Treatment of Asthma with Herbs and Acupuncture

by Dr. Alex Chen, L.Ac., O.M.D., Ph.D. and Dr. John Chen, L.Ac., O.M.D., Ph.D., Pharm.D.

WESTERN MEDICINE

DEFINITION: Asthma affects approximately 15 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, alcohol, 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 include sinusitis, allergic rhinitis, gastroesophageal reflux, cardiovascular disease, diabetes, obesity, and hyperthyroidism.

CLINICAL MANIFESTATION: 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.

1. 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 includes 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.

    

2. 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.

    

3. 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.

    

4. 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.

    

5. 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).

    

ORIENTAL 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 Oriental 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 food 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 Oriental Medicine, the passage of water is 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.

DIFFERENTIAL DIAGNOSIS

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.

1. 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.

    

   HERBAL TREATMENT: ASMATROL (COLD)

   The herbal formula of choice is Asmatrol (Cold). It dispels cold, warms up the interior, eliminates phlegm and relieve bronchial spasm. The recommended dosage is 4-6 capsules TID.

   In Asmatrol (Cold), ephedrae (ma huang) and cinnamon twigs (gui zhi) dispel the cold factor, arrest wheezing and move water by smoothing the Qi flow of the Lung. Besides the bronchodiating effect, ephedrae (ma huang) can also promote urination and thus dispel the congested fluids in the Lung. Due to the cold, patients with water metabolism problems in the Lung will experience constriction and a sudden blockage of fluids. Mustard seed (bai jie zi), asarum (xi xin) and dry ginger (gan jiang) warm the Lung, dissolve congested fluid and help the Lung resume its normal function. Magnolia bark (hou po) is used to regulate the Lung Qi which is impeded by the congested fluids. Apricot seed (xing ren), lepidium (ting li zi), and pinelliae (ban xia) eliminate phlegm, transform congested fluids and reduce wheezing. Schizandra (wu wei zi) is used to protect the Lung by preventing the leakage of Qi. Lumbricus (di long) is used to relieve wheezing and dilate the bronchi. White peony (bai shao), containing paeoniflorin helps lumbricus (di long) achieve the antispasmodic effect on the smooth muscle of the bronchi. Baked licorice (zhi gan cao) supplements Qi, stops coughing, moderates spasms, alleviate pain and harmonizes the formula.

    

   ACUPUNCTURE

    

   MAIN POINTS: Feishu UB 13, Lieque LU 7, Fengmen UB 12, Tanzhong REN 17, and Chize LU 5.

   TECHNIQUE: Acupuncture treatment for cold asthma should focus on sedating the Lung and eliminating the phlegm. The points should be sedated and left in place for 30 minutes. Renzhong REN 17 should be stimulated until the needling sensation disperses to both sides of the chest. Chize LU 5 should be needled against the flow of the channel. Feishu UB 13 and Fengmen UB 12 should be sedated for 2 minutes. For best result, cupping may be applied with acupuncture for these two points.

   SUPPLEMENT POINTS: Shenzhu DU 12 and Dazhui DU 14 may be added for patients with headache and body ache. Yingxiang LI 20 and Shangxing DU 23 may be added for stuffy nose and runny nose.
    

2. 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.

    

   HERBAL TREATMENT: ASMATROL (HEAT)

    

   The herbal formula of choice is Asmatrol (Heat). It clears Lung heat, dissolves phlegm and relieves asthma. The recommended dosage is 4-6 capsules TID.

   In Asmatrol (Heat), ephedrae (ma huang) facilitates the movement of Lung Qi and controls wheezing. Ephedrine and norephedrine in ephedrae (ma huang) have a prolonged bronchodialating effect. Gypsum (shi gao) clears Lung heat and neutralizes the warmth and diaphoretic effects of ephedrae (ma huang). Mulberry bark (sang bai pi) and lycium root bark (di gu pi), a pair also seen in Drain the White Powder (Xie Bai San), drain Lung heat and stop coughing and wheezing. Trichosanthes rind (gua lou pi) clears Lung heat, expands the chest, and dissolves the phlegm. Belamcanda (she gan) clears heat, relieves toxicity, and soothes sore throat due to heat and wheezing. Lepidium (ting li zi) drains the Lung, eliminates phlegm and reduces wheezing. Apricot seed (xing ren) stops coughing and calms wheezing. Lumbricus (di long) stops muscle spasm of the airways to relieve wheezing. A small amount of schizandra (wu wei zi) is used to inhibit the leakage of Lung Qi in order to prevent Qi loss. Baked licorice (zhi gan cao) moderates spasms, supplements Qi and harmonizes all the herbs in this formula.

    

   ACUPUNCTURE

    

   MAIN POINTS: Dazhui DU 14, Hegu LI 4, Tanzhong REN 17, Fenglong ST 40, Feishu UB 13 and Kongzui LU 6.

    

   TECHNIQUE: Acupuncture treatment for asthma due to heat should focus on disperse the Lung, clear heat, dissolve phlegm, and lower adverse rising Qi. Dazhui DU 14 and Feishu UB 13 are sedated for 2 minutes followed by immediate removal of the needles. The remaining points should be sedated and needles left in place for 20 minutes.

    

   SUPPLEMENT POINTS: Tiantu REN 22 and Dingchuan (Soothing Asthma) may be used if there is severe dyspnea. Yuji LU 10 and Daling P 7 are added if patients experience irritability and chest fullness. Zhaohai K6 and Taixi K3 are added if the patient is thirsty and drinks lots of water.
    

    

3. 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.

    

   HERBAL TREATMENT: ASMATROL (DEFICIENCY)

    

   The herbal formula of choice is Asmatrol (deficiency). It tonifies Kidney Yang, directs the rebellious Qi downward, arrest coughing, wheezing and eliminates excessive phlegm. The recommended dosage is 4-6 TID.

   In Asmatrol (deficiency), ephedrae (ma huang) expels exterior wind and relieves dyspnea. Ephedrine and norephedrine, two active ingredients of ephedrae (ma huang) are bronchodilators which can open the airway, relieve wheezing and dyspnea. Apricot seed (xing ren), perilla seed (su zi), and lepidium (ting li zi) reverse the uprising Lung Qi, eliminate phlegm, and relieve coughing and wheezing. Mustard seed (bai jie zi), gleditsia fruit (zao jiao), pinellia (ban xia), magnolia bark (hou po), and peucedanum (Qian hu) eliminate phlegm and relieve coughing and wheezing. Lumbricus (di long) stops muscle spasm of the airways to relieve wheezing. Schizandra (wu wei zi) tonifies the Lung and the Kidney to relieve wheezing. Raphanus (lai fu zi) tonifies the Spleen and reduces the production of phlegm. Citrus Peel (chen pi) dries up dampness and eliminates phlegm. To prolong inhalation, cinnamom bark (rou gui) warms the Kidney Yang and helps restore the Kidney's ability to grasp the Qi. Bupleurum (chai hu) regulates the Qi and tangkuei (dang gui) nourishes the blood in the Liver and indirectly treats coughing and other Qi-reversion symptoms by regulating the blood. Fresh ginger (sheng jiang) and perilla leaf (su ye) disperse coldness and dilate the Lung. Baked licorice (zhi gan cao) and jujube (da zao) harmonize the formula.

   Note on Phlegm:

   Since Phlegm is the fundamental cause of asthma, it is present in all types of asthma patients. For profuse, white or yellow sputum in the different types of asthma patients mentioned above, Citrus and Pinellia Combination (Er Chen Tang) can be added to dry dampness, transform phlegm and regulate Qi.

    

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.

1. 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, 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.

   For maintenance, Astragalus & Siler Formula (Yu Ping Feng San) and Ginseng & Ophiopogon Formula (Sheng Mai San) and Ginseng and Aster Combination (Bu Fei Tang) are excellent formulas to tonify the Lung and prevent recurrent asthma attacks.

   Astragalus & Siler Formula (Yu Ping Feng San) tonifies Qi and strengthens the exterior. It is commonly used for patients who have Wei (Defensive) Qi deficiency characterized by spontaneous perspiration, aversion to cold, and frequent infection of common cold and flu.

   Ginseng & Ophiopogon Formula (Sheng Mai San) and Ginseng and Aster Combination (Bu Fei Tang) tonify the source Qi, nourish Yin, and generate body fluid. It is used for Qi and Yin deficiencies of the Lung with chronic asthma, cough, scanty sputum, shortness of breath, increased respiration, spontaneous perspiration and dry mouth.

    

2. 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 teethmarks. Coating is white or greasy. Pulse is thready and soft.

   The herbal formulas of choice to tonify Spleen deficiency are Major Six Herb Combination (Liu Jun Zi Tang) and Ginseng and Astragalus Combination (Bu Zhong Yi Qi Tang). Major Six Herb Combination (Liu Jun Zi Tang) tonifies the Spleen and dissolves the phlegm. It is used for patients with Spleen deficiency with residual phlegm in the Lung. Ginseng and Astragalus Combination (Bu Zhong Yi Qi Tang) tonifies the Middle Jiao and raises Yang in the body. It is used for patients with deficiency of both the Stomach and the Spleen Qi leading to sinking of the Yang.

   If the patient shows prominent water stagnation in the middle jiao manifesting in fullness in the chest and hypochondria, shortness of breath, profuse sputum, and palpitation, Hoelen and Atractylodes C