Severe dyspnea and TCM

1. Severe dyspnea and TCM Dai Yan-cheng Longhua Hospital Affiliated to SHUTCM 2016.03.10

2. Objectives • Understand the different causes of severe dyspnea; • Be familiar with the clinical symptoms and diagnosis of dyspnea in both Chinese and western medicine. • Make a good command of emergency treatment of dyspnea in both Chinese and western medicine..

3. Definition • Dyspnea is a medical symptom in which the patient feels breathlessness. It is subjective in nature. • Most patients suffer from actual difficulty, some patients just taste an awareness of hyperventilation(换气过度). • Abnormalities of respiratory rate,depth or rhythm. • Dilatation of nares(鼻翼扇动), cyanosis(紫绀), orthopnea(端坐呼吸), use of accessory muscles of respiration.

4. Etiology Acute coronary syndrome（ACS）AnemiaAsthmaCardiac ischemiaChronic obstructive pulmonary disease (COPD)Heart attackHeart failureHyperthyroidismHypothyroidismInterstitial lung diseasePneumoniaPneumothoraxPregnancyPulmonary embolism

5. Diagnosis—Inquiry Steps • Cause, or primary disease ? • First, or recurrent attack ? • Rapid, or insidious onset ? • Activity, or Position ? • Accompanied symptoms ?

6. Diagnosis—Physical Examination • Disturbance of consciousness • Orthopnea 端坐呼吸 • Exhale shrinkage lip • Respiratory rate and depth • Abnormal signs of the Lung • Cardiac symptoms • Abdominal lesions • Neurological examination • Skin mucous membrane cyanosis

7. Diagnosis—Laboratory Examination • Blood routine • Arterial blood gas analysis • Myocardial enzymes • Myoglobin, Troponin • D- dimer

8. reference value: ≥ 94%

9. Diagnosis— Radiographs • Chest X-ray, CT • EKG and echocardiogram

10. Differential Diagnosis • Bronchial Asthma • AECOPD • Acute Left Heart Failure • Pneumothorax气胸

11. Keypoints of Treatment in TCM —— Syndrome Differentiation Heart Liver Spleen Wheezing (Xiao Zheng) Dyspnea (Chuan Zheng) Lung Distention (Fei Zhang) Phlegm-Fluid (Tan Yin) …

12. Classification of syndrome and treatment • Blockage of the lungs by cold-phlegm (寒痰伏肺） rapid breath, a wheezing sound rattling in the throat, cough with dilute sputum, fullness and stuffiness in the chest, white and slippery tongue coating, a wiry and tense pulse. • Method：Warming the lungs to disperse cold, resolving phlegm to stop asthma. (温肺散寒，化痰平喘) • Prescription: Shegan Mahuang Tang (射干麻黄汤)

13. Classification of syndrome and treatment • Blockage of the lungs by phlegm-heat (痰热蕴肺) a feeling of suffocation in the chest, cough with profuse, a wheezing sound in the throat, thick and sticky sputum, restlessness, a reddish complexion, dry mouth, spontaneous sweating, thirst, red tongue, yellow greasy tongue coating, a slippery and excess pulse. • Method：Dispersing heat, promoting the lungs’ dispersive function, and resolving phlegm to check asthma. (清热宣肺，化痰平喘) • Prescription: Dingchuan Tang (定喘汤)

14. Classification of syndrome and treatment • Lung Deficiency (肺虚证) cough, shortness of breath, clear and white sputum, low voice, a pale complexion, spontaneous sweating; or tidal fever, night sweating, feverish palms and soles, insomnia, red cheeks in the afternoon, non-productive cough or blood-tinged sputum, pale tongue with white coating, a deficiency or weak or thready pulse. • Method：Invigorating the lungs to consolidate the defensive Qi. (补肺固卫，益气平喘) • Prescription: Yupingfeng San (玉屏风散)

15. Classification of syndrome and treatment • Spleen deficiency (脾虚证) profuse sputum, allow complexion, listlessness, poor appetite, indigestion, loose stool or diarrhea, edema, pale tongue, a weak pulse. • Method：Invigorating the spleen to resolve phlegm. (健脾化痰，降逆平喘) • Prescription: Liujunzi Tang (六君子汤)

16. Classification of syndrome and treatment • Kidney deficiency (肾虚证) shortness of breath which is aggravated by exertion, lumbago, weak legs, dizziness, tinnitus, amnesia, nocturnal emission, impotence. • Kidney Yin deficiency: red tongue, yellow coating. • Kidney Yang deficiency: pale tongue, white coating. • Method：Tonifying the kidneys to promote their function of cotrolling. (补肾纳气) • Prescription: Jingui Shenqi Wan (金匮肾气丸)

17. Classification of syndrome and treatment • Qi stagnation and blood stasis (气滞血瘀证) stabbing or gripping pain in precordial region with a fixed location, extending to the shoulder and mainly the left shoulder, cyanosis of lips and mouth, dark reddish tongue, a faint and thready or choppy pulse. • Method：Activating the circulation of blood to remove blood stasis, replenishing Yang-Qi. (活血化瘀，通阳散结) • Prescription: Xuefu Zhuyu Tang(血府逐瘀汤)

18. Classification of syndrome and treatment • Dyspnea prostration(正虚喘脱) pale complexion, shortness of breath, clammy skin, irritability, less urine, a thready and rapid pulse. severe dyspnea represents breathing with opened mouth and raised shoulders, dilatation of nares, cyanosis of lips and mouth, profuse sweating, cold limbs, no urine, a faint and thready pulse with intermittent beats. • Method：Rescuing Yang to relieve collapse and consolidating renal Qi. (回阳救逆，益气固脱) • Prescription: Shenfu Tang(参附汤)

19. Emergency treatment—— in western medicine • Symptomatic treatment • Inhale oxygen. • To stabilize breathing and circulation. • Supportive treatment.

20. Etiological treatment Bronchial asthma beta 2 agonists bronchodilators + glucocorticoids

21. Etiological treatment AECOPD Improve the hypoxic state as soon as possible, control infection actively, maintain airway patency. • Antibiotics. • Bronchodilators and corticosteroids. • Noninvasive mechanical venlilation. Ventilator

22. Etiological treatment • Monitor the vital signs • Cardiotonic, diuretic and vascular dilator • Antiarrhythmic therapy when necessary Acute left heart failure

23. Etiological treatment Pneumothorax(气胸) • Conservative treatment (保守治疗): Strict bed rest. Give sedative and analgesic drugs appropriately. • Needle aspiration (胸腔穿刺术) • Placement of a chest tube (胸腔引流) • Surgury indication: internal medicine is ineffective. • Treatment of complications.

24. Emergency treatment principle—— in TCM • To clarify excess from deficiency （分清虚实） Excessive syndrome: remove the pathogenic factors. • Cold: Warm and disperse the lung. • Heat: Clear heat and disperse the lung. • Phlegm: Resolve phlegm and regulate Qi. Deficient syndrome: strengthen the function of the lungs and kidneys in dominating and receiving Qi. • Tonify the lung (补肺) • Strenthen the spleen (健脾) • Benefit the kidney (补肾) • Warm yang and nourish yin (温阳滋阴)

25. Emergency treatment principle—— in TCM • Syndrome of intermingled deficiency and excess （虚实夹杂） • distinguish priorities • judge the root cause and symptoms • prescribe according to specific syndromes

26. Emergency treatment —— in TCM • Use Chinese patent drug (中成药) Dyspnea prostration (喘脱危证) Heixi Dan+ gecko powder + Shenfu Tang. 黑锡丹 蛤蚧粉 参附汤 (Galenite Elixir)

27. Emergency treatment —— in TCM Injection of Chinese herbs (中药针剂) • Shenfu Injection: rescue yang to relieve collapse and consolidate kidneyqi. • Shengmai Injection: invigorate qi and tonify yin.

28. Emergency treatment —— in TCM Excessive syndrome: Reducing manipulation • Main points: Lieque (LU 7), Tiantu(RN 22), Feishu(BL 13), Zhongfu(LU 1), Dingchuan(EX-B 1), Danzhong(NR 17) • Heat invading the Lung: + Chize (LU 5) • Blockage of the lung by phlegm turbidity: + Fenglong (ST 40) • Damage of the lung by stagnated liver Qi: + Qimen (LR 14) Acupuncture

29. Emergency treatment —— in TCM Deficient syndrome: reinforcing manipulation • Main points: Feishu (BL 13), Gaohuang(BL 43), Shenshu(BL 23), • Taiyuan (LU 9), Taixi (KI 3), Zusanli (ST 36), Dingchuan (EX-B 1) • Dyspnea prostration: + Xinshu, Guanyuan, Qihai, Zusanli Acupuncture & Moxibustion

30. Case Study A 52-year-old female received treatment on January 24, 2016. The patient has experienced years of dyspnea and wheezing, and presented with a sudden marked worsening of symptoms in winter. She presented with rapid breathing, wheezing sounds in the throat, a sense of fullness and obstruction in the chest and diaphragm, mild coughing with difficult expectoration of scanty, white, thin and foamy sputum, a gray-bluish complexion, desire to drink hot water, cold limbs and cold intolerance especially on her back. The tongue coating was white, moist and slippery. The pulse was thready and wiry. Explanation: Cold phlegm in the lung coupled with Qi stagnation may narrow the airway, leading to dyspnea, wheezing and rapid breathing; lung-Qi failing to disperse may cause a sense of fullness and obstruction in the chest and diaphragm; lung-Qi obstruction may result in mild coughing with difficult expectoration of scanty sputum; cold fluid retention may lead to white, clear sputum; yin-cold excess inhibiting yang-Qi may cause a gray-purple complexion, cold limbs, cold intolerance and desire to drink hot water.

31. Case Study A 52-year-old female received treatment on January 24, 2016. The patient has experienced years of dyspnea and wheezing, and presented with a sudden marked worsening of symptoms in winter. She presented with rapid breathing, wheezing sounds in the throat, a sense of fullness and obstruction in the chest and diaphragm, mild coughing with difficult expectoration of scanty, white, thin and foamy sputum, a gray-bluish complexion, desire to drink hot water, cold limbs and cold intolerance especially on her back. The tongue coating was white, moist and slippery. The pulse was thready and wiry. • Syndrome differentiation: Blockage of the lungs by cold-phlegm • (寒痰伏肺） • Method：Warming the lungs to disperse cold, resolving phlegm to stop asthma. (温肺散寒，化痰平喘) • Prescriptions: Shegan Mahuang Tang (射干麻黄汤)

32. Case Study Acupuncture treatment: Prescription: Feishu (BL13), Tiantu (RN 22), Fengmen (BL12), LieQue (LU 7) Method: • Apply reducing manipulation to the above points. • Moxibustion can also be combined. • Cupping can be applied to the points on the back.

33. HOMEWORK • What’s the emergency treatment principle of dyspnea in TCM? • What are the treatments for dyspnea in TCM? • How to treat pneumothorax in emergency?

34. Thanks for Your Time