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Treating Cough with Acupuncture & Chinese Herbs

by John Stan | Jan 05, 2016
Article is written by Jake Schmalzriedt, DOM

Cough is the most frequent illness-related reason for patient visits to their primary care physician in the U.S.  Chinese herbs offer very effective treatment option for cough.

Etiology and Pathogenesis
External
The lung is known as the “delicate organ.”
It is extremely sensitive to the external environment and pernicious climatic influences.  The lung is especially affected by wind, but also can be damaged by cold, heat, dry, and damp (in excess). External pathogenic influences invade the body, damaging wei qi and may inhibit the lung’s dispersing function, resulting in cough. This type of acute and sudden onset is always considered an excess condition, though there may be underlying deficiencies that precipitate the external invasion. External conditions that don’t resolve and/or if left untreated can become internal, chronic conditions.

Internal
Internal conditions can be either deficient or excess in nature and are broken down as such:
1) Deficiency: the lung is too weak to descend qi due to a deficiency of qi and/or yin. 
2) Excess: a blockage of qi. This blockage can be due to phlegm or damp accumulation, heat, or stagnant qi. A prime example would be phlegm obstructing the lung’s ability to descend qi. This usually develops gradually and can commonly be due to an underlying deficiency, like damage to the spleen and stomach caused by a poor diet—including the ingestion of excessive cold raw foods, high sugar intake, and greasy or fried foods. The spleen’s transportation and transformation function becomes inhibited leading to damp accumulation, which over time turns to phlegm that is stored in the lung. This obstruction leads to cough.

Organ Patterns Associated with Cough in Oriental Medicine
The etiology of cough is further defined in relation to each organ associated with this condition. The lungs are the primary organ associated with dysfunction resulting in cough. Other organ systems involved include the kidney, spleen, and liver.

The lungs are mainly associated with deficiency patterns when attributed to the primary cause of cough. A sedentary lifestyle including a lack of exercise and feeble breathing can damage lung qi. Excessive or prolonged grief and sadness also damages lung qi. Environmental dryness as well as smoking and inhalation of drugs damage lung yin. Weak lung qi and wei qi make the body vulnerable to external invasions and may allow excess conditions to take hold.

Deficiency of the spleen can contribute to lung deficiency as a weak spleen is unable to support the lung (the “mother/son” relationship). Spleen patterns arise are due to overwork, excessive worrying, and poor diet including overconsumption of cold or raw foods, sugar, dairy, and greasy foods damaging the middle burner, inhibiting the transportation and transformation function,  and producing excess phlegm. This excess accumulation is stored in the lungs, resulting in cough.

Cough can also arise from excessive stress and other emotional disharmonies leading to an excess in the liver insulting the lungs through the reverse controlling cycle.

The kidney is associated with deficiency patterns, including kidney qi, yin, and yang deficiencies. The kidney plays an important role in respiration, specifically inhalation. A weak kidney is unable to grasp the qi. The kidney assists the lung during inhalation, grasping and drawing down the qi that is inhaled. This mutual relationship is critical for smooth respiration. If the kidney fails to grasp the qi respiratory issues like cough, wheezing, and shortness of breath occur. Kidney yin deficiency with deficient heat dries up lung yin resulting in a chronic dry cough. Kidney yang, along with spleen yang deficiency, leads to water metabolism issues causing damp and water accumulation in the lung which results in cough.

Diagnosis
Oriental medicine has defined effective treatments dependent on the presentation of the cough. There are several key factors to pay attention to: 1) Time—whether the cough is acute, sub-acute, or chronic. An acute cough is considered an excess condition. A


Expectorate Characteristics

Color

White

Cold

Clear

Wind-cold

Yellow

Heat

Green

Heat-toxin

Blood tinged

Dryness, heat, yin deficiency, deficient heat

Quality

Watery

Yang deficiency

Thin

Yin deficiency, wind invasion

Turbid

Phlegm

Sticky

Damp-heat, wind-heat

Quantity

Profuse, copious

Phlegm, damp, damp-heat

Scanty, no expectoration

Heat, dryness, yin deficiency

Easy to expectorate

Cold

Difficult to expectorate

Heat

Smell

Foul

Damp-heat, heat-toxin

chronic cough, defined as cough lasting more than eight weeks, can be either excess or deficient. A post-acute or post-infectious stage includes the time from two to eight weeks. This cough can show attributes that can be classified as either acute or chronic, and generally denotes the pathogen moving internally. Frequency of cough, a subcategory of
time, describes the period between episodic bouts of the cough with frequent episodes of severe attacks being excess conditions. 2) Sound quality is another key to categorizing cough. Loud or barking cough is excess and always denotes heat. Weak and feeble cough is deficient. 3) Sputum characteristics include color, quality, quantity, and smell;  4) Other considerations include: if the cough is worse in the morning it indicates a presence of phlegm; if it is worse in the afternoon or evening it is often due to yin deficiency; if it is worse upon exertion or when tired it is due to deficiency; and if the cough is worse with stress then it indicates an excess liver pattern. It is also important to use other general diagnostic tools, like tongue and pulse and accompanying signs and
symptoms when defining or clarifying specific patterns.

Patterns
Traditional Chinese Medicine patterns for cough are broken down several different ways; acute / chronic, excess / deficient, and interior / exterior. Acute cough is excess and external. It includes wind-cold, wind-heat, warm-dryness, and cool-dryness patterns. Chronic cough is internal and is subdivided into excess and deficient categories. Excess patterns include lung heat, damp-phlegm, lung phlegm-heat, liver fire, and blood stagnation. Lung heat and lung phlegm-heat can also be considered post-acute conditions. Deficient patterns include lung (kidney) qi deficiency, lung (kidney) yin deficiency, and spleen and kidney yang deficiency. The following table provides key identifiers of each pattern.

Pattern

Cough characteristics

Accompanying signs and symptoms

Tongue and pulse

External

 

 

 

Wind cold

Acute cough with thin white sputum; Frequent and loud sound

Chills and fever, body ache, runny nose, sneezing, stiff neck, no sweating

Floating tight pulse

Wind heat

Acute cough with sticky yellow sputum that can be difficult to expectorate

Sore throat, fever, yellow nasal discharge

Floating rapid pulse

Warm dryness

Dry cough with scant or no expectoration

Dry mouth, throat, nose, chest pain, mild fever

Dry tongue; Floating thin rapid pulse

Cool dryness

Dry cough with scant or no expectoration

Dry mouth, throat, nose, slight chills

Dry tongue; Floating tight pulse

Internal

 

 

 

Lung heat

Dry cough with little or no sputum that is difficult to expectorate; Rough barking or hacking sound

Fever, tight chest, stifling sensation in chest, thirst, dry mouth

Red tongue with yellow coat; Rapid pulse

Damp-phlegm

Cough with profuse white sputum that is easily  expectorated; Heavy turbid sound

Fullness in the chest, wheezing, dyspnea; nausea, poor appetite, fatigue, feeling of heaviness

Pale swollen tongue with white greasy coat; Slippery pulse

Lung phlegm-heat

Cough with profuse yellow sticky sputum; Barking turbid sound

Fullness in chest; fever, restless thirst

Red tongue with yellow greasy coat; Slippery pulse

Lung (kidney) qi deficiency

Weak feeble cough; low sound

Shortness of breath, spontaneous sweating, fatigue, wheezing, weak voice

Pale tongue; Weak pulse

Lung (kidney) yin deficiency

Dry chronic cough with scanty sputum, (possibly blood tinged)

Dry cough, mouth, throat, sore throat, night sweating, low grade fever, five palm heat

Red tongue with no coat; Thin pulse

Spleen kidney yang deficiency

Cough with watery sputum; Low weak sound

Shortness of breath, oppression in chest, fatigue, cold, poor appetite

Pale swollen tongue with white coat; weak pulse

Liver fire insulting the lung

Sudden intense cough with little or no expectorate; barking sound; worse emotional stress

Hypochondriac pain, red face, red eyes, easily angered, dizziness, vertigo, and headache

Red tongue with yellow coat; wiry rapid pulse

Blood stagnation

Cough with localized chest or rib pain; may see blood tinged or blood clots

Worse at night, cold extremities

Purple tongue or purple spots on tongue; wiry or choppy pulse

Acupuncture and Chinese Herbs
For acute conditions acupuncture can be quite effective. For chronic conditions herbal therapies tend to be more effective. A combination approach is suggested for optimal results when treating both acute and chronic stages.

Acupuncture Points for Cough
LU 1 alleviates cough, and is especially beneficial when the cough is due to phlegm and heat, but can be used to clear any excess. In the classics, He-sea points are indicated for the counterflow of qi. LU 5 is generally indicated when heat is associated with the condition causing the qi rebellion. LU 5 can be used to treat cough for phlegm heat, liver fire, phlegm damp, wind heat, wind cold, and lung yin deficiency. Also, according to the classics the jing-river points are used for cough and dyspnea. LU 8 is generally used for excess cough and fullness in the chest. LU 9 is the shu-stream and source point of the lung and is especially beneficial for lung qi and yin deficient conditions characterized by a chronic weak cough. This point can also be beneficial in the presence of phlegm as it will help support the qi in order to move the phlegm out. The ying-spring point, LU 10, main function is to clear heat in the lung and can be used for both excess and deficient heat affecting the organ. RN 12 is the first point on the lung meridian and has the function to open the lung. RN 17 descends rebellious lung qi due to either excess or deficiency. RN 16 opens the chest and relieves cough. RN 22 is a local point to address cough. UB 13 is the back shu of the lungs. This point tonifies the lung and disperses and descends lung qi, treating cough. DU 12 is level with the lung shu and has the action to stop cough. The extra point Bailao has the function to arrest cough.

Herbal Formulas for Cough
Wind-Cold
Apricot Seed and Perilla Formula (Xing Su Yin; KPC 1520) is a good formula to treat cough due to wind cold invasion. This formula’s primary action is to resolve the exterior and address the impaired lung qi’s function. Another formula that can be used to treat cough due to wind cold invasion is Citrus and Aster Formula (Zhi Sou San, KPC 0870). This formula is known as “Cough Relieving Powder” and is a basic formula for treating cough due to wind cold invasion. Zhi Sou San is a good base formula for cough, but it is not often used by itself, and should be combined with other formulas or single herb additions depending upon presentation. In this particular case, Zhi Sou San can easily be combined with a formula like Cinnamon Twig Formula (Gui Zhi Tang) to address the external invasion and increase effectiveness.
Acupuncture point combinations: LI 4, LU 7, GB 20, UB 12.

Wind-Heat
Mulberry and Chrysanthemum Combination (Sang Ju Yin, KPC 2440) is the primary formula to treat cough due to a wind-heat invasion. Sang Ju Yin’s main focus is treating cough and secondarily releasing the exterior. This formula can be augmented with Yin Chiao Formula (Yin Qiao San) or Zhong Gan Ling Formula (Zhong Gan Ling Pian) to more strongly address the wind-heat invasion.
Acupuncture point combinations: LI 4, SJ 5, LU 6, LI 11, DU 14, UB 12.

Warm-Dryness
Sang Xing Tang is the classical formula to treat cough due to warm-dryness damaging the lung. This formula is not available as a formula through KPC, but can easily be made with a granule pharmacy. An equally effective alternative is Eriobotrya and Ophiopogon Combination (Qing Zao Jiu Fei Tang, KPC 2770). This formula’s Chinese name is translated as “the Decoction to Clear Dryness and Rescue the Lung” and has a primary function to moisten the lung and clear heat. The heat-clearing ability of this formula is stronger than Sang Xing Tang. Combine this formula with Glehnia and Ophiopogon Combination (Sha Shen Mai Men Dong Tang, KPC 1410) for stronger lung-nourishing effect. Qing Zao Jiu Fei Tang is suitable to use for the western diagnosis of “cough variant asthma” which is defined as a form of asthma with the only symptom being a dry, non-productive cough; there is usually no wheezing.
Acupuncture point combinations: LU 9, LU 6, LI 4, SP 6, KI 6, UB 12.

Cool-Dryness
Apricot Seed and Perilla Formula (Xing Su Yin, KPC 1520) is classically used to addresses cough due to cool dryness. However, Apricot Seed and Perilla (Pediatric) Formula (Xing Su Yin Pediatric, KPC 1510) may be more suitable. This formula is going to be more effective at moistening and nourishing the lung, while still effectively addressing cough, dispersing lung qi, and lightly resolving the exterior addressing mild wind-cold conditions.
Acupuncture point combinations: LU 7, LU 9, SP 6, KI 6, UB 12.

Lung Heat
Heat in the lungs hinders the normal qi flow resulting in cough. Mulberry and Lycium Formula (Xie Bai San) is a classical Chinese herbal formula that addresses this issue. White mulberry root bark (sang bai pi), the chief herb, is particularly useful at draining the heat from the lung and correcting rebellious qi. It is important to note that with the absence of bitter draining herbs in this formula, this formula is safe for children and weak patients.
Acupuncture point combinations: LU 5, LU 10, LI 4, LI 11, DU 14.

Damp-Phlegm
Citrus and Pinellia Formula (Er Chen Tang) combined with Platycodon and Apricot Seed Formula (Qing Fei Yin, KPC 2810) are primary formulas that treat cough with excessive phlegm. This combination dries damp, reduces phlegm, and regulates the middle burner, the source of phlegm production. Pinellia and Magnolia Formula (Ban Xia Hou Po Tang) is another classical formula that will effectively address damp-phlegm accumulation in the upper burner. This formula has the added function of descending rebellious qi making it ideally suited for this condition. Perilla Seed Combination (Su Zi Jiang Qi Tang, KPC 4210) may be added to this formula for additional cough support.
Acupuncture point combinations: LU 5, LU 9 ST 40, SP 3, SP 6, ST 36.

Lung Phlegm-Heat
Fritillaria and Pinellia Formula (Chuan Bei Ban Xia Tang) is a modified version of Qing Qi Hua Tan Wan. This formula effectively treats lung phlegm-heat cough characterized by thick yellow sticky sputum. This formula is also available in liquid form and makes and excellent cough suppressant syrup.
Acupuncture point combinations: LU 1, LU 5, ST 40, LI 11, SP 6.

Lung Qi Deficiency
The main application of Restore the Lung Formula (Bu Fei Tang) is for treating chronic cough from lung qi deficiency. Signs and symptoms will be cough, wheezing, dyspnea, fatigue, low weak voice, shortness of breath, and spontaneous sweating. If there is expectorate it will be watery in consistency. The formula supplements lung qi, supports the kidney’s ability to grasp the qi, and arrests cough.
Acupuncture point combinations: LU 7, LU 9, SP 6, ST 36, UB 13, UB 20.

Lung Qi and Yin Deficiency
Sheng Mai Formula (Sheng Mai San) is the classical formula that tonifies qi and nourishes yin of the lung. This elegant formula uses ginseng (ren shen) to supplement qi, opiopogon (mai men dong) to nourish yin and schisandra (wu wei zi) to effectively constrains the lung and suppress cough.
Acupuncture point combinations: LU 5, LU 9, ST 36, UB 13.

Lung (Kidney) Yin Deficiency
Yin deficient cough is a chronic cough that is weak and dry in nature and is often exacerbated by deficient heat. Lily Preserve Metal Formula (Bai He Gu Jin Tang) is the exemplar formula for treating dry cough due to lung yin deficiency. This formula nourishes yin, moistens the lung, and stops cough.
Acupuncture point combinations: LU 5, LU 9, KI 3, KI 6, UB 13, UB 23.

Spleen and Kidney Yang Deficiency
Water metabolism issues involve the lung, spleen, and kidney. This pattern is defined by the spleen’s and kidney’s inability to regulate water metabolism leading to chronic retention of damp and excess fluid accumulation in the lung, among other areas of the body. Specific cough related symptoms include watery, frothy sputum. For severe cases the use of a formula like Poria 5 Formula (Wu Ling San) is key to leach out excess fluid. In less severe cases or after the initial use of Poria 5 Formula, use or add in Sea of Qi Formula (Qi Hai Yao Fang) which focuses on supplementing spleen and kidney yang, addressing the root cause of the cough. For more spleen yang involvement use Poria and Atractylodes Combination (Ling Gui Zhu Gan Tang, KPC 2000) to warm and supplement the middle burner and transform phlegm-rheum.
Acupuncture point combinations: SP 6, ST 36, KI 7, RN 6, UB 20, UB 23, DU 4.

Liver Fire Affecting the Lung
Long term liver qi stagnation leads to liver fire that invades lungs via the reverse controlling cycle. This presents as intense coughing episodes with chest and hypochondriac pain that usually coincide with intense emotional situations. Liver fire signs and symptoms will also be present like red face, red eyes, bitter taste in mouth, easily angered, dizziness, vertigo, and headache. Primary treatment includes a combination approach using Gentania Drain Fire Formula (Long Dan Xie Gan Tang) with either Fritillaria and Pinellia Formula(Chuan Bei Ban Xia Tang) or Mulberry and Lycium Formula (Xie Bai San). Secondary treatment, after acute signs and symptoms have been resolved is to address the long standing liver qi stagnation using formulas like Bupleurum and Tang Kuei Formula (Xiao Yao Wan), Free and Easy Wanderer Formula (Jia Wei Xiao Yao San), or Minor Bupleurum Formula (Xiao Chai Hu Tang).
Acupuncture point combinations: LU 1, LU 5, LR 2, LR 3, GB 34, LI 11

Blood Stagnation
This pattern is usually seen following trauma to the chest and rib area resulting in blood stagnation. Local pain will be present with cough and will generally be worse at night. Blood Palace Formula (Xue Fu Zhu Yu Tang) will move blood stagnation in the chest. For blood tinged expectorate combine with San Qi Formula (San Qi Pian). This pattern may also be seen in the end-stage of lung cancer, COPD, etc.
Acupuncture point combinations: LU 7, LU 9, SP 6, KI 6, UB 12.

CHILDREN’S FORMULAS
Children’s Clear and Release Formula (Yin Qiao Gan Mao Fang) can be used to address cough at the first signs of a cough and in conjunction with the external pathogenic wind-heat invasion. Once the cough has become internal, switch to Children’s Clear Lung Formula (Qiao Er Zi Qing Fei Fang). This formula clears lung heat, clears toxic-heat, and addresses phlegm-heat accumulation. The cough will present as a rough and barking cough and will generally be productive in nature. This formula can also be used for a cough that has become sticky and non-productive.

OTHER UNIQUE GFCH FORMULAS FOR COUGH
Ling Zhi Lung Formula (Ling Zhi Fei Pian) treats chronic cough due to lung qi deficiency. The cough will be chronic, weak, and feeble. This formula is particularly effective if the cough is associated with wheezing or labored breathing. Ling Zhi Lung Formula (Ling Zhi Fei Pian) supplements the lung, helps the kidney grasp qi, resolves phlegm, and rectifies lung qi to stop cough.

Five Mushroom Formula (Wu Gu Fang) treats cough due to deficiency manifesting as a weak and feeble cough. Five Mushroom Formula (Wu Gu Fang) bolsters the respiratory system. This blend of medicinal fungi offers excellent support to strengthen the lungs and supplement the spleen and kidney. Ling zhi, dong chong xia cao, and yun zhi directly quell chronic cough.

Viola Clear Fire Formula (Di Ding Qing Huo Pian) can treat cough due to a respiratory infection. This formula focuses on the root cause of the cough and may need to be supplemented with a formula to specifically help rectify the rebellious lung qi and alleviate the cough.

Baked Licorice Formula (Zhi Gan Cao Tang) can treat cough due to lung consumption. Cough caused by lung consumption is marked with severe deficiency of qi, yin, and body fluids, resulting in the inability of the lung to descend qi. The main signs and symptoms manifest as a persistent, chronic, feeble cough, often with frothy saliva or blood tinged expectorate. Associated signs and symptoms that may be present include shortness of breath, spontaneous sweating, dry throat, dry mouth, irritability, insomnia, constipation, and night sweats. [Note: the labeling of lung consumption and its manifestations has changed over the history of Chinese medicine with varying degrees of symptomology, including extreme presentations that have associations with pulmonary tuberculosis. Baked Licorice Formula (Zhi Gan Cao Tang) is not sufficient for this presentation.]

Minor Bupleurum Formula (Xiao Chai Hu Tang) is used for lingering cough following external invasion. Generally, during this post infectious stage you will see lingering heat signs, tight chest, as well as fatigue. The cough may or may not be productive. This formula is generally used in conjunction with another cough arresting herbal formula.

FORMULA ADDITIONS AND COMBINATIONS
Citrus and Aster Formula (Zhi Sou San, KPC 0870) is an excellent assistant formula with its focus of alleviating Cough. For fluid/water retention manifesting as asthma, wheezing, and edema, add Poria 5 Formula (Wu Ling San) to increase the effectiveness of leaching out damp. San Qi Formula (San Qi Pian) can be added to address cough with blood tinged expectorate. Combine this formula with formulas like Lily Preserve Metal Formula, Coptis Relieve Toxicity Formula, or Mulberry and Lycium Formula.


Diet and Lifestyle

Beneficial foods that can alleviate cough include almond, papaya, and walnut. Foods that help relieve cough due to lung yin deficiency include asparagus, carrot, and olive. Foods that benefit a dry cough include honey, banana, peach, fig, mulberry, pine nut, and black sesame seed. Avoid foods that are hot and acrid in nature for yin deficiency and dryness cough. Beneficial foods for lung heat cough include pear, soybean, radish, turnip, seaweed, and kelp. Avoid foods that are warm and hot in nature for lung heat cough. Foods for damp-phlegm cough include lemon, grape, onion, and cauliflower. Avoid cold raw foods, dairy products, greasy foods, and sugar for cough due to damp-phlegm retention.

Lifestyle recommendations include: Avoid smoking. For dryness, the use of a humidifier may be useful, but be sure to replace the filter on a regular basis to avoid mold. Support the lungs with breathing exercises, qi gong, tai qi, or yoga.

Click here for a full list of references:

1. Bensky, Dan, with Clavey, Steven and Stöger, Erich, Chinese Medicine Materia Medica, 3rd Edition, Eastland Press, 2004
2.Volker, Scheid with Bensky, Dan, Ellis Andrew, and Barolet, Randall, Chinese Herbal Medicine: Formulas and Strategies, 2nd Edition, Eastland Press, 2009
3. Scott, John, Monda, Lorena, Heuertz, John. Clinical Guide to Commonly Used Chinese Herbal Formulas, 5th Edition, Placitas, NM, Herbal Medicine Press, 2009
4. Chen, John K. and Chen Tina T. Chinese Medical Herbology and Pharmacology, City of Industry, CA, Art of Medicine Press, 2004
5. Chen, John K. and Chen Tina T. Chinese Herbal Formulas and Applications, City of Industry, CA, Art of Medicine Press, 2009
6. Ellis, Andrew, Notes From South Mountain, A Guide to Concentrated herb granules, New Moon Publishing, Berkeley CA, 2003
7. Maclean, Will, Lyttleton, Jane, Clinical Handbook of Internal Medicine: Vol 1-3, University of Western Sydney, 1998
8. Wiseman, Nigel, Ye, Feng, A Practical Dictionary of Chinese Medicine, Paradigm Publications, Brookline MA, 1998
9. Flaws, Bob, et al., Treatment of Modern Western Diseases with Chinese Medicine, Blue Poppy Press, Boulder, CO, 1994
10. Maciocia, Giovanni, The Practice of Chinese Medicine The Treatment of Diseases with Acupuncture and Chinese Herbs, Churchill Livingstone, 1994
11. Maciocia, Giovanni, Diagnosis in Chinese Medicine, Churchill Livingstone, 2004
12. Kastner, Joerg, Chinese Nutrition Therapy: Dietetics in Traditional Chinese Medicine, Thieme, 2004
13. Pitchford, Paul, Eating with Whole Foods: Asian Traditions and Modern Nutrition, North Atlantic Books, 2002



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