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“通关利窍”针刺法治疗脑干梗死吞咽障碍的临床研究石学敏教授ShiXueminProf.ClinicalResearchon“TongGuanLiQiao”AcupunctureTherapyfortheTreatmentofDysphagiaafterBrainstemStroke天津中医药大学第一附属医院FristTeachingHospital,TianjinUniversityofChineseMedicine研究背景BackgroundDysphagiaisacommoncomplicationofcerebrovasculardiseases，therateofdysphagiaduetostrokeis51-73%.Itcouldbringaboutcomplicationslikeaspirationpneumonia,insufficientintakeoffluidsandnutrients,asphyxia,henceaffectingthepatient’squalityoflife。Itisanimportantcauseofdeathamongststrokepatients.1of46吞咽障碍为脑血管疾病常见并发症，脑卒中急性期发生率为51-73%，可引发吸入性肺炎、水分营养物质摄入障碍、窒息等并发症，严重影响患者生存质量，是导致中风病患者死亡的重要原因之一。2005年《中国脑血管病防治指南》2005ChinaCerebrovascularDiseasesGuidelines吞咽障碍可分为真球麻痹、假球麻痹，其中真球麻痹主要为延髓疑核损伤，假球麻痹是由双侧皮质或皮质脑干束损伤造成，两者统称为吞咽困难。Dysphagiacanbecategorizedintobulbarparalysisandpseudobulbarparalysis.Bulbarparalysisisduetolesionsatthenucleusambiguousofthemedullaoblongata,whilepseudobulbarparalysisiseitherduetolesionsatthecorticobulbartractsoronboththecorticaltracts.Theyweretermedbothconditions“dysphagia”.2of46真球麻痹Vs假球麻痹BulbarParalysisVsPseudobulbarParalysis临床上鉴别真/假球麻痹多以疑核定位，疑核及疑核以下的部位病损即下运动神经元病损为真球麻痹，疑核以上部位病损为假球麻痹。临床中由于影像学对于疑核定位尚存在困难，无法清晰看到疑核受损情况，因此将延髓部位存在病损的患者归入真球麻痹。Clinically,lesionsatandbelowthenucleusthatislowermotorneuronarereferredtobulbarparalysis,whilelesionsabovethenucleusareknownaspseudobulbarparalysis.Inradiography,thelocationofthenucleusremainsunclear，thereforewebroadenedthescope,andclassifiedlesionsinthemedullaoblongataunderbulbarparalysisaswell.3of46大脑的供血系统BloodSupplyofBrain4of46研究背景Background5of46现代医学对于吞咽障碍的治疗多以留置胃管技术改善患者营养摄入，吞咽障碍已成为严重的医疗和社会问题。Modernmedicinemayattempttoimprovenutrientintakeviatheinsertionofthefeedingtube,butdysphagiaremainsaseveremedicalandsocialproblem.病案举隅AMedicalRecord马某男49岁美国人主因“四肢瘫痪伴失语、吞咽障碍16个月”于2011年8月26日入院。患者于2008年和2010年两次患脑干梗死，予气管切开置管、胃壁造瘘及保守治疗，经治病情平稳，为进一步治疗收入我院。MartinAcierno,Male,49years,American.Thepatientwasadmittedtohospitalon26August2011duetoquadriplegia,aphasiaanddysphagia.Hesufferedfrombrainsteminfarctionin2008and2010,andunderwenttrachealintubation,gastricintubationandotherconservativetreatment.Hisconditionstabilized,hencewasadmittedtoourhospitalforfurthertreatment.6of46入院时AtAdmission7of46神情，精神弱，被动体位，构音不能，面部无表情，通过眼球移动表达是和否，吞咽障碍，气切处置管，持续吸氧，痰涎壅盛，每日吸痰16次，胃壁造瘘，尿管通畅，二便失禁。Hismentalstatewaspoor,wasinapassiveposition,sufferedfromaphasiaandcouldonlycommunicateusingeyeballmovement.Hisheadcouldmoveslightly,butcouldnotopenhismouth.Hehaddysphasia,trachealintubation,requiredlongtermoxygeninspiration,hadexcessivesaliva,phlegmsuctioning16timesdaily,gastricintubation,hadclearurinarytube,urineandmotionincontinence.入院时AtAdmission8of46查体：四肢肌力0级，肌张力增高。双侧巴氏征（+）诊断：脑干梗死闭锁综合征高血压病3级肺感染泌尿系感染胃壁造瘘术后气管切开术后Physicalexamination:Levelofmusclestrength0,increasedmusclespasticity,bilateralBabinskisign(+).Diagnosis:CerebralInfarction,Locked-InSyndrome,Hypertension(Level3),trachealintubation,gastricintubation,urinaryinfection,lunginfection.治疗Treatment9of46Treatment:“TongGuanLiQiao”acupuncturetherapy,twicedaily。“通关利窍”针刺法治疗每天治疗两次病情变化ConditionChangesTheurinetubewasremovedontheSECONDdayofadmission.Afteronemonth,hisfacialexpressionsimproved.Hisswallowingimproved,andcouldingest10mlofsemifluiddiet.Oxygeninspirationwasreducedfrom24hto12handphlegmsuctioningwasreducedtoonceevery2-3hours.Perspirationimproved,andhecouldsleepbetter,butstillhadincontinence.10of46入院后第2天拔掉尿管；住院1个月后面部表情基本正常，可口入10ml半流质饮食，吸氧时间由24小时减为12小时，吸痰次数减少为2~3小时一次。治疗结果ResultsAfterthreemonths,hisspiritsandbodyconstitutionimproved.Hedidnotrequireoxygeninspiration,andhadbetterfacialexpressions.Hisswallowingabilityimprovedfurther,andcouldingest100mlofsemifluids.Hewasadmittedforatotalof178days,afterwhichhewasdischarged.11of住院3个月后，患者体质增强，无需吸氧，面部表情恢复正常，可发出低微声音，每天可口入100ml半流质饮食。共住院治疗178天，出院时可发出低微声音，口入半流质饮食可满足日常能量需要。46of病案举隅AMedicalRecord患者杜某某，男，55岁，主因“右侧肢体活动不遂伴失语、吞咽困难18天”住院。Thepatient,Mr.Du,male,55yearswasadmittedtohospitalduetodisabilityonhisright,difficultyinspeakingandswallowingfor18days.12of46入院时AtAdmission13of46入院时语言謇涩，持续右侧肢体不遂，右上肢肌力0级，右下肢肌力2级，饮水咳呛、吞咽困难，纳食自胃管注入。Duringadmission,hisspeechwasslurred,hadcontinuousdisabilityonhisright,musclestrengthontherightarmwaslevel0,rightlegwaslevel2,experiencedcoughingwhendrinkingwater,difficultyinswallowing,andhadinsertionoffeedingtube.治疗Treatment14of46针刺治疗（2次/日）上午“通关利窍”针刺治疗：针刺内关、人中、三阴交、风池、完骨、翳风，咽后壁点刺，舌面点刺下午后颅凹排刺AcupunctureThrepy:Inthemorning“TongGuanLiQiao”acupuncturetherapy,inclusiveofNeiGuan(PC6),RenZhong(DU26),SanYinJiao(SP6),FengChi(GB20),WanGu(GB12),YiFeng(SJ17),prickingoftheposteriorpharyngealwallandtongueIntheafternoonLinedacupuncturetreatmentonthebackofhishead.治疗结果ResultsAfter2weeksoftreatment,thepatientwasabletoingestlotusrootpaste,milk,coulddrinksmallsipsofwaterusingastraw,andcouldspeakclearerthanbefore.Afterthe23rdday,thepatientcoulddrinkwaterwithoutcoughing,andcouldintakeasmuchas3000mlofwater.Hewasabletosatisfyhisdailyenergyrequirement,thereforeremovedhisfeedingtubethenextday.Hisdysphagiawasconsideredclinicallycured15of46治疗2周后，患者可口入半流质饮食，构音较前清晰；治疗第23天，患者可饮水，不呛，口入量达3000ml，满足日常能量需要，吞咽障碍临床痊愈。Howisthatpossible??采用“通关利窍”针刺法