Traditional Chinese Medicine Nursing Protocols for Wheezing Disease (Bronchial Asthma)

ABSTRACT: Wheezing disease (bronchial asthma) is a common but refractory disease among pulmonary diseases. It tends to attack repeatedly, and is difficult to be cured. In recent years, some studies have shown that effective traditional Chinese medicine (TCM) nursing interventions on the wheezing disease can significantly ameliorate the treatment compliance of patients, reduce the attack and improve the quality of life. Therefore, it is important for patients with different patterns of syndrome to receive effective and reasonable TCM nursing intervention. This article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of wheezing disease in order to further develop the advantages of TCM, improve its efficacy and standardized its nursing behavior.

KEY WORDS: wheezing disease; bronchial asthma; traditional Chinese medicine TCM nursing; syndrome differentiation

As a common but refractory disease among pulmonary diseases, wheezing disease is characterized by wheezing rale in the throat, tachypnea and dyspnea, even wheezing that affects prostration. It tends to attack repeatedly, and is difficult to be cured. Some teenagers will have sufficient healthy Qi and kidney Qi as they get older, so for them, effective treatment can terminate the attack of wheezing disease. However, its attack is frequent and difficult to be completely cured for the middle-aged, aged and weak people due to declined kidney Qi. Therefore, it is particularly important for the patients with different patterns of syndrome to receive effective and reasonable traditional Chinese medicine (TCM) nursing intervention.

In modern medicine, wheezing disease is called bronchial asthma. It is believed that bronchial asthma is an allergic disease characterized by airway inflammation, airway wall remodeling and airway hyperresponsiveness[1]. It results from immune dysfunction, in which the helper T (Th) cells exert an important effect[2]. According to the statistics, 8.6% of children in the United States suffered from asthma, in which 38.4% were poorly controlled during the years 2006-2010[3]. Lack of asthma control is related to increased application of the health care system and decreased quality of life[4]. Nevertheless, good asthma control reflects the minimization of the intensity and frequency of symptoms as well as overall management of underlying airway inflammation, so positively controlling asthma becomes a primary goal of asthma care. In recent years, some studies[5-6]have shown that effective TCM nursing interventions on the wheezing disease (bronchial asthma) can significantly ameliorate the treatment compliance of patients, reduce the attack and improve the quality of life. In order to maintain and develop the advantages of TCM, improve its efficacy and standardized its behavior, TCM nursing protocols for wheezing disease is formulated by State Administration of Traditional Chinese Medicine of the People's Republic of China.

Keypointsofcommonsyndromes

Stageofattack(patientsinacutestageofattackandsomepatientsinpersistentstage)

· Wind wheezing: sometimes appearance, sometimes disappearance, wheezing rale when attack and repeated attack, but like a common person when wheezing stops; itching in the nose and throat, sneezing and cough before attack; light red tongue with white coating.

· Cold wheezing: the wheezing rale and sibilant rhonchi in the throat, tachypnea, dyspnea, much white frothy sputum, easy expectoration, no thirst or thirst but desire for hot drink, aversion to cold, easy attack on a cold day, cold limbs, lusterless complexion; white glossy tongue coating.

· Heat wheezing: the wheezing rale in the throat like a roaring, yellow sticky sputum, oppression in the chest, shortness of breath, even with nares flaring, restlessness, fever and desire for drink, or expectoration of bloody fetid sputum, chest pain, constipation, scanty dark urine; red tongue with yellow greasy coating.

·Deficient wheezing: the wheezing rale in the throat like the sound of snoring, low voice, shortness of breath, panting aggravated by movements, frequent onset, even persistent panting, weak expectation; light red, red or dark purple tongue.

Remissionstage(patientsinremissionstageandsomepatientsinpersistentstage)

· Syndrome of Qi deficiency in the lung and spleen: shortness of breath, low voice, sometimes mild wheezing rale in the throat, much white thin sputum, spontaneous sweating, aversion to wind, easy to have a cold, lassitude, poor appetite, loose stool; light red tongue with white coating.

· Syndrome of lung and kidney deficiency: shortness of breath, panting aggravated by movements, unsmooth inhalation, sticky frothy sputum, tinnitus, soreness and weakness in the waist and knees, palpitation, intolerance to exhaustion, or dysphoria in the chest, palms and soles, hectic cheek, dry mouth, red tongue with less coating, thin and rapid pulse; or aversion to cold, cold limbs, pale complexion, fatty tongue with light white coating.

Nursingforcommonsymptoms/syndromes

Pantingandwheezingrale

· Observe the frequency, rhythm and depth of respiration as well as duration of attack, and inform the doctor immediately if the abnormal condition occurs.

· Take an appropriate position, such as decubitus with high pillow, semireclining position or orthopnea position.

· Conduct auricular-plaster therapy, and select the points like Pingchuan, lung, adrenal gland, sympathy, etc.

· Massage at the acupoints like Zhongfu, Yunmen, Kongzui, Tanzhong according to the doctor's advice.

· Conduct cupping at the points of Feishu, Gaomang and Dingchuan according to the doctor's advice.

· Make acupoint application at the points of Feishu, Tiantu, Tianshu and Dingchuan, especially the acupoint application in hot summer days.

· Perform TCM soaking according to the doctor's advice.

· Perform TCM iontophoresis according to the doctor's advice.

Coughandexpectation

· Observe the nature, degree, duration and rule of cough as well as the quantity, color and texture of sputum.

· Take a semi-reclining position for cough patients accompanied by chest oppression.

· Drink warm boiled water frequently when persistent cough occurs.

· Do exercises like taking a deep breath, and learn the methods (effective cough, turning over and clapping on the back, raping on the back or application of equipments) to expectorate.

· Keep oral cavity clean.

· Conduct auricular-plaster therapy, and select the points like lung, trachea, Shenmen, subcortex, large intestine, etc.

· Conduct cupping at the points of Feishu, Gaomang, Dingchuan, Pishu and Shenshu according to the doctor's advice.

· Make acupoint application at the points of Feishu, Gaomang, Dingchuan, Tiantu, etc.

· Massage at the points like Feishu, Tanzhong, Zhongfu, Yunmen and Kongzui following the doctor's advice.

Chestoppression

· Observe the nature, duration, inducing factors and concomitant symptoms of chest oppression.

· Assist the patients to take a suitable position.

· Massage at the points like Tanzhong following the doctor's advice.

· Conduct auricular-plaster therapy, and select the points like heart, chest, Shenmen, small intestine, subcortex, etc.

TCMspecialnursing

Drugtherapy

InternalapplicationofChineseherbs

· Take hot TCM decoction for cold wheezing, while take cold decoction for heat wheezing. Take warm decoction for tonifying deficiency. Pay attention to observe the condition of sweating and vital signs of patients when Chinese herbs with ephedra are taken.

· Medication time: Each dose of herbs can be taken generally in twice or three times. The specific medication time depends on the property and function of herbs as well as the patients' pathological condition. Chinese herbs for relieving exterior and clearing heat should be taken 1 h before meals, in which application of exterior-reliving Chinese herbs should avoid wind chill, or putting on more clothes or having some porridge induces diaphoresis. Chinese herbs for promoting digestion, purgation, expelling parasites, tranquilization and tonification are taken respectively after meals, before meals, on an empty stomach in the morning, before sleep and on an empty stomach. Emergency drug use follows the doctor's advice.

· Medication temperature: The administered warm is usually adopted. For the patients with special treatment, it should be followed the doctor's advice.

· Medication dose: 200 mL is taken per time for the adult; 100 mL is taken per time for the patients with heart failure and those of controlling the dose. The elderly and children should take according to the doctor's advice.

Injection

· Inquire the history of allergy carefully before medication.

· Make allocation and administration according to the requirements and injection speed recommended in the drug instructions.

· Apply TCM injection alone, and use it right after it was ready.

· Chinese and western drugs should be separated when Chinese and western injections are in combination.

· It is inappropriate to use a venous channel for two or more kinds of drugs except for special instructions.

· Medication reactions are observed closely, especially for the elderly, children, people with liver and kidney dysfunction and those that use TCM injections initially. Medication is suspended, and the doctors should be told to deal with it if adverse reactions occur.

· Nursing for allergic reactions: stop to use the drugs immediately, change the infusion channel and inform the doctor; seal the liquid and channel that cause adverse reactions; do allergic identification and inform patients and their relatives firmly to avoid re-medication; guide the patients to have a bland diet during the treatment of allergic reactions, forbid to eat the food like fish, shrimps, etc.

ExternalapplicationofChineseherbs

· Keep dry and clean skin before medication, and do local debridement if necessary.

· Observe reactions closely after medication. For example, the doctor should be informed immediately if local symptoms like scorching heat, redness, pruritus and stabbing pain appear; The medication should be stopped immediately if the symptoms, such as dizziness, nausea, palpitation and shortness of breath, appear, and meanwhile, corresponding measures should be taken and the doctor should be informed.

· Use with caution for patients with allergic constitution.

Notes

· Notes for inhalants: sit down when drugs are inhaled, guide the patients to use inhalation equipments correctively, and insure the suction nozzle of inhalants is encased by the mouth; guide the patients to breathe correctively, inhale as soon as possible by the mouth after exhalation to exert the effect of drugs completely; after application of hormone drugs, rinse the mouth immediately to prevent the hormonal residues in the oral cavity from fungal infection; insist on using inhalants following the doctor’s advice.

· Guide the patients to take medicine on time, regulate the drugs following the doctor’s advice, and disallowed to reduce or stop drugs voluntarily.

· Tell the patients the wheezing is difficult to be cured. Although the patients in remission stage don’t feel symptoms by themselves, the airway hyperresponsiveness still exists. Therefore, the patients should insist on taking medicine for a long time.

Specialtechniques

Auricular-plastertherapy

· Embed beans at auricular points and select acupoints correctly according to the doctor's advice.

· Assess the condition of ear skin and degree of tolerance to the pain, prohibit to use them in the inflammatory, ruptured and frozen skin as well as in pregnant women.

· Keep the intensity of probe moderate and accurately seek the sensitive point in acpoint area.

· Scrub the ears with 75% alcohol.

· Observe the patients' condition, stop immediately and inform the doctor to deal with it if discomforts occur.

· Select one ear for routine performance, keep the beans usually for 3-7 days and use them in two ears alternately; guide the patients to press them correctly.

· Observe the fixed degree of auricular point sticking and the condition of symptoms and ear skin (redness, swelling, rupture, etc.).

· Record the bean-embedded location and time at auricular points as well as the patients' feelings after performance.

Acupointmassage

· Conduct acupoint massage according to the doctor's advice.

· Assess the skin condition around the massage area and degree of tolerance to the pain; prohibit using it in women during menstruation and pregnancy.

· For the operator, trim the fingernails to prevent the skin from injury.

· Keep the strength even and moderate, and pay attention to keep warm for the patients and protect their privacy.

· Observe the patients' reactions closely when operation is done; stop the massage and take corresponding measures once discomforts occur.

· Record the massage acupoints, techniques and time as well as the patients' feelings.

Cuppingtherapy

· Do cupping following the doctor’s advice, and select the correct cupping parts and methods.

· Nursing assessment: observe the condition of skin in the cupping part and the patients’ tolerance to the pain. Cupping therapy is unsuitable in the parts including skin ulcer, edema, much hair, large blood vessels, and in the lumbosacral part of pregnancy women. It is also unsuitable for the patients with convulsion due to high fever and disturbances of blood coagulation.

· Take a reasonable position to make cupping part exposed completely, and pay attention to keep warm and protect the privacy.

· Check whether there is a break at the edge of jars, and whether it is glossy. Select proper cupping jars according to different parts.

· Observe the adhesion condition and skin color during cupping. Inquiry the patients’ feelings, and take off the jars immediately to avoid empyrosis if discomforts appear.

· Do cupping accurately, rapidly and steadily, and don’t pull the jars when taking off them.

· Keep a comfortable distance for the arrangement of many jars to avoid the pain induced by jar traction.

· Generally, the local flushed or cyanosis (blood stasis) skin is normal after the jars are taken off, and it will disappear spontaneously. It is unsuitable to do cupping in the previous site if local blood stasis is severe. It is unnecessary to deal with local vesicles, but if the vesicles are bigger, the liquid in them should be extracted using the injector after the local skin is sterilized, and the sterilized dressing is covered.

· Record the cupping part, time and patients’ feelings after all the operations are finished.

Acupointapplication

· Conduct acupoint application following the doctor’s advice.

· Nursing assessment: the skin condition in the part of acupoint application; it is forbidden for pregnancy women.

· Expose the part of acupoint application completely, and pay attention to keep warm and protect the privacy.

· Keep a proper thickness of plaster (0.2～0.3 cm) and a certain humidity in order to smear easily.

· Observe the local and systemic condition. Stop to use it and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

· Avoid smoking, drinking alcohol, and taking cold, salty and spicy food, seafood, beef and mutton during application.

· Record the application part, time and patients’ feelings after all the operations are finished.TCMsoaping

· Conduct to wash with Chinese herbs following the doctor's advice.

· Assess the washing skin and sensory perception of lower limbs to the temperature, use it with caution for the patients with skin lesion and those with drug and skin allergy, and prohibit to use it for the patients with severe cardiopulmonary dysfunction and hemorrhagic disease.

· Inform the patients of washing process and cautions before operation, and communicate with the medical staff promptly once discomforts occur.

· It is inappropriate to wash with Chinese herbs in fasting state and within 1 hour after meals. Immediate washing after meals can affect digestion due to local peripheral vasodilation.

· Keep the operation environment warm, close door and windows, and be cautious to keep the patients warm and protect their privacy.

· Expose the washing location thoroughly, and make the ankle of two feet soak in the liquid.

· Keep the liquid temperature at 37-40℃ and the washing time for 20-30 min. Take the difference of disease categories into account to prevent from burn.

· Observe the local and systemic conditions of patients during treatment, and inform the doctor immediately to deal with it if the symptoms including erythema, pruritus, palpitation, sweating and dizziness occur.

· Gently make the skin dry with light towel after washing, especially interphalangeal skin, and trim the toenails if they are long.

· Inform the patients of drinking 200 mL of warm water after washing with Chinese herbs.

· Record the washing temperature, time, skin condition and the patients' feelings after operation.

TCMiontophoresis

· Conduct TCM iontophoresis following the doctor's advice.

· Nursing assessment: the skin in the part of iontophoresis; it should be used with caution for pregnant women, infants and those with drug and skin allergy.

· Inform the patients of iontophoresis process and announcements before operation, and tell the doctor to deal with it if the discomfort appears.

· Keep the operating environment warm, expose the treatment part, pay attention to keep warm and protect the privacy.

· Select the prescription following the doctor’s advice, regulate the current intensity, and inquire the patients’ feelings during treatment. The current intensity should be regulated on time if discomforts occur.

· Observe the local and systemic condition, and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

· Record the iontophoresis skin condition and patients’ feelings after all the operations are finished.

Physiotherapy

· Chest-back raping.

· Effective cough.

Breathingtraining

· Abdominal breathing.

· Pursed lips breathing.

· Breathing exercise.

Healthyguidance

Dailylife

· For the patients with cold wheezing, it is suitable to keep sufficient sunshine and comfortable temperature in the ward, and meanwhile the wind chill is avoided. For the patients with heat wheezing, it is suitable to keep cool and ventilate in the ward.

· Tai Chi and Baduanjin can be added based on cardiopulmonary rehabilitation exercise. Abdominal breathing, pursed lips breathing and breathing exercise can also be done to improve the lung's capacity and respiratory function.

· Enhance the recognition and circumvention of allergen. Detect the categories of allergen on time and keep away them in daily life.

· Self-care exercises: massage healthcare points, such as Yingxiang, Fengchi, Sanyinjiao, Tanzhong, etc.; foot bottom massage (Yongquan); clicking teeth for healthcare.

DietGuidance

It is avoided taking allergic food, such as albumen and seafood, spicy and greasy food.

·Syndromeofwindwheezing: It is advisable to eat foods that can dispel wind and remove phlegm as well as decrease Qi to relieve asthma, such as almond, radish, etc. Dietary formulae: Almond porridge.

·Syndromeofcoldwheezing: It is advisable to eat foods that can warm lung and dispel cold as well as eliminate phlegm to open orifices, such as shallot, ginger, pepper, etc. Dietary formulae: Jiaomu powder can be used as the side dish or be made into the capsule.

·Syndromeofheatwheezing: It is advisable to eat foods that can clear heat and disperse lung as well as resolve phlegm to relieve asthma, such as pear juice, almond, etc. Dietary formulae: Pear, Bulbus Fritillariae Cirrhosae and rock candy beverage.

·Syndromeofdeficientwheezing: It is advisable to eat foods that can tonify lung and govern kidney as well as decrease Qi to resolve phlegm, such as agaric, walnut, etc. Dietary formulae: Walnut porridge.

· Syndrome of Qi deficiency in the lung and spleen: It is advisable to eat foods that can reinforce spleen, replenish lung and tonify Qi, such as pumpkin, white fungus, Chinese yam, etc. Dietary formulae: Lotus seed and white fungus soup.

· Syndrome of lung and kidney deficiency. It is advisable to eat foods that can replenish lung and tonify kidney, such as almond, black soya bean, lily, etc. Dietary formulae: Ginkgo and walnut porridge.

EmotionalAdjustment

· Conduct psychological counseling, pour out the patients’ heart patiently, and avoid negative emotional stimulation.

· Encourage the relatives to accompany the patients and give them psychological support.

· Introduce the disease-related knowledge and positively coordinate treatment.

· Tell patients the effect of emotional factors on the disease.