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Asthma

Dr. Brian Grosam

Definition: Asthma affects approximately 25+ million Americans today. It’s a pulmonary disorder characterized by wheezing and dyspnea due to obstruction and inflammation of the airways. Asthma may be triggered by allergy, exertion, irritant particles, weather, psychological stress, etc.

Etiology: There are many causes of asthma. Allergens such as pollens, smoke, molds, house dust and animal hair may trigger an asthma attack. Asthma may also be induced by non-allergy related factors such as exertion, cold air, stress, anxiety, crying, hearty laughing, and viral infection. Common morbidity associated with asthma includes sinusitis, allergic rhinitis, gastroesophageal reflux, cardiovascular disease, diabetes, obesity, and hyperthyroidism.

Clinical Manifestations: In an asthma attack, there will be a combination of spasm of the bronchi, inflammation of the airways, and increased mucous secretion. In mild to moderate cases, the patients will experience shortness of breath, wheezing, hyperpnea, and use of accessory muscles (such as neck and chest muscles) to facilitate breathing. Anxiety and sweating are commonly seen in asthmatics as they struggle for air. In severe cases, the patients will experience marked respiratory distress, cyanosis, use of accessory muscles, wheezes, lethargy and possibly confusion. Patients with severe asthma may not have any wheezing, as there is very little air moving in and out of the lungs.

Diagnosis: Asthma is diagnosed based on the characteristic episodes of wheezing, coughing, dyspnea or chest tightness interspersed with asymptomatic intervals. Objective confirmation is made with repeated spirometry tests performed over symptomatic and asymptomatic periods. Spirometry is a device that measures the breathing capacity of the lungs and is helpful in making the diagnosis, assessing the severity of the illness, and monitoring the effectiveness of the treatment. If the asthma is allergy-induced, identification of the allergen is very important. Skin test for allergen, blood test for antibodies, and Inhalation Bronchial Challenge Test may assist in identifying the correct culprit. Allergic skin test helps to identify the allergen, but an allergen that causes an allergic reaction on the skin may not necessarily induce an asthma attack. Blood test for antibodies helps to determine the degree of sensitivity to that specific allergen. Additionally, an Inhalation Bronchial Challenge Test can be done to confirm the direct correlation between an allergen and an initiation of asthma attack. Since the patient will have to inhale a diluted solution of the allergen in the challenge test, there is a slight risk of a severe asthma attack.

Treatment: Drug treatments of asthma include management of an acute attack and maintenance on a daily basis. Five groups of drugs are commonly used for treating asthma.

Beta-adrenergic Drugs: Beta-adrenergic drugs are bronchodilators that relax smooth muscle and widen the airways. They are commonly used for relieving sudden attacks of asthma and preventing exercise-induced asthma. Common examples of Beta-adrenergic drugs include epinephrine (Primatene Mist or AsthmaHaler), isoproterenol (Isuprel), metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire) and albuterol (Proventil or Ventolin). Common side effects of Beta-adrenergic drugs include increased Heart rate, nervousness, restlessness, headache and muscle tremors. *This type of treatment actually makes the problem worse in the long run.

Theophylline: Theophylline also relaxes bronchial smooth muscle and is commonly used to treat and/or prevent bronchial asthma. Common trade names of theophylline include Theo-Dur, Theo-24, Uniphyl and Slo-bid. Common side effects of theophylline include nausea, vomiting, nervousness, restlessness, insomnia, and in severe cases, seizures and arrhythmia.

Corticosteroids: Corticosteroids block the inflammatory response and reduce the asthma symptoms. Systemic corticosteroids (such as prednisone) may be used to treat acute asthma attack and inhalation of corticosteroids (such as Azmacort) may reduce the likelihood of asthma attack through desensitization to allergens. Though effective, long-term use of corticosteroids has a wide range of side-effects including but not limited to poor wound healing, decreased immunity, retarded growth in children, GI bleeding, hunger and weight gain.

Cromolyn (Intal): Cromolyn (Intal) inhibits the release of inflammatory substances from mast cells and is used to prevent but not treat asthma. When taken regularly, cromolyn (Intal) is especially helpful in patients who have exercise-induced asthma. Cromolyn (Intal) is relatively safe but has occasional side-effects such as cough and hoarseness.

Anticholinergic Drugs: Anticholinergic drugs produce bronchodilation by preventing smooth muscle contraction. Anticholinergic drugs are less potent and have a slower onset of action in comparison with beta-adrenergic drugs. Examples of anticholinergic drugs include atropine and ipratropium (Atrovent).

Traditional Chinese Medicine:

Definition: In Chinese medicine, asthma is called “Xiao Chuan,” which means wheezing and dyspnea, respectively. Chinese medicine classifies xiao and chuan as two separate illnesses with different treatments. Xiao (wheezing) is characterized by a whistling sound during breathing, increased respiration rate, dyspnea and inability to rest in a horizontal position. Chuan (shortness of breath) is characterized by dyspnea, constant opening of mouth to grasp air, raised shoulder, flared nostrils and inability to rest in a horizontal position. Patients with xiao (wheezing) generally will have chuan (shortness of breath), while patients with chuan (shortness of breath) may or may not have xiao (wheezing). In Western medicine, wheezing and shortness of breath are both considered as symptoms, which may be present in many different types of pulmonary syndromes such as asthma, acute bronchitis, chronic bronchitis and emphysema.

Etiology: In Chinese Medicine, there are many factors that may trigger an asthma attack. Examples include the invasion of the external pathogenic factors, diet, emotional disturbances, congenital weakness and chronic illnesses.

External pathogenic factors: Such as cold or heat, commonly induce asthma attacks. Lung dominates the Qi and manifests on the skin. As the environment affects the skin, the change is reflected in the Lung. As the Lung is attacked, its function to regulate water passage becomes impaired, water begins to stagnate and phlegm starts to form. Asthma attacks due to the invasion of external pathogenic factors is most likely to occur when the temperature is cold or if there is a rapid change in weather. External pathogenic factors may also include pollen, cigarette smoke, and any other allergens.

Diet: Can also trigger an asthma attack. Raw and cold food may injure the Spleen and tend to contribute to the stagnation of fluid circulation and the increase in the production of phlegm. Heavy, sweet, and greasy foods tend to create phlegm and heat in the body. Fish, crabs, shellfish and other seafood have also been noted to increase the likelihood of asthma attacks as well.

Congenital weakness and chronic illness: Are also common causes of asthma. Children with asthma generally have congenital Kidney Qi deficiency. On the other hand, chronic illness, such as patients with chronic cough and recurrent cold/flu, are likely to have Lung deficiency.

Pathology: The fundamental cause of asthma is the presence of phlegm. In Chinese Medicine, the passages of water are controlled by three organs, namely Lung, Spleen and Kidney. Lung regulates the water passages in the upper jiao, the Spleen transports and transforms water in the middle jiao, and Kidney dominates water metabolism in the lower jiao. Imbalance of Yin and Yang in any of these three organs may lead to stagnation of the water circulation, which then contributes to the production and storage of phlegm in the Lung. Storage of phlegm in the Lung becomes the main cause for recurrent asthma attacks.

In addition to the phlegm, chronic asthma will lead to deficiency of Lung, Spleen and Kidney. Deficiency of the Lung creates an inability of the Lung to inhale the air, and deficiency of the Kidney creates an inability of the Kidney to receive or grasp air. This will be complicated further if the Spleen is also deficient and there is an excess amount of phlegm that obstruct the airway. Overall, the condition becomes more and more complicated as the underlying syndrome represents a “deficient” condition and the symptoms an “excess” condition.

Asthma Attack: Asthma attack is considered as the acute or excess phase of the illness where urgency of treating the symptoms may outweigh that of the cause. Treatment principles during asthma attacks should focus on lowering the uprising Lung Qi, relieving wheezing (bronchial spasms) and dyspnea, and dissolving the phlegm. Herbal treatment of asthma attack is quite effective. However, severe asthma patients who have been on long-term steroids treatment may not respond as quickly or as effectively to herbal treatment.

Asthma Due to Cold: When cold initially attacks the Lung, the normal activity of the Lung to dominate Qi and control respiration will be disturbed. The pathogenic cold factor has a tendency to constrict the bronchi leaving the patient feeling congested in the chest. Patients will show hyperventilation, shortness of breath, tachypnea, tightness and a suffocating feeling of the chest. The Lung will be also lose its function to regulate the water passages and as a result, the formation of phlegm. Clinically, the phlegm is manifested as audible wheezing in the throat, high-pitched rhonchi, thin, white foamy sputum or tenacious, white sputum that is difficult to expectorate; amount can vary from scanty to profuse. Chills, intolerance to cold (cold temperature, cold food, drinks), absence of perspiration, headache, body aches and pain, grayish, and cyanotic complexion are general signs and symptoms of cold attacking the body. Tongue coating is usually white and greasy. The pulse is wiry and tight.

Asthma Due to Heat: When heat attacks the Lung, the Lung will no longer be able to dominate Qi and control respiration. Patients generally experience a choking sensation, coughing spells and intercostal distention. Patients will also have phlegm as characterized by wheezing, crackling or moist rales, roaring sound in the throat from copious sputum that is thick and difficult to expectorate. Sputum is usually yellow but may be white in some cases where heat is not as prominent. It is common for patients to raise their shoulders to help breathing. Fever, irritability, perspiration, headache, thirst with desire to drink, flushed face, possible fever with aversion to cold are some of the symptoms of asthma due to heat. The tongue is red with yellow greasy coating. The pulse is superficial rapid or wiry.

Asthma Due to Deficiency: It is very common for patients who have recurrent asthma attacks to have Kidney deficiency. When under attack, such patients are said to have “upper excess with lower deficiency.” “Upper excess” refers to phlegm stagnation in the Lung and is characterizes by recurrent or continuous wheezing (worsens after exertion), labored inhalation and smooth exhalation, snoring sound in the throat, low-pitched rhonchi, audible wheezes, shortness of breath, a frail cough with scanty, thin, or frothy sputum, and a dry throat. “Lower deficiency refers to Kidney Qi or Yang deficiency and is characterized by difficult inhalation as Kidney cannot grasp and hold the air down. In addition, the patients may also have deficiencies of the Lung and the Spleen. Deficiency of the Lung is characterized by aversion to wind and spontaneous sweating while deficiency of the Spleen is characterized by increased production of phlegm and sputum. Patients may have red cheeks, red tongue with scanty coat. Pulse is thready and rapid.

Remission Stage: Patients in remission stage show no signs and symptoms of asthma such as wheezing or dyspnea. Compared to when they are under attack, the patients appear completely different and usually manifest little or no symptoms. Treatment principle during remission stage should focus on balancing the underlying deficiencies of the related internal organs, namely the Lung, the Spleen and the Kidney. Depending on severity, herbal treatment must continue for at least 6 month for maximum effectiveness.

Lung Deficiency: Patients with Lung deficiency commonly have asthma attacks triggered by changes in weather or exposure to known allergens or viral infections. Prodromal symptoms resemble that of allergy, which include sneezing, stuffy nose and rhinorrhea. During the remission stage, patients with chronic wheezing and dyspnea due to Lung deficiency may have mild symptoms of shortness of breath, low voice, and frequent low, wheezing sound in the throat. Sputum is clear or white, scanty or sticky. Aversion to wind and spontaneous sweating are two key signs of Lung Qi deficiency. Patients in this category usually have low immune systems and are very susceptible to catching common colds. The tongue is usually red with thin white coat or scanty coating. The pulse is weak and thready, or thready and rapid.

Spleen Deficiency: Patients with Spleen deficiency commonly have asthma attacks triggered by improper dietary intake, such as that of cold or spicy foods. During the remission stage, there may have occasional shortness of breath, dyspnea, low voice, fatigue, poor appetite, epigastric distention, loose stool or diarrhea after intake of greasy or fried foods, and possible edema. Sputum is white, thick and copious. Tongue is pale with tooth marks. Coating is white or greasy. Pulse is thready and soft.

Kidney Deficiency: Patients in this category are generally older or have a very chronic history of asthma. More patients in this category have Kidney Yang deficiency than Kidney Yin deficiency. Asthma attacks for these patients are usually triggered by over-exertion or any minute changes in the weather, lifestyle or the environment. The common symptoms of Kidney Yang and Yin deficiency include: short and accelerated respiration, labored inhalation with the key symptom of longer exhalation than inhalation; relief after deep inhalation, interrupted respiration, cough with frothy or sticky sputum, frail appearance, weakness of the lower back and knees, withered shen and dyspnea after exertion. Patients with Kidney Yang deficiency, in addition to the above symptoms, will exhibit spontaneous perspiration, coldness of the limbs and extremities, pale face, edema, a pale, tender, flabby tongue with a deep, slow pulse. In the case of Kidney Yin deficiency, patient may have flushed cheeks, dryness of throat, irritation and perspiration with oily texture, a skinny tongue with no coating and a deep, thready, rapid pulse.

1) Treatment for Acute Attacks:

The use of acupuncture during an acute asthma attack is proven to the most effective and direct treatment to relieve the patient’s difficult breathing.

Acupuncture Main Points:

Ding chuan (0.5-1.0 cun lateral to DU14 – C7):

  • Empirical point for asthma
  • Needle both sides, obtain and retain Qi for 3-5 minutes
  • Significant-breathing improvement should be noticeable

BL12 – Feng Men “Wind Gate”

  • Treats acute exterior attacks
  • Cupping and Moxa is very useful

BL13 – Fei Shu “Lung Shu”

  • Tonify the lungs
  • Cupping and Moxa is very useful

RN17 – Shan Zhong “Chest Center”

  • Unbinds the chest and descends the lung Qi

RN22 – Tian Tu “Heavenly Prominence”

  • Disperse lung Qi and opens the bronchi
  • Electro-stimulator can be used with RN17 and RN22

LU5 – Chi Ze “Cubit Marsh”

  • Clears lung heat

LU6 – Kong Zui “Maximum Opening”

  • Treats acute asthma

Secondary Points:

These points may be added to the main points for specific patterns causing the attack.

Exogenous Wind:

LU7, LI4, LI11

Heat (Infection):

LI11, LU10, DU14

Lung and Chest Spasms:

PC6, LR3

Phlegm Blocking the Airways:

PC6, ST40

Deficiency:

ST36, SP6, BL43

Calm Mind:

HT7

***Contraindications:

GB21 & LU1: Known for their action for asthma, but may cause pneumothorax during an acute attack on children.

Formulas:

Formulas can be used with acupuncture for acute asthma attacks but should be thought of an assisting treatment rather than the primary treatment. This is because herbs will take a longer time to act on the condition, which may not be fast enough for relief.

Wind-Cold Patterns:

Ma Huang Tang: Releases the exterior cold and arrests wheezing.

Hua Gai San: *Better for asthma with its stronger Qi descending actions.

Wind-Heat Patterns:

Sang Ju Yin: Disperse wind heat &facilitate flow of lung Qi.

Ding Chuan San: Disseminates & redirects the lung Qi, arrest wheezing, clears heat & transforms phlegm.

Xiao Chuan Chong Ji: *Special for asthma due to acute viral infection.

Accumulation:

Wu Ji San: Release exterior, warm interior, smooth flow of Qi, transform phlegm, invigorate blood & reduce accumulation.

2) Treatment for Chronic Asthma for Children Under 5 Years Old:

Asthma in children under 5 is almost always caused by a general lung deficiency accompanied by habitual food stagnation or phlegm with an underlying lingering pathogenic factor. Many children in this age group, who have repeated treatment of acute coughs with antibiotics, will develop asthma. Treatment revolves around tonification, moving Qi, dissolving phlegm and relieving food stagnation. Acupuncture will give quick results and may only take weeks to a few months to cure the disease, depending on the severity of the deficiency, diet and lingering pathogens.

Acupuncture Main Points:

LU5, LU7, LU9, RN12 (moxa), RN22 and ST40: Treatment for the lung deficiency and phlegm.

Secondary Points:

Lingering Pathogens:

Bai Lao, BL13 (tonify), BL18, BL20

Heat:

LU10, LR2

Accumulation:

Si Feng

*Change the child’s diet from phlegm and stagnating foods.

Deficiency:

ST36, SP6, BL43

Formulas:

San Zi Yang Zi Tang: *Appropriate for young children and their general condition.

Bai Jie Zi 9g (mustard seed): Warms & disseminates the lung Qi, reduces phlegm & relax the diaphragm. *Chronic phlegm

Zi Su Zi 9g (perilla seed): Direct lung Qi downward to stop coughing & wheezing

Lai Fu Zi 9g (radish seed): Reduce food stagnation, direct Qi downward & transform phlegm

Tuina:

Tuina may be the best-selected treatment for children under five years old. Children may have problems with the intensity of the needles or the intake of the herbs.

Asthma:

Tian Tu (RN22): Pinching or kneading 20-30 times

Tan Zhong (RN17): Separating pushing 30-60 times

Fei Shu (BL13): Kneading 50-100 times

Feng Men (BL12): Kneading 50-100 times

Si Heng Wen (Transverse Crease): Pushing 10-30 times

Fei Jing (LU): Clearing 100-500 times

Accumulation:

Zhong Wan (RN12): Kneading 100-200 times

Rubbing Fu (Abdomen): 100-200 times

Wei Jing (ST): Clear 200-300 times

Da Chang (LI): Clear 300-500 times

Ba Men (Great Thenar): Kneading 100-200 times

Nei Ba Gua (8 Diagrams): Arc-pushing 600-900 times

San Guan (3 Gates): Pushing 100-300 times

Tian He Shui (Heaven Water): Pushing 100-300 times

Feng Lung (ST 40): Kneading 50-100 times

Deficiency:

Pi Jing (SP): Pushing 600-900 times

Shen Jing (KI): Reinforcing 100-500 times

Shang Ma (SJ2): Kneading 100-500 times

Pi Shu (BL21): Kneading 50-100 times

Zu San Li (ST36): Press kneading 100-200 times

San Yin Jiao (SP6)

3) Treatment of Chronic Asthma for Children 5 Years and Older:

Most children in this category have a deep lingering pathogen at the root of this illness. As this disease progresses, too, it is more difficult to cure because their kidneys are becoming increasingly deficient especially by the Western medications. The treatment below will cover the different patterns of deficiency commonly seen in children with asthma. Many of the herb formulas will be more effective over time for the chronic deficiency patterns. The disease should improve, depending on the severity of the deficiency, over a period of 15 to 50 treatments.

Acupuncture:

Main Points:

LU5, LU7, LU9, BL13 and RN17: Use tonifying manipulation.

Secondary Points:

Spleen Deficiency:

SP6, ST36, BL20, RN12: moxa, ST40, SP3

Lingering Pathogens:

BL18, BL20: Clearing manipulation

Kidney Deficiency:

BL23: moxa, KI3, BL43: moxa, SP6, ST36, RN4: moxa, BL52, RN8: Moxa

Liver Over-action Disorders: (Childhood emotional stress)

SP4, LR14, LR3, RN17, BL18, LI4, PC6 and reduce stress

Heat:

LR2, PC6

Calm Mind:

Du24, HT7

External Herbal Treatment: A common treatment during summertime or remission stages of asthma.

Herbal Application:

Bai Jie Zi 21g, Yan Hu Suo 21g, Xi Xin 15g, Gan Sui 12g and She Xiang (If available) 12g.

  • Grind herbs into a powder then add ginger juice and honey to make a plaster.
  • Apply the plaster to acupuncture points Ding Chuan, BL13, RN20 and ST16.
  • This treatment can cause blisters.
  • Apply once every ten days.

Moxa: Indirect moxa with garlic can be applied to the following three groups. Apply once every ten days. Moxa a different group at each treatment.

  • Group 1: Bai Lao, BL13 and BL43
  • Group 2: DU14, BL12 and BL20
  • Group 3: BL11, BL13 and BL23

Formulas: 

Lung Qi Deficiency:

Yu Ping Feng San + Bu Fei Tang: Tonify lung Qi, stabilize the exterior and stops sweating.

Spleen Deficiency:

Liu Jun Zi Tang: Tonify spleen Qi and dissolve phlegm.

Bu Zhong Yi Qi Tang: Tonify the middle jiao and raises yang.

Lung Yin Deficiency:

Sheng Mai San: Augments Qi, generates fluids, preserves yin and stops sweating.

Lung Yin and Stomach Yin Deficiency:

Sha Shen Mai Men Dong Tang: Clears and nourishes lungs and stomach, generates fluids and moisten dryness.

Mai Men Dong Tang: Benefits the stomach, generates fluids and directs Qi downwards.

Lung Qi and Kidney Yang Deficiency:

Ren Shen Ge Jie San + Ba Wei Di Huang Wan: Tonify Qi and yin, nourishes blood, clear heat, transform phlegm, stops cough, arrests wheezing and stops sweating.

Lung Qi and Kidney Yang Deficiency with Internal Cold:

Su Zi Jiang Qi Tang: Direct Qi downward, arrests wheezing, stops cough and warms and transforms phlegm cold.

Lung Qi and Kidney Yin Deficiency:

Bai He Gu Jin Tang: Nourish yin, moisten lungs, transforms phlegm and stops coughing.

Ping Chuan Tang: Patent formula

Kidney Yin Deficiency:

Du Qi Wan: Chronic wheezing during exertion.

Qi Wei Du Qi Wan + Sheng Mai San: Augments the Qi, generates fluids, preserves yin and stops sweating.

Liver Qi Attacking Lungs:

Chen Xiang Jiang Qi San: Descends lung Qi, moves liver Qi and harmonizes.

Liver Fire Attacking Lungs:

Long Dan Xie Gan Tang: Drain excess fire from the liver and gallbladder and clear damp heat from the middle jiao.

*Empirical Formula: Ma Huang 3g, Zi Wan 9g, Pi Pa Ye 9g, Zhe Bei Mu 9g, Xing Ren 6g, Qian Hu 9g, Sang Bai Pi 6g, Ban Xia 6g, Chen Pi 4.5g, Yu Jin 6g, Shan Zhi Zi 6g Lian Qiao 6g, Disperse and descend lung Qi, calms asthma, resolves phlegm, clears heat and regulates the liver.