Saturday, 27 July 2013

Asthma

An Evaluation of Current Research 
Jimi Windmills

Epidemiology

Asthma is characterised by airway hypersensitivity to a variety of stimuli leading to chronic airway inflammation and obstruction. It is considered to be partially reversible, with treatment or by spontaneous resolution (Tortora and Derrickson 2009: 913). Asthma affects 3-5% of the US population and 300 million worldwide, with a steadily increasing prevalence, particularly in westernised countries. Asthma is more common in children, especially boys. However, after puberty, it more commonly affects females (Tortora and Derrickson 2009: 913; Boon et al. 2006: 670).

Aetiology and Pathogenesis

The Aetiology of asthma is complicated, and involves various environmental and genetic determinants (Boon et al, 2006: 670). People with asthma often react to triggering stimuli in concentrations too low to cause problems for people without asthma. Common triggers include allergens such as pollen, moulds, dust mites, and aspirin. Asthma attacks can also be provoked by exercise, emotional upset and breathing cold air or cigarette smoke. The resulting airway obstruction in the early (acute) phase response is due to smooth muscle spasms in the smaller bronchi and bronchioles, and may be contributed to by increased mucous secretion, oedema of the mucosa of the airways, or damage to the epithelium of the airway (Tortora and Derrickson 2009: 913). In the late phase (chronic) response we generally see inflammation, oedema, fibrosis, and necrosis of bronchial epithelial cells. These responses are mediated by leukotrienes, prostoglandins, thromboxane, platelet-activating factor, and histamine (Tortora and Derrickson 2009: 913).
Symptoms include coughing, wheezing, difficult breathing, fatigue, moist skin, chest tightness, tachycardia, and anxiety. In severe chronic cases, remodelling of the airway can occur, which may progress further to fibrosis of the wall of the airway, fixed narrowing of the airway, and a reduced response to inhaled medication (Boom et al, 2006: 671).

Diagnosis and Treatment

Asthma is diagnosed on the basis of a comparable clinical history, and demonstrated airflow obstruction. Diurnal (measured first thing in the morning and before bed) variation of more than 20% in peak expiratory flow (PEF) is diagnostic of asthma, and the degree of variability is an indication of the severity of the condition (Boon et al. 2006: 673). Treatment of asthma most commonly utilises inhaled B2-adrenoceptor agonists, and corticosteroids
Treatment of asthma in western medicine generally follows an established, five-tier system, where treatment becomes more intense until the condition stabilises, and then is gradually reduced, as the patients symptoms become less severe, and less frequent.
Acute attacks are treated with inhaled B2-adrenoceptor agonists (albuterol) which help relax the smooth muscles in the bronchioles and dilate the airways. Long-term treatment of asthma attempts to suppress the underlying inflammation. Anti-inflammatory drugs are used most often, especially inhaled corticosteroids (glucocorticoids), cromolyn sodium, and leukotriene blockers.
Patient education and avoidance of aggravating factors play a key part of the management of asthma. Patients should be advised not to smoke, and encouraged to identify other triggers, and remove them from the home environment (Boon et al 2006: 675-6).

TCM Background Asthma

Asthma, in Traditional Chinese Medicine (TCM), is called Xiao Chuan. Xiao refers to patterns of rapid shallow breathing, with wheezing, while Chuan refers to breathing which is laboured, through the mouth, with elevated shoulders and flared nostrils, breathing is so difficult that patients are unable to breath when lying flat (Wu and Fischer 2009: 28). According to Wu and Fischer, it is often difficult in practise to differentiate which pattern is predominant during an acute asthma attack, so the patterns of Xiao Zheng (Wheezing) and Chuan Zheng (Breathlessness) are often considered together (2009: 28).

Aetiology and Pathogenesis

The aetiology of asthma, according to Wu and Fischer include the six external influences, disruption of the seven emotions, improper diet and eating habits, stress and over-strain and extended illness where the physical condition is frail. However, it is noted that in Xiao conditions, the primary factor is chronic phlegm in the lung, with external pathogens and internal disharmony playing a lesser, although still important role (2009: 28).
According to Anshen Shi, asthma is considered to be a disease of latent phlegm in the lung, which is triggered by an external pathogenic influence (Shi 2003: 336). The primary aetiology of asthma in this view is phlegm. This phlegm is the result of the bodies inability to properly distribute and process fluids in an appropriate manner.
[Phlegm] results from failure of the lungs to distribute and disseminate fluids adequately, or from failure of the spleen to transform and transport fluids, or from failure of the kidneys to steam and transform fluids. Phlegm forms, accumulates and lies in the lung; latent phlegm can be stirred by weather changes (exterior wind carrying allergens), improper diet, emotional stress, and exertion (Shi 2003: 336).
This latent phlegm obstructs the airways, and impairs the lungs dispersing and descending of lung qi, which causes wheezing, breathlessness, chest congestion and a productive cough.

Patterns of Asthma

There seems to be a general consensus on the patterns of asthma. Most authors split the patterns into excess type, and deficient type asthma. Excess patterns of asthma are usually invasion of wind-cold/heat, and accumulation of phlegm/phlegm-heat in the lung. Deficient patterns are most often vacuity of the lung, and vacuity of the kidney.
A notable exception to the two excess and two deficient pattern trend comes from Cheng, who lists four deficient patterns; Asthma combined with lung qi deficiency, asthma combined with spleen qi deficiency, asthma combined with kidney deficiency, and asthma combined with heart qi and yang deficiency.
Shi, unique amongst all other authors, treats the conditions of Xiao and Chuan separately. Xiao Zheng (wheezing) has excess and deficient patterns, which Shi correlates with acute attack and remission phase asthma. In the acute phase, he gives us cold pattern and heat pattern, and in the remission phase, he lists lung deficiency, spleen deficiency, and kidney deficiency (Shi 2003: 21). Shi lists five excess patterns of Chuan Zheng (breathlessness); Wind cold invading the lung, turbid phlegm accumulation in the lung, phlegm-heat accumulation in the lung, stagnant qi obstructing the lung, and exterior cold with lung heat. The deficient patterns are lung deficiency and kidney deficiency (Shi 3002: 27). See appendix 1 for a full table of patterns.

Critical Analysis

In this section, after a brief report of the setting and methods of each study, I will critique aspects of each clinical trial against the consort check list and STRICTA guidelines, and score the study on the JADAD scale.

Databases and Journals

Search terms employed to identify relevant studies; Acupuncture, Asthma, Randomised Controlled Trial (RCT), Xiao Chuan, Childhood, Paediatric, Breathlessness, and Wheezing.
The following databases were searched; The Cochrane Library, PubMed/Medline, ScienceDirect, EBSCOhost, and Google Scholar.
This resulted in 24 articles of interest from 1996 - 2012, relating to the topic of asthma and acupuncture. Some of these were systematic reviews or meta analysis, some related to laser acupuncture, and some considered other modalities alongside acupuncture.

Paper 1.

Joos S, Schott C, Zho H, Daniel V, Martin E 2000. 'Immunomodulatory Effects of Acupuncture in the Treatment of Allergic Asthma: A Randomized Controlled Study', The Journal of Alternative and Complementary Medicine, vol. 6, no. 6, pp. 519-525.

Objectives and Methods

The authors stated objective was to investigate the immunological effects of Chinese acupuncture on patients with allergic asthma.
Setting
Department of Anaesthetics of the University of Heidelberg

Recruitment and Inclusion /Exclusion

Patients were recruited from two pulmonologic practises and via newspaper advertisements. Patients were included with mild to moderately severe bronchial allergic asthma, with at least one positive reaction to a prick test, perennial symptoms and regular use of anti-asthmatic medication. Other inclusion criteria was a disease duration of minimum 1 year and maximum of 20 years.
Patients were excluded if they had any other serious disease, or were undergoing any other type of therapy, including psychotherapy. Patients were also excluded if they were using oral steroids in doses larger than 7.5mg of Prednisone a day.

Power calculation

There was no power calculation performed to determine the number needed to treat. There was no other rationale reported as to how the number of participants needed was determined. In the discussion the author acknowledges that the study was most likely underpowered to be able to demonstrate a broader improvement in immune response.

Randomisation and Blinding

This study was a single blinded, randomised controlled trial. Patients were stratified according to their age and duration of disease. Randomisation was performed in groups of 6 to 10 patients using numbered envelopes.

Dropouts

There were no drop-outs in this study. All patients completed the study, however there were two exclusions that occurred along the way. One of the control patients was excluded since she became pregnant during the study. One of the TCM treatment group patients was excluded because of missing immunologic data.

Practitioner

Dr. H. Zho, an experienced acupuncturist from China, who works in the Department of Anaesthetics at the Heidelberg University, where the study was conducted.

Pattern Differentiation, Point Prescription, and Treatment

Dr. Zho performed a TCM differential diagnosis, and a set of fixed points were used, these being; BL 13, BL 17, LI 4 and LU 7. To these points Dr. Zho added others, based on his diagnosis, including; LU 5, LU 6, ST 36, ST 40, KI 3, KI 7, SP 6, SP 9, CV 6, CV 12, and HT 7.
Needles used were Asia-Med brand needles manufactured in Germany. All points were needled to a depth of 0.3 – 3cm, and de qi sensation was elicited from each point upon insertion of the needles, and again before they were removed. Treatments were conducted for 30 minutes, 12 times during the 4 weeks of the trial.

Control Group

This was not a placebo controlled trial, the treatment group was compared to a control group who received points that were selected by Dr. Zho, deemed to be non-specific to the treatment of acupuncture. The control group, like the treatment group received a fixed set of points; TE 3, TE 19, GB 8, and GB 34, and additional points randomly chosen from the following set; BL 38, BL 55, ST 4, ST 6, ST 32, TE 14, TE 25, and SI 5. These points were needled superficially, less then 1cm depth, and given no stimulation.

Outcome Measurements and Results

The authors report a statistically significant improvement in the general well being of the treatment group over the control group. However, the most interesting results of this study are the immunologic changes that were measured. In the TCM treatment group CD3+ lymphocytes increased by 16%, and CD4+ cells by 14%. CD8+, and CD25+ cells had non-significant increases. There were also significant changes in cytokine levels, IL-6 and IL-10 concentrations decreased, while IL-8 increased. The in vitro lymphocyte proliferation rate in the treatment group increased by 83%, and the eosinophil count decreased by 25%. In the control group on only the CD4+ lymphocytes showed a change (22% increase), and there were no significant changes to cytokine concentrations or in vitro lymphocyte proliferation rates. It was not reported that the data collation and statistical analysis was performed by an external competent blinded assessor.

Exit Questionnaire

There was no reported exit questionnaire to determine the success of the blinding

Criticisms

Practitioner

The diagnosis and point prescription was described as being made by an experienced practitioner, Dr H. Zho. We are not actually provided with his credentials except that he is from China, which is not necessarily an indication of skill or experience, and that he works in the Anaesthetics department at the University of Heidelberg, again not an indication of experience or skill as an acupuncturist. All we have to go on, to determine his skill as an acupuncturist, is that we are told he was able to perform a TCM differential diagnosis, including tongue and pulse, which would require at least some knowledge of TCM, and that his point prescription seems reasonable as a treatment for asthma.
The actual treatment of patients was performed by medical students, not Dr. Zho, and not acupuncture students or qualified practitioners. These medical students had six months training from Dr. Zho to 'achieve a comparable qualification' (Joos et al. 2000: 521). I'm not exactly sure what is intended by this statement. If it means that in six months, they had achieved a comparable level of skill and TCM knowledge to their mentor, then perhaps Dr. Zho was a “medical acupuncturist” who himself had had just six months of training. Then again he may have been a 70 year old master acupuncturist with 50 years of experience, and this is just some obscure remark by the author. Without his qualifications being reported we just do not know.

Treatment

We are to assume that all point locations are standard locations. However this is troublesome, since it depends upon whose standards you are treating in accordance with. The author makes no mention of which standard they are basing their location on, and in lieu of a reported standard, gives no anatomical description of the locations of any points.
We are told exactly which points were used as fixed points in every patient in the TCM treatment groups point prescription. However Dr. Zho's pattern specific points are not thoroughly documented. The author states that Dr Zho prescribed 'flexible points, which were variable added in accordance to the Chinese diagnosis (e.g., LU 5, LU6 […]' (2000: 521) etc. as I have listed in the above section on treatment. This is terrible reporting, in this statement, the only such listing of points in the study we are given an “e.g.”, an example of other points employed in the treatment. From this I can only conclude that we have not been provided with an exhaustive list of the points employed throughout the study. Neither were we given any information about the needles used other than their brand, or whether points were needled bilaterally or unilaterally.
This treatment would have benefited greatly from a justification for the point selection, and a demonstration of the historic usage of these specific points for asthma. In the interests of consistent treatment within the groups, a fixed point prescription would have lent greater cohesion to the study. Also, reassessing a patient and changing a point prescription after a course of treatment in a private acupuncture clinic, is a well established and acceptable practise. However, doing so during the course of a clinical trial is akin to running a pharmaceutical trial and changing dosages or even switching medications entirely in the middle of the trial based on how the patient is responding to the treatment. In the end, we do not know which set of points are responsible for the measured immunologic changes at the end of the study.

Control Treatment

The authors acknowledge the fundamental problem of using acupuncture of any kind as a control. They themselves state;
'On the one hand, the control procedure should be indistinguishable from the real treatment, which means penetration of the skin is necessary to produce pain sensation. On the other hand, the placebo has to be physically inert otherwise it is called sham control [...]. However, any needling or manipulation of the skin is believed to produce a physiologic response. Keeping these much discussed considerations in mind, it can be concluded that there is no acceptable placebo for acupuncture research' (Joos et al. 2000: 524).
The point selection for the control is interesting then, since all the fixed points have some action that affects the areas of the chest and/or throat. According to Deadman et al. the following points have these actions;
  • TE 3 – throat painful obstruction (2007: 394).
  • TE 19 – indicated for fright, pain of the chest and lateral costal region, and dyspnoea (2007: 409).
  • GB 8 – eliminates wind, and harmonises the diaphragm and stomach (2007: 427)
  • GB – 34 – spreads liver qi and benefits the lateral costal region, treats all disorders of the lateral costal region, expels pathogens from the shaoyang [which runs over the lungs in the costal region and over the top of the lungs, on the upper back and shoulders] (2011: GB-34).
Now these might not be the first points you would pick to treat asthma, but they obviously have a general, if not a specific effect on the lungs and throat. Without looking at the specific actions and indications of the variable points in the control treatment, I would note that the channels on which they are located (bladder, stomach, triple energiser [San Jiao] and small intestine), all travel over the area of the lungs/throat.

Outcomes and Conclusions

This study is interesting in that, unlike others studies, the effects of acupuncture as a treatment for asthma are not measured by lung function, but rather by measuring immunologic blood parameters. This is a stated goal of the study and they certainly achieved some interesting results. I find it interesting that while pulmonary function tests were performed at the beginning of the study (FEV1 - forced expiratory volume in 1 second), the only actual measurement of improvement in the patient’s condition taken at the end of the study, is their subjectively reported general wellbeing. On top of this, there is no explanation of how general wellbeing was measured except that patients were asked at the end of the study if they thought their general wellbeing had improved, and the answers were recorded by their practitioners. This seems very sloppy, as there is no baseline being measured at the beginning of the study, and there is no particular scale, or specific wellbeing questionnaire used to make any sort of accurate or objective measurement. In this study, given the sloppy measurement and reporting of wellbeing, and given that no pulmonary function tests were taken after the course of treatment, I do not think that the authors conclusion that acupuncture is an effective treatment for patients with allergic asthma is at all valid. Rather, as the authors have stated, acupuncture does seem to have a strong immunomodulatory effect in patients suffering allergic asthma, but without pulmonary function tests it is not a valid conclusion to say that this correlates to an improvement in the severity of frequency of the patient’s condition.

JADAD

Jadad Calculation

Score
Was the study randomised
0/1
1
Was the randomisation method appropriate
0/1
1
Double Blinded
0/1
0
Blinding described and appropriate
0/1
1
Description of withdrawals and dropouts
0/1
1
Randomisation described but inappropriate
0/-1
0
Described as double blind but blinding inappropriate
0/-1
0
Total Jadad Score

4

Paper 2.


Schween S, Vogt L, Minakawa S, Eichmann D, Welle S, Stachow R, Banzer W 2011. 'Acupuncture in Children and Adolescents with Bronchial Asthma: A Randomised Controlled Study', Complementary Therapies in Medicine, vol. 19, pp. 239-246.

Objectives and Methods

The objective of this clinical trial was to collect data in the field of paediatric pulmonology and acupuncture on the basis of a randomised clinical trial. The study aimed to evaluate the immediate effects of acupuncture as an adjunctive treatment in children and adolescents with mild to severe bronchial asthma.

Setting

This study was set in an inpatient rehabilitation centre, It does not report the location of the centre nor does it report exactly what type of rehabilitation typically occurs there. We can only assume that it is an inpatient rehabilitation centre for those with chronic respiratory conditions.

Recruitment and Inclusion / Exclusion

The inclusion criteria for the study was children between 12 and 17 years of age with bronchial asthma who were currently being treated with chronic use of inhaled corticosteroids. These patients were assigned randomly to either the acupuncture or control group. Patients with diseases which might have affected the development of asthma, for example, obesity, were excluded. As was any patients who had been assigned to the non-acupuncture group who expressed a desire to be included in the acupuncture group.
Power Calculation
Power calculation was performed using specific software, and taking into consideration previous research. The total sample size needed was 47 in each group, a total of 94 patients. Taking into account a 30% dropout rate 130 patients were recruited for the study.
Randomisation and Blinding
The study was randomised, but there is no mention of the method of randomisation. There was no blinding attempted in this study. Since there were only two groups, one who underwent the normal rehabilitation programme, and the other who participated in the same program, but also received acupuncture, it was quite obvious who was, and who was not in the acupuncture group. In their discussion, the authors point out the fundamental flaws in placebo and sham acupuncture as control methods, and deliberately avoided using them.
Dropouts
Full data was collected for 93 subjects, 46 in the acupuncture group, and 47 in the control group. There was an overall dropout rate of 27%. Reasons reported for exiting the study were life events, health issues and lack of personal motivation.
Practitioner
The authors report that the acupuncture was performed by three acupuncturists, belonging to the German Medical Acupuncture Association. These medical acupuncturists had many years of experience in practical acupuncture.
Pattern Differentiation, Point Prescription, and Treatment
Acupuncture treatment happened three times per week for each participant in the acupuncture treatment group. The treatment consisted of 3 fixed points; BL 13, CV 17, and LU 7, and then a number of individual points between 2 and 6, that were specific to the patients TCM diagnosis. Examples of these variable points are ST 40, KI 6, LI 11, ST 41, and BL 42. de qi was attained at each point, and needles were retained for 30 minutes. The needles used were uncoated steel acupuncture needles, 0.18 x 13mm, and 0.3 x 30mm.
Control Group
The control group in this study, instead of receiving acupuncture, attended a group discussion to clarify questions on the topic of the study, to explain their role as reference patients and to motivate them to continue in the study.
Outcome Measurements and Results
This study found comparable results between both groups. There were no improvement differences between the groups in lung function, provocation testing and quality of life scores. At the end of the study, 50% of patients had reduced medication use but there was no significant difference between the groups.
In the discussion the authors report that there was a significant therapeutic effect of acupuncture in regard to bronchial hyper-reactivity (PEF measurement), which indicates better asthma control since it points to a reduction of inflammatory cytokines, and processes in the bronchial mucosa. The authors also report a significant decrease in anxiety sensation in the acupuncture group.
Exit Questionnaire
Since there was no blinding, there was no exit questionnaire to determine its success. The patients were asked four months after the study to rate their quality of life, and the majority reported a continued improvement of the subjective quality of life. The authors do not attribute this to acupuncture, as the change was the same in both groups.

Criticisms

Practitioner
The authors of the study reported that the 'acupuncture was carried out by three acupuncture physicians with many years continuous experience of practical acupuncture' (2011: 240), who were members of the 'German Medical Acupuncture Association' (2011: 240). The authors fail to report the actual qualifications of these “medical acupuncturists”.
My main contention here is the distinction that is often present between a real TCM acupuncturist, and these so called “medical acupuncturists”. Citing a number of years of experience of practical acupuncture means nothing. If I, having attended a few weekend seminars on “medical acupuncture”, go off and for the next 25 years stick needles in people I can say I have many years experience of physically needling people and yet have absolutely no understanding of TCM theory. The term the authors use is practical acupuncture. This is a far cry from being a true TCM acupuncturist who has completed a degree or perhaps even post graduate studies in TCM, and has a thorough understanding of complex TCM theory to back up their many years of clinical and theoretical experience.
To be fair, the practitioners in this study may well have been physicians who have also extensively studied TCM. The problem here is that the authors failed to make this distinction bringing the practitioners qualifications, and skill into question.
Treatment
The authors reporting of the acupuncture intervention was actually very good, with a few exceptions that I will cover first. The locations of the points were not specified as belonging to any particular standard, nor were the anatomical location described. This is a shortcoming that is shared with Joos et al, and of most of the research that I read. Also in common with Joos et al., is a failure to give a complete list of points that were used. Again we are treated to an example of other points that were used, leading to the conclusion that this is by no means a definitive list.
To the authors credit, They included the length and gauge of needles, as well as the angle and depth of insertion. However, angle of insertion is only included for the fixed points that were used. Additional points that made the list, were given needle depth, as well as the indication for choosing each point, e.g. 'mucous symptoms: St (stomach) 40; 10 – 15mm, kidney Qi deficiency: Ki (kidney) 6; 2 – 3mm' (2011: 240).
Control Treatment
The control group was a simple non-acupuncture treatment group.
Outcomes and Conclusions
This study in somewhat conflicting. On the one hand they report that acupuncture was completely ineffective in improving pulmonary function, based on a range of function tests, and that it did not improve the patients reported quality of life, as measured by an asthma specific quality of life questionnaire. On the other hand, in the discussion, they tell us that acupuncture had an immunomodulating effect which reduced inflammatory cytokines and processes in the bronchial mucosa, and had a marked impact on asthma related anxiety.
I find it somewhat perplexing to expect patients who are dependant on anti-asthma medication and have a history of chronic use of broncho-dilating inhaled corticosteroids, to show significant improvement in pulmonary function in one month. I find it even more difficult to understand the idea that if you take away someone’s medication, upon which they have been dependant for a long time and which specifically dilates the airways, for an entire day, then make them run for 6 minutes as a provocation test, that you would expect anything other than broncho-constriction to occur.
With these methods, it is hardly surprising that no significant improvement of pulmonary function occurred in the acupuncture group over the control group.
The author’s statement that acupuncture had an effect on reducing inflammatory cytokines, and inflammatory processes in the bronchial mucosa is completely unfounded based on this study. While this statement agrees with previous studies such as Joos et al., it is still not a valid conclusion of the study. No inflammatory markers were measured in this study, therefore no statement should be made about presumed changes in inflammatory cytokine levels, leading to better control of asthma.
A nice outcome of this study is that in measuring with a questionnaire, the patients change in anxiety related to asthma, the authors have confirmed this finding from Joos et al, who only had subjective patient reports as a measurement. While the authors state that acupuncture provided no improvement to quality of life for the patients in the treatment group, I would say that reduced anxiety and fear related to asthma, is probably an improvement.
JADAD
Jadad Calculation

Score
Was the study randomised
0/1
1
Was the randomisation method appropriate
0/1
0
Double Blinded
0/1
0
Blinding described and appropriate
0/1
1
Description of withdrawals and dropouts
0/1
1
Randomisation described but inappropriate
0/-1
0
Described as double blind but blinding inappropriate
0/-1
0
Total Jadad Score

3

General Remarks


There does not appear to be much in the way of recent, well performed, research into the efficacy of acupuncture as a treatment for asthma. Certainly the material reviewed here leaves a lot to be desired in terms of quality methodology in the clinical trial and the quality of the reporting. This especially seems to be the case when it comes to reporting the treating acupuncturists credentials, what point location standards were utilised, using a fixed treatment protocol so as to provide a specific set of points to which any significant change can be attributed and when using a variable point prescription actually providing an exhaustive list of every point that was needled during the course of the study. Without these fundamental issues being addressed it is my opinion that the research cannot be considered to be thorough.
Criticisms aside, it is very encouraging to see the results obtained by Joos et al, pointing to the immunomodulating effects of acupuncture in patients with asthma. It would be especially interesting to see more studies along similar lines that aim to measure both immune markers and changes in pulmonary function in patients with a new diagnosis of asthma who have not yet started on conventional treatment. I would say the future looks strong for research into acupuncture and asthma, and hopefully the effect of acupuncture on immune responses.

Appendix 1

Patterns of asthma according to various authors

Deficient patterns of asthma


Shi
Wu and Fischer
Cheng
Patel
Lung Xu
Spontaneous sweating, aversion to wind, slight wheezing sound in the throat, induced by changes in weather. In the aura stage there will be sneezing and nasal congestion with clear, watery discharge. Shortness of breath, low voice, pale complexion, and clear white sputum. Pale tongue with thin white coat, Weak and thready pulse.
Shortness of breath, feeble voice, weak forceless coughing and wheezing, spontaneous perspiration, sensitivity to draughts, expectoration of thin runny phlegm. Tongue: pale. Pulse: weak

Pale complexion, spontaneous sweating, aversion to cold, shortness of breath, tiredness, sneezing, stuffy nose. Tongue: Pale with thin white coat. Pulse: Thin fast and weak.
Short and quick breathing, weak and low voice, hydrosis, weak pulse.
Spleen Xu
Poor appetite, epigastric and abdominal distension, loose stools and wheezing elicited by excessive consumption of cold, raw, sweet, and greasy food. Shortness of breath, low weak voice and fatigue. Tongue with thin greasy or white moist coating. Pulse thready weak and soft.
No pattern
Pale complexion, poor appetite associated with phlegm, lassitude, loose stool, or diarrhoea. Tongue: Swollen, thick greasy coating. Pulse: slow and slippery.
No pattern
Kidney Xu
Shortness of breath, shallow rapid breathing aggravated by exertion, more difficulty inhaling than exhaling, wheezing triggered by exertion and fatigue, soreness and weakness of the lower back and knees.


Kidney Yang Xu – cold intolerance, cold limbs , pale complexion and spontaneous complexion. Swollen tongue with white coating, Deep thready pulse.


Kidney Yin Xu – Red cheeks, irritability, sensation of heat and night sweating. Red tongue with scanty coating. Thready rapid pulse.
Persistent wheezing aggravated by physical exertion, shallow inspiration, shortness of breath, difficulty in maintaining regular rhythm of respiration, fatigue, lassitude, physical cold, cold extremities and greenish complexion, Tongue: Pale. Pulse: Deep, weak, and thready.
Dark complexion, shortness of breath and becoming quite severe after activities, associated with heart palpitations, dizziness, ringing ears, soreness, weakness, and cold lower back and knees. Tongue: Pale with a thin white coat. Pulse: Thin and weak.
Dyspnoea upon exertion, chilliness with cold extremities, deep thready feeble pulse.
Heart Qi and Yang Xu
No pattern
No pattern
Heart palpitations, sweating, restlessness, green or purple colour on the lips, nails and tongue. There may be a cold or freezing sensation in the extremities. Tongue: Dark with a white coat. Pulse: Tiny, weak and irregular.
No pattern


Excess patterns of asthma


Shi
Wu and Fischer
Cheng
Patel
Wind-cold invading the lung
Xiao Zheng pattern – Rapid breathing with wheezing sound in the throat, stifling sensation in the chest and diaphragm, scanty sputum that is difficult to expectorate, and wheezing aggravated by cold weather. Dull complexion, no thirst, aversion to cold and cold limbs. Tongue White moist coat. Pulse: wiry tight or floating tight.


Chuan Zheng pattern – Audible signing dyspnea with coughing and gasping, rapid breathing, stifling sensation in the chest, and abundant thin white sputum. Aversion to cold, fever, headache, absence of sweating and no thirst. Tongue: Thin white slippery coating. Pulse: Floating and tight
Rapid, laboured breathing, oppression in the chest, coughing and expectoration of this white and sometimes foamy phlegm. Aversion to cold, fever, headache, lack of perspiration without apparent thirst and aching joints. Tongue: Thin white coat. Pulse: Tight and floating.
Fullness and distress in the chest, and dyspnea that are associated with wheezing sound in the throat, cough with thin sputum, headache, frequent attacks during the cold seasons or caused by cold. Tongue: Pale with moist or greasy coating. Pulse: Floating and tight.
Cough with thin sputum, shortness of breath. Usually there are accompanying symptoms of fever, chills, anhydrosis, white coating on tongue, superficial pulse.
Turbid phlegm accumulation in the lung
Audible sighing Dyspnea, stifling sensation in the chest, cough, copious sticky white sputum that is difficult to expectorate. Poor appetite, sticky sensation in the mouth, no thirst, nausea and vomiting. Tongue: Thick white greasy coating. Pulse: Slippery
No Pattern
No Pattern
No Pattern
Phlegm-heat accumulation in the lung
Xiao Zheng pattern - Heavy breathing sound with high-pitched wheezing choking cough, and thick sticky yellow sputum that is difficult to expectorate. Anxiety, sweating, red face, thirst with desire to drink, headache, fever and aversion to wind. Tongue: Red with yellow greasy coating. Pulse: Slippery rapid or slippery wiry.


Chuan Zheng pattern – Audible sighing with dyspnea, heat sensation in the chest with distension and pain, coughing up copious thick yellow sputum that might be blood tinged. Thirst with desire to drink cold beverages, irritability, red face, dry throat, dark urine, and constipation. Tongue: Yellow greasy coating. Pulse: Slippery and rapid.
Short rapid respiration, loud husky voice, wheezing, coughing, oppression in the chest, expectoration of thick yellow phlegm, fever, perspiration, thirst with preference for cool drinks, constipation and dark urine. Tongue: yellow slimy coating. Pulse: rapid and slippery.
Dyspnea with wheezing, irritability, oppressed sensation in the chest, gasping for breath, cough with yellowish thick sputum, red complexion, fever, sweating, thirst, and onset closely associated with the warmer seasons. Tongue: Red with yellow greasy coating. Pulse: Slippery and rapid.
Rapid and coarse breathing, stifling sensation in chest, thick purulent sputum, thick yellowish coating on tongue, rapid rolling and forceful pulse.
Stagnant qi obstructing the lung
Sudden attacks of breathlessness elicited by emotional stress, rapid short breathing with a suffocating sensation or constriction in the throat, chest oppression and pain. Insomnia, palpitations, stuffiness and pain in the hypochondriac and chest regions. Tongue: Thin white coating. Pulse: Wiry


No Pattern
Exterior cold with lung heat
Audible sighing dyspnea, rapid breathing, chest distension or pain, dilated nostrils, and stick yellow sputum that is difficult to expectorate. Slight aversion to cold, fever with or without sweating, thirst, irritability, and headache. Tongue:Thin white or yellow coating. Pulse: Floating or slippery and rapid.


No Pattern


Bibliography

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