Lung pattern identification

The process of diagnosing a morbid condition as a disease pattern of the lung.

Physiology Recap

The lung draws in air to contribute to the production of the body’s qì. Lung qì acts within the lung to power respiration (with the help of ancestral qì) and moves outside the lung to perform other functions. It has two movements:

Diffusion is an upward and outward movement that

• expels air from the lung;
• keeps the upper airways free;
• carries defense qì to the exterior to protect the body against external evils; and
• ensures the movement of fluids in the upper and outer body.

Depurative downbearing is a downward movement that

• draws air into the lung;
• helps carry excess fluid downward to the lower burner, and
• keeps the lung free of phlegm.

Regulation of the waterways is the combined action of diffusion and downbearing in the elimination of excess water-damp in the body.

Pathomechanical Features

All pathologies of the lung involve impaired diffusion and downbearing. Some are caused by insufficiencies of qì or yīn, while others result from external or internal evils.

The salient manifestations of lung disease are cough, breathing disorders, upper respiratory tract (nose and throat) disorders, exterior patterns, phlegm patterns, and water swelling.

Impaired Diffusion and Downbearing

Disturbances of diffusion and downbearing play a role in all conditions of the lung, whether they form vacuity or repletion patterns.

• Nose signs (nasal congestion, runny nose) and throat signs (sore throat, hoarse voice) reflect a disturbance of diffusion.
• External evils are easily contracted when reduced diffusion of lung qì weakens defense qì; once they have entered the body, they inhibit the diffusion of both defense qì and lung qì.
• Cough, breathing disorders, phlegm-rheum, and some types of water swelling reflect a disturbance of both diffusion and downbearing.
• Severe phlegm congestion, oppression in the chest, severe lung qì ascending counterflow (difficulty in inhalation accompanied by a sensation of upward movement of qì that occurs in some forms of panting) indicate failure of depurative downbearing in which the lung fails to bear qì downward and keep the lung clear of phlegm.***

Note that the lung’s function of depurative downbearing is assisted by the kidney’s function of absorbing qì, while its function of regulating the waterways is assisted by kidney yáng.

Insufficiency of Qì and Yīn

Lung qì vacuity and lung yīn vacuity are the only pure vacuity patterns of the lung. Although the lung has yáng qì and yīn blood, its qì and yīn are the most important elements in lung pathology. Lung qì vacuity and lung yīn vacuity results from:

• insufficiency of qì or yīn spreading to the lung from other viscera;
• damage to qì or yīn by external evils; and/or
• persistent cough (from any cause) damaging lung qì.

Insufficiency of qì or yīn affects diffusion and downbearing, giving rise to cough. Insufficiency of lung qì can also give rise to panting and susceptibility to external contractions.

External Evils and Exterior Patterns

Of all the viscera, the lung is in closest contact with the environment and most susceptible to external evils, which are directly inhaled or enter the body via the skin and body hair (which is governed by the lung) and hence usually affect the lung and the exterior simultaneously, causing heat effusion and aversion to cold as well as cough, panting, nasal congestion, and a painful swollen throat.

The evils most commonly affecting the lung are:

• Wind-cold
• Wind-heat
• Dryness

In addition, externally contracted evils can combine with phlegm arising internally. Also, wind obstructing diffusion can affect the movement of bodily fluids in the upper and outer body, causing water swelling of rapid onset, spreading from the upper body downward (a yáng water pattern).

The lung patterns marked by exterior signs are wind-cold fettering the lung, wind-heat invading the lung, dryness evil invading the lung, and wind and water contending with each other. Cold damage and warm disease schemes present a more finally differentiated array of patterns. See externally contracted disease pattern identification.

Internal Evils and Interior Patterns

The lung is susceptible to water-damp, phlegm-rheum, heat, and cold of internal origin. These give rise to lung patterns without exterior signs, that is, interior patterns. Interior patterns may also involve evils of external origin (heat evil and cold evil).

Heat: The lung can be affected by externally contracted heat evil and wind-cold entering the exterior and transforming into heat. It is also susceptible to fire from the liver (liver fire invading the lung).

Cold: The lung can be affected by externally contracted cold evil and vacuity cold arising internally.

Phlegm and rheum, terms denoting thick and thin pathological substances respectively, arise when fluids accumulate and concentrate. In lung patterns, phlegm and rheum arise in the following ways:

• Accumulation of water-damp: Water-damp accumulates when the spleen fails to move and transform water and/or the lung fails to regulate the waterways. When it fails to move, it can concentrate into phlegm or rheum.
• Cold: Repletion cold, which results from externally contracted cold evil or vacuity cold arising from insufficiency of yáng qì, can foster the concentration of water-damp into phlegm and rheum.
• Heat: Externally contracted heat evil or heat forming from depressed qì boils and concentrates fluids into phlegm.

Phlegm can also develop when depressed liver qì causes fluids to stagnate and bind, but this is not a prominent feature of lung disease.

The lung patterns caused by external evils affecting the interior are more finely differentiated cold damage and warm disease theory. See externally contracted disease pattern identification.

Relationship to Other Bowels and Viscera

The lung stands in exterior interior relationship with the large intestine. The lung has pathomechanical relationships with all the other viscera, and with its associated bowel, the large intestine. This section discusses the lung’s relationship to the heart. Relationships with the other viscera and the large intestine are discussed further ahead.

Heart and Lung

Both the heart and lung are driven by ancestral qì. The heart governs the blood and vessels, while the lung assembles the hundred vessels, helping to propel the blood. Pathologies involving both heart and lung are disorders of qì and blood.

Heart affecting the lung: When insufficiency of heart qì or heart yáng inhibits the movement of blood, the blood condition can affect the lung’s diffusion and depurative downbearing action. The resulting condition manifests in heart palpitation and oppression in the chest on the one hand and cough and rapid panting on the other.

Lung affecting the heart

• When lung qì is insufficient or diffusion and depurative downbearing are impaired, the qì condition can affect the heart’s function of governing the blood and vessels and cause blood stasis. When this happens, cough, shortness of breath, and oppression in the chest are accompanied by heart palpitation and green-blue or purple lips.
• When insufficiency of lung qì and ancestral qì affects the heart, lung qì vacuity gives way to heart-lung qì vacuity. When this occurs, cough, shortness of breath or panting, faint breathing, and low voice are seen in tandem with heart palpitation.

Lung Signs

Lung signs include cough, breathing disorders, nose and throat signs, and exterior signs.

Cough and Expectoration

Cough (咳嗽 ké sòu): Cough reflects lung qì ascending counterflow attributable to disturbances of diffusion and downbearing. It can occur in any lung pattern. It is often associated with expectoration of phlegm and in some cases with coughing of blood (see below). A dry cough (干咳 gān ké) is a cough with little or no expectorate.

Expectoration of phlegm (咯痰 kǎ tán): Expectoration of phlegm accompanies cough in most cases, not only in phlegm patterns, where phlegm is prominent. The color and consistency of phlegm expectorated through coughing help identify the pattern.

• Clear thin phlegm indicates qì vacuity (qì failing to retain fluids).
• Phlegm that is white rather than clear indicates wind-cold fettering the lung or phlegm obstructing the lung.
• Little or no phlegm indicates lung yīn vacuity or dryness invading the lung.
• Thick yellow phlegm indicates wind-heat invading the lung, intense lung heat, or phlegm-fire congesting the lung.

Coughing of blood (咳血 ké xuè): Sometimes seen in severe patterns of lung yīn vacuity or dryness evil invading the lung.

Expectoration of pus and blood (咳吐脓血 ké tǔ nóng xuè): Coughing of phlegm with pus and blood is a sign of pulmonary welling-abscess, which develops when phlegm-heat causes qì and blood to stagnate, causing putrefaction.

Breathing Disorders

These are attributed to impaired diffusion and downbearing. They include three levels of breathing difficulty (scantness of breath, shortness of breath, panting), wheezing, faint breathing, and rough breathing.

Panting (气喘 qì chuǎn, 喘 chuǎn): The most severe breathing disorder marked by labored breathing, with short rapid breaths with discontinuity between breaths (failure to catch the breath), as well as signs not seen in other breathing disorders, including flaring nostrils (鼻翼煽动 bí yì shān dòng), open mouth and raised shoulders (张口抬肩 zhāng kǒu tái jiān), also called raised-shoulder breathing (肩息 jiān xī), and inability to lie flat. Distinction is made between vacuity and repletion panting.

Repletion: Panting that develops suddenly, with rough loud breathing, long deep inbreaths, and relief experienced on exhalation is repletion panting. It is accompanied by oppression in the chest, raised head and protruding eyes, and a replete and a forceful pulse. It is usually observed in people with firm bodies and strong constitutions. It occurs most commonly in wind-cold fettering the lung, intense lung heat, phlegm-heat congesting the lung, and cold phlegm obstructing the lung. It also occurs in qì depression damaging the lung, when depressed liver qì affects breathing.

Vacuity: Panting that develops gradually, makes a faint low sound with short hasty breaths and is relieved only when a long inhalation is achieved is vacuity panting. It varies in severity at different times and is exacerbated by physical exertion. It occurs in patients with lung-kidney depletion when the kidney fails to absorb qì, the downbearing of lung qì is disturbed, and vacuous qì floats upward. Vacuity panting also occurs in kidney vacuity water flood with water-cold shooting into the lung.

Wheezing (哮 xiāo): Wheezing is a high-pitched whistling sound made by breathing when the airways are congested with phlegm. The sound is often described as a frog rale in the throat because its sound is similar to the prolonged low croaking of a frog, although this term is also used to describe other phlegmy breathing sounds. Wheezing is always associated with hasty panting, and the combined condition is known as wheezing and panting (哮喘 xiāo chuǎn), which corresponds to the Western medical concept of asthma. Wheezing and panting arises when phlegm-rheum is stirred by an external contraction or when externally contracted evils fail to disperse and stagnates in the lung. It thus presents as phlegm-heat congesting the lung, cold phlegm obstructing the lung, or wind-cold fettering the lung. Other factors include living in cold damp surroundings for a long time and excessive consumption of sweet, salty, raw, or fishy-smelling food. It is difficult to treat.

Shortness of breath (短气 duǎn qì): Breathing marked by short rapid shallow breaths with discontinuity between breaths (difficulty in catching the breath). However, there is no raising of the shoulders, flaring nostrils, or inability to lie flat as in panting. There is no phlegm rale as in wheezing. Shortness of breath appears in numerous patterns, both vacuity and repletion.

Vacuity patterns are characterized by short faint breaths, with general weakness of the body, lassitude of spirit, dizzy head, and lack of strength. They are caused by insufficiency of lung qì or great vacuity of original qì.

Repletion patterns are characterized by rough short breaths, accompanied by breathing, asphyxiating oppression in the chest, distension and fullness in the chest and abdomen. It is caused by phlegm-rheum, stagnant qì, or blood stasis obstructing the chest and abdomen.

Scantness of breath (少气 shǎo qì): A mild feeling of breathlessness, accompanied by a faint low voice. It is mostly attributed to lung qì vacuity and occurs in all vacuity taxation patterns. Also called scantness of qì (气少 qì shǎo), although this is term may also loosely mean qì vacuity.

Faint breathing (息微 xī wēi), weak faint breathing (呼吸微弱 hū xī wēi ruò): Breathing that is not easily detected visually or audibly. It is mostly a sign of lung qì vacuity.

Rough breathing (气粗 qì cū): Respiration that produces a harsh crackling sound. It is attributable to the presence of phlegm in the lung.

Yawning (呵欠 hē qiàn): Opening the mouth wide and taking a deep breath as an involuntary reaction to fatigue or boredom. It is attributable to depressed liver qì, to qì stagnation and blood stasis, or to spleen-kidney yáng vacuity. It often appears in smallpox.

Chest

Oppression in the chest (胸闷 xiōng mèn): A feeling of constriction and discomfort in the chest. It indicates that yáng qì is failing to move or that evils are causing obstruction. Oppression in the chest occurs in heart disease, notably heart yáng vacuity and heart vessel obstruction, and in lung patterns involving phlegm, such as cold phlegm obstructing the lung or phlegm-heat congesting the lung. Less commonly, it occurs in spleen patterns involving dampness and in depressed liver qì. See oppression in the chest under Heart Signs above.

Chest pain (胸痛 xiōng tòng): Also called pain in the chest. Pain anywhere in the chest. It occurs in heart disease, lung disease, and liver disease.

In lung disease, chest pain is associated with breathing disorders and is mostly attributable to phlegm turbidity causing obstruction or fire damaging the network vessels of the lung. It is observed in intense lung heat or phlegm-fire congesting the lung and sometimes in rheum collecting in the chest and rib-side. It is especially prominent in pulmonary welling-abscess. See chest pain under Heart Signs.

Nose and Throat

Air enters at the nose and passes through the throat. Nose and throat signs arise from non-diffusion of lung qì. Most frequently, they are attributed to externally contracted evils.

Nasal congestion (鼻塞 bí sè): Copious nasal discharge from the nose that obstructs the airways. It is caused by wind-heat or wind-cold. In general, wind-cold causes the thin runny discharge (all disease with watery humors that are clear, pure, and cold is ascribed to cold), while wind-heat, by concentrating fluids, tends to produce a thicker turbid yellow discharge.

Runny nose with clear snivel (流清涕 liú qīng tì): Thin discharge from the nose, usually attributable to wind-cold fettering the exterior. See nasal congestion above.

Runny nose with turbid yellow snivel (流黄浊涕 liú huáng zhuó tì): Discharge from the nose that is yellow and turbid. See nasal congestion above.

Sneezing (喷嚏 pēn tì): Sudden spasmodic expulsion of breath through the nose and mouth with a characteristic hissing sound resulting from irritation of the airways. In illness, it is caused by wind-cold and other evils affecting the diffusion of lung qì. It occurs in wind-cold fettering the lung, measles, and smallpox.

Flaring nostrils (鼻翼煽动 bí yì shān dòng): Dilation of the alae nasi on inhalation. It is common in panting.

Hoarse voice (声音嘶哑 shēng yīn sī yǎ); loss of voice (失音 shī yīn): Partial or complete loss of the ability to produce sounds from the larynx can occur in vacuity and repletion.

Repletion: Hoarse voice or loss of voice is most commonly caused by external evils invading the lung, impairing diffusion of lung qì and giving rise to replete metal failing to sound (金实不鸣 jīn shí bù míng).

Vacuity: Hoarse voice or loss of voice may also be caused by insufficiency of yīn-liquid of the lung depriving the voice of moisture, which is called broken metal failing to sound (金破不鸣 jīn pò bù míng).

Quality of voice

• A heavy turbid voice (声音重浊 shēng yīn zhòng zhuó), which is a deep, muffled voice, mostly occurs in external contraction of wind-cold or in phlegm-damp obstruction that causes non-diffusion of lung qì and blockage of the nose.
• A faint low voice (语生低微 yǔ shēng dī wēi) is a sign of qì vacuity. A faint low voice is usually accompanied by laziness to speak (懒言 lǎn yán), a lack of energy or inclination to talk.

Painful red swollen throat (咽喉红肿痛 yān hóu hóng zhǒng tòng): This is mostly attributable to wind-heat invading the lung, but mild forms may also occur in wind-cold or in lung yīn vacuity. Severe painful swollen throat is sometimes referred to as throat impediment, reflecting the sensation of blockage that a severe sore throat can cause.

Itchy throat (喉痒 hóu yǎng): This is usually attributed to wind-cold impairing diffusion of lung qì. Less commonly, it is attributed to wind-heat invading the lung, dryness evil invading the lung, or lung yīn vacuity.

Exterior

Aversion to cold with heat effusion (恶寒发热 wù hán fā rè): The simultaneous occurrence of aversion to cold and heat effusion is a major sign of exterior patterns, when externally contracted evils settle in the body’s exterior. Aversion to cold is attributed to defense qì failing to produce its warming action, while heat effusion results from defense qì struggling to expel the evil.

Susceptibility to common cold (易于感冒 yì yú gǎn mào): A sign of insufficiency of lung qì and failure of defense qì to protect the exterior against the invasion of external evils (insecurity of the defensive exterior).

Spontaneous sweating (自汗 zì hàn): Sweating more than usual and exacerbated by physical exertion. It is attributable to insufficiency of yáng qì causing insecurity of the defensive exterior and loosening of the interstices. Spontaneous sweating is contrasted with night sweating, which is attributed to yīn vacuity.

Pulse

Vacuous pulse (虚脉 xū mài): A vacuous pulse occurs in qì vacuity and reflects the inactiveness of qì.

Floating pulse (浮脉 fú mài): A floating pulse marks exterior patterns caused by externally contracted evils. It reflects defense qì fighting with the evil at the surface of the body.

Rapid pulse (数脉 shuò mài): A rapid pulse indicates heat.

• A pulse that is fine and rapid occurs in vacuity heat.
• A pulse that is rapid and a forceful pulse occurs in repletion heat.

Slippery pulse (滑脉 huá); stringlike pulse (弦脉 xián mài): A slippery or stringlike pulse marks phlegm patterns, and reflects the slippery, sticky nature of phlegm.

Lung-Related Diseases

Cough, wheezing, and panting, traditionally regarded as diseases as well as symptoms, are described under Lung Signs above. Lung-related diseases include the following:

Pulmonary welling-abscess (肺痈 fèi yōng): A welling-abscess of the lung, marked by cough with expectoration of sticky fishy-smelling purulent phlegm that in severe cases is flecked with blood, together with heat effusion and shivering, chest pain, and rapid breathing. Pulmonary welling-abscess arises when heat from externally contracted evil toxin or heat forming from wind-cold scorches the lung, fosters phlegm, and causes congestion of qì and blood to create static blood that in time putrefies. Hence, it falls within the scope of phlegm-heat congesting the lung.

Pulmonary consumption (肺痨 fèi láo): A contagious disease characterized by cough with expectoration of blood, accompanied by severe yīn vacuity signs, such as tidal heat effusion, night sweating, emaciation, and a pulse that is fine and rapid. It corresponds to pulmonary tuberculosis in biomedicine, which is cause by Mycobacterium tuberculosis.

Pulmonary distension (肺胀 fèi zhàng): A chronic condition of lung qì ascending counterflow characterized severe fullness in the chest, with copious phlegm, and vexation and agitation. It involves internally contracted evils and insufficiencies of the lung, spleen, and kidney.

Pulmonary wilting (肺痿 fèi wěi): A chronic condition of depletion of lung qì and lung yīn, caused by febrile disease, enduring illness, or pulmonary consumption. The main sign is cough with expectoration of turbid mucus. Signs vary depending on whether it takes the form of vacuity cold or vacuity heat.

Sniveling nose (鼻鼽 bí qiú): Runny nose with clear nasal mucus, mostly attributable to wind-cold fettering the lung. Acupuncture texts often give sniveling and nosebleed (鼽衄 qiú nǜ) as indications for certain acupoints that treat both conditions.

Deep-source nasal congestion (鼻渊 bí yuān): Persistent nasal congestion with turbid snivel, attributed to wind-cold, wind-heat, or gallbladder heat. It corresponds to paranasal sinusitis or chronic rhinitis in biomedicine.

Throat impediment (喉痹 hóu bì): Any painful and swollen condition of the throat. The term often refers to severe conditions.

Throat wind (喉风 hóu fēng): A severe painful swelling of the throat, with panting, discomfort in swallowing, phlegm-drool congestion, difficulty speaking, and in severe cases clenched jaw and clouded spirit. It corresponds to biomedical conditions such as peritonsillar abscess, retropharyngeal abscess, and acute epiglottitis. It is caused by wind-heat with preexisting lung-stomach heat.

Throat moth (喉蛾 hóu é): Also called baby moth (乳蛾 rǔ é). Painful redness and swelling of either or both of the throat nodes (喉核 hóu hé, tonsils), with a yellowish-white discharge visible on their surface. It is most commonly attributed to lung-stomach heat in warm-heat disease with further contraction of wind evil. The wind and heat contend with each other and ascend the channels to the throat. Throat moth corresponds to tonsillitis in biomedicine.

Lung Patterns

Below is a brief description of the major lung disease patterns, with links to entries that provide more detail.

Simple Patterns

Lung qì vacuity (肺气虚 fèi qì xū): Forceless cough and panting; expectoration of clear thin phlegm; qì vacuity signs. It stems from damage to the lung by persistent cough and panting; spleen vacuity affecting the production of qì.

Lung yīn vacuity (肺阴虚 fèi yīn xū): Dry cough with scant sticky phlegm or no phlegm; yīn vacuity signs. It stems from dryness or heat evil assailing the lung; contraction of pulmonary consumption; smoking, drinking, hot spicy dry foods; or enduring cough or other enduring illness damaging lung yīn.

Wind-cold fettering the lung (风寒束肺 fēng hán shù fèi): Cough and panting with clear thin white phlegm; wind-cold exterior signs. It results from external contraction of wind-cold.

Wind-heat invading the lung (风热犯肺 fēng rè fàn fèi): Cough with expectoration of yellow phlegm; wind-heat exterior signs. It results from external contraction of wind-heat.

Dryness evil invading the lung (燥邪犯肺 zào xié fàn fèi): Dry cough with little phlegm; dry nose and mouth; mild exterior signs. It results from external contraction of dryness.

Intense lung heat (肺热炽盛 fèi rè chì shèng): Cough; panting; painful swollen throat; signs of interior repletion heat. Factors: warm-heat evil invading the lung; wind-cold transforming into heat, entering the interior, and settling in the lung; or internal heat affecting the lung.

Phlegm-heat congesting the lung (痰热壅肺 tán rè yōng fèi): Heat effusion; cough; panting; copious thick yellow phlegm or fishy-smelling phlegm with pus and blood. It results from heat evil scorching lung liquid, causing phlegm-heat or from depressed phlegm transforming into heat.

Cold phlegm obstructing the lung (寒痰阻肺 hán tán zǔ fèi): Cough; panting; easily expectorated copious white phlegm; cold signs such as cold limbs. It results from phlegm combining with externally contracted cold evil or developing with vacuity cold.

Rheum collecting in the chest and rib-side (饮停胸胁 yǐn tíng xiōng xié): Distension, oppression, and pain in the chest and rib-side; short rapid breathing; coughing and expectoration that cause pain. It results from spleen yáng failing to transform water or from external evils disturbance of the lung’s diffusion and downbearing.

Wind and water contending with each other (風水相搏 fēng shuǐ xiāng bó): Sudden puffy swelling of the head and face with exterior signs. It arises when external contraction of wind-cold or wind-heat obstructs the normal movement of water through the body so that it spills out into the skin.

Combined Patterns

Water-cold shooting into the lung (水寒射肺 shuǐ hán shè fèi): A vacuity-repletion complex in which the lung is affected by water qì resulting from kidney yáng vacuity. It is marked by cough, panting, and copious thin white phlegm-rheum.

Lung-kidney yīn vacuity (肺肾阴虚 fèi shèn yīn xū): Dry cough with scant phlegm; hoarse voice; seminal emission; menstrual irregularities; vacuity heat signs. It develops when enduring cough damages the lung and lung vacuity affects the kidney or when, in vacuity taxation, kidney disease affects the lung.

Dual vacuity of the spleen and lung (脾肺气虚 pí fèi qì xū): Reduced eating; abdominal distension; sloppy stool; cough; panting; shortness of breath; qì vacuity signs. It develops when enduring cough causes damage to lung qì, which affects the spleen (disease of the child affecting the mother) or when dietary irregularities cause damage to the spleen that affects the lung (spleen failing to engender earth).