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in ICU Severe Patient
Hongmei Li ShuSen Li
A case study of an ICU severe patient’s experience with the application of pulse-respiration ratio
Case:
Patient: Female, 72 years old. Fall down and be unconscious for 1 week.
Medical History: The patient developed symptoms on 2/28/2023, presenting with respiratory distress and chest pain due to a lung infection, which progressed to acute respiratory failure and led to hospitalization. Upon admission, the patient had a pulse rate of 97 beats per minute and a respiratory rate of 15 breaths per minute. According to the patient’s family, the patient had been using a tracheal tube at home for over five years. With treatment, the patient’s condition improved. On 3/5/2023, the patient was found collapsed on the ground with a right frontal head injury. The tracheal tube was beside the bed, and the patient was unconscious. Immediate PCR testing and cardiopulmonary resuscitation were performed. The patient was subsequently transferred to the ICU. In the ICU, the patient received cardiac monitoring, tracheal intubation, nasogastric tube placement, and urinary catheterization. The patient stayed in the ICU for 10 days.
The patient’s family requested traditional Chinese acupuncture treatment. The attending Western physician invited consultation with a traditional Chinese medicine (TCM) practitioner.
Past Medical History: The patient had a history of hypertension, coronary artery disease, chronic kidney disease, ovarian cancer (10 years post-surgery), uterine cancer, type 2 diabetes, COVID-19 sequelae, and tracheostomy (7 years ago).
Western Medical Diagnoses:
1.Hypoxic brain injury with cerebral edema
2.Acute encephalopathy
3.Rib fractures
4.Acute hypoxic hypercapnic respiratory failure
5.Pneumonia
6.Coronary artery atherosclerosis
7.Chronic kidney disease
8.COVID-19 sequelae
9.Bilateral flaccid paralysis of the upper limbs
The patient’s family requested TCM acupuncture treatment. The attending physician of Western medicine invites a TCM doctor for consultation .
Initial Consultation：3/15/2023: The patient was unconscious, with closed eyes, a sluggish pupillary light reflex. Other superficial reflexes were present. The jaw was tightly closed, and the patient was unresponsive to questions.
The patient had a sutured wound on her right frontal area and wore a cervical collar. She had bilateral flaccid paralysis of the upper extremities, but the extremities were warm, with no edema. The patient had an endotracheal tube, nasogastric tube, and urinary catheter in place. Pulse: 110 beats/min, stringy and rapid; the tongue coating cannot be seen as the teeth are tightly closed. Blood pressure: 135/50mmHg; Respiration: 31 times/min, cardiac monitoring was in place.
MRI Findings:
1.Cerebral edema
2.Spinal cord edema at C5-C6
3.Left 4th-6th rib fractures; right 4th-5th rib fractures
TCM Diagnosis:
1.Closed wind stroke, Zang-Fu disharmony
2.Syncope
3.Acute respiratory failure
4.Blood stasis and Qi stagnation
5.Traumatic rib fractures
6.Lung and kidney deficiency
7.Heart and spleen deficiency
8.Concretions and agglomerations
Initial Acupuncture Treatment:
1. 12 jing-well point acupuncture therapy;
2. Jiao’s scalp acupuncture;
3. Lu’s jumping needle; Shuigou (GV 26), Zhongchong (PC 9): used to refresh the brain; Wailaogong (Extra point on dorsum of hand opposite PC 8), Yongquan (KD 1) is used to clear the heart and reduce adverse events;
Hegu (LI 4), Taichong (LV 3): used to regulate Qi and blood.
One acupuncture treatment per day, 5 days as a course of treatment.
Patient’s Response: After the Master Lu jumping needle treatment the patient’s limbs experienced twitching. Following acupuncture treatment, the patient was able to open her eyes, blink, respond to her daughter’s call, open her mouth to show her tongue coating, and move her feet, though she could not answer questions.
03/22/2023: Hemodialysis was performed.
03/25/2023: After taking the first An Gong Niuhuang Pill, the patient’s blood pressure increased, particularly systolic pressure. However, the pulse-respiration ratio was 3.4.
03/26/2023: The patient was able to yawn but not consciously. Her tongue coating was white and greasy, and her pulse was weak. How should the pulse be analyzed? The pulse-respiration ratio was 78/27 = 2.8.
03/31/2023: Under the guidance of Professor Li Shusen, acupuncture was administered at Tianzhu (BL 10), Dazhu (BL 11), Zhongchong (PC 9), and Yongquan (KD 1) using a balanced reinforcing-reducing method. Needles were retained for 20 minutes, with treatments administered every other day.
04/01/2023: Pulse-respiration ratio: 82/18 = 4.6. Can we consider that the patient’s condition has improved? The patient is still not fully conscious, with reactive pupils and shallow reflexes. However, she cannot respond to questions.
04/03/2023: As planned, the patient was stably transferred out of the ICU. Upon transfer, the patient’s pulse-respiration ratio was 4.3, indicating a stable condition. However, the prognosis is still not optimistic, and close observation and treatment are still needed.
The following is the pulse ratio recorded by the application of pulsation technique:
| Date P R P/R |
| 02/28/2023 97 15 6.5 |
| 03/07/2023 95 18 5.3 |
| 03/10/2023 80 21 3.8 |
| 03/15/2023 110 31 3.6 |
| 03/16/2023 80 27 3.0 |
| 03/18/2023 87 23 3.8 |
| 03/19/2023 88 22 4.0 |
| 03/21/2023 87 25 3.5 |
| 03/22/2023 100 24 4.2 |
| 03/23/2023 105 23 4.6 |
| 03/25/2023 88 25 3.5 |
| 03/26/2023 78 27 2.8 |
| 04/01/2023 82 18 4.6 |
| 04/02/2023 94 23 4.1 |
| 04/03/2023 85 20 4.3 |
Explanation of Pulse-Respiration Ratio Technique:
This technique was developed by Professor Li Shusen. One calculates the ratio between pulse rate and respiratory rate as the pulse divided by the respiration, which equals the Pulse-Respiration Ratio.
Diagnostic Pulse-Respiration Ratio Categories
1.Pulse-Respiration Ratio of less than 4:Qi Deficiency or Cold Syndrome.
Treatment: Xiaojian Zhong Tang-tonifying method. For “Qi Deficiency” in any disease, build the qi of the middle burner. For men, use Huangqi (Astragalus) to build the central qi; for women, use Danggui (Angelica Sinensis) to build the central qi. Imbalance of “Heart Governs Blood, Lungs Govern Qi” functions results in Qi Deficiency.
2. Pulse-Respiration Ratio 4-5: Neutral State (Ping Ren). While this is “balanced”, it is no “healthy”. This is ostensibly a person blanched between an excess and a deficiency, although there is a disease present, one should follow the rules to treat it, one must balance and harmonize the mix of vacuity and repletion. Xiao Jian Zhong Tang and Da Chai Hu Tang are the governing formulas. Acupuncture should be used to regulate the channel system.
Acupuncture Treatment: When there is shortness of breath and Neutral State, the disease mechanism is in the area under Tianshu (ST 25), and one should employ points on the six channels of the leg for its treatment.
3.Pulse-Respiration Ratio > 5: Restless Pulse-This indicates an excess or heat syndrome. Treatment: The governing formula is Dachaihu Tang.
Acupuncture: Drain Yang meridians, tonify Yin meridians. Yang Qi is floating outwards, and Yin is unable to restrain Yang.
Acupuncture treatment: Restless Pulse patterns occur in the area above Tianshu (BL 25); select points from the six hand channel. Points used: Drain Erjian (LI 2), supplement Yuji (LU 10), and drain Zhigou (SJ 6). Stomach qi is the foundation of human beings, regardless of breathlessness, restless pulse, or an even presentation, regulating stomach qi is the first priority.
Discussion
1.The patient was in critical condition. Based on the recorded Pulse-Respiration Ratio, the patient’s condition changed continuously from admission to discharge. When admitted to the hospital due to infection of community pneumonia with fever, rapid heartbeat and pulse, and dyspnea, a pulse-to-breath ratio of 6.6 is considered restless pulse; After treatment, the Pulse-Respiration Ratio improved to 5.3 (Neutral State). Following a fall and subsequent ICU admission, the patient’s Pulse-Respiration Ratio ranged between 3.0 and 4.0 (Qi Deficiency). With combined Western and Chinese medicine treatment, the Pulse-Respiration Ratio shifted to 4.5 (Neutral State). Can we consider this as an improvement? It is evident that the patient was in a coma, emphasizing that Neutral State does not necessarily equate to health. The condition may have included a mixture of cold and heat, indicating a critical situation. This case highlights the challenges in diagnosis and treatment.
2.Because the patient was unconscious, the medicinal An Gong Niuhuang Wan was administered via gastric tube. Blood pressure increased, and the Pulse-Respiration Ratio decreased to 3.4. After one week, the Pulse-Respiration Ratio ranged from 4.1 to 4.6. Can we infer that the patient’s consciousness improved following the administration of An Gong Niuhuang Wan?
3.The Pulse-Respiration Ratio provides a reference for assessing the patient’s condition. Similar to the use of MRI and ECG in Western medicine diagnosis, clinical treatment should consider the patient’s individual situation for optimal results. This patient demonstrated strong vitality and benefited from both Western medicine and the unique efficacy of traditional Chinese medicine.
4.Professor Li Shusen’s teaching emphasizes the importance of the Pulse-Respiration Ratio in Changsangjun Pulse Diagnosis, and he proposes treatments for the three presentations of Qi Deficiency, Neutral State, and Restless Pulse. Through observation of this case, it is believed that this technique can provide significant clinical guidance.
NOTE: Chang Sang Jun, mentioned above, was a legendary doctor of the Warring States period who was the teacher of Bian Que, who is the reputed author of the Nan Jing.
Author information:
Hongmei Li Senior acupuncturist Cedars-Sinai Medical Center ，Los Angeles, CA.
ShuSen Li Founder of Chang Sang Jun Pulse Method， Academic Advisor of Swiss Chinese Medicine Association
一例ICU重症病人脈息術應用體會
李紅梅 李樹森
下面就將一例ICU重症病人應用脈息術/脈息比體會報告如下：
病例：女性病人，72歲。跌倒昏迷不醒1週。
現病史：病人於2/28/2023，因感染肺炎，而導致呼吸困難，胸痛繼而發展為急性呼吸衰竭入院。入院時，脈搏97次/分；呼吸15次/分。經病人家屬反映，該病人在家裡用氣管插管五年多。經治療病人病情有所好轉。 3/5/2023，病人被發現倒在地上，右前額受傷，氣管插管在床邊，病人神誌不清，隨即行PCR，心肺復蘇術。繼而轉到ICU病房。行心電監護，氣管插管，鼻飼管，導尿管。在ICU住院10天。
過去病史：病人有多年高血壓病史；冠狀動脈疾病；慢性腎臟疾病；卵巢癌術後十年；子宮癌；二型糖尿病；新冠后遺症；氣管切開插管七年等。
西醫診斷：
1.缺氧性腦損傷伴腦水腫；
2.急性腦病；
3.肋骨骨折；
4.急性缺氧性高碳酸血症性呼吸衰竭；
5.肺炎；
6.冠狀動脈硬化疾病；
7.慢性腎臟疾病；
8.新冠后遺症；
9.雙側上肢弛緩性麻痺。
病人家屬請求中醫針灸治療，西醫主治醫師邀請中醫會診。
首診： 3/15/2023，病人神誌不清，閉目，瞳孔對光反射遲鈍，淺反射存在。牙關緊閉，病人不能回答任何問題。右前額縫合的傷口，頸部有頸托固定，雙側上肢遲緩性麻痺，四肢溫暖，無水腫。氣管切開插管，上鼻飼管及導尿管。脈搏：110次/分，脈弦，數；舌苔不能看到，牙關緊閉。血壓：135/50mmHg; 呼吸：31次/分。心電監護。
MRI:
1 大腦水腫；
2 頸部 C5-C6 脊髓水腫；
3 左側4th-6th肋骨骨折；右側4th-5th肋骨骨折。
中醫辨證：
1.中風,中臟腑，閉症；
2.昏厥；
3.急性呼吸衰竭；
4.血瘀氣滯；
5.外傷肋骨骨折；
6.肺腎兩虛；
7.心脾兩虛；
8.癥瘕
首診針灸治療：
1.12 井穴點刺療法；
2.焦氏頭針；
3.陸氏跳針；水溝，中衝：用醒腦開竅；外勞宮，湧泉用於清心降逆；
合谷，太衝：用於通調氣血。
每天一次針灸治療，5天為一療程。
病人反應：陸氏跳針扎跳後病人的胳膊、腿、手腳有抽動。病人經過針灸治療後，可以睜眼睛，眨動眼睛，病人的女兒呼叫，可以睜眼睛，並能張口讓我們看舌苔，可以移動雙腳，但不能回答問題。
3/22/2023，給血液透析。
3/25/2023，服用了第一顆安宮牛黃丸24h後，病人的狀況：血壓升高了，尤其是收縮壓升高了。表格是服用前後血壓及生命體徵的對照。但是脈息比為3.4。
3/26/2023，可以張口打呵欠，但不是有意識的。所以看到舌苔是白膩苔，脈搏細弱。該如何分析脈相？脈息比78/27=2.8。
03/31/2023，李樹森老師指導針法：天柱，大杼，中衝，湧泉。平補平瀉。留針20分鐘，隔天一次。
04/01/2023，脈息比: 82/18 =4.6是否可以認為病情有所好轉？病人神誌不清，瞳孔對光反射存在；淺反射存在。但是病人不能夠回答任何問題。
04/03/2023,按計劃該病人已平穩轉出ICU。該病人轉如其他醫院時，病人的脈息比為4.3，轉為平人。但預後任然不容樂觀，還需繼續密切觀察和治療。
下面是應用脈息術記錄的脈息比：
| Date P R P/R |
| 02/28/2023 97 15 6.5 |
| 03/07/2023 95 18 5.3 |
| 03/10/2023 80 21 3.8 |
| 03/15/2023 110 31 3.6 |
| 03/16/2023 80 27 3.0 |
| 03/18/2023 87 23 3.8 |
| 03/19/2023 88 22 4.0 |
| 03/21/2023 87 25 3.5 |
| 03/22/2023 100 24 4.2 |
| 03/23/2023 105 23 4.6 |
| 03/25/2023 88 25 3.5 |
| 03/26/2023 78 27 2.8 |
| 04/01/2023 82 18 4.6 |
| 04/02/2023 94 23 4.1 |
| 04/03/2023 85 20 4.3 |
方法：應用李樹森老師創建的脈息術/脈息比。
脈息比：脈搏與呼吸頻率之間的比值; 脈搏/息=脈息比值
脈息術標準界定：脈息比
1.脈息比<4，少氣：虛證/寒證：小建中湯，補法。百病若”少氣”，必建 ”中”。男性宜用黃耆建中；女性宜用當歸建中湯。“心主血，肺主氣”之功能失衡，少氣在年輕人心肺可能有實質性，在老年人可能有器質性病。
2.脈息比4-5，平人，脈息比正常，但有病症，應依法論治，平和/虛實交雜，小建中湯合大柴胡湯，針灸調經脈。
注：平人不等於完全健康。
針灸治療:少氣和平人，病機在天樞以下部位，取用足六經穴為主治療。隨經補足三里，提插補氣海，隨經補太淵。
3.脈息比>5 脈躁，實證/熱證 ，大柴胡湯。針灸瀉手陽經，補手陰經。陽氣浮越在外，陰不能斂陽。
針灸治療：脈躁病機在天樞以上部位，取用手六經穴治療。取穴: 瀉二間，補魚際，瀉支溝。
人以胃氣為本，無論少氣、脈躁、平人、均以調胃氣為先。
討論
1. 該病人屬於病危狀況。單從記錄的脈息比觀察，該病人從住院到出院，病情是在不斷地變化：因感染社區肺炎有發熱，心跳及脈搏增快，呼吸困難而入院時，脈息比為6.6為脈躁；經治療後病情好轉，脈息比為5.3，但因跌倒而昏迷進入ICU，在ICU第一周，其脈息比在3.0-4.0之間，為少氣；隨著中西醫的治療，起脈息比有所改變為4.5，變成了平人脈。是否可以認為該病人病情有所好轉呢？顯然，該病人是昏迷狀態，這就應了李老師在講課中所講到的平人不等於健康。可能是寒熱夾雜，病情危重。在診治此病人時，深有體會。
2.因為病人神誌不清，所以我們給病人通過胃管服用了安宮牛黃丸，但用了中藥以後血壓升高了，脈息比降低了3.4。服藥觀察一周後，她的脈息比4.1—4.6。是不是說明服用安宮牛黃丸以後，病人神誌有所改善呢？
3.脈息比在臨床上可以給我們一個觀察病情的參考數據，就像在臨床上，西醫應用MRI和心電圖給病人診斷一樣，臨床上還是要根據病人的具體情況，綜合考慮給病人治療，才能達到最佳效果。此病人有頑強的生命力，也藉助於西方現代醫學的研究成果，和有東方傳統經典中醫的獨特功效。
4.李老師的第一講提出長桑君脈法的脈息比重要性，更提出少氣，平人和脈躁的解決方案，通過對本例病人病情的觀察，個人認為是具有重要的臨床指導作用。
注：上文提到的長桑君是戰國時期的傳奇醫生，是《南經》著名作者扁鵲的老師。
作者簡介：
李紅梅，資深針灸師，美國洛杉磯西奈山醫學中心
李樹森，长桑君脉法创始人，瑞士华人中医药学会学术顾问
