethods with APACHE II in predicting short-term mortality amongthe critically ill J.Methods Inf Med,2018,57(1):81-88.11 Al-Kalaldeh M,Suleiman K,Al-Kalaldeh O.Prognostic performanceof NUTRIC score in quantifying malnutrition risk in the critically illin congruence with the bioelectrical impedance analysis J.NutrClin Pract,2020,35(3):559-566.12 Pasinato VF,Franzosi OS,Loss SH,et al.SAPS 3 in the modifiedNUTrition RIsk in the Critically ill score has comparable predictiveaccuracy to APACHE II as a severity marker J.Rev Bras Ter Inten-siva,2021,33(3):394-400.13 Kasapolu US,Kamaz O,Gk A,et al.Prognostic factors for 30-daysmortality in eighty years aged and older critically ill patients:A sin-gle center retrospective cohort study J.Turk J Med Sci,2021,51(6):2968-2977.14 Li CH,Li FH,Han B,et al.The predictive value of serum D-dimer,procalcitonin and Apache score on the prognosis of elderly patientswith SCAPJ.Hainan Medical Journal,2020,31(14):1790-1793.李朝晖,李复红,韩蓓,等.血清D-二聚体,降钙素原联合APACHE评分对老年 SCAP 患者预后的预测价值J.海南医学,2020,31(14):1790-1793.15 Sundararajan K,Schoeman T,Hughes L,et al.Predictors and out-comes of acute pancreatitis in critically ill patients presenting to theemergency department of a tertiary referral centre in Australia J.Emerg MedAustralas,2017,29(2):184-191.16 Kane WJ,Hassinger TE,Elwood NR,et al.Fever is associated withreduced mortality in trauma and surgical intensive care unit-acquiredinfections J.Surg Infect(Larchmt),2021,22(2):174-181.(收稿日期：2022-08-31)针灸联合肺康复训练对卒中性肺炎患者肺功能及外周血炎症因子的影响张彩艳，张广飞，杨翠花榆林市第一医院康复医学科，陕西榆林719000【摘要】目的探究针灸联合肺康复训练对卒中性肺炎患者肺功能及外周血炎症因子的影响。方法选取2021年1月至2022年8月期间在榆林市第一医院康复医学科治疗的100例卒中性肺炎患者进行研究，按照随机数表法分为对照组和研究组各50例。对照组患者采用常规肺康复训练，研究组患者采用针灸联合肺康复训练，两组患者均进行康复治疗14 d。治疗后比较两组患者的治疗效果，以及康复治疗前后的肺功能指标用力肺活量(FVC)、第一秒用力呼气容积(FEVl)、呼气峰流速(PEF)、平均最大呼气流量(MMEF)，外周血炎症因子C-反应蛋白(CRP)、降钙素原(PCT)、白细胞计数(WBC)水平和肺炎症状消退时间(咳嗽消失时间、咳痰消失时间、湿啰音消失时间)。结果研究组患者的临床治疗总有效率为98.00%，明显高于对照组的82.00%，差异有统计学意义(P0.05)；治疗后，两组患者的FVC、FEVl、PEF、MMEF 水平均明显升高，且研究组患者的FVC、FEVl、PEF、MMEF 水平分别为(3.940.42)L、(3.050.45)L、(3.720.91)L/s、(0.920.11)L/s，明显高于对照组的(3.150.45)L、(2.430.42)L、(2.870.78)L/s、(0.770.10)L/s，差异均有统计学意义(P0.05)；治疗后，两组患者的CRP、PCT、WBC水平均明显降低，且研究组患者的CRP、PCT、WBC水平分别为(8.091.28)mg/L、(0.360.05)ng/L、(7.541.32)103/L，明显低于对照组的(18.931.41)mg/L、(0.780.12)ng/L、(9.381.52)103/L，差异均有统计学意义(P0.05)；研究组患者的咳嗽消失时间、咳痰消失时间、湿啰音消失时间分别为(7.561.58)d、(8.061.34)d、(8.161.16)d，明显短于对照组的(10.521.54)d、(11.122.42)d、(12.692.68)d，差异均有统计学意义(P0.05)，具有可比性。本研究经我院医学伦理委员会批准，所有患者及家属均签署知情同意书。1.2治疗方法1.2.1对照组该组患者进行为期14 d一个疗程的肺康复训练治疗。(1)基础性治疗：在患者脑卒中渡过危险期，病情稳定、意识清晰后，给予患者改善脑循环、降压、止咳、化痰、抗感染等药物治疗，并对患者采取低流量吸氧、雾化等治疗措施。(2)肺康复训练：患者在临床医生的指导下进行肺康复训练，包括呼吸控制训练及呼吸肌训练，其中呼吸控制训练为2次/d，30 min/次的缩唇及腹式呼吸训练，而呼吸肌训练为2次/d，15 min/次的膈肌阻力、吸气肌训练。肺康复训练治疗过程中要密切关注患者身体状况，当患者出现呼吸困难等情况时则应立即停止一切康复治疗，待患者急性症状缓解，临床医生对患者身体情况进行评估后，再决定是否继续开展肺康复训练治疗。一个疗程MethodsOne hundred patients with stroke-associated pneumonia who were treated in the Department of Rehabilita-tion Medicine,Yulin First Hospital from January 2021 to August 2022 were selected amd randomly divided into a con-trol group and a study group,with 50 patients in each group.The patients in the control group received routine lung reha-bilitation training,and the patients in the study group received acupuncture and moxibustion combined with lung rehabil-itation training.Both groups were treated for 14 days.After treatment,the therapeutic effects of the two groups werecompared,as well as the pulmonary function indexes before and after treatment forced vital capacity(FVC),forced ex-piratory volume in the first second(FEVl),peak expiratory flow rate(PEF),and mean maximum expiratory flow(MMEF),the levels of peripheral blood inflammatory factors C-reactive protein(CRP),procalcitonin(PCT),whiteblood cell count(WBC),and time for the disappearance of pneumonia symptoms(cough disappearance time,sputumdisappearance time,wet rale disappearance time).ResultsThe total effective rate of clinical treatment in the studygroup was 98.00%,significantly higher than 82.00%in the control group(P0.05);after treat-ment,the levels of FVC,FEVl,PEF,and MMEF in both groups of patients significantly increased,and the levels in thestudy group were(3.940.42)L,(3.050.45)L,(3.720.91)L/s,and(0.920.11)L/s,which were significantly higherthan(3.150.45)L,(2.430.42)L,(2.870.78)L/s,and(0.770.10)L/s in the control group(P0.05);aftertreatment,the levels in both groups were significantly reduced,and the levels in the study group were(8.091.28)mg/L,(0.360.05)ng/L,and(7.541.32)103/L,which were significantly lower than(18.931.41)mg/L,(0.780.12)ng/L,and(9.381.52)103/L in the control group;the differences were statistically significant differences(P0.05).The cough dis-appearance time,sputum disappearance time,and wet rale disappearance time of the study group were(7.561.58)d,(8.061.34)d,and(8.161.16)d,respectively,which were significantly shorter than(10.521.54)d,(11.122.42)d,and(12.692.68)d in the control group(P0.05).ConclusionAcupuncture and moxibustion combined with lung rehabili-tation training can effectively improve the lung function and peripheral blood inflammatory factor indicators of patientswith stroke-associated pneumonia,with good therapeutic effect and clinical application value.【Key words】Stroke;Stroke-associated pneumonia;Acupuncture and moxibustion;Lung rehabilitation training;Lung function;Peripheral blood inflammatory factor1837海南医学2023年7月第34卷第13期Hainan Med J,Jul.2023,Vol.34,No.13结束后，对患者的肺功能、炎性因子等指标进行评估。1.2.2研究组该组患者在对照组肺康复训练基础上给予针灸治疗。针灸治疗具体方法：取患者双侧太阳、风池、太冲、四神聪、合谷、廉泉、百会、印堂等穴位实施平补、平泻的针灸方法，1次/d，15 min/次。14 d为一个疗程。1.3观察指标与评价(检测)方法(1)临床疗效5：治疗14 d后评估临床疗效。显效：咳嗽、咳痰、湿啰音等症状消失，患者肺功能指标恢复良好，外周血炎症因子水平趋于正常，CT显示患者肺部密度影病灶消失；有效：咳嗽、咳痰、湿啰音等症状及患者肺功能指标、外周血炎症因子水平明显改善，CT显示患者肺部密度影病灶减小；无效：咳嗽、咳痰、湿啰音等症状及患者肺功能指标、外周血炎症因子水平无改善或加重。治疗总有效率=(显效+有效)/总例数100%。(2)肺功能指标：治疗前及治疗14 d后，采用肺功能检测仪检测两组患者用力肺活量(FVC)、第一秒用力呼气容积(FEVl)、呼气峰流速(PEF)、平均最大呼气流量(MMEF)水平。(3)外周血炎症因子：治疗前及治疗14 d后，所有患者采集空腹外周静脉血5 mL，以3 000 r/min离心10 min，分离血清后通过免疫比浊法检测C-反应蛋白(CRP)，通过电化学发光法检测降钙素原(PCT)，全自动血细胞分析仪检测白细胞计数(WBC)。(4)肺炎症状消退情况：治疗中动态监测两组患者肺炎症状，记录咳嗽消失时间、咳痰消失时间、湿啰音消失时间。1.4统计学方法应用SPSS18.0统计软件进行数据分析。计量资料以均数标准差(x-s)表示，组间比较采用t检验，计数资比较采用2检验。以P0.05为差异有统计学意义。2结果2.1研究组典型病例治疗前后CT图像资料研究组一例59岁卒中性肺炎患者在脑卒中病发后引发吸入性肺炎，症状为咳嗽、呼吸困难、肺部听诊有啰音、浓痰等，典型图像见图1。2.2两组患者的临床治疗效果比较研究组患者的临床治疗总有效率为98.00%，明显高于对照组的82.00%，差异有统计学意义(2=8.273，P=0.0040.05)；治疗后，两组患者的 FVC、FEVl、PEF、MMEF水平均较治疗前升高，且研究组患者的FVC、FEVl、PEF、MMEF水平明显高于对照组，差异均有统计学意义(P0.05)；治疗后，两组患者的CRP、PCT、WBC 均较治疗前降低，且研究组患者的CRP、PCT、WBC水平明显低于对照组，差异均有统计学意义(P0.05)，见表3。2.5两组患者的肺炎症状消退时间比较研究组患者的咳嗽消失时间、咳痰消失时间、湿啰音消失时间明显短于对照组，差异均有统计学意义(P0.05)，见表4。表1两组患者的临床治疗效果比较(例)Table 1Comparison of clinical treatment effects between the twogroups(n)组别研究组对照组例数5050显效3823有效1118总有效率(%)98.0082.00无效191838Hainan Med J,Jul.2023,Vol.34,No.13海南医学2023年7月第34卷第13期表2两组患者治疗前后的肺功能比较(x-s)Table 2Comparison of lung function between the two groups before and after treatment(x-s)组别研究组对照组t值P值例数5050治疗前2.410.312.450.330.6250.267治疗后3.940.42a3.150.45a9.0750.001治疗前1.470.211.510.220.9300.177治疗后3.050.45a2.430.42a7.1220.001治疗前2.250.652.220.680.2260.411治疗后3.720.91a2.870.78a5.0150.001治疗前0.550.060.540.080.7070.241治疗后0.920.11a0.770.10a7.1350.001注：与本组治疗前比较，aP0.05。Note:Compared with that in the same group before treatment,aP0.05.FVC(L)FEVl(L)PEF(L/s)MMEF(L/s)3讨论近年来，因脑卒中引发卒中性肺炎并发症临床常见。由于卒中性肺炎会导致患者肺间质发生炎性反应，因此临床针对患者肺部炎症情况开展肺部病原菌检测，锁定病原菌特点及其药物的抗菌谱、抗菌活性，有针对性开展抗感染药物治疗，如选取阿莫西林、克拉维酸、头霉素类、氧头孢烯类等抗感染药物对患者开展治疗很有必要6-8。唐子文等9研究表明，对卒中性肺炎患者开展治疗，除了有效的抗感染治疗外，还需要对患者开展必要的肺康复训练治疗，如呼吸控制训练及呼吸肌训练。周金花等10的一项对60例卒中性肺炎患者治疗研究表明，提升患者肺通气功能以及增强患者呼吸肌力量及耐力是提高患者 FVC、FEVl、PEF、MMEF 水平，改善患者肺部炎症反应的关键因素。而呼吸训练中的缩唇、腹式呼吸训练通过反复让患者保持用口呼气及用鼻吸气训练方式，以及通过呼吸肌训练方式让患者依靠膈肌阻力、吸气肌呼气吸气，帮助陷入机体障碍的患者控制呼吸方式，从而培养患者正常呼吸模式，提高患者呼吸气道的廓清能力，促进患者气管、支气管内诱发咳嗽的痰液排出，改善肺部感染11。且杨亮12研究指出，肺康复训练可通过呼吸效率提升促进患者肺泡扩张，增加肺容量，提高患者脑摄氧量，从而帮助患者康复。由于中医疗法具有副作用小、并发症少等优点，已在临床中被广泛使用，因此在脑卒中并发症治疗中引入中医疗法如针灸治疗等可有效提升治疗效果。中医认为中风是风邪侵袭，气血痹阻，筋脉失养导致痰瘀内阻，蕴积于肺脏，从而引发咳嗽、痰黏等肺部感染症状13。且中医研究表明，人体太阳、风池等穴位与脑部循环有关，太冲、合谷、廉泉等穴位则与人体气道及肺部经络密切相关，对上述穴位实施针灸治疗，可达到开窍醒脑、解表止痛、宣肺清热、止咳化痰、宽胸理气等功效14。而杜俊涛等15研究表明，针灸联合肺康复训练一方面促进患者脑部微循环，减轻脑供血不足的脑部神经损伤，另一方面提升患者呼吸肌神经兴奋性，使得中枢反射得到强化，从而增强患者呼吸肌耐力，提高患者廓清能力等。这一结果在本次研究中得以证实，即治疗后采用针灸联合肺康复训练患者的肺功能指标FVC、FEVl、PEF、MMEF水平均明显高于仅仅采用肺康复训练患者，差异均有统计学意义(P0.05)。本研究还发现，采用针灸联合肺康复训练治疗的患者，其CRP、PCT、WBC水平明显低于仅仅采用肺康复训练者，且治疗后前者咳嗽消失时间、咳痰消失时间、湿啰音消失时间明显短于后者，前者治疗总有效率明显高于后者，差异均有统计学意义(P0.05)，说明针灸联合肺康复训练疗效好。综上所述，针灸联合肺康复训练治疗卒中性肺炎能改善患者肺功能，减轻炎症反应，治疗效果好，具有临床应用价值。表4两组患者的肺炎症状消退时间比较(x-s，d)Table 4Comparison on the time for the disappearance of pneumoniasymptoms between the two groups(x-s,d)组别研究组对照组t值P值例数5050咳嗽消失时间7.561.5810.521.549.4860.001咳痰消失时间8.061.3411.122.427.8220.001湿啰音消失时间8.161.1612.692.6810.9690.001表3两组患者治疗前后的外周血炎症因子比较(x-s)Table 3Comparison of peripheral blood inflammatory factors between the two groups before and after treatment(x-s)组别研究组对照组t值P值例数5050治疗前115.3910.07112.7510.321.2950.099治疗后8.091.28a18.931.41a40.2500.001治疗前1.440.211.410.220.6980.245治疗后0.360.05a0.780.12a22.8450.001治疗前13.942.0114.012.020.1740.431治疗后7.541.32a9.381.52a6.4630.001注：与本组治疗前比较，aP0.05。Note:Compared with that in the same group before treatment,aP0.05.CRP(mg/L)PCT(ng/L)WBC(103/L)1839海南医学2023年7月第34卷第13期Hainan Med J,Jul.2023,Vol.34,No.13参考文献1Guan TY,Xiao YN,Lu PY.Progress in clinical diagnosis and treat-ment of ischemic stroke in recent years J.Chinese Journal for Clini-cians,2021,49(6):658-660.管天媛,肖伊宁,吕佩源.近年来缺血性脑卒中临床诊治进展J.中国临床医生杂志,2021,49(6):658-660.2Eltringham SA,Kilner K,Gee M,et al.Impact of dysphagia assess-ment and management on risk of stroke-associated pneumonia:A 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