Pneumonia is a common disease of the respiratory system characterized by inflammation of the lung parenchyma. Clinically, there are two methods to classify the disease. Anatomically, it can be divided into lobar pneumonia, bronchopneumonia and interstitial pneumonia, while etiologically, it can be divided into bacterial pneumonia, fungus pneumonia, AND viral pneumonia, etc. In TCM, "pneumonia" refers to such diseases as lung abscess, wind-warm syndrome, lung-heat, cough, dyspnea or chest pain.

Pneumonia is often induced by exposure to cold, being caught in the rain or over-fatigue. The onset is sudden and about 50% of patients present symptoms of infection of the upper respiratory tract. Usually chills occur first, then there is a high fever up to 39 or 40 degrees C. (102 – 104 degrees F). Chest pain is mostly stabbing in nature. In typical cases, there is a cough with rust-like or blood-stained sputum and flaring of the nares or cyanosis. If the infection is very critical, there will be rapid deterioration of the condition with signs of failure of the peripheral circulation.

1. Etiology and Pathogenesis

2. Essentials of Diagnosis

In Western medicine, the disease is diagnosed based on the followings, sudden onset, chills, high fever, chest pain, cough with iron-rust sputum, pulmonary infiltration along the lobes in X-ray examination, bacteria found in sputum.

In TCM, the disease belongs to invasion of pathogens on the exterior of the human body at the initial stage, as it often presents fever, chills and cough, the manifestations of exterior syndrome. At the middle stage, it is mostly a syndrome caused by exuberance of phlegm heat in the lung since this stage is often manifested as high fever, cough with yellow thick sputum, dyspnea, etc. At the later stage, it is often a syndrome marked by deficiency of both Qi and yin as a result of the pathogenic heat impairing Qi and yin. If the heat is too strong, it may cause sudden exhaustion of Yang Qi and so a Yang prostration syndrome will follow.

3. Types and Treatments

Main Manifestations: Fever with mild chills, headache, general aching, cough with white thick or yellowish sputum, chest pain, dry mouth, red tongue with white or yellowish tongue coating, and floating rapid pulse.

Symptom Analysis: This syndrome arises from pathogenic wind heat invading the exterior and the lung with the exterior syndrome the main site of manifestation. As the pathogen stays in the exterior, there are fever, chills, headache and general aching. Then, as the pathogens invade the lung and disturb the dispersion and descending of lung Qi, there is coughing with white thick or yellowish sputum and chest pain. A dry mouth means that body fluid is injured, while a red tongue indicates that pathogenic heat is strong and has involved the lung or the interior of the human body.

Therapeutic Principles: Relieve the exterior syndrome with pungent and cool herbs, clear lung heat and dissolve phlegm.

Prescription: Yin Qiao San with modifications.

Ingredients: Jin Yin Hua 15g, Lian Qiao 15g, Niu Pang ZI 10g, Jie Geng 10g, Dan Zhu Ye 12g, Lu Gen 20g, Jing Jie 10g, Bo He 6g, Sang Bai Pi 15g, Qian Hu 12g, Gua Lou Pi 12g, Yu Xing Cao 30g, to be taken orally after decoction in water, one dose daily.

Explanation: In this formula, Jin Yin Hua and Lian Qiao are used to disperse wind, clear heat and relieve the exterior syndrome, Dan Zhu Ye and Lu Gen clear heat and promote production of body fluid, Bo He and Niu Pang Zi treat sore throat and relieve the exterior syndrome with their pungent taste and cool nature, and Sang Bai Pi, Gua Lou Pi, Qian Hu and Yu Xing Cao to clear heat and dissolve phlegm.

Modifications: For cases with exuberant heat, add Sheng Shi Gao 30g and Huang Qin 30g. For cases with severe cough, add Xing Ren 10g. For cases with thick sputum, add Tian Zhu Huang 12g and Chuan Bei 1.5-3g (powdered, to be taken with water) and Zhe Bei Mu 15g. For cases with constipation, add Da Huang 9g and Mang Xiao 3g (powdered, to be taken with water).

2. Accumulation of Heat and Phlegm in the Lung

Main Manifestations: High fever, frequent cough with yellow thick sputum difficult to expectorate, iron-rust colored or blood-stained sputum, dyspnea, stabbing chest pain, constipation, dark scanty urine, red tongue with yellow dry coating and slippery rapid pulse.

Symptom Analysis: This syndrome often arises from pathogens entering the lung, turning body fluid into phlegm and the ensuing accumulation of phlegm heat in the lung, which is seen mostly in the middle stage of pneumonia. High fever indicates excessive heat in the lung, and frequent coughing with thick sputum means that phlegm heat is disturbing the flow of lung Qi, causing lung Qi to go upward and turning body fluid into phlegm. Thirst indicates impairment of body fluid by heat, and a slippery rapid pulse suggests both phlegm and heat in the lung.

Therapeutic Principles: Clear heat, remove toxic materials, dissolve phlegm and facilitate the flow of lung Qi.

Prescription: Ma Xing Shi Gan Tang and Qian Jin Wei Jing Tang with modifications.

Ingredients: Zhe Bei Mu 15g, Ma Huang 12g, Sheng Shi Gao 30g 10g, Dong Gua Ren 20g, Tao Ren 20g, Yu Xing Cau 15g, Sang Bai Pi 15g, Shan Zhi 10g, Huang Qin 15g, Gua Lou Pi 15g, Jie Geng 10g, Lu Gen 30g, Yi Yi Ren 30g, to be taken orally after decoction in water, one dose daily.

Explanation: In this formula, Sang Bai Pi, Shan Zhi, Huang Qin, and Sheng Shi Gao function to clear lung heat, Ma Huang relieves dyspnea, Zhe Bei Mu and Xing Ren induce lung Qi to flow downward to relieve cough, Lu Gen clears heat and promotes the production of body fluid, Yi Yi Ren, Yu Xing Cao and Dong Gua Ren clear heat and dissolve phlegm and Tao Ren relieves cough.

Modifications: For cases with coughing up of blood, add Bai Mao Gen 15g and Ce Bai Ye 15g. For cases with coma and delirium, add An Gong Niu Huang Wan to the prescription, one pill once a day. For cases with constipation, add Da Huang 9g and Zhi Shi 12g.

3. Consumption of Both Qi and Yin

Main Manifestations: Cough, low fever or afternoon fever, hotness in the palms and soles, spontaneous sweating, listlessness, or appetite, dry mouth, red tongue with little coating and fine pulse.

Symptom Analysis: This syndrome is often seen in the later stage of pneumonia in which both Qi and Yin are impaired by phlegm heat and the pathogens are about to be eliminated completely. As a result of Yin impairment, there is heat in the palms and soles and dry mouth. As a result of the impairment of Qi, there is listlessness, spontaneous sweating, poor appetite. Red tongue with little coating suggests Yin impairment.

Therapeutic Principles: Supplementing Qi, nourishing Yin, moistening the lung and dissolving phlegm.

Prescription: Yang Yin Qing Fei Tang with modifications:

Ingredients: Sheng Di Huang 20g, Mai Men Dong 15g, Bai Shao 15g, Xuan Shen 15g, Chuan Bei 12g, Mu Dan Pi 10g, Xing Ren 10g, Tai Zi Shen 24g, Di Gu Pi 15g, Huang Jing 20g, Zi Wan 12g, Sang Bai Pi 15g, to be taken orally after decoction in water, one dose daily.

Explanation: In this formula, Sheng Di Huang is used to nourish the kidney Yin, Mai Meng Dong to nourish the lung Yin, Xuan Shen to clear heat of deficiency type and detoxicfy, Chuan Bei Mu to moisten the lung and dissolve phlegm, Bai Shao to preserve Yin and clear heat, Tai Zi Shen and Huang Jing to moisten the lung, Xing Ren, Sang Bai Pi and Zi Wan to dissolve phlegm and relieve cough, and Di Gu Pi to clear heat of deficiency type.

Modifications: For cases with chest pain, add Tian Qi 3g (powdered, to be taken with water) and Yu Jin 15g. For cases with spontaneous sweating, add Wu Mei 12g and Fu Xiao Mai 30g. For cases with dry mouth and cough with sputum, add Tian Hua Fen 15g. And for cases with apparent low fever, add Bai Wei 15g and Qing Hao 9g.

4. Sudden Collapse of Yang Qi

Main Manifestations: Sudden reduction of high fever followed by pale, profuse sweating, cold limbs, listlessness, rapid breath, wheezing sound in the throat, cyanosis of lips, pale or dark tongue and feeble and indistinct pulse.

Symptom Analysis: This syndrome is often seen in patients with toxic shock due to high fever, which is considered to be a syndrome of sudden collapse of Yang Qi following excessive pathogens consuming vital Qi of the human body suddenly in TCM. As a result of sudden collapse of Yang Qi, vital Qi fails to fight against pathogens, so the fever subsides. Failure of Yang Qi to perform its warming effect causes cold limbs and pale complexion, while failure of the deficient Yang to consolidate sweat pores causes profuse sweating. The deficient Yang floats upward, so there is rapid breath. Cyanosis of lips suggests blood stasis caused by failure of Yang Qi to warm the blood vessels and promote the movement of blood.

Therapeutic Principles: Supplementing Qi to treat prostration and rescuing Yang from collapse.

Prescription: Sheng Mai San and Shen Fu Tang with modifications.

Ingredients: Ren Shen 10g, Shu Fu Zi 10g, Mai Dong 15g, Wu Wei Zi 6g, Huang Qi 30g, Sheng Long Gu 15g, Sheng Mu Li 15, Zhi Gan Cao 10g, to be taken orally after decoction in water, one dose daily.

Explanation: In this formula, Ren Shen is used to supplement the primordial Qi, Shu Fu Zi to strengthen the kidney Yang and combine with Sheng Long Gu and Sheng Mu Li to rescue Yang from collapse, Huang QI to supplement Qi, Mai Dong to moisten the lung and nourish Yin and Wu Wei Zi to astringe the lung to stop sweating and promote production of body fluid.

Modifications: For cases with severe cyanosis of lips, add Dan Shen 20g and Dang Gui 10g.

4. CASE STUDIES

Case One
Zhang was a 26 years old male patient who developed headache, chills, high fever (39.6C), cough with yellow thick sputum, occasional pain in the left side of chest, bitter taste in the mouth, dry mouth, constipation, scanty dark urine, red tongue with yellow coating and floating rapid pulse after caught by rain 4 days ago. On physical examination, he had a complexion of acute disease, coarse breathing sound in both the lungs, and X-ray examination showed mild infection in the low field of the left lung. Then he was diagnosed as pathogenic factors attacking the lung and the exterior and Yin Qiao San was prescribed with modification:

Jin Yin Hua 15g, Lian Qiao 15g, Qing Hao 10g, Wei Ling Xian 15g, Lu Gen 20g, Bo He 6g, Huang Qin 15g, Sang Bai Pi 15g, Yu Xing Cao 30g, Gua Lou Pi 12g, Chai Hu 15g.

After 5 doses were administered continuously for 5 days, the fever subsided, the cough was relieved and the sputum turned from yellow to white, showing that his condition was greatly improved.

Case Two
Su was a 37 year old worker who was admitted into our hospital with a complaint of high fever, cough and chest pain for five days. On admission, he had cough with yellow thick sputum and blood-streak, pain in the right side of chest, high fever (40C – 104F), scanty dark urine, constipation, red tongue with yellow coating and slippery rapid pulse. His condition was diagnosed as accumulation of phlegm heat in the lung and Ma Xing Shi Gan Tang was prescribed to clear heat, detoxify, purge the pathogen from the lung and relieve cough. Herbs prescribed are as follows:

Zhe Bei Mu 15g, Zhi MU 10g, Dong Gua Ren 20g, Yu Xing Cao 30g, Sang Bai Pi 15g, Huang Qin 15g, Sheng Shi Gao 30g, Xing Ren 10g, Ma Huang 10g, Bai Mao Gen 30g, to be taken orally after decoction in water, one dose daily.

Five days later, his body temperature reduced to 37.5C (99.5F), the coughing of blood stopped and the sputum turned from yellow to white in color.

Case Three
Liu was a 46 year old female who was admitted into the hospital with a complaint of repeated cough with sputum for one month and low fever for one week. One month before her admission, she began to have high fever and cough with thick yellow sputum which were diagnosed as infection of the left lung in a hospital through X-ray examination. She then received antibiotic treatment in the hospital which reduced the fever to 37.5-38C (99.5.F–100.4). Thereafter, the fever continued, more severe in the afternoon with occasional cough, some thick sputum, heat in the palms and soles, dream-disturbed sleep, insomnia, spontaneous sweating, red tongue and fine pulse. A diagnosis of deficiency of both Qi and Yin was made and she was given Yang Yin Qing Fei Tang to supplement Qi and nourish Yin.

Sheng Di Huang 20g, Mai Dong 15g, Bai Shao 15g, Xuan Shen 15g, Xing Ren 10g, Tai Zi Shen 24g, Di Gu Pi 12g, in Chai Hu 12g, Sang Bai Pi 12g, Fu Xiao Mai 30g, to be taken orally after decoction in water, one dose daily.

After seven days of continuous administration of the formula, her symptoms were about fully relieved and X-ray examination and blood test both revealed no positive findings.

Case Four
Huang was a 58 year old male patient who was admitted into hospital for observation with a complaint of cough with sputum and dyspnea for twenty days and which were aggravated two hours prior to admission. Twenty days earlier, this patient presented a cough with thick yellow sputum, dyspnea, chest fullness, fever 39C (102.2F) and mild chills after exposure to cold. He was treated in a village clinic with Western medicine which reduced the fever suddenly, but his cough and dyspnea worsened and as a result his family sent him to our hospital. On examination, he had cough, dyspnea, inability to lie flat, wheezing sound in the throat, cyanosis of the lips, disinterested expression, dark tongue and fine rapid pulse. An chest x-ray indicated lobar pneumonia. According to TCM, this case indicated prostration of Yang Qi and the following herbs were then prescribed:

Ren Shen 10g, Shu Fu Zi 10g, Mai Dong 15g, Wu Wei Zi 6g, Huang Qi 30g, Sheng Long Gu 20g, Sheng Mu Li 20g and Zhi Gan Cao 10g, to be taken orally after decoction in water, one dose daily.

After three weeks of treatment, his disease was cured.

5. Summary