中西醫結合治療吸入性肺炎合併膿胸病例報告

Intervention with Integrated Chinese and Western Medicine in Aspiration Pneumonia with Empyema: A Case Report

本病例報告為一位51 歲食道癌放化療後持續咳嗽有白痰的男性病患，化療後三天，因突發喀血，胸部X 光顯示右下肺浸潤增加與胸膜積液（RLL increased infiltration and right pleural effusion），懷疑右下肺葉肺炎伴隨咳血而住院。經本院血液腫瘤科抗生素治療26 天後，胸腔超音波顯示右肺積膿（right empyema）並放置引流管（pig-tail），由於患者自住院後整日咳嗽有黃白痰已34 天，夜咳甚，影響睡眠，故會診中醫內科合併治療。經中西醫結合治療56 天後，病人順利出院。我們將討論此病例肺積膿之中醫病因、病機及理法方藥。由於化學及放射治療損傷肺胃之氣陰，黏膜受損形成氣管食道瘻管，故口腔菌伺機感染肺部，痰熱壅肺，形成肺癰。中醫診斷為，熱毒壅肺、痰熱化膿、氣陰兩傷。治則為清熱解毒、化痰排膿、益氣養陰。使用方藥為黃芩、桑白皮、生大黃通腑清熱、瀉肺止咳；栝蔞實、冬瓜子、浙貝母、桔梗、生甘草化痰散結排膿；黃耆補氣托膿、沙參養陰清肺。並探討中西醫結合的優勢，中醫介入的時機，為舒緩病人的不適，幫助病人清熱消癰排膿，縮短治療時間的參考經驗。

 

This was a 51-year-old male who had esophageal cancer presented with persistent productive cough and white sputum after receiving radiotherapy and chemotherapy. Three days after his latest chemotherapy, he was brought to the emergency department of this hospital for evaluation due to sudden hemoptysis. In the emergency department, chest radiography revealed increased RLL infiltration and right pleural effusion. The patient was admitted with empirical antibiotics therapy, and right lower lobe pneumonia with hemoptysis was suspected. After 26 days of antibiotic therapy in the hematology and oncology ward, right empyema was found by thoracic ultrasonography and a pigtail was placed. However, his cough with profound yellow and white sputum was not improved for another 2 weeks, and the refractory cough became irritable during sleep. Therefore, a consultation with physicians of Traditional Chinese Medicine (TCM) was arranged. With 56 days of integrated traditional Chinese and Western medicine treatment, the patient was discharged in well condition. In this case report, the possible cause, pathological mechanism and principle for treatment of empyema from the TCM perspective were made. The damage of lining mucus that chemo- and radio- therapies brought to Qi, Yin of lung and stomach was proved by the tracheoesophageal fistula observed under thoracic ultrasonography. Through this pathological structure, oral bacteria flora became an opportunistic infection source in the respiratory tract. Pulmonary welling-abscesses were formed following the refractory phlegm-heat congesting in the lung, and the Chinese medical diagnosis was heat-toxin congesting lung with phlegm-heat and pus formation, which finally caused the dual vacuity of Qi and Yin. The therapeutic principles of TCM were to clear heat and to detoxify, with phlegm resolving and pus eliminating in order to boost Qi and nourish Yin. The rationales beneath the prescriptions were including: Hwang Chyi, Sang Bai Pi, Sheng Di Huang to move the bowels, clear inner heat, clear and drain the heat in lung, and relieve cough; Gua Lou Shi, Dong Gua Zi, Zhe Bei Mu, Jie Geng, Sheng Gan Tsao to help phlegm resolving, binds dispersing, and pus eliminating; Hwang Chyi for Qi supplement and pus exuding; and Sha Shen to nourish Yin and clear the lung. Further, the advantages of integrated traditional Chinese and Western medicine and the timing of Chinese medicine intervention were discussed. Hopefully, this case report could be example when the combination of modern medicine and TCM is concerned to relieve discomfort, clear inner heat, eliminate abscesses, and shorten patients’ hospital courses.