Asthma is principally characterized by air hunger, to the point of necessitating breathing with open mouth and raised shoulders and by refusal or inability to lie down. As a symptom, asthma may appear in the course of various acute and chronic illnesses. When it becomes the main symptom at a certain stage of these illnesses, it is called asthma syndrome.
Etiology and Pathology
The basic pathogenic factor of asthma syndrome is either exogenous attack or internal injury. Exogenous attack is invasion by the climatic pathogenic evil of Wind, Cold, Dryness or Heat, or a combination of these. A variety of internal injuries may also lead to asthma syndrome.
Attack by Climatic Evils. The climatic evils invade the body via the body surface, mouth and nose. The skin and hair are the external counterpart of the lung and the lung opens to the outside via the nose. When exogenous evils invade the body the exterior-Defensive Level becomes blocked. This in turn leads to failure of lung-Qi to disperse normally, stagnation of lung-Qi and failure of the lung’s functions of depuration and descent. As a result breathing becomes rapid and urgent, giving rise to asthma syndrome.
Injury by Passions. Excessive passion affects the normal physiological functions of the viscera and induces disharmony between them. As with exogenous evils this may lead to stagnation of lung-Qi and loss of its dispersion and depuration. At the same time, extreme passion is also one of the causes of the production of Phlegm and Rheum. The reason is that excessive passions cause illness mainly by disturbing the liver, which controls conveyance and dispersion. When excessive rage injures the liver, liver-Qi moves abnormally and injures the spleen and the kidney.
Accumulation of Phlegm and Rheum. Phlegm and Rheum are pathological products of body fluids. Phlegm arises when Fire scorches body fluids and Rheum arises when Cold induces gelling of body fluids. Phlegm and Rheum are closely related and each can cause and result from the other. The thick and turbid is Phlegm and the clear and thin is Rheum. “Phlegm is thickened Rheum and Rheum is thinned Phlegm.” Both can attack the lung and block the lung’s meridians, thus leading to asthma.
Improper Diet. Overeating especially of rich and spicy foods may lead to food retention and impaired digestion. This disturbs the functions of the spleen and the stomach, and the retained foods may transform into turbid Phlegm or Fire. The ascending and descending activities of Qi become compromised, and asthma may ensue.
Fatigue, Excessive Sexual Activity and Chronic Illness. Fatigue, excessive sweating, chronic cough, chronic Phlegm-Heat, Rheum, frequent attacks by exogenous evils, and chronic illness can all lead to deficiency of lung-Qi and lung-Yin. Impaired Qi regulation leads to shortness of breath, wheezing and gasping respiration.
The kidney resides in the lower-jiao. It is the root of Qi and governs the reception of Qi. If the kidney is injured by excessive sexual activity or weakened by chronic illness, it becomes insufficient. Kidney insufficiency leads to the failure of acceptance and regulation, so that exhalation becomes prolonged and inspiration shortened. Any physical exertion aggravates the gasping respiration and wheezing. The kidney also regulates water and houses the Fire of the Vital Gate. If Vital Gate Fire weakens, for example by excessive sexual activity, water metabolism becomes impaired. Excess water overflows upward and transforms into Phlegm-Rheum, again leading to asthma.
Pathology. The fundamental pathological process is disordered functions of the lung, the spleen and the kidney. Asthma due to attack by exogenous pathogenic evil is an illness of strength. Asthma due to internal injury may be of strength or of deficiency.
In general, in asthma of the strength type illness is located in the lung. This may be due to lodging of Wind-Cold in the interior, lung attack by Wind-Heat or accumulation and gelling of turbid Phlegm causing stagnation of liver-Qi, which in turn causes blockage of lung-Qi. Thus, the key abnormality is disturbance of lung-Qi activities.
In asthma of the deficiency type, the illness is located in the kidney. This may be due to exhaustion, chronic illness, sexual overindulgence or deficiency of genuine Qi. The key abnormality is impairment of the kidney’s ability to receive Qi, which in turn leads to impairment of the lung-Qi to disperse and depurate.
In complex cases, there may be lower (kidney) deficiency and upper (lung) strength.
If the lung and the kidney are both insufficient, the illness is severe and serious. When the isolated Yang is on the verge of collapse, the heart is frequently affected so that heart-Qi becomes deficient as well. In such a situation, severe wheezing and profuse sweating exhaust both Yang and Yin.
Clinical Manifestation
In asthma syndrome of the strength type, the illness develops rapidly. Respiration is coarse and loud, sometimes necessitating an open mouth and elevation of the shoulders. In asthma of the deficiency type, the illness develops more gradually but there may be anxiety and urgency in respiration. Exhalation is prolonged and inhalation is shortened. Physical exertion tends to aggravate the respiratory symptoms.
Asthma differs from wheezing and dyspnea. Clinically asthma is seen in the course of a variety of illnesses, both urgent and gradual. Wheezing is an illness that stands on its own. Wheezing is always accompanied by asthma, and is characterized by recurrence and noisy respiration in the throat. Dyspnea is shortness of breath with inadequate movement of air, as though respiration is unsteady. It resembles asthma but there is no gurgling in the throat and the shoulders are not elevated. It should be noted, however, that dyspnea is often an early stage of asthma.
Key Points of Analysis
Strength versus Deficiency. Asthma that begins abruptly, has a rapid course and shows symptoms of the exterior is mostly an illness of strength. Asthma that begins gradually, has a longer course, recurs and does not show symptoms of the exterior is mostly an illness of deficiency.
An illness is of the strength type if the following apply. Respiration is deep and prolonged. The face is flushed, and the body is warm. The tongue is red, with a thick and greasy or yellow and dry coating. The pulse is floating, large, slippery and rapid.
An illness is of the deficiency type if the following apply. Respiration is shallow and weak, and exhalation is longer than inhalation. The patient is anxious. The complexion is pallid or dusky, and there is cold sweat on the forehead. The tongue is pale, with white and smooth or black and moist coating, or without coating. The body is wasted or has edema. The pulse is indistinct and feeble or floating, large and hollow.
In some cases, there is a gurgling noise in the throat accompanying asthma. Respiration is intermittent and requires an open mouth and raised shoulders. The patient refuses to lie down. The limbs are cold, with a pallid complexion and sweat pouring out as oily beads. The pulse is difficult to find, as though sometimes present and sometimes absent, in all six positions. These together indicate that genuine Qi is on the verge of collapse, and the illness is critical
Cold versus Heat. In asthma due to attack by exogenous Cold the sputum is thin like water or white and foamy, the complexion is blue-gray and there is no thirst or thirst with preference for warm drinks. The tongue is pale, with white and smooth coating, and the pulse is floating and tight or taut and slow.
In asthma due to attack by exogenous Heat the sputum is difficult to expectorate. It is yellow and viscid or white but viscid. The complexion is red and there is thirst with preference for cold drinks. The tongue is red, with yellow coating that is greasy or dry. The pulse is slippery and rapid.
Herbal Treatment
In treating asthma syndrome of the strength type, the urgent task is to eliminate the pathogenic evil. If the evil is in the exterior, release it. If it is in the interior, purge it. If the cause is Cold-Phlegm, the approach is to apply warming to unblock the lung. If it is Heat-Phlegm, the approach is to apply cooling to clear the lung. If it is Dampness-Phlegm, the approach is to dry Dampness and regulate Qi.
In treating the deficiency type of asthma, the basic approach is to support genuine Qi and restore normal function. This may require strengthening the lung, the spleen or the kidney. Yang deficiency requires warm restoration. Yin deficiency requires nourishment.
In treating asthma with the mixed strength and deficiency conditions, with both Cold and Heat, it is imperative to distinguish between and weigh the primary and the secondary processes and to select the therapeutic approach based on the actual clinical condition.
Strength-Type Asthma
Wind-Cold Constraining Lung
Main Symptoms. Cough, asthma, chest tightness, clear thin sputum; absence of thirst; initially, chills and fever without sweating; headache, body aches; and throat and nasal itch. The tongue is not red and the tongue coating is thin and white. The pulse is floating and tight.
Therapeutic Principle. Release the exterior by acrid-warm herbs, unblock the lung and relieve asthma.
Treatment. Mahuang Tang (Ephedra Decoction) with modifications.
For severe asthma, add zisuzi (Penila) and Qianhu (Peucedanum) to lower abnormally risen Qi and to relieve asthma.
If sputum is copious, add banxia (Pinellia) and juhong (Citrus tangerina) or bile-treated nanxing (Arisaema erubescens) and baijiezi (Brassica) to dry Dampness and dissipate Phlegm.
For chest tightness, add zhiqiao (Poncirus trifoliata), jiegeng (Platycodon) and zisu stem (Perilla).
If asthma persists following diaphoresis or there are wind-intolerance and a floating and even pulse following diaphoresis and fever, use Guizhi Jia Houpo Xingzi Tang (Cinnamon Plus Magnolia and Apricot Decoction) to regulate the Nutritive and Defensive Levels and to lower abnormal risen Qi and stop asthma. Guizhi Jia Houpo Xingzi Tang has the following composition: guizhi (Cinnamomum), baishaoyao (Paeonia), shengjiang (Zingiber), gancao (Glycyrrhiza), dazao (Ziziphus), houpo (Magnolia), and xingren (Prunus armeniaca).
If symptoms of the exterior are not severe, remove guizhi from the formula.
For an elderly patient with a constitution of Qi definciency, there is concern in treating with mahuang and guizhi. Use Shen Su Yin (Ginseng and Perilla Drink) instead.
Exterior-Cold and Interior-Heat
Main Symptoms. Urgent asthma; agitation; yellow and thick sputum, difficult to expectorate; chills and fever, with little or no sweat, and thirst. The tongue coating is thin and white or slightly yellow. The pulse is floating and rapid.
Therapeutic Principle. Release the exterior, purge the interior, dissipate Phlegm and relieve asthma.
Treatment. Ding Chuan Tang (Asthma-Relieving decoction).
If sputum is copious and viscid, add Sichuan beimu (Fritillaria), gualou (Trichosanthes), yuxingcao (Houttuynia), dongguazi (Benincasa hispida) and yiyiren (Coix).
For high fever, add huangqin (Scutellaria) and shigao (gypsum).
For asthma associated with much gurgling in the throat from sputum, add tinglizi (Lepidium) and dilong (Pheretima).
Phlegm-Dampness Blocking Lung
Main Symptoms. Asthma; cough, much viscid sputum, difficult to expectorate; chest tightness; and nausea. The tongue coating is white and greasy, and the pulse slippery.
Therapeutic Principle. Dissipate Phlegm, suppress the abnormally risen Qi, unblock the lung and relieve asthma.
Treatment. San Zi Yang Qing Tang (Three Seeds Decoction for the Aged) and Er Chen Tang (Two Aged-Herbs Decoction) together.
If there is Cold as well, add warming herbs or use Suzi Jiang Qi Tang (Perilla Qi-Suppressing Decoction) to dispel Cold and warm the interior, suppress the abnormally risen Qi and relieve asthma.
If there is Heat as well, add cooling herbs such as huangqin (Scutellaria), gualou seed (Trichosanthes), danxing (Arisaema consanguineum), haigeqiao (Cyclina sinensis) and sangbaipi (Morus).
If abnormally risen Qi is particularly marked, add bitter xingren (Prunus), ziwan (Aster tartaricus) and xuanfuhua (Inula britannica).
Phlegm-Heat Blocking Lung
Main Symptoms. Urgent asthma, chest tightness; yellow viscid or white viscid sputum, difficult to expectorate; flushed face; high fever; and dry mouth. The tongue is red and the coating yellow, greasy but dry. The pulse is slippery and rapid.
Therapeutic Principle. Cool Heat, dissipate Phlegm, unblock the lung and relieve asthma.
Treatment. Ma Xing Shi Gan Tang (Ephedra, Almond, Gypsum and Licorice Decoction). Yiyiren (Coix), dongguaren (Benincasa hispida), dilong (Pheretima) and other herbs are often added to enhance the actions of cooling Heat, dissipating Phlegm and relieving asthma.
If interior Heat is marked, add huangqin (Scutellaria), daqingye (Isatis tinctoria), banlangen (Isatis indigotica) and Qiyeyizhihua (Paris polyphylla) to purge Heat and detoxify poisons.
For sputum that is yellow and has a fishy odor, add yuxingcao (Houttuynia).
If asthma is severe and there is copious sputum, add shegan (Belamcanda), sangbaipi (Morus) and tinglizi (Lepidium).
For constipation and abdominal distention, add juemingzi (Cassia), gualou kernel (Trichosanthes) and dahuang (Rheum palmatum).
Liver-Qi Stagnation with Lung Blockage
Main Symptoms. Sudden and urgent asthma, chest tightness and distention, choking in the throat often precipitated by passion; or, chest pain, mental depression, insomnia and palpitation of the heart. The tongue coating is thin, and the pulse taut.
Therapeutic Principle. Unblock the liver, relieve depression and lower the abnormally risen Qi to relieve asthma.
Treatment. Xiao Yao San (Carefree Powder) modified by removing baizhu and adding yujin (Curcuma), xiangfu (Cyperus), chuanxiong (Ligusticum), zhizi (Gardenia jasminoides) and mudanpi (Paeonia suffruticosa).
For Qi stagnation accompanied by Phlegm, add zisuzi (Perilla), kuxingren (Prunus armeniaca) and chuanpohua (Magnolia).
If there are palpitation of the heart and insomnia, add baihe (Lilium), hehuanhua (Albizia julibrissin), suanzaoren (Ziziphus) and yuanzhi (Polygala).
Alternately, for severe stagnation of liver-Qi and blockage of the lung, instead of modifying Xiao Yao San, use it in combination with Wu Mo Yin Zi (Drink of Five Ground Substances). The latter has the following composition: wuyao (Lindera strychnifolia) 9 g, chenxiang (Aquilaria sinensis) 9 g, binglang (Areca catechu) 6 g, zhiqiao (Poncirus trifoliata) 9 g and muxiang (Aucklandia lappa) 6 g.
Deficiency-Type Asthma
Insufficiency of Spleen and Lung
Main Symptoms. Urgent asthma, shortness of breath, tiredness, cough and thin sputum. There usually are additional symptoms, as follows: spontaneous sweating, wind-aversion, pallid complex, pale tongue and threadlike and feeble pulse; or, flushed complexion, dry mouth, throat discomfort, night sweats, a red tongue with little coating or exfoliate coating and threadlike and rapid pulse; or, anorexia, epigastric distention and discomfort following meals, loose feces or defecation promptly after eating or sensation of incomplete defecation, wasting of muscles, and copious sputum.
Therapeutic Principle. Strengthen the spleen and augment Qi (Invigorate the Earth Element to generate the Metal Element).
Treatment. Bu Zhong Yi Qi Tang (Middle-Restoring and Qi-Augmenting Decoction) combined with Sheng Mai San (Pulse-Generating Powder).
If sputum is thin, the body is cold and there is no thirst, there is deficiency-Cold in the lung. Remove maimendong and add ganjiang (Zingiber) to warm and nourish Yang-Qi.
If lung-Yin is deficient, use Sheng Mai San with added baihe (Lilium), nan-shashen (Adenophora tetraphylla, axilliflora, pereskiaefolia), beishashen (Glehnia) and yuzhu (Polygonatum). Alternately, use Baihe Gu Jin Tang (Lily Metal-Solidifying Decoction).
Depletion of Kidney-Yang
Main Symptoms. Chronic asthma, more exhalation than inhalation, aggravated by even slight activity, shortness of breath, much thin sputum; timidity; sweating; cold limbs, aching waist; nocturia, edema in the face and legs; lassitude, and dispiritedness. The tongue is pale. The pulse is deep, threadlike and forceless, or taut, large and depletive.
Therapeutic Principle. Warm the kidney and restore its ability to receive Qi.
Treatment. Jin Gui Shen Qi Wan (kidney-Qi Pill from the Golden Cabinet). It has the following composition: shudihuang (Rehmannia) 12 g, shanyao (Dioscorea) 12 g, shanzhuyu (Cornus) 12 g, fuling (Poria) 9 g, zexie (Alisma) 9 g, mudanpi (Paeonia suffruticosa) 9 g, guizhi (Cinnamomum) 3 g, and fuzi (Aconitum) 3 g.
Renshen (Panax) may be added to enhance augmentation of lung-Qi if it is a case of singnificant deficiency of Qi.
If deficient kidney-Yang is unable to metabolize water, so that Rheum forms and floods upward, use Zhen Wu Tang (True Warrior Decoction) combined with Ling Gui Zhu Gan Tang (Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction), with an increased amount of fuzi.
If Phlegm is abundant and causes much blockage, with upper strength and lower deficiency, add as clinically appropriate the following herbs to supper abnormally risen Qi and dissipate Phlegm: zisuzi (Perilla), Qianhu (Peucedanum), haigeqiao (Cyclina sinensis), xingren (Prunus armeniaca), juhong (Citrus tangerina) and cheqianzi (Plantago).
If asthma is severe, with agitation, fearfulness, cold limbs, sweat like oily droplets, a floating, large and rootless or swift, rapid and vague pulse, the condition is critical for collapse of both Yin and Yang. This requires emergency treatment with Shen Fu Tang (Ginseng-Aconitum Decoction) with added longgu (fossil bone), muli (Ostrea), guizhi pith (Cinnamomum), gejie (Gekko gecko), zishiying (fluorite), wuweizi (Schisandra) and maimendong (Ophiopogon) and in combination with Hei Xi Dan (Black Tin Pill). This treatment is designed to rescue genuine Qi, prevent collapse and stabilize kidney-Qi. Hei Xi Dan has the following composition: chuanlianzi (Melia), huluba (Trigonella foenum-graecum), muxiang (Aucklandia), fuzi (Aconitum), roudoukou (Myristica), buguzhi (Psoralea), chenxiang (Aquilaria), xiaohuixiang (Foeniculum vulgare), yangqishi (actinolite), rougui (Cinnamomum), heixi (tin), and liuhuang (sulfur).
Deficiency of Kidney-Yin
Main Symptoms. Asthma, aggravated by exertion, shortness of breath; tinnitus; aches in the waist; dry mouth; agitation; hotness in the palms and soles; flushed face; recurrent fever, night sweats; and yellow urine. The tongue is red, and the pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin, replenish essence and receive Qi to relieve asthma.
Treatment. Qi Wei Du Qi Wan (Seven-Ingredient All-Qi Pill) or Heche Da Zao Wan (Placenta General Restorative Pill).
Qi Wei Du Qi Wan has the following composition: shudihuang (Rehmannia) 15 g, shanzhuyu (Cornus) 12 g, slightly baked shanyao (Dioscorea) 12 g, mudanpi (Paeonia suffruticosa) 10 g, peeled fuling (Poria) 10 g, de-haired zexie (Alisma) 10 g, and wuweizi (Schisandra) 3 g.
He Che Da Zao Wan has the following composition: ziheche (human placenta) 15 g, shengdihuang (Rehmannia) 10 g, guiban (Chinemys) 10 g, huangbai (Phellodendron) 10 g, duzhong (Eucommia) 10 g, renshen (Panax) 10 g, tianmendong
(Asparagus chochinchinensis) 10 g, maimendong (Ophiopogon) 10 g, niuxi (Achyranthes) 10 g, sharen (Amomum) 6 g, and fuling (Poria) 12 g.
If genuine Qi is on the verge of collapse, with severe asthma, it is appropriate to treat with Renshen Hutao Tang (Ginseng-Juglans Decoction), Shen Ge San (Ginseng-Gecko Powder) or Ziheche Fen (Placenta Powder).
If there is deficiency of lung-Yin as well, add Sheng Mai San (Pulse-Generating Powder) and Baihe Gu Jin Tang (Lily Metal-Solidifying Decoction).
Acupuncture Treatment
Strength-Type Asthma
Wind-Cold Constraining Lung. The therapeutic method is to unblock the lung and to dispel Cold. Select the acupoints Lieque (LU-7), Tanzhong (CV-17), Feishu (BL-13), Fengmen (BL-12) and Hegu (LI-4). Apply the reducing method and add moxibustion.
Phlegm-Heat Blocking Lung. The therapeutic method is to dissipate Phlegm and purge Heat. Select the acupoints Chize (LU-5), Zhongfu (LU-1), Fenglong (ST-40) and Dingchuan (EX-BA-1). Use filiform needles and apply the reducing method.
Deficiency-Type Asthma
Deficiency of Lung-Qi. The therapeutic method is to augment lung-Qi. Select the acupoints Tanzhong (CV-17), Zhongfu (LU-1), Feishu (BL-13), Taiyuan (LU-9), Zusanli (ST-36). Apply the reinforcing method and add moxibustion.
Failure of Kidney to Receive Qi. The therapeutic method is to strengthen the kidney and enable it to receive Qi. Select the acupoints Feishu (BL-13), Gaohuang-shu (BL-43), Shenshu (BL-23), Qihai (CV-6), Guanyuan (CV-4), Zusanli (ST-36), Taixi (KI-3) and Chuanxi. (Chuanxi is an extra-meridian acupoint; it is located 1 cun lateral to the acupoint Dazhui, GV-14.) Apply the reinforcing method and add moxibustion.
Case Study
The patient was a 65-year old female who had chronic asthma and cough. Ten days earlier, during winter, she walked in the open country during the night and was exposed to wind and cold. Shortly thereafter, her asthma worsened markedly, with shortness of breath and gurgling in the throat. The cough also worsened and produced much sputum that was thin but foamy. She refused to lie down flat, and felt tightness in the chest. She had mild chills and fever, which did not subside with sweating.
Her tongue coating was white, greasy and moist. Her pulse was threadlike and slippery. The chest was distended, with reduced respiratory vital capacity.
Diagnosis. Asthma due to exogenous evils attacking the exterior and the Defensive Level. This activated Cold and Phlegm in the lung, leading to failure of lung-Qi to disperse.
Therapeutic Principle. Warm the lung and dissipate Phlegm.
Treatment and Course. The patient was treated with the herbal formula with the following composition: processed mahuang (Ephedra) 3 g, guizhi (Cinnamomum) 3g, baishaoyao (Paeonia) 10 g, xixin (Asarum) 1.5 g, ganjiang (Zingiber) 3g, wuweizi (Schisandra) 3 g, processed banxia (Pinellia) 6 g, parched zisuzi (Perilla) 10 g, roast baiqian (Cynanchum) 6 g, and fried gancao (Glycyrrhiza) 3 g.
Following three daily doses, the mild chills and fever resolved and the asthma improved but persisted. The patient continued to cough, with gurgling and much sputum. The tongue coating was dirty and greasy. The formula was modified as follows. Wuweizi was removed and baijiezi (Brassica) 5 g, parched laifuzi (Raphanus) 10 g and roast ziwan (Aster tartaricus) 10 g were added.
After two daily doses, asthma and paroxysmal cough both resolved. Sputum became scant. Chest tightness resolved. The therapeutic gains were consolidated by an additional day of treatment, and the patient was then discharged from hospital.
