Poisoning Bacteria And Governance-based Theory, Diagnosis And Treatment Of Clinical Analysis Of 108 Cases Of Influenza A (h1n1) Critically Ill Patients

Research Back ground:In March 2009, A/H1N1 influenza was outbreak in Mexico, which quickly spread wordwide. On June 11,2009, WHO elevated the pandemic flu warning to level 6, declared the world was already at the begining of 2009 influenza pandemic. On August 10,2010, WHO announced the A/H1N1 flu was on the post period of 2009 influenza pandemic. There were a total of 652 patients reported dead in China during the year 2009 and accumulative total reported 147 death cases in 2010 and in January 2011, the number were 15. To conclude the clinical features, age distribution of critical cases and morbidity of A/H1N1 influenza, they were difference from seasonal flu.Traditional Chinese medicine had a broad participation in the treatment of A/H1N1 influenza cases in mainland China, for the curative effect of mild and severe flu has been reported, which shows that TCM can effectively shorten the duration of fever and improve the clinical symptoms, which have a similar effect as Oseltamivir. At present, although there were some study on the existing investigation of intervention on TCM therapy for A/H1N1 flu critical cases and report of a some sample proven cases, the curative effect of critical cases of huge sample are not yet discussed.Research objective:To summarize the epidemiological characteristics of the A/H1N1 flu sever and death cases, conclude the risk factors and clinical characteristics of the critical cases, analyze the rule of TCM pattern development and pathogenesis characteristics, the rule of syndrome differentiation and treatment from the perspective of "toxin". Evaluate the clinical curative effect of combining traditional of Chinese and Western medicine based on the theory of "treating both germs and toxin".Research Methods:Firstly, this research summarizes the characteristics of A/H1N1 influenza virus and the current research progress of A/H1N1 influenza, also introduced my adviser's understanding and treatment based on the "treating both germs and toxin", i.e., using antiviral drugs and antibiotics together, based on etiology and pathogenesis of A/H1N1, by using pattern identification and trearment, to eliminate the toxin factor which has an adverse effect to human body.Clinical research was a retrospective study, collected critical cases from hospitalized patients with laboratory-confirmed 2009 H1N1 infection, patients were from Beijing Ditan Hospital, Chengdu Infectious Disease Hospital, Xinjiang Infectious disease hospital, Shanghai public health center and hainan province people's hospital etc, during the period from September 12th 2009 to February 5th 2010. We analyzed the morbidity, clinical manifestation, auxiliary examination and treatment of patients, concluded the high risk factors and clinical features of those critical severe cases. According to the prognosis, we divided the cases into survival group and death group, using single factor comparative method to analysis high risk factors of death group, and using multivariable binary logistic regression-forward stepwise regression, to further observed the protection factors and risk factors associated with death group. At last, we analyzed two typical cases of 2011, one finally cured and one case finally death.Research Results:A total of 108 confirmed critical severe cases were collected, including 63 male,45 female;the average(SD) age was 40.99±20.63 years old; age was more focused on 18～65 years, the morbidity peaked at November 2009, the median time from symptom onset to first medication was 0.5 days (in range of 0-9 days), and from symptom onset to hospitalized was 5 days (in range of 0-20 days). At least of one comorbidities present in 72 patients (66.7%), common comorbidities were diabetes, Cardiovascular and Cerebrovascular and COPD, by 21.3%,19.4% 12.0% respectively. Drug treatments included neuraminidase inhibitors oseltamivir (108 patients; 100%) for a median of 5 days range from 0 to 15 days, antibiotics (107 patients; 99.1%), antifungals(41 patients; 8.0%),corticosteroids (78 patients; 72.2%) and Traditional Chinese Medicine (52 patients; 48.15%).67 patients(62.0%) were admitted to ICU for a median of 8 days (range,1-33 days), and 41(38.0%) patients received invasive mechanical ventilation. Besides the common symptoms of fever, cough and cough up phlegm, there were higher chance to havce panting, shortness of breath, chest tightness, breath-holding and weakness, when disease become worsen,the dominant symptoms were continued high fever, rough cough, difficulty in breathing, bloody sputum. The common complications were pneumonia (99.1%), I type of respiratory failure (63.9%),acute respiratory distress syndrome (50%), acute liver damage (35.2%). Overall 29 cases finally died with fatality rate at 26.6%.By single factor analysis between the death and the survival group, loss of consciousness and delirious speech, hematemesis,the first ALT, AST,BUN, CK-MB, LDH,oxygen partial pressure after admission to the hospital and invasive mechanical ventilation rate,Ⅱtype respiratory failure, shock, acute renal failure, cardiac enzyme anomalies and multiple organ dysfunction etc., were statistically significant (P<0.05). The first ALT,AST,BUN,CK,LDH and invasive mechanical ventilation rate,Ⅱtype respiratory failure, shock, acute renal failure, cardiac enzyme anomalies and multiple organ dysfunction in the death group is higher than the suvival group. Oxygen partial pressure in the death group is lower than the suvival group.Analyzing 20 factors by multivariable binary logistic regression method, the protection factors of critical cases associated with death were received antiviral therapy within 2 days, combining traditional Chinese and western medicine treatment; Risk factors were with acute renal failure,shock, MODS and invasive mechanical ventilation. After layered analysis, the treatment group (combining traditional Chinese and western medicine treatment) and the control group (western medicine treatment) combined shock patients have statistically significant. By removed shock confound factors, there were significant differences between treatment and control group, the treatment group mortality risk was 0.252 times from control group. Research conclusion:A/H1N1 influenza patients can be divided into initial, advanced, extreme and recovery period for the pattern identification and treatment.During the initial period, primarily symptoms were fever, cough, sore throat, muscle ache, which caused by toxin pathogen attacking lung, part of cases had gastrointestinal symptoms; For adveranced period, symptoms were panting shortness of breath, chest tightness and breath-holding, whicn because of lung blocked and shut by toxic heat; extremely period behave as agitated, loss of consciousness, bloody sputum, pink-tinged sputum, vomitting blood and so on, which caused by toxin damage lung vessels leading to external bleeding. If the disease further developed, toxin would inward invasion leading to internal block and external collapse. During recovery period, the characteristics of residual heat and damage of Qi and Yin syndrome can be seen. The bases disease of premorbid was important factors which casuse the disease develop to critically cases and even death, it fits the theory of "internal danaged is foundation of external contraction". Its transmutation was by Defense, Qi, Nutrient and Blood, if there are loss of consciousness and delirious speech, hematemesis caused by heat go deeply into Nutrient and Blood aspect may indicate an extremely dangerous state. But the toxin primary go deeply into blood aspect of lung, the frenetic movement of blood due to heat toxin leading to bleeding and hematozemia are rare. It is coexisted of "hot, toxin, turbidity, stasis and deficiency" in A/H1N1 flu critical cases, which determines the outcome and prognosis of illness. The treatment of "Treat both germs and toxin" includes not only clearing heat and detoxifying, but also clearing heat and resolveing phlegm, resolveing stasis and water-draining, boost and reinforce the healthy qi. Reinforce the healthy qi and clearing detoxifying should be used in the early stage to prevent the toxin inward invasion leading to internal block and external collapse.The stand out representation of A/H1N1 influenza in critical cases was refractory hypoxemia, critical cases affect widely, serious in degree, involved heart, liver, kidney and other organs, causing shock and multiple organ failure. The clinical studies showed that, antiviral treatment in time(within 2 days) can improve the prognosis of critical cases and combining traditional Chinese and Western medicine based on "treat both germs and toxin " played a positive role in the treatment of A/H1N1 critical cases.