I. Overview: Interstitial lung fibrosis is a difficult disease of the respiratory system, the incidence of which has been on the rise significantly in recent years due to the invocation of high-definition screening methods such as CT and the increase in environmental pollution. The clinical manifestation is a group of lesions mainly characterized by dyspnea with movement, shortness of breath, dry cough and wheezing. Idiopathic pulmonary interstitial fibrosis refers to pulmonary interstitial fibrosis with no obvious cause. The causes are complex, and modern medicine believes that the causes are related to inhalation of various dusts, toxic gases, environmental pollution, and viral infections. Complex pathogenic factors excite various cellular active substances to form immune complexes with inflammatory cells, fibroblasts aggregation, initially in the alveoli and alveolar walls, manifesting as inflammation, leading to alveolitis. If the disease is chronic or progressive, inflammation spreads to adjacent interstitial parts and blood vessels, undergoes fibrotic repair, and excessive collagen deposition eventually produces scarring and destruction of lung tissue, resulting in interstitial fibrosis of the lung. The result is scarring and destruction of lung tissue, which in turn leads to significant gas exchange difficulties. The disease often starts insidiously, progresses progressively and leads to death due to respiratory failure, with an average loss of life expectancy of 3-5 years for patients. Yang Xiaohua, Department of Respiratory Heat Diseases, Oriental Hospital, Beijing University of Traditional Chinese Medicine
In March 2011, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) jointly published evidence-based guidelines for the diagnosis and treatment of idiopathic interstitial pulmonary fibrosis, which re-evaluated the drug treatment of IPF. In March, the American Thoracic Society and the European Respiratory Society jointly published evidence-based guidelines for the management of idiopathic interstitial fibrosis. In view of the findings suggesting potential benefits, the guidelines suggest that for well-informed patients who strongly desire pharmacological treatment, they may start with (1) acetylcysteine + azathioprine + prednisone (2) acetylcysteine monotherapy (3) anticoagulant therapy (4) pirfenfetamine (5) and (6) anticoagulation (6). Anticoagulation (4) Pirfenidone and other 4 options.
In recent years, the role of TCM in the treatment and prevention of pulmonary fibrosis has been widely appreciated due to the experimental studies and clinical research work on its role.
Prof. Pingan Zhou is a well-known expert in respiratory and infectious diseases and difficult diseases in China, chief physician and doctoral supervisor. He is an expert of the Public Health Emergencies Expert Committee of the State Administration of Traditional Chinese Medicine, an expert of the Infectious Disease Prevention and Control Expert Group of the State Administration of Traditional Chinese Medicine, and an expert of the Influenza A (H1N1) Expert Group of the Beijing TCM Bureau. He is a famous doctor of Beijing Chinese Medicine Salary and Fire Inheritance Famous Doctor Workstation, and a mentor of the fourth batch of National Old Chinese Medicine Experts Academic Experience Inheritance Work of the State Administration of Traditional Chinese Medicine. Prof. Zhou Pingan has been in clinical practice for more than 40 years, with remarkable clinical efficacy. Many difficult patients who have been treated by Prof. Zhou can often be relieved of their chronic diseases.
In the last decade or so, he has conducted in-depth research on interstitial lung fibrosis. He has a unique understanding of the name and mechanism of the disease in Chinese medicine, and has a unique way of identifying and prescribing medication, with positive clinical results. I became the academic successor of Prof. Zhou Pingan in October 2008, and studied under him for three years, summarizing more than 100 cases of interstitial lung fibrosis treated by Mr. Zhou, with remarkable clinical efficacy.
(2) Academic thoughts on the treatment of interstitial lung fibrosis
In terms of the name of the disease, Mr. Zhou believes that it should be classified as pulmonary paralysis. This is based on the book “Su Wen? In the “Treatise on the Inversion of the Four Signs”, “Shao Yin has a surplus of the disease, and the disease has a hidden rash of skin paralysis, while the deficiency of the disease is lung paralysis. The theory of paralysis”, “wind, cold, and dampness are combined to form paralysis. …… The paralysis of the skin does not cease, but is repeatedly affected by evil, and is internally surrendered to the lung. ……”, etc. Combined with modern clinical practice, it is proposed that lung paralysis can also be associated with The lung palsy can also correspond to pulmonary fibrosis secondary to connective tissue diseases such as dermatomyositis, scleroderma and other dermatopathies. If the patient has a surplus of Shao-Yin, the patient will only present with connective tissue disease and will not develop interstitial lung fibrosis “internally in the lung”. Based on the patient’s clinical symptoms and pathological changes, Mr. Zhou believes that this is a case of pulmonary paralysis. The name “pulmonary paralysis” was first mentioned in the Nei Jing. Su Wen? The theory of paralysis says: “The five organs are all united, and those who have been ill for a long time and do not go away, are internally surrendered to their unity. …… The skin paralysis does not cease, and is again affected by evil, and is internally surrendered to the lungs. …… “Where the paralysis of the guest of the five organs, lung paralysis is annoying full panting and vomiting, panting and panting, paralysis gathered in the lungs ……” “Its entry into the organs die, its stay even between the tendons and bones pain for a long time, its stay between the skin easy has.” In terms of pathogenesis, he considered blood stasis as the basic pathological product of paralysis blocking the lung ligaments. As the patient was weak and repeatedly felt external evil, the lung is the master of qi and respiration, the lung loses its master qi, and when the qi is weak, it is unable to transport blood and the blood stagnates. The lung is the master of qi and the source of anger. The lung is the master of regulating water channels and the source of water, and at the same time it is a delicate organ, vulnerable to external evil. The lung is the main regulator of the joints. The lung qi assists the heart and regulates the operation of the blood vessels, and all the vessels are directed to the lung. If the lung qi is not favorable, the governing joints become irregular and the blood stagnates and water stops. External evil repeatedly invades, the condition gradually aggravates, and over time the son steals the mother’s qi, affecting the function of the spleen and stomach, and the water and grain gather as phlegm and turbidity stored in the lungs, so there is “the spleen is the source of phlegm, the lungs are the storage of phlegm”. At the same time, the spleen and stomach loss, but also to the Qi and blood biochemical source, the disease is long and the kidney, or kidney deficiency asthma, or kidney yin deficiency, internal heat burning fluid phlegm, or kidney yang deficiency, water dampness up for phlegm. The lung is the main organ for the promotion of phlegm, and it is the reservoir of phlegm. Blood stasis and phlegm often form the poisonous evil that paralyzes the lung interstitium together. Due to the blockage of the lung channels by the poisonous evil, the lung loses its ability to promote and descend, and the lung loses its main qi. From the histological point of view, the lung ligament is composed of qi lou, the terminal airways, and blood lou, the capillaries, which is considered by Chinese medicine as the meridian, the smaller one as the lou, and the smaller one as the sun lou. While identifying the disease from a general perspective, he also has a deeper and more detailed understanding of the disease from a microscopic perspective combined with Western medical pathology reports. According to Prof. Zhou, the basic pathology of interstitial lung fibrosis is the blockage of capillaries and capillary bronchi.
Based on the principle of combining disease identification and evidence identification, Prof. Zhou Pingan believes that since paralysis is the main pathogenesis of interstitial lung fibrosis, the general rule of treatment is to regulate the Qi and Blood channels, to treat both Qi and Blood, to benefit Qi and Blood, and to open the paralysis. The main formula used is the folk formula “three taels of three”, also known as “three taels of three money three”. It is named after the quantity of the formula, which is usually five flavors of medicine. For each of the three taels of three soup prescriptions, the ancients had three parts of confidential medicine, and the ruler, minister, adjuvant and ambassador were strictly coordinated. In modern times, Prof. Zhou Pingan and Prof. Fang Dingya of Xiyuan Hospital often use the formula of “three two three”, which is 30g of raw astragalus, 30g of silver flower, 30g of angelica, and 9g of raw licorice. 30g (one two) of each of the first three flavors are used in the formula, making a total of 90g (three two). The formula was named “Qi Yin San San San” by Mr. Zhou. Mr. Zhou’s medicine also has an evolutionary process. Looking through his cases, we can see that before 2008, the composition was raw astragalus, silver flower, angelica, raw licorice, orris, whirling daisy, zhebei, and guahu bark. Radix Platycodon grandiflorus and Radix et Rhizoma: focus on regulating Qi, invigorating Blood, lowering Qi and resolving phlegm. The formula focuses on promoting Qi, activating Blood circulation, resolving phlegm, opening up paralysis. In the final stage, the cough and asthma is prolonged, and shortness of breath and weakness are obvious.
(C) Identification and treatment of pulmonary interstitial fibrosis typology of drug use rules and evidence
Through the summary of more than 100 cases of interstitial lung fibrosis in the past three years, Mr. Zhou’s treatment of interstitial lung fibrosis is summarized as follows.
1, phlegm-heat blocking lung type.
Symptoms: prolonged fever after external sensation, aggravation of cough shortness of breath, white and yellow sputum in large amount. The pulse is fine, the tongue is dark red, and the coating is thin and yellow.
This syndrome is mostly seen in patients with interstitial fibrosis of the lung. After the external sensation of wind-cold evil, the surface evil has been resolved and heat has entered the lung. The dark red tongue, thin yellow coating and thin pulse are also signs of stasis and internal obstruction by phlegm and heat.
Differentiation: The surface evil has not been cleared and phlegm-heat is blocking the lung.
Treatment: Clearing heat from the exterior, resolving phlegm and clearing ligaments.
Analysis: Phlegm-heat blocking the lung, internal heat not resolved, so the fever persists, so the urgent treatment of its symptoms first to eliminate evil, and then turn to treat fibrosis after the heat subsides. It is given to benefit Qi, clear heat and remove heat, and clear phlegm. Raw Astragalus: Benefit Qi to support the righteousness, mostly used for fever that does not subside for a long time, considering that the patient has a deficiency of Qi and Yin injury, so use Astragalus to support the righteousness to help expel the evil, at the same time, because of the use of antiphlogistic drugs, fear of aggravating Qi deficiency. Jin Yin Hua, Dandelion and Wild Chrysanthemum clear the lung heat, while Chai Hu, Scutellaria and Artemisia penetrate the evil outside. The herbs are used to clear the heat and penetrate the exterior.
2. Yin deficiency and blood stasis type.
Symptoms: Patients with interstitial lung fibrosis, cough with shortness of breath, little-colored phlegm, chest and back pain, tingling paroxysms, dislike of drinking, frequent nighttime urination, insomnia, red tongue, little coating, slippery pulse.
Analysis: cough with shortness of breath due to deficiency of qi and yin, less phlegm and white color, red tongue with less moss, stagnation of blood and obstruction of blood vessels, inaccessibility of blood vessels, pain due to inaccessibility, chest and back pain and tingling paroxysms, dislike of drinking, deficiency of yin and blood, insomnia due to blood not nourishing the heart.
Differentiation: deficiency of Qi and Blood, inaccessibility of the lung and blood vessels
Treatment: Benefit Qi, nourish Blood, open the lung ligaments and open paralysis.
Analysis: Astragalus membranaceus, Yinhua, Radix Angelicae Sinensis, Radix Glycyrrhiza Uralensis benefit Qi, invigorate blood circulation, resolve phlegm and open the ligaments. Ganoderma lucidum and Rhodiola rosea: Benefit the Qi, support the righteousness and nourish the deficiency of the body. Aster, Radix et Rhizoma, Radix et Rhizoma: stopping cough, resolving phlegm and clearing paralysis. Together, they can benefit Qi, nourish Yin, resolve phlegm and promote paralysis.
3.Qi and Yin deficiency type.
Symptoms: Diagnosed as a patient with interstitial lung fibrosis, manifesting as cough shortness of breath, fatigue and body fatigue, dry eyes, easy sweating, dry cough with little phlegm, normal bowel movements. Pale tongue with white coating and sunken pulse
Identification: deficiency of Qi and Yin, internal obstruction of phlegm and stagnation
Treatment: Benefit qi and nourish yin, open paralysis.
Herbs: Astragalus membranaceus 20g, Yinhua 20g, Radix Angelicae Sinensis 10g, Glycyrrhiza glabra 5g, Zhaobei 10g, Psidium Guadua 15g, Panax notoginseng 15g, Shiwei 15g, Ganoderma lucidum 15g, Rhodiola rosea 15g, Radix Codonopsis pilosulae 10g, Semen spleen
10 grams, 15 grams of Radix Rehmanniae, 15 grams of Rhizoma Chuanxiong, 15 grams of Fructus Crataegus, 15 grams of Dendrobium, 10 grams of Aconite
In this formula, the formula is based on Astragalus and Yin San Er San to benefit Qi, activate blood circulation, promote blood circulation and dissolve phlegm. Chuanxiong and Jiao Shanzha: open paralysis through the channels. The whole formula is a double tonic for qi and yin, resolving blood stasis and opening the channels.
4. Liver and kidney deficiency type.
Symptoms: Patients with interstitial fibrosis fibrosis of the lung see chest tightness, breath-holding, cough, wheezing, speech, activity wheezing aggravated , sputum less white, boiling hot sweating bouts, dry mouth and throat, frequent night urination, stool regulation, red tongue, thin coating, thin and sunken pulse.
Identification: deficiency of liver and kidney, deficiency of qi and phlegm stasis
Treatment: Tonify the liver and kidney, nourish Yin and submerge Yang.
Herbs: Astragalus membranaceus 20g, Yinhua 20g, Radix Angelicae Sinensis 10g, Radix Glycyrrhiza Uralensis 6g, Panax quinquefolium 15g, Shiwei 15g, Zhaobei 10g, Psidium guajava 15g, Aster 10g, Flos Daturae 10g, Rhodiola Rosea 15g, Ganoderma lucidum 15g, Sanguinariae 10g, Radix Bacopa monnierae 10g, Radix Chrysanthemum salinae 15g.
Xian Ling Spleen and Baji Tian: tonify kidney yang, commonly used when the patient has kidney deficiency; Salt Cyperus: nourish yin, submerge yang and calm the liver; Chicken Nei Jin: collect astringent and astringent sweat.
5. Lung and spleen qi deficiency type.
Symptoms: chest tightness and shortness of breath, cough with little phlegm, dry mouth and gum pain. Red tongue with white fur, sunken pulse, auscultation: restricted bursting sound in both lower lungs.
Identification: deficiency of lung and spleen qi, paralysis of the ligaments
Treatment: Tonifying Qi, strengthening the spleen, and clearing the ligaments to disperse the nodules
Radix Astragali 20, Radix Angelicae Sinensis 20, Radix Glycyrrhiza Uralensis 5
Radix et Rhizoma Polygonatum 10, Radix Platycodon 6, Radix zebrazi 10, Psidium guajava 15
Radix et Rhizoma Polygonatum 10, Radix Reishi 15, Poria 15
Radix et Rhodiola 15 Radix et Rhodiola 10 Radix et Rhizoma 10 Radix et Rhizoma 10
Analysis: Astragalus membranaceus, Yinhua, Radix Angelicae Sinensis, Glycyrrhiza glabra, Zhaobei, Psidium guajava, Pierced Mountain Dragon, and Guangdi Long are the basic formula of Mr. Zhou for treating interstitial lung fibrosis.
6. Lung, spleen and kidney deficiency type.
Symptoms: cough, shortness of breath for a long time, chest suffocation, asthma is obvious after exercise, loose stools, 3-4 times/day, sweating, mute voice, thin pulse, dark red tongue with white coating.
Differentiation: deficiency of both lung, spleen and kidney qi, paralysis of lung channels
Treatment: Benefiting Qi, strengthening the spleen, tonifying the kidney, resolving phlegm, and clearing ligaments
Astragalus membranaceus 20g, Radix Angelicae Sinensis 20g, Radix Angelicae Sinensis 10g, Glycyrrhiza Uralensis 5g.
Zhaobei 10g Guaou Piper 15g Dianshanlong 15g Shiwei 15g
Ganoderma Lucidum 15g Rhodiola Rosea 15g Radix Codonopsis Pilosulae 10g Atractylodes Macrocephala 10g
Chuanxiong 15g Mulberry Leaf 30g Xian Ling Spleen 10g Zhi Mu 6g
7. Interstitial fibrosis of the lung using hormones.
Symptoms: Interstitial fibrosis of the lung has been treated with hormones, with no significant improvement in symptoms. Cough, not much sputum, shortness of breath after activity, nagging, loose stools. The pulse is sunken, the tongue is red, the coating is white and greasy, and on auscultation: limited popping sounds in the lower lobes of both lungs.
Differential diagnosis: dampness in the lung and spleen, deficiency of kidney yang
Treatment: Benefit Qi, strengthen the spleen, resolve phlegm, and promote circulation.
Prescription: Astragalus membranaceus 20g, Radix Angelicae Sinensis 20g, Radix Angelicae Sinensis 10g, Radix Glycyrrhiza Uralensis 5g.
Radix et Rhizoma Polygonatum 10g, Radix Platycodon 6g, Radix Zebrazi 10g, Psidium Guadua 15g.
Radix et Rhizoma Polygonatum 15g, Radix Reishi 15g, Rhodiola Rosea 15g
Radix Codonopsis Pilosulae 10g Fried Atractylodes Macrocephalae 10g Coke Hawthorn 15g Chuanxiong 15g
(D) Evidence and treatment insights.
For interstitial lung fibrosis, Prof. Zhou Pingan has his complete academic thought, and his treatment is based on modern pharmacological drugs that have the ability to reverse fibrosis and drugs that have the ability to regulate immune function, and at the same time, herbs that benefit qi, invigorate blood, resolve phlegm, and open ligaments and palsy. “Qi Yin San Liang San”. Three two three party, originated from folk experimental prescription, learned from Professor Song Xiaozhi, the formula consists of five flavors of medicine, the specific drugs are variable, five drugs together to play a therapeutic role, the first three flavors of each medicine amount to one tael, the next one a penny, the last confidential medicine for three points, with the disease and change, so the name of the formula three two three. Professor Zhou Pingan, based on Song and his personal experience, has applied the “Three Two Thirds” formula to treat difficult diseases with remarkable clinical results.
Among them, raw astragalus is sweet, slightly warm, and belongs to the lung and spleen meridian. Modern research suggests that Astragalus can significantly improve the body’s non-specific immunity, humoral immunity, cellular immunity, broad-spectrum anti-bacterial, anti-viral effects, can improve blood rheology, promote hematopoietic function, dilate blood vessels, increase blood flow, improve microcirculation to enhance the repair of necrotic tissue, is “sore family holy medicine”. There are also heart-strengthening, liver protection, improve kidney function, anti-emergency, detoxification, sedation, pain relief and other effects. Yinhua is sweet and cool in nature, and belongs to the lung and stomach meridians. The True Tradition of Medicine: “Gold flower goes to the blood, while silver flower goes to the qi, and the medicine to harmonize the qi and blood. What diseases should not be treated? Does it have to be used after canker sores and poison? The “You Yuzhai medical words”: “gold silver flower, sweet and flat, in addition to heat detoxification ……” modern research that gold silver flower in vitro on a variety of bacilli, coccus have inhibitory effect. The combination of raw Astragalus and Yinhua, Astragalus tonifies the Qi and moves the blood, while Yinhua opens up the blood vessels, warming and cooling, with a calming nature, the two together can strengthen the effect of opening up the blood vessels. Zhou believes that the combination of Astragalus and Yinhua, one hot and one cool, the combination of the two to support the righteousness, the other to dispel the evil, benefit the Qi and detoxify the blood vessels. Qi is the handsome of blood, Huang Qi tonifies Qi and moves blood; blood is the mother of Qi, Angelica nourishes blood and moves Qi, Qi follows blood, blood grows with Qi, the two used together is Angelica tonifying blood soup, both tonifying Qi and blood, and opening lung channels. Modern pharmacological research shows that Astragalus membranaceus and Angelica sinensis can regulate immune function, promote hematopoiesis, protect blood vessels, and reverse lung and liver fibrosis. Zhe Bei Mu clears heat, dissolves phlegm and disperses nodules; Gua Pou Pi expels phlegm and clears heat; Dian Shan Long dispels wind and dampness, activates blood circulation, dispels phlegm and calms asthma, and has anti-inflammatory and anti-metabolic effects; Shi Wei clears the lung and relieves cough, calms asthma and diuresis.
Most patients with interstitial lung fibrosis show chronic progression, and clinical manifestations can be divided into remission phase and acute exacerbation phase. The remission phase is characterized by Qi deficiency, blood stasis and loss of lung circulation and descent, while the acute exacerbation phase is characterized by phlegm-heat stasis and loss of lung circulation and descent. According to their different clinical manifestations, TCM doctors identify the evidence and add and subtract drugs. In case of Qi stagnation, add Xiang Gu Pi, Buddha’s Hand, and Fragrant Herb; in case of combined infection with fever, add Chai Hu, Artemisia annua, and Scutellaria baicalensis; in case of excessive sweating, add Calcined Oyster, Fried Atractylodes Macrocephalae, and Fucus vesiculosus. If coughing and wheezing for a long time, shortness of breath and weakness are obvious add Rhodiola Rosea and Ganoderma Lucidum. Among them, Rhodiola rosea benefits Qi and blood, clears heat and moistens the lungs, resists fatigue, hypoxia and aging; Lingzhi nourishes Qi and blood, stops cough and asthma, nourishes the heart and calms the mind, scavenges oxygen free radicals with antioxidants and strengthens the body’s resistance.
The most common drug used in Western medicine for interstitial lung fibrosis is hormone therapy, and Mr. Zhou advocates not to use hormones for a long time. The long-term use of hormones has huge side effects and limited therapeutic effect, and he advocates controlling the disease with Chinese medicine as much as possible. However, most of the patients who come to the clinic have been treated by multiple Western and Chinese doctors, and there are few who are using hormones and immunosuppressants. For such patients, Mr. Zhou does not ask the patients to stop using hormones immediately, but helps them gradually withdraw hormones to reduce their toxic side effects. Hormones have the effect of stimulating the Yang energy of the body, and when reducing the dosage of hormones, it will cause the Yang energy of the body to be insufficient. Appropriate application of ginseng and licorice can reduce the reaction caused by the withdrawal of hormones and achieve the purpose of smooth withdrawal of hormones. According to Shennong Ben Cao Jing, ginseng is “sweet and slightly bitter in taste, main tonic for the five organs, light for a long time and prolongs the life of the body”. In the Compendium of Materia Medica, it is written that
”Ginseng root can be used as medicine to nourish the qi, restore the blood, nourish the heart and tranquilize the mind, quench thirst and produce body fluid, nourish the lungs and calm asthma, strengthen the spleen and stop diarrhea, and remove poison and sores. Modern pharmacology believes that ginseng can enhance the immune function of the body, has anti-inflammatory function, and has stimulating effect on adrenal-pituitary gland, and the combined use of licorice can make the effect last. Western medicine pharmacology found that licorice agent has anti-inflammatory and anti-metabolic functions, so it can be used as a clinical palliative. In addition, licorice can play the role of deoxycorticosterone, which has good effect on chronic hyperalgesia; the flavonoids of licorice have anti-inflammatory, antispasmodic and antacid effects. The specific practice is to start taking Chinese medicine with the original hormone dosage unchanged, when the Chinese medicine has control over the disease, then you can start to gradually reduce the hormone dosage, the beginning can be reduced by one piece per month, the reduction should be more cautious in the later stage, the deceleration should be slower to prevent the rebound, in the middle if the disease recurrence is suspended. When the condition is stable, clinical symptoms are gradually reduced, and the condition can be completely controlled with Chinese medicine, then gradually reduce the dosage to completely stop the drug. According to the patient’s specific condition, ginseng can be replaced by American ginseng, Radix et Rhizoma ginseng and prunus ginseng. The choice of ginseng should be based on the patient’s symptoms. If the patient’s spleen deficiency is mainly manifested by sluggishness and loose stools, use Radix Codonopsis Ginseng, 15-30 grams per day; if the patient’s qi deficiency is heavy, short of breath, weakness, mental fatigue, Yang deficiency and coldness, use Ginseng; if the patient’s yin deficiency is internal heat, dry mouth, thirst for cold drinks, red tongue, little coating, thin pulse, use 30 grams of prince’s ginseng; if both qi and yin deficiency are heavy, use American ginseng.