Western Medicine

 During asthma attack, the bronchial smooth muscle

Asthma is a lung condition where inflammation (swelling) and tightening of the airways causes difficulty breathing air into and out of the chest.

Different cells, most of them immune cells, produce this inflammation when triggered by contact with irritants. The inflammation blocks the airways, making it difficult to breathe normally.

Recurrent bouts of wheezing, breathlessness, chest tightness and coughing, usually at night or in the morning, are brought on by the inflammation.

The inflammation is reversible, either spontaneously or with treatment but it can leave the airways more likely to overreact to various triggers.

Chinese Medicine

Asthma is classified, in Traditional Chinese Medicine (TCM), as wheezing and/or panting syndromes. It was first described in the ancient medical book Summary of the Golden Chamber. Asthma was mentioned as a kind of "cough resulting from the ascending movement of qi (panting)." A narrowed airway caused a whistling sound during breathing, which was described as a "chicken sound in the throat." Another medical book, Treatise on the Causes and Symptoms of Disease (610 AD), also pointed out other asthma characteristics such as its "regular recurrence" in individuals.

Although both of these syndromes are associated with asthma in western medicine, they have distinct differences. The Chinese term for wheezing is "xiao." A wheezing syndrome is characterized by congestion with phlegm (bronchial secretions) and gasping which produces a whistling sound in the "throat." (The word "throat " refers to the whole respiratory tract). It also is associated with rapid breathing and shortness of breath. In severe cases, these symptoms cause difficulty lying down.

The Chinese term for panting is "chuan." A panting syndrome is characterized by rapid breathing, an open mouth, dyspnea (difficulty breathing) and elevated shoulders. Elevated shoulders occur when individuals have persistent difficulty breathing and need to use their shoulder muscles in addition to their chest muscles to support respiration. In western medicine, this is referred to as the use of accessory breathing muscles.

Wheezing and panting syndromes can occur simultaneously or alone. TCM treats asthma according to the classification patterns and symptoms the individual exhibits.

Western Medicine

While the causes of asthma are not completely understood, some factors are strongly associated with its development. These are:

• Genetics-a family history of asthma or allergy-based illness.
• Atopy- a condition where the immune system reacts more sensitively to contact with allergens.
• Wheezing when suffering from a viral infection: Infants and children who develop wheezing when infected with a cough or cold may go on to develop asthma that persists throughout childhood.
• Occupational exposure to substances likely to cause allergic lung irritation such as wood dust, resins, metals, animal products or enzymes.
• Intrinsic asthma is a condition seen most often in adults and its development is not related to allergies. The cause of this type of asthma is not really understood, but adults who have this type may have coexisting problems such as sinusitis, sensitivity to aspirin and/ or non- steroidal anti-inflammatory drugs (NSAIDS), or nasal polyps.

Triggers of asthma include:

• Exposure to allergens such as dust mites, mold, cockroaches, the dander (skin flakes) of cats and dogs, bird feathers and pollen.
• Smoke (tobacco & wood)
• Exposure to irritants such as laundry soap, strong smells, perfume, dust and pollution
• Viral infections such as respiratory syncytial viruses (RSV), influenza viruses, and rhinoviruses
• Exercise
• Certain Drugs such as: aspirin and NSAID's (i.e. ibuprofen)
• Weather changes
• Food additives
• Environmental changes
• Emotions

Chinese Medicine

Asthma presents as a wheezing and/or panting syndrome.

Wheezing syndromes are caused by:

1. Pernicious evils (environmental factors leading to illness).
2. These include wind, summer heat, dampness, dryness, cold and fire.
3. Improper diet
4. Emotional disturbance
5. Stagnation of liver qi (When the liver is healthy, it maintains the smooth movement of qi though its flowing and spreading functions.)

These factors impair the organs, (lung, spleen and kidneys), responsible for fluid metabolism. As a result, an accumulation of unhealthy dampness in the body, known as "phlegm," occurs. Obstruction of the airways develops when phlegm rises with qi. Phlegm also hinders the movement of qi. When this happens, the lungs cannot descend and disseminate qi properly. As a result, the airway will narrow and phlegm and qi will fight each other, producing a wheezing or whistling sound in the throat.

Panting syndromes are mostly caused by lung and kidney disharmony.

Normally, the lungs descend and disseminate the different types of qi to the rest of the body. If lung disharmony is present, panting will occur. There are several reasons for this:

1. The attack of wind-heat or wind-cold (two types of pernicious evils) leads to a problem with regulating sweat.
2. Normal sweat regulation is important for the healthy dissemination of lung qi.
3. Spleen disharmony causes problems with the body's digestive functions and results in an accumulation of dampness or "phlegm." When the phlegm is sent upwards to the lungs, it affects their normal descending properties.
4. Emotional disturbance
5. Emotional disorders lead to either stagnation of qi or liver disharmony. As the lungs rule qi, and the liver rules the flowing and spreading of qi, any stagnation will cause disharmony of lung function.

Kidney disharmony also plays a role in panting syndromes. The kidneys rule the grasping of qi (the regulation of healthy inhalation), and the lungs rule qi (regulation of breathing). A deficiency in either the lungs or kidneys can lead to a panting syndrome.

Western Medicine

1. Cough, often worse at night
2. Difficulty breathing or shortness of breath
3. Wheezing
4. Chest tightness
5. Thick or increased sputum production

The above symptoms occur periodically and should be at least partially if not fully reversible.

Symptoms of an asthma exacerbation/or attack:

Progressively worsening shortness of breath, cough, wheezing, chest tightness or a combination of these symptoms all indicate an exacerbation that should be treated immediately.

Chinese Medicine

Asthma symptoms are grouped into different classification patterns depending on their manifestations.

Exacerbation period

During an exacerbation of asthma, two different clinical patterns can present. These are the cold and heat types. Cold and heat influences are either environmental or physiological factors that trigger the exacerbation. They both belong to the "pernicious evils" in TCM.

1. Cold type asthma

Cold influences cause stasis (a condition where the flow of a substance is either slowed down or stopped), just as oil becomes viscous (thick) when its temperature is lowered. When a cold influence affects the body, phlegm turns white, thick and sticky, and it is not easily loosened with a cough. Cold phlegm has stasis properties, which lead to chest congestion and obstruction of qi movement and breathing. This results in wheezing and a feeling of chest tightness and fullness. Lastly, the lungs lose their ability to descend and disseminate qi properly.

Phlegm is a manifestation of an excessive yin pattern. (Yin is usually used to describe material things.) An accumulation of phlegm leads to an imbalance, which results in an excess of yin and a relative deficiency of yang. This causes a dim and bluish complexion, cold limbs, an aversion to cold temperatures, and a preference for warm drinks. Individuals may only sweat a small amount because the cold symptoms are unable to escape to the exterior of the body. People with cold type asthma have a white and greasy or white and slippery tongue coating and a floating, tight pulse.

2.Heat type asthma

Heat influences have "excitation" properties which manifest as excessive yang patterns. They produce yellow, sticky and thick phlegm and coarse breathing. As lung qi is reversed from its normal descending flow, a paroxysmal cough and a roaring wheezing sound occur because of an accumulation of "heat phlegm." With the flare up of "heat phlegm," individuals also experience chest discomfort and thirst. People with heat type asthma have a red face and a red tongue with a yellow, greasy coating. The pulse usually feels slippery and rapid.

Non-exacerbation period

During a non-exacerbation period, the symptoms of asthma can be classified into deficiencies of the lungs, spleen and kidneys or any combination of these.

1.Deficiency of lungs

Normal lung function affects the health of some exterior body parts such as the hair, skin and sweat glands. If the exterior is weak and lacks sufficient support from protective qi, (a type of qi which acts like the immune system), the body is easily attacked by the "pernicious evils" (environmental factors which cause illness). With weakened lung qi, spontaneous sweating and an aversion to wind occur. Because the lungs open into the nose, individuals may experience sneezing and nasal congestion with a clear discharge. Deficient lungs cannot properly rule qi, which leads to symptoms of shallow breathing and a cough with thin, white sputum. Individuals with a lung deficiency look pale and have a tongue with a thin white covering. A thin and weak pulse is felt upon palpation.

2.Deficiency of spleen

The spleen is an essential organ in TCM. It is responsible for digestion and transforming food into food essence, which is in turn transported to the lungs and distributed to the rest of the body. A spleen deficiency can cause asthma, because when it is unable to transform fluids, phlegm accumulates. People with a spleen deficiency have poor appetites and can develop epigastric (stomach region) problems, loose stools or even diarrhea. The spleen is also essential for production of qi and blood and rules the limbs. A deficiency can cause fatigue, shortness of breath and a low voice. A pale tongue with a thin, greasy or white, slippery coating and a thin, soft pulse are the usual signs of spleen deficiency.

3.Deficiency of kidneys

The kidneys rule the grasping of qi, which is responsible for healthy, deep inhalation when breathing. If there is a kidney deficiency, qi is said to be unable to return to its origin, (the kidney region), and shallow breathing occurs. The shallow breathing becomes worse on exertion and leads to wheezing or shortness of breath. The kidneys also rule the bone and are responsible for producing bone marrow. Soreness and weakness of the waist and legs and insufficient nourishment of the brain causing ringing in the ears are other symptoms that can occur with a kidney deficiency. If the kidney deficiency belongs to a yang deficiency, individuals have cold limbs and an aversion to cold, but if the deficiency belongs to a yin deficiency, individuals have red cheeks, night sweats and afternoon hot flashes.

Western Medicine

The diagnosis depends on three things:

1. Symptoms of airflow obstruction.
2. Airflow obstruction must be at least partially reversible.
3. Alternative diagnoses such as sinusitis, hay fever, foreign body in the windpipe or lungs, lung infection, heart disease or other conditions that cause wheezing have been ruled out.

Western doctors diagnose asthma from a history of episodes of wheezing, family history and history of allergies. The physical exam reveals wheezing, an expanded chest wall, use of extra muscles to assist breathing and evidence of allergies such as eczema or atopic dermatitis. (Note: Wheezing may not always be heard on a physical exam but this does not rule out a diagnosis of asthma.) Tests used to confirm or rule out asthma include lung function tests that measure the amount of air exhaled and peak expiratory flow testing, which can be measured at home. This test also measures the amount of air exhaled. Other tests that may be performed include chest x-rays, allergy testing, blood work or other tests that evaluate nasal polyps and sinus disease.

TYPES OF ASTHMA
The classification of asthma varies from country to country, even among western doctors but in the US it is divided into four types. These are:

1. Mild intermittent asthma where symptoms occur two times or less per week, the person is normally healthy between asthma episodes, each episode is quite brief and night symptoms occur two times or less per month.
2. Mild persistent asthma where symptoms occur more than two times per week but less than once per day, night symptoms occur more than two times per month and the asthma episodes may interfere with daily activities.
3. Moderate persistent asthma where symptoms occur daily, a bronchodilator medication is needed to relieve symptoms every day, asthma episodes interfere with daily activities, asthma episodes occur more than two or more times per day and may last for days and night symptoms occur more than once a week.
4. Severe persistent asthma where continual symptoms are present, the person has limited physical activity because of his asthma symptoms and night symptoms are frequent

Chinese Medicine

Using the four examination techniques of looking, listening and asking questions, smelling and touching, TCM practitioners analyze asthma symptoms and diagnose individuals according to the different TCM classification patterns.

Differentiation between wheezing and panting

Wheezing is characterized by a whistling sound, while panting is when individuals have difficulty breathing. Both of them can be manifestations of asthma and related to acute or chronic disease.

Differentiation between chronic cough and asthma

Asthma or wheezing/panting syndrome is associated with episodes of remission and serious exacerbations, whereas a chronic cough is persistent and does not go away. They can be further differentiated by the characteristics of the cough. With a chronic cough, the coughing sound is usually stronger than the wheezing sound. With asthma, the reverse is true. In general, the wheezing sound is stronger.

Differential classification of disharmony patterns

Asthma belongs to a disharmony pattern featuring both excessive pernicious evils and deficient normal qi. Mainly an excess of pernicious evils, (environmental factors that cause illness) causes exacerbations of asthma. This type of asthma is associated with coarse breathing and a high-pitched wheezing sound. Each breath is long and deep with a rapid expiration time. The pulse is strong, and generally, the body is not in a weak state.

The non-exacerbation period is related to a deficiency of normal qi. Asthma due to deficient normal qi is associated with weak breathing and a low wheezing sound. The breath is short and not smooth. There is usually a long history of asthma, where the individual experiences difficulty with inspiration. This deficient-type of asthma is associated with a sinking and weak pulse or a thin and rapid pulse .

After differentiating between an excessive evil type and a deficient normal qi type, it is also necessary to distinguish the type of phlegm (hot or cold) and identify the disharmonious organs. Details of the corresponding symptoms are listed under the "Symptoms Section".

The major disharmony patterns of asthma are as follows:

Exacerbation:

1. Cold type asthma
2. Heat type asthma

Non-exacerbation:

1. Lung Deficiency
2. Spleen Deficiency
3. Kidney Deficiency

Western Medicine

The goals for treating asthma are:

1. Prevent symptoms that are bothersome.
2. Maintain normal or near normal lung function.
3. Maintain normal activities and exercise.
4. Provide drug therapy if needed and minimize side effects.
5. Prevent exacerbations and hospitalizations.
6. Make sure the expectations of people with asthma and their families are met.

Drug (Pharmacologic) Therapy:
Understanding how medications work and why they are prescribed are essential for successful asthma management. There are several groups of medication used to treat asthma which are briefly described below.

Medications used for quick relief of asthma symptoms:

1. Short-acting beta2-agonists: These medications are used for quick relief of asthma symptoms and for exercise induced asthma (i.e. albuterol or Proventila or Ventolina).
2. Anticholinergics: This medication is usually given together the beta2 -agonists for severe episodes or given to people who cannot tolerate beta2-agonists (i.e. ipratropium bromide or Atroventa).
3. Systemic corticosteroids: These medications are used in moderate to severe asthma exacerbations to speed recovery. They are often given together with beta2 agonists (i.e. methylprednisolone, prednisone and prednisolone).

Medications used for long-term control of asthma:

1. Corticosteroids: These are the most effective and potent of the anti -inflammatory medications. They are usually inhaled when sued long-term to minimize side-effects but can be given as tablets or even injections during a serious acute episode of asthma (i.e. beclomethasone diproprionate, budesonide, & flunisolide).
2. Cromolyn sodium and nedocromil: These are mild to moderate anti-inflammatory medications often used in children because of their minimal side effects. They may also be used before exercise to prevent wheezing. People continually exposed to allergens also benefit from using them.
3. Leukotriene Modifiers: These are relatively new medications used in the treatment of mild to moderate asthma in teenagers and adults. They are used as alternatives to corticosteroids or cromolyn sodium and nedocromil (i.e. zafirlukast, zileuton or montelukast: approved for children).
4. Methylxanthines: These have a mild to moderate bronchodilator effect and help clear lung secretions. They are usually used together with inhaled corticosteroids to control nighttime asthma symptoms ( i.e. sustained release theophylline).
5. Long-acting beta2 agonists: These medications are usually used with inhaled corticosteroids to gain long-term control of asthma symptoms, especially nighttime symptoms. This type of medication should never be used to treat a sudden onset of asthma symptoms or to treat an asthma attack (i.e. salmeterol).

Note: All of these medications have potential side effects that need to be monitored by your healthcare provider. People with asthma need to know what their medications are treating and be able to recognize potential side effects.

What to do during an asthma attack:

1. EARLY TREATMENT is the BEST.
2. Recognize the symptoms of an attack: increasing cough, wheeze and breathlessness.
3. Always carry medications needed for quick treatment as well as a written plan stating how to recognize an attack, what medications should be started, how frequently they should be given and who to call for help.
4. Seek medical care early if the attack is severe, if the medications do not provide quick relief or sustained improvement, and/ or the symptoms get worse.
5. Make sure you always have the right medications and equipment needed at home to start treatment.

Other Considerations:

• Underlying conditions such as rhinitis, sinusitis and gastroesophageal reflux should be treated as they can exacerbate asthma symptoms.
• People with aspirin or NSAID sensitivities should avoid taking these drugs and check all medications for these ingredients. People with severe asthma or nasal polyps should also be aware of the potential of these drugs to cause an asthma attack.
• Some people are allergic to sulfites, which are used to preserve foods and beverages. Sulfites can trigger an asthma attack and foods such as processed potatoes, wine, beer, dried fruit, and others containing sulfites should be avoided.
• Nonselective beta-blockers are used as heart medications and are also used in certain eye solutions. People with asthma should be aware these medications might cause asthma attacks and avoid using them. Discuss alternatives with your healthcare provider.
• Allergen immunotherapy (allergy shots) may be effective for some people. This may be needed when a person has repeated exposure to an allergen they cannot avoid, has asthma symptoms for a major portion of the year, or has symptoms that are difficult to control.
• Yearly flu shots are recommended for people with asthma because viral infections can worsen asthma symptoms, especially in young children.

SPECIAL AGE CONSIDERATIONS:

Infants & Children under 5 years old:

• In this age group it can be difficult to diagnose asthma due to challenges in obtaining reliable lung function testing. Underdiagnosis of asthma still remains a significant problem in this age group. Children are often labeled as having frequent viral infections, chronic bronchitis, wheezy bronchitis, or gastro-oesophageal reflux. When this happens these children often do not receive adequate therapy to relieve their symptoms. It has been estimated between 50-80% of children who have asthma will experience symptoms before the age of five. Most commonly asthma symptoms will present with a viral infection in this age group. Your healthcare provider may prescribe a trial of asthma medications to see if symptoms improve and use a stepwise approach to either escalate or decrease therapy.

School Age Children & Adolescents:

• Adolescents and younger children, when mature enough, should be included in developing a plan to manage their asthma. Adolescents, especially, may not understand the significant health risks they are taking when their asthma is poorly controlled. In addition, it may be difficult to accept asthma as a chronic illness at a time when they are developing independence from their family. Fostering a positive self-image and encouraging personal responsibility for managing asthma are necessary.
• The healthcare provider and parents should provide the school with an asthma plan that explains the medications the student is taking and what to do in case of an asthma attack.
• Children with asthma should not be discouraged from physical exercise and sports. The child may need to take medication before and/or during a physical activity. Limiting physical activity should only be used as a last resort.

Older Adults:

• Older adults may have other conditions such as chronic bronchitis or emphysema that cause asthma symptoms. In this case, the symptoms may not be reversible . Therefore, it is important to assess whether medications really can help relieve asthma symptoms.
• Asthma medications can be absorbed and metabolized differently in elderly people causing an increase in unwanted side effects. The healthcare provider should monitor these people carefully for side effects or reactions to other medications and make adjustments where appropriate.

SPECIAL SITUATIONS:

Surgery:

• People with asthma undergoing surgery should see the healthcare provider managing their asthma before going ahead with the operation. Every attempt should be made to have the best possible lung function before going ahead with a procedure. The healthcare provider may need to increase or change medications before or after the surgery.

Pregnancy:

• The overall goal is to maintain adequate lung function so that the fetus can get an adequate oxygen supply. If asthma is not treated sufficiently during pregnancy it can increase the baby's risk of perinatal mortality, prematurity or a low birth weight.
• Most of the common asthma medications will not put the fetus at increased risk.
• Medications that do pose a risk to the fetus include: epinephrine, brompheniramine, and alpha-adrenergic medications. Medications that have potential risks to the fetus include decongestants, antibiotics, live virus vaccines, immunotherapy (allergy shots), and iodides.
• People with asthma should discuss all their medications with their healthcare provider and eliminate or change those likely to pose a risk to the baby.

Chinese Medicine

The TCM treatment strategy for asthma is based on the diagnosed disharmony patterns.

Cold type asthma
This type of asthma is caused by the cold evils, the therapeutic aim is to remove the cold evils by warming the lungs. In addition, this decoction helps remove the phlegm and relieve the wheezing.

Decoction examples:
Shegan mahuang decoction

In this decoction, She gan and ma huang are responsible for relieving the cough and wheeze, easing the throat and removing the phlegm. Gan jiang, xi xin and ban xia warm the cold phlegm in the lung and reverse the movement of qi. Zi wan, kwuan dong hua and gan cao relieve the cough and remove the phlegm. Wu wei zi stops the lung qi from traveling in the wrong direction and relieves the cough. Da zao helps support the normal qi in the body.

Other related patterns
Wind-Cold tightens the lungs
Wind-cold is an exterior syndrome because it is a pernicious evil which attacks the body from the outside first. The therapeutic goal is to relieve this exterior syndrome with herbs, which are pungent in flavor and warm in property. This helps the lungs to resume their dissemination of qi and provides relief of the asthma symptoms.

Decoction Example
Modified powder of huagai

Heat type asthma
Because this type of asthma is caused by heat evils, the therapeutic goal is to clear away the heat and resume the dissemination of lung qi. Treatment will also remove phlegm and relieve coughing.

Decoction Example
Ding chuan decoction

In this decoction, ma huang restores the lungs' ability to disseminate qi. Huang qin and san bai pi clear away the heat in the lung and restore the liquefying function of the lungs. Xin ren, ban xia, kuan dong and su zi remove the phlegm and redirect qi's movement to descend. Bai guo arrests lung qi. Gan cao keeps the other herbs in balance and supports the body's normal qi.

Other related patterns
Heat retention in lungs
The therapeutic aim is to clear away lung heat and remove phlegm.

Decoction Examples
Maxing shigan decoction with modification

Stagnation of phlegm dampness in middle warmer (spleen and stomach)
The therapeutic goal to expel the phlegm and support the qi descending function of the lungs. This decoction also helps relieve wheezing.

Example decoction
Daotan decoction combined with sanzi yangqin decoction

Lung Deficiency
The lungs are responsible for governing the health of protective qi, which is part of our immunity. When lung disharmony occurs the aim is to restore normal lung function and consolidate the exterior and protective qi in the body so illness can be avoided

Decoction examples
Yu ping feng powder

In this decoction, huang qi and bai zhu support qi and consolidate the exterior. Fang feng also helps support exterior consolidation and in addition removes wind evils. Wind evils usually attack the lungs when the exterior of the body is weak.

Shengmai decoction and erchen decoction with modifications

This is another example of a decoction used to restore lung function.

Spleen Deficiency
The spleen is responsible for transforming fluids into substances that are essential to maintain health. Therefore, in order to restore the healthy balance of the spleen, it is necessary to support the spleen's transformation function and remove the excess unhealthy fluids known as phlegm.

Decoction example
Liu junzi decoction

In this decoction, dang shen, bai zhu, fu lin and gan zao are excellent combination herbs for strengthening the spleen and replenishing qi. Chen pi and ban xia are good for removing phlegm and regulating qi. All the herbs in this combination work together to support the spleen's transformation function.

Kidney Deficiency
The kidneys also play an important role in regulating healthy breathing. Therefore, the treatment goal is to replenish the kidneys and support their qi grasping function so healthy breathing can be resumed.

Decoction example
Jingui shengqi pill

This is a famous decoction for supporting kidney yang. Di huang is good herb for nourishing the kidney yin. It is usually supported by sha zhu yu and shan yao which enhance the spleen's functions. As di huang has certain wet properties, ze xie is added to remove the excessive fluids and regulate the fluid channels. Fu lin helps support the spleen and transform fluids. Dan pi releases and clears away liver fire resulting from deficient heat. After this, fu zi and gui zhi are added to support the kidney yang. Fu zi helps replenish the yang and dispels the cold while gui zhi warms the meridian so there can be smooth movement of fluids inside the blood vessels.

Other related patterns
Yin difficiency of lungs and kidneys
The therapeutic aim is to nourish the yin and keep the yang in its original place without overwhelming other organs.

Decoction example
Liuwei dihuang decoction combined with shengmai decoction

Western Medicine

Prevention strategies aim to decrease exposure to the allergens triggering asthma attacks.

Prevention Strategies:

1. Dander (skin flakes), urine, feces, feathers and saliva of animals can all cause allergic reactions.
   • Remove the animal from the home.
   • Remove all products made with feathers.
   • If you cannot remove the animal, keep the animal out of the bedroom and keep the door closed. Remove carpets and upholstered furniture that trap dander particles and keep the pet away from the affected individual as much as possible.
2. Dust mites are prevalent in areas of high humidity. Mites like to live on pillows, mattresses, bedcovers, pillows, upholstered furniture, carpets, and on stuffed toys.
   • Cover the mattress and pillow in an allergen impermeable cover such as plastic. If unable to cover pillows they should be washed weekly.
   • Wash sheets, blankets, and pillowcase at least once a week in 130 °F or 54.4 °C.

   If Possible:

   • Reduce humidity indoors to < 50%.
   • Avoid sitting or sleeping on upholstered furniture.
   • Remove carpet from bedroom or carpet laid on concrete.
   • Don't let an asthmatic child sleep with stuffed toys or keep them on the bed. Wash stuffed toys at least once a week in hot water > 130°F or 54.4 °C.
3. Cockroach allergies are common in inner city areas.
   • Do not leave food and garbage exposed.
   • It is best to use poison traps not chemical sprays because these can be inhaled and trigger an asthma attack.
   • If fumigating, do not let the person with asthma come back into the home until the odor has gone .
4. Indoor molds (fungi) are present in areas of high humidity and in damp homes.
   • Use measures to control humidity and dampness in the home such as a dehumidifier.
5. Trees, grass, weed pollen, and mold spores are outdoor allergens. Pollen and mold spores are highest during midday and afternoon hours.
   • Stay indoors with windows shut in an air-conditioned environment during midday and afternoon when pollen and spore counts are the most elevated.
   • When possible, do outdoor activities just after sunrise when pollen counts are lower.
6. Air pollutants
   • Tobacco smoke: People with asthma should never smoke nor be exposed to tobacco smoke. Exposure to smoke can cause a decrease in lung function. Babies and children exposed to tobacco smoke by parents are more likely to develop asthma.
   • When air pollution levels are high, people with asthma should stay indoors and especially avoid exercise outdoors.
   • Avoid other irritants like strong odors, wood-burning appliances, smoke from fireplaces, or fumes from gas, oil or kerosene stoves, which can trigger asthma attacks.
7. Occupationally induced asthma is important to recognize early on because symptoms may not be reversible over time and asthma may persist even after exposure to the irritant has subsided.
   • With occupational asthma, symptoms usually improve when away from the work environment.
   • Establishing you have occupational asthma can be difficult especially when symptoms occur several hours after exposure.
   • Prevention consists of eliminating exposure to the offending agent.

DO's:

1. Have someone who does not have asthma vacuum one to two times a week to decrease dust accumulation. If you have asthma and must vacuum wear a mask that filters dust.
2. Use air conditioning when the weather is warm to prevent exposure to outside allergens and reduce humidity in the home.
3. Use a dehumidifier in damp homes or areas of high humidity to reduce dust mite levels.

DON'T use a humidifier because increased humidity can increase house dust mite levels and growth of mold. In addition, improper cleaning of the equipment leads to mold being spread into the air.

Chinese Medicine

Prevention is essential for maintaining the health of asthma patients. The following issues should be remembered:

1. Pay attention to changes in the weather; because, they can trigger asthma exacerbations.
2. Pay attention to environmental influences such as the pernicious evils, which cause illness.
3. Keep healthy and avoid getting a cold or the flu.
4. Avoid smoking and keep away from other stimulating substances cause asthma exacerbations such as smoke and pollens.
5. Stay on a simple, healthy diet. Avoid eating raw, cold, greasy or pungent food. Also avoid eating shrimps or crabs.
6. Get adequate rest. Avoid exhaustion and mental stress because they can trigger asthma.
7. Exercise daily to keep your body healthy and strong.

Western Medicine

1. Beijing University of Traditional Chinese Medicine: Traditional Chinese Internal Medicine, Academy Press, (2000).
2. Guang Anmen Hospital (Traditional Chinese Medicine Institute of China): The Diagnosis and Treatment Principle of TCM, Publishing House of Ancient Books of TCM, (1989).
3. Kelly, William N. Textbook of Internal Medicine,3rd Edition, Philadelphia & New York: Lippincott-Raven, (1997).
4. National Institutes of Health, Expert Panel Report 2:Guidelines for the Diagnosis and Management of Asthma, NIH publication No.97-4051, April 1997
5. Zhang Enqin, Clinic of Traditional Chinese Medicine (I), Publishing House of Shanghai College of TCM, (1990).
6. 張伯臾等：《中醫內科學》，上海 上海科學技術出版社，(1993)。

Written By:
Wu Chun Sang, Traditional Chinese Medicine Doctor,
Wu Chun-Sang Clinic Traditional Chinese Medicine Clinic, Hong Kong
Angela Collingwood, MSN, Chief Editor
Integrated Chinese Medicine Holdings Ltd.
Edmond Li, Medical Consultant,
The Hong Kong Association For Health Care Ltd.
Yu Ting, Chinese Medicine Researcher

Edited by:
Angela Collingwood, MSN, Integrated Chinese Medicine Holdings Ltd.
Angelo Chung, B Pharm., Integrated Chinese Medicine Holdings Ltd.
Margaret Harris, MD, Integrated Chinese Medicine Holdings Ltd.

Chinese Medicine

1. Beijing University of Traditional Chinese Medicine: Traditional Chinese Internal Medicine, Academy Press, (2000).
2. Guang Anmen Hospital (Traditional Chinese Medicine Institute of China): The Diagnosis and Treatment Principle of TCM, Publishing House of Ancient Books of TCM, (1989).
3. Kelly, William N. Textbook of Internal Medicine,3rd Edition, Philadelphia & New York: Lippincott-Raven, (1997).
4. National Institutes of Health, Expert Panel Report 2:Guidelines for the Diagnosis and Management of Asthma, NIH publication No.97-4051, April 1997
5. Zhang Enqin, Clinic of Traditional Chinese Medicine (I), Publishing House of Shanghai College of TCM, (1990).
6. 張伯臾等：《中醫內科學》，上海 上海科學技術出版社，(1993)。

Written By:
Wu Chun Sang, Traditional Chinese Medicine Doctor,
Wu Chun-Sang Clinic Traditional Chinese Medicine Clinic, Hong Kong
Angela Collingwood, MSN, Chief Editor
Integrated Chinese Medicine Holdings Ltd.
Edmond Li, Medical Consultant,
The Hong Kong Association For Health Care Ltd.
Yu Ting, Chinese Medicine Researcher

Edited by:
Angela Collingwood, MSN, Integrated Chinese Medicine Holdings Ltd.
Angelo Chung, B Pharm., Integrated Chinese Medicine Holdings Ltd.
Margaret Harris, MD, Integrated Chinese Medicine Holdings Ltd.