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The Treatment of Acute Phases of Chronic Obstructive Pulmonary Disorder (COPD) – 慢性阻塞肺病急性发作期的辨治要点

慢性阻塞肺病急性发作期的辨治要点
作者:周仲瑛

译者:何安杰  (美国谦益翻译公司)

The Treatment of Acute Phases of Chronic Obstructive Pulmonary Disorder

Author:  ZHŌU Zhòngyīng
      Translated by  J. Heaverlo & XU Zhi-jun

慢性阻塞性肺疾病 (COPD, 简称慢阻肺)是具有气流阻塞特征的慢性支气管炎和(或)肺气肿。气流阻塞进行性发展,但部分有可逆性, 可伴有气道高反应性。慢性支气管炎,某些支气管哮喘患者, 在疾病进程中发展为不可逆性气流阻塞, 当支气管哮喘与慢性支气管炎和(或)肺 气肿重叠存在或难以鉴别时,也列入慢性阻塞性肺疾病范围。在慢性阻塞性肺疾病发展过程中,根据病情可分为急性加重期和稳定期。急性加重期,患者在短期内咳 嗽,喘息加重,痰呈脓性或黏液脓性,量明显增加,可伴发热等炎性表现。稳定期,患者咳嗽,咳痰,气短等症状稳定或症状轻微。

Chronic Obstructive Pulmonary Disorder (C.O.P.D) is a condition that is characterized by an obstruction of the pulmonary airflow. It is commonly seen with chronic bronchitis or emphysema.  Obstruction of the airflow is typically a progressive development, however some cases may be reversible. It is possible that an obstruction may accompanied by a hyperreactive airway.  Chronic bronchitis and some bronchial asthma patients, during the course of their illness, will develop irreversible pulmonary obstruction.  With bronchial asthma and chronic bronchitis patients, there may be some overlapping occurrences of emphysema, as well as the development of Chronic Obstructive Pulmonary Disorder.  This makes for difficulty in differentiating the separate diseases.  During the development process of COPD, it is possible to divide each case into one of three stages: acute stage, mid-term stage, and a stable stage.  In the acute and mid-term stage, the patient within a short period of time will develop coughing, panting, and gasping for breath that becomes increasingly severe.  There will be phlegm and pus, or sticky mucus with pus.  Symptoms will become increasingly obvious and possibly accompanied by fever and other inflammatory conditions.  During the stable stage, the patient will experience coughing, coughing with phlegm, and shortness of breath.  Symptoms will not increase in severity and will be relatively light in nature.

中医学把慢阻肺归于慢性咳嗽,喘证,肺胀等疾病。外邪侵袭,饮食不当,情志刺激,体虚劳卷等都可以导致慢性阻塞性肺疾病。急性期以实证邪盛为主,如风寒犯 肺,谈热,痰湿等蕴肺,缓解期以肺脾肾虚为主,兼有痰浊与瘀血阻肺。发作期治疗,主要集中在清热化痰,清热活血,化痰祛瘀,通腑泄热等方面,也有并用益气 活血,补肾健脾,温阳扶正者。对于缓解期治疗,基本以补肺,健脾,益肾为主,兼以祛邪。总之,通过临床观察证候规律大致为发作期多伴有热象,治以清热化痰 活血;迁延期多以痰,瘀,虚为主,治从化痰活血,兼加补益,或益气,或益气养阴,或助阳;缓解期以虚为主,兼有痰瘀,治疗在益肺健脾补肾基础上化痰,活 血。

Chinese Medicine categorizes COPD as chronic cough, panting, and lung distention.  In addition, external evil attack, improper diet, irritability, weak constitution, and fatigue can all lead to the development of COPD.  An acute-stage of COPD is governed by replete exuberant evils.  Such as, wind-cold invading the lungs, phlegm-heat, and phlegm-damp collecting in the lungs.

During the non-acute stages, , the organs governed by vacuity are lungs, spleen, and kidney.  Simultaneously, there will be phlegm turbidity and blood stasis obstructing the lungs.  In an acute stage, the chief concentration of the treatment should be to clear heat and transform phlegm, clear heat and quicken the blood, transform phlegm and expel stasis, open the  organs and drain heat.  In addition, boost the and quicken the blood, supplement the kidneys, strengthen the spleen, warm the yáng, and support the upright .
During a stable-stage, the treatment principles are to supplement the lungs, strengthen the spleen, and boost the kidneys while simultaneously expelling evil.

Furthermore, during an acute-stage, after completing an examination to determine the patterns for treatment, it is possible to find various overlapping signs of heat.  The treatment method is to clear heat, transform phlegm, and quicken the blood.  Periods of long delays between symptoms are governed by phlegm, stasis, and vacuity.  Therefore, the treatment principles are to transform phlegm, quicken the blood, while simultaneously supplementing and boosting, or boosting the , or boosting the  and nourishing the yīn, or assisting the yáng.

The stable-stage is governed by vacuity.  Additionally, there will be phlegm and stasis.  The treatment principles are to boost the lungs, strengthen the spleen, and supplement kidneys while employing a foundational treatment to transform phlegm and quicken the blood.

周民认为,慢性阻塞性肺病的临床表现主要为咳嗽,咳痰,气喘,属于中医学肺胀,痰饮,咳喘等病症范畴。主病之脏在肺,可累及脾,肾和心,病理性质多属标实本虚,寒热错杂,病机特点为肺虚痰瘀。  由于本病多为发作与缓解交替,发作期偏于标实,多属感受外邪诱发;缓解期偏 于本虚,多属脏气不足。本着急则治标,缓则治本的原则,应矛分别处理。慢性阻塞性肺病急性发作期以邪实为主,治疗重在缓解标急,外解表邪,内祛痰瘀,且应杂合。

ZHŌU Zhòngyīng believes the chief clinical manifestations of chronic obstructive pulmonary disorder are coughing, coughing with phlegm, and asthma.  He believes it belongs in the Chinese medicine disease category of lung distention, phlegm-rheum, coughing and panting.  The primary organs involved in this disorder are the lungs, exhaustion reaching the spleen, the kidneys, and the heart.  The main pathological nature is; repletion in the branch, vacuity at the root, cold and heat combined, lung  vacuity with phlegm, and stasis.

With COPD there will be an alternating between acute stages and periods of symptom relief.  During the acute-stage the branch becomes replete, mostly due to externally contracted evils.  During stable periods where there is relief from symptoms, there is a tendency towards the root being vacuous, which is largely categorized as organ insufficiency.  In the acute-stage treat the branch.  In the stable-stage treat the root.  There should be a clear distinction between the two methods of treatment.  Acute stages of COPD are governed by replete evils.  The chief objective of the treatment is to settle the acute branch by releasing the exterior and resolving external evils, while simultaneously expelling phlegm and stasis internally.

1。祛邪
久病咳喘,肺虚卫外不固,外邪每易反复侵袭,诱使急性发作。对外邪的班证,既应区别其寒热属性,分风寒,风热治疗,更要重视其内外合邪,同气相召,互为关联影响。如寒痰(饮)蕴 肺者易为风寒所乘,表现外寒内饮证,治当解表散寒,温肺化饮,方如小青龙汤;痰热郁肺者,易为风热所伤,治当解表清理,清肺化痰,方如越脾加半夏汤,麻杏 石甘汤;若外寒束表,肺热内郁,客寒包火,又当加重辛散解表药的药味和用量,如小青龙加石膏汤;若寒邪入里化痰,则当清肺化痰,入桑白皮汤。必须注意外邪 的病理性质,每与内在宿邪及体质有关, 阳虚寒痰蕴肺者,外邪易从寒化而表现为内外皆寒,甚至因机体外邪的反应能力低下,虽为感受邪热,仍可见邪从寒化者;阴虚痰热郁肺者,外邪又易从热化,表现 为表里皆热。基于反复感邪的病理根由是正虚,或耗气,或伤阴,若气虚可配党参,黄芪,太子参,阴虚可配沙参,麦冬,知母。治疗时要做到祛邪不忘扶正,但又 忌恋邪。

1.  Expel Evil
In chronic diseases of coughing and panting the lungs will become vacuous allowing for the defensive  and exterior to become insecure.  This insecurity will make it possible for wind evil to easily attack, thereby causing an acute episode.  When diagnosing the nature of the exterior evil pattern, one should clearly differentiate between either a hot condition or a cold condition.  Thereby, separating the treatment into either wind-cold or wind-heat.  Equally important, one must carefully inspect to determine whether the internal and external evils have mutually combined or if they are conjointly influencing one another.

For example, cold phlegm collecting in the lungs is easy to be taken advantage by cold evil.  It will manifest as a pattern of exterior cold with internal phlegm.  The treatment principles are to release the exterior and disperse cold, warm the lungs and transform rheum.  The exemplar formula is xiǎo qīng lóng tāng.

In cases of phlegm heat depressing the lungs it is easy for wind and heat to cause damage.  The treatment principles are to release the exterior and clear interior, clear the lungs and transform phlegm.  The exemplar formula is yuè pí jiā bàn xià tāng, and má xìng shí gān tāng.

With the diagnosis of external cold evil binding the exterior, lung heat internal depression, and guest cold binding heat, use acrid, dispersing, exterior resolving medicinals.  The exemplar formula is xiǎo qīng lóng tāng jiā shí gān tāng.

With cold evil entering the interior and transforming heat the treatment methods are to clear the lungs and transform phlegm.  The exemplar formula is sāng bái pí tāng.

It is very important to pay close attention to the pathological nature of the exterior evil. Each external evil has a particular relationship with evils currently lodged within the interior of the body.  In yáng vacuity with cold phlegm collecting in the lungs, an external cold evil readily transforms in to an interior-exterior cold pattern.  Even though the body’s ability to react is lowered and it has contracted an exterior heat evil, it is still possible to see the evil transforming from cold; In yīn vacuity with phlegm heat depressing the lungs, an externally contracted evil easily transforms into heat.  It will manifest as both internal and external heat.  When there is repeated contraction of external evils it will lead to a vacuity of the upright  or will eventually damage the yīn.  If there is  vacuity use dǎng shēn, huáng qí, and tài zǐ shēn.  If there is  yīn vacuity use shā shēn, mài dōng, zhī mǔ.  When treating, one should not only expel evil without forgetting to support the upright  but also separate from evil.

麻黄辛温解表散寒,宣肺止咳平喘,故为久病咳喘,感邪诱发之首先药,历来用治咳喘的麻黄类方甚多,且可根据辩证配药,较广泛地应用多种证候。如麻黄配石膏 辛凉宣泄,外解在表之风寒,内清肺经之郁热,适用于表寒里热证;配黄芩清宣肺热,适用于痰热郁肺,肺失宣降之证;配葶苈子泻肺祛饮,宣泄肺气,适用痰饮壅 肺,肺气上逆之证; 配大黄宣上导下,适用于肺胃热盛,痰饮壅肺,肺气不通之证;配五味子,散敛相合,适用肺虚气逆,寒饮内停,肺失宣降之证;配熟地滋肾平喘,适用于肺实痰 壅,肾阴亏耗,肺气上逆,肾虚不纳之证;配黄芪一散一固,宣肺平喘,益气固表,适用于寒痰阻肺,气虚卫弱之证。

Má huáng is acrid and warm.  It releases the exterior and disperses cold, diffuses the lungs, stops coughing, and arrests wheezing.  Therefore, it is appropriate to select this herb in chronic diseases of cough and panting or externally contracted evils. According to the individual diagnosis, má huáng may also be paired with other herbs and has a relatively wide range of suggested usage for many types of patterns.  For example, má huáng may be paired with shí gāo.  Where one herb is acrid, the other is cold.  Where one herb diffuses, the other drains.  Together, they release the exterior and expel wind-cold, while at the same time internally clear depressed heat in the lung channel.  It is suitable to use in cases of exterior cold with internal heat.  When combined with huáng qín, the pairs herbs are capable of diffusing lung heat and can be used with patterns of phlegm heat depressing the lungs, or lungs failing to diffuse and down-bear.  The combination of má huáng and tíng lì zi can drain lungs and expel phlegm-rheum, as well as diffuse and descend lung qi.  This combination of herbs is suitable for use with phlegm-rheum obstructing the lungs or lung qi counter-flowing upwards.  When combined with dà huáng, the combination can diffuse the upper and simultaneously guide downward.  It is appropriate to use with lung and stomach heat exuberance, phlegm-rheum obstruction and binding, and blocked organ Má huáng with wǔ wèi zi, where one herb disperses, the other astringes.  It is suitable to use with lung  vacuity with counter-flow, cold rheum internally collecting, and lungs failing to diffuse and descend.  Má huáng with shú dì enriches the kidneys and calms panting.  It is suitable in cases of lung repletion with phlegm stagnation, kidney yīn depleted and consumed, lung  counter-flow, and kidney vacuity not receiving.  Má huáng paired with huáng qí, where one herb disperses and the other herb secures.  Together they can diffuse the lungs and calm panting, boost the and secure the exterior.  This combination is appropriate for cold phlegm obstructing the lungs, and  vacuity with weakened defensive 

另一方面,特别要注意掌握麻黄治喘的禁忌证,如额头汗出清冷,心悸喘促,气短息弱,有喘脱征象者;痰少而黏,不易咯出,咽干,手足心热,舌红苔少或光剥,脉细数等肺肾阴液亏竭者;平素肝阳上亢,头痛眩晕者,均不宣用。

In addition, it is especially important to have a firm understanding of the contra-indications for má huáng in regards to its application of treating cough patterns.  For example, it is contra-indicated when there is sweating of the forehead with chills, heart palpitations, rapid panting, shortness of breath with weak inhalations,panting leading to desertion, small amounts of phlegm or sticky phlegm that is difficult to expectorate, dry throat, five palm heat, a red tongue with little coating or peeled; a rapid, thin pulse, or lung and kidney yīn fluid depletion and exhaustion.  Commonly, these patients will also have liver yáng overbearing with headaches and dizziness.  The use of má huáng is contra-indicated for use with all the above conditions.

2。涤痰
感受外邪诱致本病急性发作时,每因外邪引触肺中伏痰而致痰浊壅阻气道,肺气不 利,痰涌气闭,导致窒息危候,此时痰黏稠浊腻,难化难消,已属顽痰,老痰一类,故涤痰利肺最为当务之急。如能及时祛除气道的胶痰,通过吐利荡涤排出,则窒 息之势自可逆转,方如六安煎,三子养亲汤,葶苈泻肺汤,药如半夏,白芥子,桔梗,莱菔子,葶苈子,海浮石,礞石,泽漆,皂荚等,并伍沉香,苏子,陈皮,厚 朴顺气导痰。寒痰可加干姜,细辛,热痰加知母,黄芩,竹沥,肺热腑实加大黄,风化硝。

2。 Flush Phlegm
When the contraction of an external evil occurs it is possible for it to cause an acute episode of COPD.  No matter which external evil it is, it can lead to the lungs being overcome by phlegm or phlegm turbidity obstructing the air passages, which in turn causes the lung  to become inhibited.  The phlegm bubbles upward to obstruct the air circulation leading to choking sensations and other critical signs.  At this time the phlegm will be sticky, thick, turbid, greasy, difficult to transform, and difficult to eliminate.  This type of phlegm belongs to the category of “stubborn” phlegm.  Phlegm that has been retained for a long period of time is another example.  Therefore, the treatment must flush the phlegm and disinhibit the lungs.  It is important to promptly expel and eliminate the glue-like phlegm from the airways by means of vomiting or disinhibiting.  It is likely, once the phlegm has been expelled and cleaned up, that the sensation of choking will naturally resolve.  The exemplar formula is liù ān jiān, sān zi yǎng qīn tāng, tíng lì xiè fèi tāng, with medicinals such as bàn xià, bái jiè zǐ, jié gěng, lái fú zi, tíng lì zi, hǎi fú shí, méng shí, zé qī, zào jiá, together with chén xiāng, sū zi, chén pí, hòu po to assist in smoothing the to help guide out the phlegmIn the case of cold phlegm add gān jiāng and xì xīn.  In the case of hot phlegm add zhī mǔ, huáng qín, and zhú lì.  When there is lung heat organ repletion add dà huáng or fēng huà xiā.

猪牙皂与皂荚同功而祛痰开闭尤佳,历来用于痰喘气闭,顽痰壅塞气道,黏稠难咯,胸满,气逆,闷塞绝之急症。虽属劫夺之品,劫有开上导下,利肺通腑之神功,周民用于咳喘壅气闭之实证,屡获奇效。每次用量2-3g,可入煎剂,或配入丸散中。入属痰热闭肺,喘促气粗,胸满胁胀,痰涎壅盛,甚则动风痉厥者,可用猴枣散(药物组成:猴枣,羚羊角,天竺黄,川贝,礞石,沉香,麝香,硼砂),清热豁痰,息风开窍。用法:每次服0。3-0。6g, 每日2次。验之临床,中药祛痰药颇具尤势,其疗效机理多端,轻者可化,可豁,进而可祛,可涤,甚者予以吐利攻逐。若能辩证选药,根据治痰药的性味,功用特点组方配药,合理使用,更能提高疗效。

Other herbs that are particularly effective in expelling phlegm and opening obstruction are zhū yá zào and zào jiá.  Historically these herbs are used with cases of; phlegm panting and  obstruction, stubborn phlegm obstructing the airways, sticky, dense and difficult to expectorate phlegm, chest fullness,  reversal, plus oppression and congestion that is inconsolable.  Even though these herbs belong to the category of “expelling” nevertheless they can miraculously open the upper and guide downward, disinhibit the lungs and open the zàng organs.  ZHŌU Zhòngyīng is able to repeatedly receive wonderful results when administering these herbs for repletion patterns such as coughing and panting, phlegm obstruction, and  blockage.  With phlegm heat obstructing the lungs with hasty panting, rough breathing, chest fullness, rib-side distention, phlegm-drool encumberance and congestion leading to stirring wind and tetanic reversal use hóu zǎo sàn (hóu zǎo, líng yáng jiǎo, tiān zhú huáng, chuān bèi, méng shí, chén xiāng, shè xiāng, péng shā) to clear heat, sweep phlegm, extinguish wind and open the orifices.  Directions: each dose administer 0.3g-0.6g, twice per day.
Through clinical examinations, Chinese herbal medicines have displayed outstanding potential for expelling phlegm.  The mechanisms by which its curative effects are attained are multi-fold.  They can gently gently transform phlegm, clear phlegm, even penetrate deeper to expel lodged phlegm.  Chinese herbal medicines are commonly used to expel phlegm and re-open air passages.  When selecting herbs according to the identified patterns, selections will be based on the herb’s nature, flavor and special characteristics. When used appropriately,they can increase the efficacy of treatment.

3。化痰
久病咳喘,痰浊潴留,肺气不利,治节失司,心血营运不畅,而致肺病及心,瘀血阻碍肺气,瘀滞心脉,表现久病入络,痰瘀互结同病的病理变化。不仅要痰瘀同治,且应重在治瘀。
若痰饮壅阻肺气,喘而气逆痰涌,胸部憋闷,胁肋胀痛,面黯,唇甲青紫,舌苔浊,质紫,脉细滑者,当化痰祛瘀,选用杏苏二陈汤合加味旋覆花汤,药如苏子,白芥子,葶苈子,法半夏,杏仁,桃仁,当归,旋覆花,茜草根,降香等。
如痰瘀壅肺,肺失吸清呼浊之职,浊邪害清,上蒙神机,以致神志淡漠,恍惚,烦 躁,昏昧,面黯,唇紫,喘促气逆,痰黏难咯,舌苔浊腻,质紫,脉细滑数,治当涤痰泄浊,化瘀开窍,选用涤痰汤合通窍活血汤,药如半夏,南星,天竺黄,炙远 志,陈皮,茯苓,菖蒲,郁金,丹参,赤芍,川芎,桃仁,红花,麝香等。

3. Transform Phlegm
In chronic illnesses of coughing and panting phlegm turbidity pools and lodges, therefore causing the lung  to become inhibited and lose its management and regulation. Cardiovascular transportation will become impeded as the lung disease reaches the heart.  Static blood will in turn obstruct the lung, as well as stagnate the heart channel.  Chronic disease manifests in the luò channels.  Phlegm and blood stasis will eventually combine and transform into one disease. In this situation it is not sufficient to merely treat the phlegm stagnation but it is equally necessary to treat blood stasis.
If phlegm-rheum obstructs the lung  there will be panting,  counterflow with phlegm regurgitation, chest oppression and stifling, rib-side distention and pain, and a dark complexion.  The lips and nails will be greenish purple.  The tongue coating will show turbidity and the tongue body will be purple in color.  The pulse will be thin and slippery.  The treatment principle is to transform phlegm and expel stasis.  The exemplar formula is xìng sū èr chén tāng with xuán fù huā tāng, with such medicinals as sū zi, bái jiè zǐ, tíng lì zi, fǎ bàn xià, xìng rén, táo rén, dāngg uī, xuán fù huā, qiàn cǎo gēn, jiàng xiāng. 

如痰瘀壅阻气机,脉络不通,气化失宣,津液失于输化,则可导致血瘀水停,身肿 足浮,腹满,喘急咳逆,心慌动悸,颈脉动甚,面唇,爪甲,舌质暗紫,脉来三五不调,表现肺心同病之候,治疗当重在瘀利水,药用苏木,泽兰,路路通,当归, 丹参,桃仁,茯苓,泽泻,汉防己,泽漆,万年青根,蟾皮,茶树根等。苏木咸能入血,辛能走络,功能活血祛痰消肿。参苏饮,取人参,苏木二味,一补肺气,一 降瘀血。周民常用苏木以治肺心喘满,咳逆胸胀,面浮色紫之症。泽漆辛苦而凉,功能行水消肿,祛痰散结,主药,用治喘咳痰多,身肿。周民曾用治肺心病房颤, 喘咳面浮,手臂肿胀之患者。而苏木与泽漆合用,祛痰散结以行水,相得益彰。

If there is phlegm-stasis obstructing the  dynamic, the vessels and network channels will become blocked causing the  transformation to lose its ability to diffuse.  Hence, there will be a loss of fluids and fluid transformation, which, in turn can lead to blood stasis with water collecting.  The entire body will be swollen and the feet will have floating edema. There will be abdominal fullness, rapid panting, cough with counterflow, flustered emotions, palpitations and stirring of the neck vessels.  The face, lips, fingernails, and tongue body will all be dark purple.  The pulse will be irregular.  In addition, there will be clinical manifestations of a lung and heart combined illness. It is important for the treatment to transform phlegm and disinhibit water.  Use medicinals such as sū mù, zé lán, lù lù tōng, dāng guī, dān shēn, táo rén, fú líng, zé xiè, hàn fáng jǐ, zé qī, wàn nián qīng gēn, chán pí, chá shù gēn.

Sū mù is salty and therefore capable of entering the blood.  Its acrid nature allows it to reach the luò vessels.  Its functions include quickening the blood, expelling stasis, and dispersing swelling.  The formula  shēn sū yǐn combines rén shēn and sū mù.  One herb boosts the lung  while the other descends bloods stasis.  ZHŌU Zhòngyīng often uses sū mù to treat lung and heart patterns characterized with panting and fullness, cough with counterflow, chest distention,and a facial complexion that is transient purple.
Zé qī  is acrid, bitter, and cool.  Its functions are to move water and disperse swelling, expel phlegm, and disperse binding.  It is mainly used to treat water swelling with lower abdominal fullness, phlegm-rheum, panting and coughing, plus scrofula patterns. Zé qī tāng utilizes zé qī as the chief ingredient to treat panting and coughing with copious amounts of phlegm and swelling of the entire body.  ZHŌU Zhòngyīng uses this formulation to treat lung and heart illnesses characterized by atrial fibrillation, panting and coughing, facial edema with hand and arm swelling, plus distention.  Furthermore, su mu and ze qi can be combined together to expel phlegm, disperse binding and move water.  As a pair herb combination they achieve a synergistic effect to maximize efficacy.

[周仲瑛。慢性阻塞肺病急性发作期的辨治要点。江苏中医药2006;27(7):5]

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