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咳嗽反复老不好,中医治疗有妙招-
咳嗽反复老不好,中医治疗有妙招

咳嗽反复老不好,中医治疗有妙招

导读:慢性咳嗽已成为一个临床诊断,不少医院还特设咳嗽专科门诊。目前界定慢性咳嗽的标准是连续咳嗽大于等于8周。中医诊治咳嗽的辨证思路宗明·张景岳以表里为纲,一曰外感,一曰内伤。但慢性咳嗽表证已不明显,即使有表证亦属余邪未清;而里证也分虚实,虚者内伤,实者寒、热、风、痰、瘀均可存在。

初来诊时当以祛邪为主,其中以痰为辨治重点。咳嗽有痰,笔者以为痰为水饮所聚,有痰必有湿,燥湿化痰是主要治则,首选半夏、南星、苍术、白术。半夏、南星,成人用量15g/d,不必先煎。笔者亦以生南星配开金锁温清并用治痰湿,或生半夏配黄连、黄芩、干姜,兼顾肺胃。痰多属湿,痰黄为火,痰绿属风,可酌情选用蒲公英、紫地丁、半枝莲、白花蛇舌草、鱼腥草、炒山栀、紫草、水牛角片,紫草、水牛角为风火所设。化痰峻剂宗张仲景桔梗白散、皂荚丸之意,以桔梗、皂荚为主,配破坚散结之皂角刺,润肺化痰之川贝、枇杷叶。现代研究佛耳草、矮地茶含岩白菜成分,化痰作用强。明·绮石《理虚元鉴》称佛耳草为大圣药,有理可据。刘河间、朱丹溪均主张“治痰先治气”、“治痰先顺气”。部位在上,可选用瓜蒌、杏仁;在中,可选用枳实、川朴;柴胡、郁金偏胁;广木香、香橼皮、陈皮不分部位均可作顺气药用。有痰而咳,兼痞塞胸闷、气促可选用泻肺,因肺与大肠相表里,可选用葶苈子、熟军、白芥子、莱菔子、桃仁之类。咳痰日久,必致痰瘀入络,三棱、生炒蒲黄、郁金、蜈蚣、地龙、川芎、丹参均可使用。

慢性咳嗽无痰,祛邪重点为肃肺清肝、搜络,桑白皮、白果仁、百部、胡颓叶、黄荆子、茅根、菊花可选;搜肺络用三组虫类药,蜈蚣、全蝎,蟾皮、蜂房,僵蚕、蝉衣,按中医辨证选用,可取桴鼓之效。干咳致肺气散应敛肺,罂粟壳6g或配五味子、白芍、乌梅、百部、天浆壳。清·沈金鳌《杂病源流犀烛》列出乌梅膏、百部膏,单味煎膏含化治久咳,即敛肺之法。

慢性咳嗽定性为内伤咳嗽,补虚是理所当然的,有痰者常补肺脾之气,如雾露之溉,运化水谷,使水饮不聚为痰。无痰者补肺肾之阴,降逆气顺呼吸。临证时重视舌脉、面色。苔白、苔腻者补气运化为主,苔少舌红者养阴润肺为主。脉细缓沉迟者补气温阳,浮滑数者考虑补阴清润。面色无华补脾气,面色泛红养肺阴。病久兼气短者纳肾气、助肾阳。养肺肾阴取南北沙参、麦冬、玉竹、百合、生地、女贞、桑椹、山茱萸、枸杞子;补肺气与补脾气药物相同,以党参、太子参、黄芪、白术、黄精、甘草为主。现在西洋参、白参、红参、移山参、野山参也已广泛采用,价虽高,效果确切。太子参为儿童及气阴两虚、易化火出血、多汗患者所备。补肾气笔者习用仙灵脾、巴戟天、菟丝子、补骨脂。需要温肾阳者取阳和汤之意加减,外科方为内科用。

慢性咳嗽属邪实正虚,祛邪扶正同时兼顾,补泻比例按邪正走势而定。慢性咳嗽常寒热错杂,外寒内热,内寒外热,寒化热,故一方之中寒热之品酌情同用方为巧手。慢性咳嗽邪去正安,病情控制,尚需要继续调理,可巩固疗效,减少再发之虞。此时以补益为主,但不能纯补,于益气填精之品中加入柴胡、黄芩、法半夏、香橼皮等和解疏理药物收效明显。

现代医学提出鼻炎、咽炎、食道反流、过敏、心理因素等亦是慢性咳嗽的重要成因,与中医“非独肺也”的观点相符。诊治时应查明原因,综合治疗。鼻炎后滴漏所致,可选苍耳子、辛夷、石菖蒲、广郁金;清涕,喷嚏加附片、桂枝、细辛;黄脓涕重用黄芩、黄连、茵陈、藿香。慢性咽炎可呈现单声或称半声咳嗽,咽部似咳不咳,似嗽不嗽,时以咳声示人。《理虚元鉴》曰:“其心肾不交,心火炎而乘金,天突急而作痒,咯不出,咽不下,喉中如有破絮黏塞之状。”绮石判为劳嗽已成。书中未列处方,笔者常用养阴利咽之剂加射干、山豆根、苏子、莱菔子、槟榔、枳实、川朴清火畅中之品而取效。

食道反流咳嗽见白天或直立咳嗽,与进餐有关,或有嗳气、泛酸、胸骨后烧灼感。此肺胃之气上逆,《内经·咳论》对咳嗽的病机总结为“聚于胃,关于肺”,一语中的。《杂病源流犀烛》列出的胃虚冷嗽取半夏温肺汤:半夏、细辛、桂心、旋覆花、陈皮、人参、桔梗、白芍、甘草、生姜、赤苓。笔者常用旋覆代赭汤,降胃气也以小柴胡汤、温胆汤、左金丸、半夏泻心汤出入,加肃肺化痰之品为治。其轻者,仍以治咳治痰为法,加入自拟藿香、鸡内金、草豆蔻为小复方,顺气和胃即可。

过敏性干咳即干咳性哮喘,中医已有大量报道,当另立专题讨论。至于心脏病、降压药以及月经、孕产、更年期出现慢性咳嗽,症情也极为复杂,中医方药也较广泛。

慢性咳嗽多见于呼吸系统疾病,结合现代诊断,针对不同病种在诊疗时辨证施药可更为贴近病理病机,更符合病人的病情及体质,从而调制出更合适的处方,效果一定更好。

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