Wheezing is a condition that flares up paroxysmally. It falls in the category of latent Rheum accumulation among illnesses of Phlegm-Rheum. It is characterized by a whistling sound during exhalation, rapid breathing and dyspnea. In severe cases the patient has great difficulty breathing in a recumbent position and prefers to be upright.
Etiology and Pathology
In general the basic pathology that produces wheezing is Phlegm lodged in the interior and stimulated to act by a new exogenous pathogenic agent attacking the body. It blocks the air passages and impairs the dispersion and descent of lung-Qi. Phlegm is an abnormal product, the result of transformation from the body fluids.
The spleen is located at the center of the body. It governs the transportation and transformation of the essences of food as well as fluids; hence it is said, “the spleen is the source of Phlegm.” However, disturbance of the functions of the other visceral organs can also produce Phlegm, and at the same time the process cannot be severed from the influence of the many exogenous pathogenic agents on the human body. For example, when Wind-Cold or Dryness-Heat attack the lung, these exogenous evils may become lodged in the lung system and impair the movement of both Qi and fluids, and after many days turbid Phlegm is formed. An inappropriate diet, such as excessive raw and cold foods, foods of strong flavors, or foods laden with fats or sweets, may lead to injury of the spleen. Inhaled pollen, fumes and noxious gases, as well as cigarette smoke over many years can also irritate the air passages and cause the production of Phlegm.
In addition, in certain situations in which genuine Qi becomes injured or deficient Phlegm may also form. These include frustration of the passions, impairment of Qi flow leading to Qi stagnation, weakening of the body following a major illness and not properly managed, impairment of the functions of various visceral organs, inherent deficiency of kidney-Qi leading to diminished resistance, deficiency of lung-Qi, and deficiency of Yin permitting the rise of endogenous Heat.
Whenever Phlegm is formed and permitted to lodge in the interior, it may gel and not dissipate. In this state, when stimulated by an additional pathogenic agent it can stir, follow Qi in movement and accumulate in the lung system. In this way it is potentially an ever-present cause of wheezing.
The lung governs Qi movement and regulates respiration. It links with the skin and hair on the surface and is responsible for the functions of dispersion and depuration. Failure of lung-Qi to disperse and descend is the basic mechanism leading to wheezing. Since turbid Phlegm often lodges in the lung, “the lung is the container of Phlegm.” Because Phlegm tends to remain in the body it gradually wears down genuine Qi. If the spleen now becomes insufficient, so that its transportation and transformation functions are impaired, then new Phlegm is formed. If lung-Qi is depleted the resistance of the Defensive Level is weakened, allowing exogenous agents to attack effectively or endogenous factors to arise. In such circumstances, Phlegm readily compromises the dispersion and depuration actions of lung-Qi, forcing it to rise abnormally and resulting in wheezing, rapid breathing and dyspnea.
Clinical Manifestation
Wheezing is typically associated with air hunger, gasping wet-sounding whistling in the throat, cough with sputum and chest tightness. The whistling characteristically resembles the croaking of frogs.
It tends to develop abruptly or follows chills and fever, sneezing, nasal and throat itch, cough or chest tightness, nausea and vomiting, abdominal distention, or emotional distress. It tends to worsen. The patient has difficulty breathing, with a prolonged exhalation phase, and often resists lying down. Coughing tends to be unproductive, but may bring up mucoid or water-like sputum; and if the patient is able to expectorate mucoid sputum the wheezing may be briefly alleviated. If wheezing is severe, the patient may attempt to breathe with an open mouth and raised shoulder (to strengthen expansion of the chest). There may be palpitation of the heart, anxiety and agitation, profuse cold sweat on the forehead, cyanosis of the lips, bulging of the eyeballs and distress. Each attack of wheezing may last a few minutes, several hours or even several days.
During remission patients may be free of all symptoms or may have mild productive cough or slight shortness of breath. If the illness is chronic and the attacks recurrent, even during remission there may be gasping breathing, noisy breathing, spontaneous sweating with wind-intolerance, fatigue, emaciation, flank aches and edema.
In general, wheezing first appears during childhood, and may be precipitated by Wind injury, seasonal changes, excessive fatigue, intemperate diet, and irregular living habits. It often recurs repeatedly over several years or several decades. Wheezing attacks show a strong relationship to seasons, occurring most commonly between early autumn and early winter, and next most commonly during spring. Few attacks occur in summer. Some patients, however, have attacks all year round.
Wheezing is often hereditary and affects relatives as well.
Key Points of Analysis
Wheezing is the result of combined exogenous evil strength and genuine Qi deficiency. During an attack the exogenous evil is the principal factor; during remission genuine Qi deficiency is the principal factor. New onset wheezing is mainly due to strong exogenous evil; chronic recurrent wheezing is often due to Qi deficiency of the lung, the spleen and the kidney.
Exogenous wheezing may be precipitated by Cold or Heat. If precipitated by Cold it is known as Cold-wheezing. In general, Cold is in both the interior and the exterior. Its main symptoms are respiration that sounds like frog-croak, cough with thin-clear or white-foamy sputum, no thirst, a pale tongue with white and smooth coating, and floating and tight pulse. If precipitated by Heat it is known as Heat-wheezing. In this case, generally Phlegm and Fire are both strong. Its main symptoms are coarse breath sounds that resemble sawing, barrel chest, cough, yellow and viscid sputum that is difficult to expectorate, thirst with desire to drink, a red tongue, yellow and greasy tongue coating, and a slippery and rapid pulse.
Deficiency wheezing may be due to Qi deficiency of the lung, the spleen or the kidney. In deficiency of lung-Qi wheezing is associated with spontaneous sweating, wind-intolerance, shortness of breath, and weakness. In deficiency of spleen-Qi it is associated with anorexia, diarrhea, and copious sputum. In deficiency of kidney-Qi it is associated with lumbar aches, tinnitus, and wheezing and fatigue on engaging in any activity.
Herbal Treatment
In treating wheezing, during an attack treat the symptom (appearance). During remission from wheezing treat the cause (root). During an attack the focus is on unblocking the lung and eliminating Phlegm. During remission the focus is on the diseased visceral organ.
During Attack
Cold-Wheezing
Main Symptoms. Initially, cold-aversion, fever, headache, no sweating, cough, dyspnea, itch in the throat, nose or body, and watery nasal discharge. There follow worsening of dyspnea, wheezing, and frog-croak-like gurgling in the throat. Additionally, there may be cough that produces thin sputum, refusal to lie down, chest distention and tightness, a pallid or bluish-gray complexion, coldness in the back, no thirst or thirst with preference for warm drinks, a pale tongue with white and smooth coating, and a floating and tight pulse.
Therapeutic Principle. Unblock the lung, dispel Cold, dissipate Phlegm and relieve wheezing.
Treatment. Shegan Mahuang Tang (Belamcanda-Ephedra Decoction) and Xiao Qing Long Tang are commonly used.
Shegan Mahuang Tang is especially suitable for Cold in both interior and exterior with persistent cough. Its composition is as follows: shegan (Belamcanda) 9g, mahuang (Ephedra) 9g, shengjiang (Zingiber) 12 g, xixin (Asarum) 9g, ziwan (Aster tartaricus) 9 g, kuandonghua (Tussilago farfara) 9 g, wuweizi (Schisandra) 3 g, dazao (Ziziphus) five pieces and processed banxia (Pinellia) 9 g.
Xiao Qing Long Tang is especially suitable for Cold in the exterior and Rheum in the interior. If turbid Phlegm is particularly abundant, add laifuzi (Raphanus) and baijiezi (Brassica alba).
For the chronically ill with deficiency of genuine Qi, frequently recurring attacks of wheezing and strong Phlegm, use Suzi Jiang Qi Tang to dissipate Phlegm and regulate Qi and complement it with Jun Zi Tang to strengthen the spleen and dissipate Phlegm.
Heat-Wheezing
Main Symptoms. Fever, headache, sweating, shortness of breath, barrel chest, coarse and gurgling wheeze in the throat, open mouth, raised shoulders, refusal to lie down, yellow and viscid sputum, chest tightness, agitation and anxiety, flushed face, thirst with desire to drink, and constipation. The tongue is red, with a yellow greasy or smooth coating. The pulse is slippery and rapid.
Therapeutic Principle. Unblock the lung, cool Heat, dissipate Phlegm and facilitate Qi movement.
Treatment. Ding Chuan Tang (Asthma-Relieving Decoction).
For thick and viscid sputum, add zhuru (Phyllostachys nigra), Sichuan beimu (Fritillaria), whole gualou (Trichosanthes), yuxingcao (Houttuynia), sangbaipi (Morus) or similar herbs that cool Heat and dissipate Phlegm.
If the wheezing is especially severe, add xingren (Prunus armeniaca) and dilong (Pheretima). If the mouth is dry and the tongue is red, add nanshashen (Adenophora tetraphylla) and tianhuafen (Trichosanthes).
For Phlegm and blazing Fire injuring the fluids, causing a yellow and dry tongue coating and constipation, use Mengshi Gun Tan Wan to purge Phlegm and Heat, or Da Cheng Qi Tang combined with Xiao Xian Xiong Tang (Minor Lung-Clearing Decoction) to clear the viscera and to purge Heat.
During Remission
Deficiency of Both Spleen and Lung Qi
Main Symptoms. Shortness of breath, cough with thin clear sputum; pale complexion: spontaneous sweating with wind-aversion; anorexia, loose stool; and edema of head, face and limbs. The tongue is pale and plump, with indentations along the edges, and the tongue coating is pale white. The pulse is soft and feeble.
Therapeutic Principle. Strengthen the spleen and augment Qi of the lung (invigorate Earth to generate Metal).
Treatment. Si Jun Zi Decoction, often with added shanyao (Dioscorea) and yiyiren (Coix) for their sweet flavor and bland nature to strengthen the spleen and wuweizi (Schisandra) to promote the acceptance of Qi by the lung.
For deficiency of Defensive Qi with spontaneous sweating add fried huangqi (Astragalus), fuxiaomai (Triticum) and dazao (Ziziphus). If this is ineffective, further add fuzi (Aconitum), longgu (fossil bone) and muli (Ostrea) to astringe sweat and strengthen Defensive Qi.
For poor appetite, abdominal distension and much sputum add processed banxia (Pinellia), chenpi (Citrus tangerina) and Qianhu (Peucedanum).
For pale complexion, cold body and loose stool, add guizhi (Cinnamomum) and ganjiang (Zingiber) to warm the spleen and the lung and to resolve fluid retention.
Insufficiency of Both Lung and Kidney
Main Symptoms. Cough with shortness of breath; rapid breathing on activity; spontaneous sweating with wind-aversion; lumbar and knee aches and weakness; tinnitus; night sweats; and spermatorrhea. The tongue is pale and the pulse is feeble.
Therapeutic Principle. Nourish the lung and the kidney simultaneously.
Treatment. Si Jun Zi Tang combined with Jin Shui Jun Jian. The composition of Jin Shui Jun Jian is as follows: danggui (Angelica) 10 g, shudihuang (Rehmannia) 15 g, chenpi (Citrus tangerina) 6g, banxia (Pinellia) 10 g, fuling (Poria) 12 g and fried gancao (Glycyrrhiza) 6 g.
If deficiency of lung-Qi is the principal abnormality, add huangqi (Astragalus), shanyao (Dioscorea) and herbs with similar actions.
If deficiency of lung-Yin is the principal abnormality, add maimendong (Ophiopogon), baihe (Lilium) and beishashen (Glehnia).
If deficiency of kidney-Yang is the principal abnormality, add buguzhi (Psoralea), pieces of lujiao (Cervus nippon), tusizi (Cuscuta), and yinyanghuo (Epimedium).
If deficiency of kidney-Yin is the principal abnormality, add shanzhuyu (Cornus), zishiying (fluorite) and the gelatin from guiban (Chinemys).
Wheezing Crisis (Abrupt Collapse of Yang-Qi)
Main Symptoms. During the course of wheezing, the patient may develop abrupt vomiting and diarrhea, muscular cramps or tetany, severe fatigue, facial cyanosis, oily sweat, coldness in all limbs, cyanosis of the tongue with a smooth white coating, and a pulse that is indistinct and on the verge of cessation.
Therapeutic Principle. Restore Yang and rescue the patient from collapse.
Treatment. Si Ni Decoction with added renshen (Panax).
If the face and the tongue are purple, add taoren (Prunus persica) and honghua (Carthamus) to mobilize blood and remove stasis.
If there is collapse of Yang-Qi and depletion of body fluids, the treatment is to restore Yang, consolidate Yin, augment Qi and re-activate the pulse. Use Hui Yang Ji Jiu Tang (Emergency Yang-Rescue Decoction). Its composition is as follows: processed fuzi (Aconitum), ganjiang (Zingiber), rougui (Cinnamomum), renshen (Panax), baizhu (Atractylodes), fuling (Poria), chenpi (Citrus tangerina), fried gancao (Glycyrrhiza), wuweizi (Schisandra), processed banxia (Pinellia) and shexiang (Moschus).
Acupuncture Treatment
Illnesses of Strength. Acupuncture is suitable. The most commonly selected acupoints are Dazhui (GV-14), Shenzhu (GV-12), Fengmen (BL-12), Feishu (BL-13), Fenglong (ST-40), Tanzhong (CV-17), Quchi (LI-11), Hegu (LI-4), Waiguan (SJ-15), Shangyang (LI-1) and Yuji (LU-10).
For Cold-wheezing select Tanzhong (CV-17), Feishu (BL-13), Fengmen (BL-12) and Lieque (LU-7). Use the reducing method and apply moxibustion.
For Heat-wheezing select Zhongfu (LU-1), Feishu (BL-13), Chize (LU-5) and Fenglong (ST-40). Use filiform needles and the reducing method.
Illness of Deficiency. Moxibustion is suitable. The most commonly selected acupoints are Feishu (BL-13), Xuanji (CV-21), Tanzhong (CV-17), Tiantu (CV-22), Qihai (CV-6), Guanyuan (CV-4), Gaohuang (BL-43), Shenque (CV-8), Sanyinjiao (SP-6), Shenshu (BL-23), Fuliu (KI-7) and Mingmen (GV-4).
Case Study
The patient was a 28-year old female. She had recurrent wheezing attacks for over 3 years. Despite repeated treatment with anti-asthma drugs, antibiotics and high-dose glucocorticoids, as well as Chinese medicines and cutting of the acupoint Tanzhong (CV-17), the attacks became more frequent and more severe during the past year. She was transferred from another hospital.
At the time of admission her main symptoms were frog-croak-like respiration with gurgling, cough, shortness of breath and refusal to lie down. Her sputum was expectorated with difficulty, and was white, sticky and foamy, or sometimes yellow and viscid. She had chest tightness and pain, aggravated by cough. Her throat was itchy and her mouth dry.
The patient sat upright and refused to lie flat. She was restless and agitated. She had cold-aversion and her hands and feet were cold. Her respiration was rapid and shallow, at a rate of 64 breaths per minute. She was covered with sweat. Her face was flushed, and her lips and nail beds were cyanotic. The tongue was red, with pale yellow and greasy coating, and her pulse was threadlike and slippery. Auscultation of the lung revealed wheezing throughout and fine rales in the left lower lung.
Diagnosis. Wheezing illness.
Therapeutic Principle. Started with the accumulation of Phlegm and Heat in the lung and treated its loss of dispersion and descending functions. Used the method of cooling Heat, to unlock the lung and dissipate Phlegm.
Treatment and Course. The prescription was based on a combination of Ding Chuan Tang and Ma Xing Shi Gan Tang. The combined composition is as follows: fried mahuang (Ephedra) 3 g, Guangdong xingren (Prunus armeniaca) 10 g, shigao (gypsum) 30 g (decoted first), gancao (Glycyrrhiza) 3 g, zhimu (Anemarrhena) 6 g, huangqin (Scutellaria) 6g, shegan (Belamcanda) 5 g, sangbaipi (Morus alba) 10 g, processed banxia (Pinellia), haifushi (pumice) 10 g and lugen (Phragmites) 30 g.
Following administration of this herbal formula cough and wheezing improved noticeably. After a week of successive daily doses fever, agitation, and flushed face were resolved, and wheezing disappeared. The patient still had a dry cough, occasionally producing viscous sputum. She had abnormal Fire and Qi in the throat causing a dry mouth and throat and red lips. These residual symptoms indicated that the gelled Phlegm and Heat had injured Yin and fluids. The prescription was altered by removing mahuang, banxia and shegan, and adding nanshashen (Adenophora tetraphylla), tianmendong (Asparagus chochinchinensis) and gualou (Trichosanthes) to nourish Yin and generate fluids. The patient completely recovered. After consolidating the therapeutic effect, she was discharged from hospital.
