Evaluating cough through Traditional Chinese Medicine lens

Photo Cred: Cottonbro/Pexels

By Melissa Carr, BSc, DrTCM

Coughing in public has gotten a lot more complicated. It doesn’t matter if it’s allergies, a smoker’s hack, or food that went down the wrong way—these days, coughing makes everyone look and take a step back. Of course, in reality, coughing is a lot more specific than whether it’s caused by an infection or not, and Traditional Chinese Medicine (TCM) has its own assessment of coughs that integrative practitioners can apply in their practices.

Eight Principles

TCM practitioners can first assess a cough based on eight main factors: is it caused by something off balance externally or internally, hot or cold, excess or deficient, and Yang or Yin?

An externally caused cough is usually from some sort of viral or bacterial infection. An internally derived cough could be from an organ disfunction like asthma, gastroesophageal reflux disease (GERD), or congestive heart failure. It might also be created by strong or long-standing emotions.

Signs of heat related to a cough include yellow phlegm, fever, and burning sensation. Cold coughs might have white or clear phlegm, feeling cold, and pale complexion.

Excess coughs can be identified by their loud sound. They are usually acute or occur with those who are robust. Strong pain with coughing, a feeling of distension in the chest, and coarse breathing are also possible with excess cases. Those who are weaker, older, or who have been sick for a while may have a deficiency cough, and this is typically quieter in sound and associated with fatigue and shortness of breath.

Yang and Yin assessments can show up as Yang excess or deficiency and Yin excess or deficiency. Since external, hot, and excess are all more Yang in nature, a Yang excess cough would have yellow phlegm, be loud and forceful, and is often from infection, while a Yin deficiency cough might be dry, sound weak, and often affects someone who is older or has chronic health conditions.

Lung Qi Uprising

Coughs, most simply, are from Lung Qi uprising. Lung Qi is always supposed to travel down. When it rebels and travels upward, cough and shortness of breath are the main symptoms. The Lungs, in TCM, are called “delicate organs.” They have the most exposure to the external world, with anything inhaled being filtered by fine hairs and mucus. Colds and flus affect the Lungs, with viral and bacterial infections most commonly diagnosed as either Wind-Cold or Wind-Heat external invasion.

In addition to coughing up thin or white phlegm, the patient suffering with Wind-Cold external invasion of the Lungs may also have body aches, a headache, a stuffy or runny nose, sneezing, and a scratchy throat. Some common Chinese herbal formulas to treat this include Gui Zhi Tang, Xing Su San, and Ge Gen Tang, but make sure to include herbs that can help sedate the cough, like ku xing ren (apricot kernel), jie geng, and bai qian.

For those with yellow phlegm, fever, yellow nasal discharge, and sore throat, Wind-Heat external invasion of the Lungs can be addressed with Lian Qiao San or Gan Mao Ling, but San Ju Yin or Ning Sou Wan will do a better job of addressing the cough. If the first formulas are prescribed, add in herbs for the cough, like chuan bei mu, xing ren, zi su ye, and sang bai pi.

Cough may also occur when the Lungs become too dry or too wet. A dry cough needs to be treated with moist herbs and foods like sang ye, mai men dong, hei zhi ma (sesame seeds), ma zi ren/huo ma ren (hemp seeds), and xing ren (apricot kernels). Steaming pears in honey is a classic TCM food cure remedy for a dry cough. A phlegmy (wet) cough is treated with expectorants like pi pa ye, gua lou or gua lou ren, and chuan bei mu. A well-known expectorant TCM cough syrup that has made it to mainstream and is now found sold in pharmacies and on Amazon is Nin Jiom Pei Pa Koa.

For those with shortness of breath, wheezing, fatigue, and a weak voice, Lung Qi deficiency may predominate, so add herbs to strengthen the Lungs, such as ren shen (ginseng), dang shen (codonopsis), ling zhi (reishi), and huang qi (astragalus). Bu Fei Tang, Bu Zhong Yi Qi Tang, and Yu Ping Feng San are common formulas to support Lung Qi, with this last formula used to help those who often catch colds.

Organ Differentiation

While, for obvious reasons, the main TCM organ related to coughs is the Lungs, other organ systems may also be involved.

The TCM Kidneys are said to help draw the Lung Qi down, so weakness of the Kidney system can result in shortness of breath or weak coughs. Anger and frustration may cause Liver Qi stagnation or Liver Fire which then invades the Lungs. Spleen Qi or Yang deficiency might cause an accumulation of Dampness in the body, allowing for Phlegm and Dampness to impede the Lungs. Just like Lung Qi should travel downward, so too should Stomach Qi. So, when Stomach Qi is rebellious and goes up, there is nausea, vomiting, or GERD, and Lung Qi sometimes goes along for the ride. With the Heart and Lungs as close neighbors, problems with the emotional Heart—trauma, lack of joy, grief, and sadness—or Heart Yang deficiency allowing for an accumulation of fluids around the Lungs (congestive heart failure) can both cause a chronic cough.

With as many as 75 different TCM diagnoses, it’s difficult to fully cover this one seemingly basic symptom of cough but starting with the eight principles and which organs are most involved helps clarify a TCM diagnosis and treatment plan.

Case Study

Ben is a 70-year-old patient with recent worsening of a chronic cough. We did his consultation by video because a couple of days prior he started feeling sick with a sore throat, stuffy nose, and coughing up thick yellow phlegm. After testing negative for the novel coronavirus (COVID-19), though the other symptoms were slowly improving, the cough remained.

Coughing was not a new symptom for him, as he also had asthma, GERD, and was on an ACE inhibitor for his hypertension. In addition, he had sleep apnea, and his sleep was greatly impacted by the cough, especially as it was hard for him to use his CPAP machine.

I diagnosed him with external Wind-Phlegm-Heat attacking the Lungs, combined with Heart and Lung Qi deficiency and Dampness accumulation. The first step, however, was to help his body clear out the infection. I created a TCM herbal prescription for him, including the antiviral herbs, lian qiao, chuan xin lian, and ban lan gen, along with sedating the cough herbs xing ren, sang ye, and jie geng. Since he has several chronic health issues and is often fatigued, I also included ling zhi and dang shen to support his Lung and Heart Qi. Gan cao (licorice root) is a common herb for addressing GERD, but in TCM, it’s also used to harmonize the other herbs in a formula, so it too was included.

Once his acute cough is settled, we can address his chronic health issues more directly.