Author: Physician Niklas Seet | June 2021 | Zhongjing TCM
Disclaimer: This article is discussing chronic cough from a TCM perspective, referring to coughing episodes that are persistent or recurring for 8 weeks or longer. In light of the current epidemic, please refer to the latest guidelines regarding acute respiratory infections (ARIs) and their associated symptoms released by your local healthcare authorities, of which cough is one of the symptoms. If you have just developed a cough, it is still advised to report to your local healthcare facility for your safety.
What is cough?
Coughing is a reflex action of the respiratory tract. It is used as a means of clearing it, either of irritants such as dust or mucus which may build up in the tract. By doing so, foreign bodies which are not supposed to be in the lungs and airways will be removed. Generally, cough can be a symptom on its own, or it can be part of another disease, such as pneumonia, asthma, and other viral diseases.
In Chinese Medicine, cough can be a symptom of lung system diseases caused by an adverse upward rising of lung Qi. Physiologically, lung Qi rises and descends in balance, but when this balance is upset, lung Qi would then flow adversely and rise upwards, manifesting as a cough.
External and internal factors can disturb this balance. External factors refer to the various pathogenic factors such as cold, heat, dryness and dampness. Internal factors often are referred to as “internal injury” (内伤) in TCM, usually due to dysfunction of the Zang-Fu organs in the body. In the Internal Canon of the Yellow Emperor (Huang Di Nei Jing; 黄帝内经), there is a line that translates into “coughing can be caused by the five Zang and six Fu organs, not just the lungs” (“五脏六腑，皆令人咳，非独肺也”), meaning that a cough can be caused by any of the five Zang (脏) organs and their corresponding Fu (腑) organs.
For example, due to poor spleen transportation, there is a build-up of phlegm, resulting in the phlegm obstruction of the lungs. The imbalance of lung Qi’s dispersing and descending therefore leads to adverse upward flow of lung Qi and subsequently cough. This demonstrates the holistic nature of TCM, showing that our organs are closely connected within.
What are the TCM organs involved in cough and their associated symptoms?
Lung
Whenever cough is mentioned, many would immediately think that the lungs are involved. The lungs are recognised as the “delicate organ” in TCM, with its function being easily affected by external and internal factors. Lung as the canopy of the body also acts as the first line of defence against pathogenic forces that may attempt to invade the body. Pathogenic forces invade the lungs, causing a disturbance of Qi flow within the lungs. With Qi flow being obstructed, it may turn to rising upwards adversely presenting as a cough.
In TCM, the lung is also the reservoir of phlegm, meaning that phlegm in the body would accumulate and stagnate in the lungs until it is expelled. The presence of phlegm can further aggravate the disturbed Qi flow of the lungs, worsening the cough. Depending on the nature of the cough, phlegm can be either white (suggesting cold) or yellow (suggesting heat or fire) in colour, and it can also be viscous or fluid-like as well.
For acute episodes of cough, it could be due to catching a cold/flu (especially if seasonal). This type of cough is usually “productive” with yellow or white phlegm, and may appear with streaks of blood. Other body symptoms such as body aches, headache, sore, itch or discomfort in the throat, runny or blocked nose. For chronic coughs, they may be due to improper treatment, or other prolonged/chronic disease. Cough may or may not be productive.
Lung-related coughs are usually categorised into dampness-phlegm, phlegm-heat, or Yin deficiency.
For dampness-phlegm cough, coughing is often with large volume of phlegm, coughing sound deep and heavy. Phlegm is white, thick or fluid-like. Usually more prominent in the morning, and coughing is usually due to phlegm (once the phlegm is expelled, cough would subside). Other symptoms include discomfort in the chest, distension in the epigastric region, nausea, poor appetite and soft stools.
For phlegm-heat cough, coughing is accompanied by wheezing and shortness of breath, or sound of phlegm in the throat. Phlegm is large in volume, usually thick and yellow, and difficult to cough out. Phlegm may have a strong smell, or have blood streaks. Other symptoms include chest distension, with pain when coughing, face is red, body may feel warm, mouth dryness with a desire to drink water.
For Yin deficiency cough, the coughs are dry, or cough with scanty amount of white phlegm or phlegm with slight blood streaks, hoarse voice, shortness of breath. Other symptoms include hot flushes with pink cheeks, warm sensation in the chest, palms and soles, night sweat, mouth and throat dryness, fatigue.
Spleen/stomach (Think: digestion)
The spleen and stomach, often associated with digestion, can also cause conditions for a cough to develop. The spleen is often considered the “origin of phlegm”; this type of cough is often brought about due to the build-up of phlegm in the body, causing blockages in Qi flow, prompting the body to respond by coughing in order to expel such blockages.
Often, this type of cough is triggered by the ingestion of food, or specific types of food. For example, consuming too much oily and fried foods can trigger productive cough. Once the phlegm is expelled, the coughing bout would subside. After digestion of food, a few hours later, this type of cough would usually resolve on its own, until the next meal time. This is similar to dampness-phlegm cough for lung cough, only that the differing factor is that it is triggered by diet.
As such, for a cough due to spleen deficiency with phlegm and dampness, it is usually triggered by certain foods (e.g. greasy or oily or sweet foods), or after meals. Cough may or may not have phlegm, phlegm is white, thick or fluid-like and will often resolve a few hours after food. Some may also notice phlegm in the morning. Other symptoms include discomfort or distension in the gastric and abdominal regions which worsens after meals, belching or hiccups, weakness and fatigue in the limbs, poor appetite, soft stools.
Another type of cough that is related to the stomach would be the reflux of gastric fluids into the oesophagus, thereby irritating the airways. In TCM, gastric reflux is often due to “fire” in the stomach, which can be aggravated by hard-to-digest, oily, and/or spicy foods. Other accompanying symptoms include a warm sensation in the body, specifically at the epigastric region or below the heart, and thirstiness with the desire for a drink.
Liver (Think: emotion)
The liver is a Zang organ that is associated with anger and stress. Stress would cause Qi flow to be impeded, resulting in a stagnated Qi. Over time, this stagnation would cause internal fire to slowly fester within. When anger is experienced, or the level of stress is suddenly increased, the internal fire would be further aggravated. It would then travel upwards to affect the lung’s descending function, leading to adverse rise of lung Qi and subsequently cough.
For this type of cough, usually due to liver-fire, emotions such as anger or stress would be the main trigger for a dry bout of cough. During cough episodes, face and eyes can turn red, and accumulated by chest pain. Once the emotional trigger is relieved, the cough would subside. Other symptoms include irritability and warm/hot sensation in the body, throat dryness or irregular sensation in throat, and in some cases feeling like there is a lump in the throat (a condition known as globus hystericus) , bitter taste in mouth and distension in the hypochondriac area.
When the trigger for the emotions have been resolved, there would be a lower incidence of coughing bouts.
Kidney
For cough involving the kidney, this is often observed either in the elderly, or those with chronic diseases. There is mutual reliance between the lungs and kidneys of Yin and Yang. Based on the five elements theory of TCM, metal (lungs) generates water (kidney). Thus, when lung Yin is sufficient, Yin is transported downwards to the kidney. Being the root of Yin, when kidney Yin is sufficient, it is transported upwards to nourish the lungs. This mutual relationship could eventually lead to the syndrome of lung and kidney Yin deficiency leading to interior heat.
The kidney, being the root of Yang, contributes to lung Yang to warm lung Yin and fluids. So, if the kidney is deficient, this lung fluids will stagnate in the lung, forming phlegm.
As mentioned earlier, this type of kidney deficiency cough usually observed in the elderly or those with chronic diseases. These coughs may be without or with phlegm, but phlegm is usually white and fluid-like, shortness of breath or wheezing, and the cough may also be aggravated on physical exertion. Other accompanying symptoms include weakness and soreness in the lumbar and knees, aversion to cold and limbs feel cool/cold to touch, tinnitus, mouth dryness.
How to better manage it?
TCM proprietary medicines
There are many TCM proprietary medicines available for sale over-the-counter (OTC). These medicines are often safe for consumption, but it is still best to consult a qualified TCM practitioner for better advice that may be tailored to your condition.
One of the commonly used proprietary medicines that many are familiar with is Pei Pa Koa. It is a natural herbal remedy that can be easily consumed as it has a sweet taste. Some can find relief from their throat discomfort or cough simply by consuming the syrup, but quite a few individuals describe their symptoms worsening after trying it out as a remedy. This is due to the cooling function of the formula, which can result in more phlegm being produced by those with cooler constitutions. This is because this formula is rich in sugar, so if you consume too much of it at once, it will easily beset the spleen and stomach and produce phlegm. Instead of taking it directly in its syrup form, the syrup can be mixed in hot water, left to cool slightly and consumed warm. For those who are diabetic, there is also a “No Sugar Added” formula which uses sugar substitutes.
Herbal brews
A traditional herbal brew that most families would use when there is some discomfort in the throat would be to boil monkfruit, otherwise known to many as Luo Han Guo. It could be either brown or golden in colour, but both serve the same purpose – to soothe the throat and clear lung heat.
Other herbs that can be added to this would include:
Liquorice root (Gan Cao) – A natural anti-inflammatory herb, it is commonly used for sore throat or discomfort. However, due to its sweetness, it is contraindicated for those who are diabetic. However, as it is a naturally occurring steroid, it is not recommended to consume this herb in copious amounts over a prolonged period of time.
Chinese barley (Yi Yi Ren) – It aids in promoting urination and getting rid of dampness, while also nourishing the spleen.
American Ginseng (Xi Yang Shen) – The ginseng root itself or the rootlets of the herb can be used. It nourishes both Qi and Yin to strengthen the physical constitution. This is an herb that some would use to infuse as tea to consume when they are burning the midnight oil. It can be used on its own, or strengthen its Yin-nourishing properties by adding Ophiopogon tuber (Mai Dong).
Tea
Teas can also be used to aid with soothing the throat as well as strengthen the body’s constitution.
Pu-Er tea is a tea that is believed to warm the spleen and aid with stomach function. Consuming the tea on a daily basis and after meals, can help with digestion, especially if the meal is a little greasier or if more meat is consumed than usual.
In TCM, there is a theory that “fragrance can help with resolving dampness” (芳香化湿), so you can also try other teas that has a fragrance to it, such as earl grey or lady grey.
Do note that if you are taking any form of TCM medications, it is advised to consume tea roughly 30 to 60 mins after the last dose.
Besides using conventional teas, herbs or a combination of them can also be used to make herbal teas. These herbs can be placed into a hot water flask or cup and steeped in hot water. You can continually refill with hot water after drinking, each time the taste getting more and more bland. At the end of the day, the dregs of the herbs can be then discarded.
Food therapy and dietary regulations
On the topic of food, it is advised that certain foods are to be avoided, to reduce irritation on the throat or stomach. Generally, foods that are too spicy or too sour should be avoided. For those whose cough is stimulated due to food (spleen cough), foods that are hard to digest, greasy or oily should be avoided. It is also to be noted not to over-indulge in food, putting more stress on the stomach – rule of thumb is 70% full!
For those who often have phlegm-dampness cough, you can cook porridge using 50g of rice, 10g of Chinese barley (Yi Yi Ren) and 15g of Chinese yam (Shan Yao). Rock sugar can be added to taste.
For cases of phlegm-heat, you can try an easy-to-follow recipe, using Chinese pear or Snow pear, and Chuan Bei:
Exercise
It is also recommended for individuals to partake in some physical training to strengthen the body constitution. A moderate and healthy amount of cardio training can strengthen the lungs as well as increase metabolism, allowing for better digestion as well. TCM theory suggests that the muscles in the body is governed by the spleen, so by training the muscles the spleen’s function can be regulated and strengthened to an extent as well.
Do note that every person’s body is different, if you have some physical injury or are unsure whether an activity is suitable for you, please check with your trusted medical practitioner to ensure safety. It is also advised to do a quick check before every training session, such as using the PAR-Q questionnaire to ascertain safety.
Therefore, according to TCM theories, a cough may not be as simple as it looks, but rather a symptomatic presentation of a problem somewhere else. After reading this article, if you identify with a certain type of cough, you may try some of the methods listed above. While the medicines mentioned are generally safe to consume, please note that if you do not see any positive results after trying them, it may be time to consult your local registered TCM practitioner for more information about your constitution and physiology. It is never a good idea to consume medicines, whether natural or otherwise, over a prolonged period without understanding your condition.
