FANG Hui (方 輝), PAN Hui (泮 輝), XIAO Dang-sheng (肖黨生)

1. Department of Internal Medicine, the First Af filiated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, China

2. Department of Lung Transplantation, the First Af filiated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, China

3. VIP Ward, the First Af filiated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, China

ABSTRACT Ventilator-assisted ventilation and lung transplantation are the final treatments for the patients with end-stage respiratory failure. A patient, who has been diagnosed as end-stage respiratory failure and received tracheal intubation with mechanical ventilation, received the treatment of Chinese herbal medicine on the principle of TCM and got some recovery gradually. After two months, the patient got rid of mechanical ventilation successfully. This case implies that TCM will be an alternative treatment for the patients with the similar conditions.

KEYWORDS Respiratory failure; Mechanical ventilation; System biology; Herbal medicine; Traditional Chinese Medicine

INTRODUCTION

Mechanical ventilation is the final therapy for the patients with acute or end-stage respiratory failure. Unfortunately, there is little alternative for these patients to get recovery from the mechanical ventilation except lung transplantation. In china,utilization of Traditional Chinese Medicine (TCM)always brings some surprising benefits for patients.For example, Ye Zao-li also reported that utilization of acupuncture help a patient get recovery from mechanical ventilation. However, utilization of TCM only plays a dispensable role for the rescue of such severe patients in intensive care unit (ICU). How to give the just assessment and ideal therapies for those patients with the mechanical ventilation is rarely under discussion in the paradigm of TCM. We had cured a patient with end-stage respiratory failure according the principle of TCM who got recovery from the mechanical ventilation after two months therapies.

CASE REPORT

Mr Li, a sixty-year-old peasant, is admitted to our hospital for his chronic obstructive pulmonary disease (COPD). This patient had been taking more than forty cigarettes per day for thirty years and began to give up smoking six years ago. In recent eight years, the patient had recurrent cough, dyspnea and chest distress and was diagnosed as COPD with the treatment of seretide and atrovent. One year ago,he began to receive therapies of BiPAP (two hours per day) and oxygen. Twenty days before admission,the patient had a fever and his temperature reached 38.8℃ with serious cough, dyspnea and chest distress. Sixteen day before admission, the patient went to other hospital for treatment. Tazobactam/piperacillin, meropenem and azithromycin were injected intravenously for pulmonary bacterium infection while fluconazole, voriconazole, caspohungi were used successively for the fungi infection.The prednisolone is also used for decreasing the inflammatory reaction. Two days before admission,serious chest distress and breath shortness recurred after diet and then the oxygen saturation (SPO2)went on decreasing to 49% even with the utilization of BiPAP. So, the patient received tracheal intubation with mechanical ventilation and then entered ICU. In 2015-01-29, he was sent to emergency ICU (EICU) in our hospital for more therapy.

Physical Examination at Admission: T: 36.5℃,P: 75beats/min, BP: 128/72mmHg.

The patient kept in sedation induced by medicine with tracheal intubation and mechanical ventilation. Breath sounds were low with no obvious wet and dry rales being detected. No other physical signs were found. Sputum culture in other hospital:Bauman AcinetobacterandAspergillus spp. Computerized Tomography: chronic bronchitis;emphysema; in flammation in right upper lung

Diagnosis at admission for the patient: COPA,Acute exacerbation, Type 2 respiratory failure.

After admission, the patient kept on the therapies with tracheal intubation and mechanical ventilation. Many antibiotics, such as sulperazon,fluconazole, were injected intravenously for the therapy of infection while some routine therapies were used for eliminating sputum and maintaining the stability of internal environment. The results of sputum smear in 2015-1-30: a large number of gram-negative bacillus and coccobacillus; many gram-positive coccus; no mould spore and hyphae being found.

From 2015-01-29 to 2015-03-11, the patient got more serious and received the incision of trachea with mechanical ventilation. Many antibiotics with other medicines such as parenteral alimentation,antianxiety and improving gastrointestinal motility,were also used for this patient. Unfortunately, the patient had no trend for recovery while irregular fever, abdominal distention, constipation as well as other syndromes appeared repeatedly. Furthermore,there was no possibility for the patient to get rid of mechanical ventilation. Since 2015-03-11, the patient began to receive the treatment of Chinese herbal medicine on the principle of TCM and got some recovery gradually. After two months, the patient got rid of mechanical ventilation successfully.All therapies were listed as following.

The First Consultation in 2015-03-11

The prescription of Chinese herbal medicine was given as follows:

Banxia (Rhizoma Pinelliae) 9g, Houpo (Cortex Magnoliaf Officinalis)18g, Cangzhu (Rhizoma Atractylodis) 10g, Dangshen (Radix Codonopsis)10g, Muxiang (Radix Aucklandiae) 10g, Wuyao(Radix Linderae Aggregatae) 12g, Doukou(Fructus Kravanh) 9g, Danggui (Radix Angelicae Sinensis) 10g, Wuweizi (Fructus Schisandrae) 5g,Tusizi (Semen Cuscutae) 12g, Guizhi (Ramulus cinnamomi) 10g, Mudanpi (Cortex Moutan Radicis)10g, Zexie (Rhizoma Alismatis)15g, Maiya (Fructus Hordei lemmatibusgerminatus) 15g, Gancao (Radix Rhizoma Glycyrrhizae) 6g, (mixed with honedey).

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for five days.

The Second Consultation in 2015-03-16

After five days' therapy, the patients got recovery with some relief of abdominal distention and dysphoria while the patient could not go on receiving the therapies of prednisolone, olanzapine and quetiapine. The second prescription was following:

Banxia 9g, Houpo 18g, Cangzhu 10g, Dangshen 10g, Muxiang 10g, Wuyao 18g, Doukou 9g, Danggui 10g, Wuweizi 5g, Tusizi 15g, Guizhi 10g, Mudanpi 10g, Cheqianzi (Semen Plantaginis) 15g, Maiya 15g,Jiegeng (Radix Platycodonis) 9g, Gancao 6g (mixed with honedey).

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for five days.

The Third Consultation in 2015-03-24

The patient felt more comfortable than ever.X-ray implied the infection in lung which had no sign of getting worsen. Positive end expiratory pressure got some decreased. The third prescription was following:

Banxia 9g, Houpo 18g, Cangzhu 10g, Dangshen 10g, Muxiang 10g, Doukou 9g, Danggui 10g, Wuweizi 5g, Tusizi 15g, Duzhong (Cortex Eucommiae) 10g,Huangjing (Rhizoma Polygonati) 18g, Guizhi 10g,Mudanpi 10g, Cheqianzi 18g, Maiya 30g, Jiegeng 9g, Kuxingren (Semen Armeniacae Amarum) 15g,Gancao 6g (mixed with honedey).

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

The Forth Consultation in 2015-04-01

The patient's condition is stable and the abdominal distention was the main symptoms of the patient. The forth prescription was following:

Banxia 12g, Houpo 18g, Baizhu (Rhizoma Atractylodis Macrocephalae) 15g, Dangshen 12g,Muxiang 10g, Wuyao 15g, Huoxiang (Herba Cablin)10g, Caodoukou (Semen Alpiniae Katsumadai)10g, Tusizi 15g, Buguzhi (Fructus Psoraleae) 10g,Danggui 10g, Baishao (Radix Paeoniae Alba) 10g,Zhizi (Fructus Gardeniae) 12g, Guizhi 10g, Tinglizi(Semen Sophiae) 12g, Jiegeng 9g, Jinqiancao(Herba Lysimachiae) 30g, Meiguihua (Flos Rosea Rugosea) 10g, Zhishi 12g, Danshen (Radix Et Rhizoma Salviae Miltiorrhizae) 15g.

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

The Fifth Consultation in 2015-04-09

The patient's condition got better and the abdominal distention was still the main symptoms of the patient. The fifth prescription was following:

Banxia 12g, Houpo 18g, Baizhu 15g, Dangshen 12g, Muxiang 10g, Wuyao 18g, Huoxiang 10g,Caodoukou 10g, Tusizi 15g, Buguzhi 12g, Danggui 10g, Baishao 10g, Zhizi 12g, Guizhi 10g, Tinglizi 12g,Jiegeng 9g, Jinqiancao 30g, Meiguihua 10g, Zhishi(Fructus aurantii immaturus) 12g, Danshen 15g.

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

The Sixth Consultation in 2015-04-17

The patient's condition was better. Since 2015-04-09, the patient began to stop the therapy of antibiotic. Latterly, the patient only received the therapy of vancomycin for only three days. No fever recurred. The sixth prescription was following:

Banxia 12g, Houpo 18g, Cangzhu 10g,Dangshen 12g, Muxiang 10g, Wuyao 18g, Huoxiang 10g, Zisu (Folium Perillae) 10g, Caodoukou 10g,Tusizi 15g, Xianlingpi (Rhizoma Epimedii) 15g,Danggui 10g, Baishao 10g, Zhizi 12g, Guizhi 10g,Tinglizi 12g, Jiegeng 9g, Jinqiancao 30g, Meiguihua 15g, Zhishi 12g, Danshen 15g, Tianhuafen 30g,Maiya 30g, Gancao 6g (mixed with honedey).

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

The Seventh Consultation in 2015-04-30

The patient began to sit on bed and take some diet by himself. It was observed that the patient had the opportunity of getting rid of mechanical ventilation. So, the herbal medicines in the seventh prescription got some revised for helping the patient recover from the mechanical ventilation. Since then,the patient began to intake semi liquid by himself.

Banxia 9g, Houpo 18g, Baizhu 30g, Dangshen 12g, Hongjingtian (Radix Et Rhizoma Rhodiolae Crenulata) 10g, Huoxiang 10g, Zisu 10g, Caodoukou 10g, Buguzhi 15g, Tusizi 15g, Danggui 10g, Baishao 10g, Zhizi 12g, Meiguihua 15g, Guizhi 10g, Tinglizi 12g, Zhishi 12g, Tianhuafen (Radix Trichosanthis)30g, Danshen 10g, Wuweizi 5g, Xianhecao (Herba Agrimoniae) 24g, Maiya 30g.

All of these herbal medicines were mixed and boiled as routine in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

The Eighth Consultation in 2015-05-06

The patient's condition got better. PEEP got decreased to 6cmH2O. The eighth prescription was following:

Banxia 9g, Houpo 18g, Baizhu 30g, Dangshen 12g, Hongjingtian 12g, Huoxiang 10g, Zisu 10g,Caodoukou 10g, Buguzhi 15g, Tusizi 15g, Danggui 10g, Baishao 10g, Zhizi 12g, Meiguihua 15g, Guizhi 10g, Tinglizi 12g, Zhishi 12g, Tianhuafen 30g,Danshen 10g, Wuweizi 5g, Xianhecao 24g, Maiya 30g.

All of these herbal medicines were mixed and boiled routinely in our hospital. 400ml decoction was collected for the therapy of the patient (200ml every time, nasal feeding, BID). This prescription was used for seven days.

Notice: since then, the patient was consulted twice while his condition got better and better. In 2015-05-06, the model of mechanical ventilation began to revise as SPON model. Since 2015-05-24, the patient could stop the therapy of ventilatory support in daytime. Since2015-05-28, Ventilator was weaned. Four days later, the patient left the EICU to the general ward.

DISSCUSION

The final goal for the integration of Traditional Chinese Medicine (TCM) and modern medicine is to find the just treatment for patient. TCM, as one of the most important components of CAM[1], has some advantages in the treatment and prevention of certain diseases, such as cancer[2], diabetes[3],hyperlipidmia[4]and pain[5]. Unfortunately, there is rare report about the utilization of TCM in the patient with severe disease. In this case, the patient was diagnosed as COPA, acute exacerbation, type 2 respiratory failure and treated with breathing machine while his condition kept on getting worsen. So, the final treatment for such patients is continuous ventilator assisted ventilation or lung transplantation. After the utilization of herbed medicines according the principles of TCM, the condition of this patient had got reversed and finally,the patient obtained the opportunity for getting rid of the therapy with mechanical ventilation, which implied that TCM can afford the help for rescuing patients at severe condition.

In TCM, yin and yang are the vocabularies to definite the nature of life[6-8]. Perhaps, abstracting an idea definition of life and giving physiological and pathological explanations on yin and yang are the other methods for the modernization of TCM. In Past, the de finition of living multicellular organisms can be modi fied as following:

Living multicellular organism is a chemical system capable of undergoing the metabolisms of energy agents and stem cell proliferation and differentiation (SCPD) for the energy transformations.

In this definition, all metabolisms in our body are abstracted into two fundamental pathways: the metabolisms of energy agents which should be regarded as yang and the stem cell proliferation and differentiation (SCPD) which should be regarded as yin. These two fundamental pathways are composed of a series of biochemistries while all behaviors of our body including diseases are the collective interrelationships of the two pathways. However,the releasing of end products can be bene ficial for the undergoing of both processes so as that our body and all organs could get the suf ficient energy for their function with the suf ficient somatic cells for self-renewal. During the oxidation of food, much energy will be released and water, one of end products in the oxidation of food, is the major carrier of energy, which can be concluded with Newton's law and the formula E=1/2MV2. Therefore, it can be concluded that heat energy will generates the excretion of water, carbon dioxide and other end products so as to keep all biochemistry undergoing continuously. SCPD is another important process in our body, for stem cell will produce all somatic cells by proliferation and differentiation to replace the dead one so as to keep the stability of tissues and organs in structure and function. Another function of SCPD is to repair the damaged tissue and organs[9].Mesenchymal stem cells in bone marrow are more important than the others. Evidences confirm that bone marrow mesenchymal stem cells not only can differentiate into hematopoietic stromal cells, but also can migrate to other tissue to form the tissuespecific cells[10,11]. So, the mesenchymal stem cells in bone marrow are also regarded as stem cell reservoir. Although the researches on the stem cell are the hot point in biology, there is still little method to assess the SCPD in our body. Chronic inflammation implies the deficiency of SCPD for stem cell can not produce the suf ficient somatic cell to resist the in flammation and to repair the damaged tissues[9]. In all, according to TCM theory, energy metabolism is regarded as yang while the SCPD are regarded as yin. The interrelationships of both processes are the base of all physiological functions of tissues and organs while our illness stem from the abnormality of one or both of processes.

Figure 1. the Abstraction about Metabolisms in Human Body

Before prescription, a TCM clinical should give a systemic assessment in term of TCM theories so as to find out the just therapy which will take many bene fits for patient with few side effects.Huangdi Neijngis the ancient theoretic document of TCM, in which many principles for therapies are recorded. Also there is a record about the oxidation of food and our medical interpretation about this record is as following:

Foods, that are taken, will be digested into energy agents which will be transported to all the cells in out body for storage or oxidation after being absorbed. Oxygen getting from lung will oxidized all of energy agents into end products just like water,carbon dioxide and other small molecular agents which will be excreted by urinary system. At the case that these pathways are in normal, our body will stay in health and we will not get any illness.

This document is the ancient abstraction about the pathways of food oxidation. When we get illness, this pathway must be out of order. Now, we will take this patient as an example. Although the breathing machine is an effective method to rescue the patient with the end-stage respiratory failure for its improvement of the lung ventilation, it can also take several disadvantages for such patients.The first disadvantage is to disturb the releasing of water. There are three main methods for the releasing water: urination, sudation and respiration.However, utilization of breathing machine disturbs the water releasing by respiration. Humidifier is an important part in breathing machine, which can improve the humidity and temperature of the gas for the patient. In the natural condition, the humidity and temperature of the air are much lower than that in respiratory tract, which is called the gradients of the humidity and temperature. This gradient, which is bene ficial for the releasing of water, is reduced by the humidifier and more water must be discharged by urination and sudation. At the conditions the function of kidney and skin for the releasing of water reached the saturation, water will be retained in our body. This is perhaps one of the reasons for the appearance of edema in the patient with the therapy of breathing machine. Water is an important end product. At the condition that much water is retained in our body, many chemical reactions will get decrease for the basic principle of chemistry is that the removal of end products will be bene ficial for the undergoing of chemical reactions. The oxidation of foods is composed of a series of chemical reaction.The retaining of water decreases all metabolisms in cell. Perhaps, this is the one of causal factor for the occurrence of respiratory failure and abdominal distension.

The second disadvantage of mechanical ventilation is the alteration of ventilation/perfusion ratio. Positive end expiratory pressure (PEEP) can keep pulmonary alveoli in expanding with the side effect that blocks the blood perfusion of alveoli.So the ventilation/perfusion ratio will increase with disturbance of gas exchange while the hypoxia and carbon dioxide retention will appear. Therefore, the PEEP is a critical parameter for patient to get rid of the therapy of mechanical ventilation. The secondary effect of the hypoxia and carbon dioxide retention is the reduction of food oxidation which will decrease the function of tissues and organ.

Now, it is obvious that one treatment will take many secondary effects on our body while the assessment of patients in the principles of TCM always focuses on the disturbances of all pathways instead of several causal targets. Diaphoresis,diuresis and slowing absorption are the principles for the treatment of this patient. In our prescriptions,Cheqianzi (Semen Plantaginis), Tinglizi (Semen Sophiae), Zhizi (Fructus Gardeniae), Zexie (Rhizoma Alismatis) and Jinqiancao (Herba Lysimachiae)have the function of diuresis while Muxiang(Radix Aucklandiae), Doukou (Fructus Kravanh),Cangzhu (Rhizoma Atractylodis), Guizhi (Ramulus Cinnamomi) and Zisu (Folium Perillae) have the function of diaphoresis. By the utilization of these herbal medicines, the function of tissues and organs get partly recovery. The initial goal of consultant for this patient is the treatment of abdominal distention.In the ancient document《Shanghanlun》(傷寒論) and 《Jinkuiyaolue》(金匱要略), there are many prescriptions for this syndrome. According to these prescription, Banxia (Rhizoma Pinelliae), Houpo(Cortex Magnoliaf Officinalis), Cangzhu (Rhizoma Atractylodis) and Dangshen (Radix Codonopsis)are the core herbal medicines for the treatment of abdominal distention with Muxiang (Radix Aucklandiae), Doukou (Fructus Kravanh), Wuyao(Radix Linderae Aggregatae), Zhishi (Fructus Aurantii Immaturus), Dangshen (Radix Codonopsis)as assistant medicines.

It is always accepted that our body has an ability of self-repairing which is regarded as living force. Up to date, few researchers can tell us where the living force stems from. The definition of life implied that the living force stems from the SCPD,by which our body can undergo self-repairing for resisting the harm, such as infection, inflammatory and so on. Until now, there are few medicines or methods to regulate the SCPD in human body although the researches on stem cells are hot points for the researchers. In case that we regarded SCPD as yin, we should present the hypothesis that many herbal medicines has the possibility to promote the SCPD in our body, such as Tusizi (Semen Cuscutae), Duzhong (Cortex Eucommiae), Buguzhi(Fructus Psoraleae) and Danggui (Radix Angelicae Sinensis), which are used in the prescriptions. The rest herbal medicines such as Hongjingtian (Radix Et Rhizoma Rhodiolae Crenulata), Gancao (Radix Rhizoma Glycyrrhizae), Meiguihua (Flos Rosea Rugosea) and Xianhecao (Herba Agrimoniae) are regarded as assistant medicine for the therapy of this patient.

In all, integration of TCM and modern medicine will take some novel ideas and therapies on the disease. In the past, we had presented theoretical models to uncover the nature of life and give the physical and pathological explanations on the yinyang and wuxing theory. In this case, many syndromes of this patient are reevaluated according to the principles of TCM and new theorertical model.So, utilization of herbal medicines is always focusing on the deviations of metabolic pathways and affords the helps for the self-repairing of our body instead of concerning several causative targets. This case also illustrates that many principle of TCM and utilization of herbal medicines can take same bene fits for the patients with serious disease.