um and you know there is a little bit of a rationale in the organization of of the symptomology that we're we're looking at here you know we talked about uh uh things coming in from the outside with wind cold and wind heat and different differences in temperature then we started talking about headache and now we're talking about cough and now panting and then we'll get to chest pain as well and palpitation so we are kind of kind of moving through the body and you know digestion does sort of Follow that but um when we talk about panting we're talking about We're translating shran and there's a few different ways that we can think about this and a few different ways that the literature refers to it um generally panting is thought of as being some sort of shortness of breath or Hasty breathing that might not be as full as normal so sometimes Hasty panning counterflow panting and this counterflow here is speaking to um an inability of the lung to work as well as it should right dpia is the is the biomedical word for shortness of breath and so so just means shortness of breath that's that's a common medical abbreviation for it so if you do see so on a chart they're not talking about the patient being a bad person they're talking about you know shortness of breath um a lot of modern diseases that we would call asthma were traditionally diagnosed as shrin as some sort of panting right um the differentiator being that panting uh that's accompanied by audible sounds is called wheezing right and one of the shortcuts that we have from our medicine is that anytime you can hear wheezing it's assumed there's some sort of Flem right so we could have shortness of breath from lung Chi deficiency in fact that's that's one of the chief signs or symptoms of lung Chi deficiency is shortness of breath and fatigue right in fact shortness of breath would is probably the main reason that we would diagnose lung chat deficiency instead of spleen Che deficiency right um maybe fatigue is common to both we have shortness of breath for lung sheet deficiency let me just write this down because I think this is useful differentials so we could have you know cheat deficiency in the middle and this has fatigue um and then over here we have lung cheat deficiency fatigue with so and we have speni deficiency which has fatig what else this is very useful for us right when we can do our differentiation and somebody says oh I'm really fatigued you know patient comes in cheap complaint I have really bad fatigue and then we say what question can we ask them do you have shortness of breath and if so we say oh you have lung cheat deficiency oh I have fatigue how's your appetite it's bad okay we have Spen te deficiency I have both of these I have shortness of breath fatigue indigestion and then I also have frequent urination and lower back pain well I've got my spleen with the indigestion I've got my lung with my shortness of breath and then I have got my kidney over here so we could say that this person has spleen lung and Kidney Chi deficiency right but it all starts in fatigue and then we ask questions to get where we need to get to from from the rest of this um and you know we may see this in the pulse as well if we want to be very very textbook then in our pulse here we expect you know the first position the sun should be weaker here we expect the second position or the Guan position to be weaker and here for the kidney we expect the third position the CH position to be weaker so I I would suggest that clinically maybe our our pulse diagnostic skills don't don't get us there for the first 20 years of practice um you know or maybe for the first 10 years if we're very very sensitive to identify which organ in particular is involved with the chat deficiency but you know you can start to look for it you can start to feel like oh okay no it really does feel like there's not as much Chi getting up to the upper Jou in this first position maybe that's longer maybe heart Chi deficiency we didn't add heart so let's add heart heart Chi deficiency what might we expect with a heart sheet efficiency that's not in the other ones [Music] fatigue probably probably some sort of palpitations which we're going to talk about soon but some awareness some subject awareness of your heartbeat would be sort of the textbook um for heart shei and maybe maybe we get the edge of a psych emotive kind of um complaint maybe I feel a little anxious or a little vexed or something like that okay um so uh let's move on to a nice fresh slide when we talk about panting um we said that if if there's wheezing if wheezing is present panting or shortness of breath if we have wheezing which means you can hear it think F beyond that there's really two main organs that are involved in respiration and we identified one of them already which is the lung and the other one is is the kidney and I think we talked about last week that the lung is theoretically governing the exhale and the kidney is theoretically governing the inhale and so you will find in the sources certain things that say well if the inhale is shorter and the exhale is longer that's a disorder of the kidney if the exhale is shorter and the inhale is longer that's a disorder of the lung um I would suggest you not be too tight in that thinking but maybe use it just as a guideline and just recognize that yes both lung and kidney are involved D um in breathing um and this kidney just to you know just to break this out to a little bit of a bigger domain you know the kidney intelligence or a affect is called The Jerk which we learned in tcm1 is often associated with the will but it's not just the will like I really want to do this it's actually the will to survive and on a very very very root level if we don't breathe then we don't survive right so um this kidney is involved in inhalation and so far as every as long as we have some sort of kidney Jing going kidney will going we're going to try to keep breathing right and once we run out of that attempt to keep breathing well we have our last exhale right and that's it you know the jur stops asserting itself and then we just we just kind of stop breathing so let's talk a little bit about the different patterns that we might see um and you know we can I'm not actually going to leave this to to you all on your own level of curiosity you can you can look into to dung and kind of he talks a little bit more about different severities of um of wheezing panting shortness of breath I don't think we actually need to get in that right now um but in a general overview the main patterns that we're going to talk about is some sort of either um side effect of some sort of external Evil coming in and affecting the lung usually wind cold or some sort of heat eval excess some sort of long longer term damage to the lung Yin or the lung Chi and then maybe something involving the kidney right um some of these we've already talked about so for instance wind cold exterior Invasion we said that cough and panting are possible symptoms right um and we know all the signs and symptoms for this chills predominant over fever um and we could have uh you know tyion coold damage here we could also have external wind strike we won't review those now but we expect there to be other signs and symptoms accompanying any kind of cough and panting and really ety how long have you had this were you just sick this is kind of this will kind of indicate to us what's going on here um if these Evils are not addressed on the exterior level we could end up with heat evil congesting the lung and the heat evil we're talking about here is really fleem uh I think Kim cam actually calls this flam heat in the long again we can expect our panting and Loud cough because it's a heat evil an excess evil right uh we we could have um uh thick yellow or green FL I'll say expector it just to emphasize that it's coming out right uh chest pain we know about already and our tongue should have a yellow coat at this point maybe a red body and pulse is going to be rapid indicating our heat and then sometimes described as a rolling or a slippery pulse if the FL is predominant so we we've certainly seen this pattern before both of these and we can also think about these patterns as steps you know where if you have a wind cold exterior Invasion and it's not treated then it can certainly become some sort of wind heat um sorry Flem heat now congesting the lung let's just do a couple more patterns and we'll certainly take a break um the next patterns are actually um recap capitulating the the the the rooms that we just talked out to to to a large extent so D talks about fleem obstructing the lung actually he says F [Music] turbidity um the interesting thing here is that we're not naming it hot or cold so we assume it's either neutral when we look at the signs and symbols we think it might actually be a little bit on the cooler side but you know panting is a big part of this panting may be wheezing it could be audible because FL is involved um we already talked about this with cough is this G to be a scanty cough or a thick cough Opus flim right uh and then we could certainly have any kind of fullness or oppression of the chest we could have heavy limbs as the flame is kind of spilling out a little bit fatigue um our tongue is going to show this slimy sticky tongue coat right the pulse here would be slippery or rolling if this FL is really copious then we might have some digestive signs too um so we think about this is affecting the stomach uh and interestingly dung highlights that we may have a constipation not working but we could also have or loose sticky stools yeah yeah copious and then also if it's really affecting the digestion more you know so we know fleem starts in the digestive system and then is drafted to the lungs and then if it's percolating down into the large intestines it can disrupt the chii of the large intestines leading to either constipation things are bogged up and kind of stuck or sticky stools that are also often loose okay so just to put a bow on it let's talk about the two kinds uh it's actually we're going to talk about three kinds of room here um just to tie it all together then we're going to take a bro a Break um and we've already mentioned these so this is just by service of of review here so we certainly can of have shortness of breath due to suspended room and suspended room we were suspended in the chest and ribs side um and so the the chief thing we're talking about here is Hasty panting difficulty breathing shortness of breath they may have cough chest fullness and when we look at this diagnostically there's not a lot to kind of differentiate it from FL turbidity turbidity obstructing the lung the last pattern that we talked about um except that FL turbid um obstructing the lung probably has more likelihood of affecting the digestion than suspended room because suspended room we're talking about the location in this chest and Rib side then propping room which we already discussed we mentioned that propping room the two things that we're most looking for with propping room is a positional preference for being propped up that will reduce the symptom of panting that we're talking about and also that we may have um floating edema which just to remind you floating edema is the face and head [Music] um this definitely has some you know this is a chronic condition it does have some overlap with chronic obstructive pulmonary diseases as does the next one which is spillage room or water cold invading the lung so I'll just touch on that really brief briefly and then we'll take a break so water cold invading lung is just about the same as spillage room where we um expect to have some sort of swelling of the limbs the room is Spilled Out into the limbs so not only do we have cough and shortness of breath but we have some sort of swelling as well um and you know we think that we can almost just infer that there's going to be some sort of spleen and kidney Yong deficiency underlying because these fluids are not [Music] transforming and this last point is actually pretty important because when we get to herbal medicine if we just think that oh somebody's all puffy and swollen so let's just make them you know let's increase urination and increase sweat that's going to get rid of the excess fluids but it's not going to get rid of the it's not going to boost the ability of the of the body to transform fluids hence forth so we actually need to keep need to include some herbs in here to warm up the spleen Yang so and the kidney Yang so futa would be something we would put in here Ginger we could put in here other kinds of herbs to kind of tonify the spleen and the kidneys so that there's more warmth in the system not just to get rid of the excess but to transform the fluids in the future as well the next section is actually pretty short and sweet if we can remember our foundations uh Zang Fu diagnosis around these patterns so we talked about excess we um talked about how this excess usually fluids in the in the chest can cause all sorts of different issues with our breathing right um and we had the opportunity to review some of these different uh fleem room patterns and also the just remember that if we get a cold we could end up with panting and coughing if we get heat evil that's actually lodged in along with sort of something a little bit more progress then we could have coughing and panting as well um when we look at vity patterns for panting um and wheezing as well if there's if there is a presence of f there's really we look at the lung and we look at the kidney and then we're sort of done um there's not that much distinctive to talk about with each of these patterns outside of the normal ways that we recognize these patterns so let's actually make it a little bit of a discussion just to liven things up how do we differentiate between lung Chi deficiency and lung Yin deficiency patient comes to see you says hey Doc um you know I have a shortness of breath and maybe you feel their pulse and you're like oh that first position is pretty weak I think there's something going on with your with your lung how are we going to tell whether it's just a little bit of lung lung Chi deficiency or something that's you know potentially more chronic which would be like a lung Yin deficiency what are some additional questions we can ask for what are some signs or symptoms or just what are some textbook um uh line items that you remember differentiating these patterns okay my my's proposal is that you know shortness of breath which actually could be lung y deficiency or Lungi deficiency hesitation to speak for lung Chi deficiency yeah I actually like that and actually that kind of soft voice and a soft cough but I will propose that you could have both of those in lung Yin deficiency as well dryness yeah worse after exertion we could have it for both of these um although I I would suspect lung chei deficiency the worst with exertion would be um a little bit more in the for ground um but yes dryness would be a great place to look so if the the yin of the lung is declining then we expect there to be deficiency heat signs or symptoms along with the lung Chi deficiency signs or symptoms so um dryness could be of the skin it could be a dry cough it could also be um write this down dryness dry cough uh we could also have thirst right so the thing to remember is that every time that we see lung Yin deficiency we're also talking about Yin deficient heat that may be present exactly exactly so um goes back to what we were saying about the temperature different differentiation we start to try to see is there something in this that points to something deeper but really generally what we're looking for is exactly that the dryness you know they made um complain of dry skin throat they may have a heness to their voice right and lung cheat deficiency you know worse with exertion whatever conditions it is and uh you know if there is any kind of cough or anything like that it'll be um forceless forceless speech we actually expect if somebody's lung Yin is damaged and by lung Yin we're talking about things towards the substance end of the spectrum you're saying that there there's something about their lung organ which is damaged right so we could expect you know uh getting sick of in shortness of breath all these things could could also be happening with lung Yin but maybe they just wouldn't be in the foreground as much um but they could be common to both of these yeah we don't really talk about the lung Yang that much right that isn't something that we we we don't really diagnosed lung Yang deficiency very I've never seen it seen it diagnosed so um we kind of think of uh first the lung Chia damage and the disease progression then goes to the the fluids excuse me the fluids of the longer damage which means lung dryness and if that persists we get to lung Yin deficiency in that progression so that's really all we're talking about if we do see vity panting we just need to understand you know what what makes us think of lung and then do we think more dryness and heat and that's going to be lung inefficiency and this is also going to be more longstanding probably right um clinically in my practice the place where I see lung Yin deficiency the most is usually in the winter months after people have had that fall cold and then not recovered and their lungs are a little bit dried out and maybe they've been taking um things to dissolve fleem for a long time that have dried their lungs out like taking mcin for an extended period of time will start to dry your lungs out a little bit um so we talked about how the lung and the kidney are the main organs involved in respiration how the kidney is generally involved with inhalation and the lung is thought to be involved more in exhalation and these are classic textbook reasons that we might differentiate but if if somebody's short of breath and maybe we start to suspect that the kidney is involved how do we differentiate between kidney Yang deficiency and kidney Yin deficiency are some signs and symptoms that can point you in those directions yeah so we'll definitely see things on the tongue and in the pulse and this is again are we expecting a little bit more with kidney yangong deficiency we accept um Yang deficient cold signs and with kidney Yin deficiency we accept expect Yin deficient heat signs so all of the dryness and thirst and all that kind of stuff that we saw with lung IND deficiency we could also see with kidney whereas here here we would expect to see a little bit more along the lines of maybe fluid accumulations um uh more General weakness in the body um in the pulse we're going to see weaker pulses in the third position and then there's a there's a sign here which actually I have seen in patients I have one patient he's actually young but he has a congenital issue where he has um he has COPD um chronic uh uh obstructive pulmonary disease um uh and when he lies on the table he always has short shortness of breath and when you watch him breathe he uses these ancillary muscles of his body so it's not just the diaphragma and the intercostals working but there's what's called indrawing of the Flesh of the neck and if you've been around people that are very um that have reduced uh reduced pulmonary capacity if their lung function is down you'll often see them enlisting these muscles around the neck and throat it's called in drawing of the flesh around the neck and throat and this is when you're really trying to breathe with everything you have it'll also happen when any people are just exhausted so if you you know watch athletes at the end of races you know they'll move over into positions where they can use extra muscles to breathe with so we'll say the in drawing of the Flesh of the neck which is really you know ancillary which means helper ancillary respiratory muscles so our lungs are much bigger than a lot of us think they go all the way up to here we learn about this in Acupuncture school we'll talk about this later today about not hitting the lung with needles um but the lungs actually go up pretty high and if we want the lungs to open sometimes we'll use muscles of the neck and shoulders to actually open up the top of the lungs right um if your kidney Yang is really declined and this is actually much more common in old people kidney kidney yin and yang decline we may see this labored breathing that invokes the use of uh anill respiratory muscles um when we talking about Yin deficiency we talked about thirst dryness Yin deficient heat um I'll also say that Yin deficiency is moving towards Jing deficiency and when we talk about Jing deficiency see we're really talking about um the aging process so if you have somebody with shortness of breath that looks prematurely aged or if they are very old then you might start to think about Yin deficiency um you may end up with um you know forgetfulness both of these can have lumbar soreness um with a kidney young deficiency a very interesting thing that that dung notes for the kidney inde deficiency um panting pattern is that the tongue is potentially purple which is weird and the reason he say he say says that it's purple is that y deficiency this Yin deficient heat has penetrated and lasted so long that it scorched things and now the tongue looks purple from this y deficiency heat so I bring this up not because I I expect you to necessarily memorize it but to kind of highlight the fact that not all these tongues and pulses are exactly as you'd expect them to be but there is a rationale why that might be um what would a textbook y deficiency tongue be yes it should be a red tongue and actually this is a very distinctive part of Y deficiency and um maybe you all haven't had the opportunity to look as many tongues during covid time as you would would have otherwise um but I encourage you to look for this Yin deficient tongue when you see it it's very distinctive this kind of um full body red tongue that's often a little bit dry looking and maybe a little bit shrunken right um so we don't need to belabor this point just to remember that okay wheezing panting wheezing there's probably fleem involved panting if it's deficiency it's going to be lung or kidney the chi or the yin or the Yang of each of the or these organs then then you just do your differential diagnosis um the last pattern that we'll mention is this dual vacuity of lung and kidney and this is actually a more more serious disease and you know we're expecting to see this actually in our terminal patients or our patients towards the end of their lives um uh dung says the Yang is Desiring to depart and the image here is an agitated person on their deathbed panting and they may be sweating as well so I don't expect us to see that clinically very often but more to show us that there is this relationship um between as our Chia is expiring as Chia of the lung and the kidney run out um this is really when our breathing is getting towards the end and we're almost done for this go around with our breathing and we start to pant be agitated often um and obviously this isn't a serious condition um dung goes on to talk about a few sort of miscellaneous conditions that may cause wheezing and panting and I just want to mention those but I certainly don't want to um emphasize them over much because I don't think that we're going to see very many of these and I think that if you do see them uh then you'll know where to look um so he talks about miscellaneous patterns one of them that that's definitely worth mentioning is that it's it's natural if you're pregnant to have a little bit of shortness of breath um and this can happen actually as early as the first trimester where women are are or pregnant people are short of breath um initially this can be because the blood volume hasn't picked up with the new demands on the body um towards the third trimester or even the the the second trimester it's because that diaphragm doesn't have as much room to move you know it used to have all this room in the Torso to move and now there's this Critter inside the belly that's getting in the way so the diaphragm which is supposed to you know flatten out on the inhale and Dome on the exhale it starts to flatten out and it hits this you know enlarged womb so not having as much breath is very normal for um a pregnant obviously if it's more severe or if the person has pre-existing conditions asthma something like that they may need additional support um there's also just to build your vocabulary this whole category of things that I'm not going to get into called throat wind right so acute throat wind putrifying throat wind throat locking wind and throat entwining wind and I invite you to kind of read through dung on your own and familiarize yourself here but there's some things here that are like a kind of a strey over-the-top infection and some of these things are actually a little bit more like an anaphylaxis reaction so um anaphylaxis one of the things that happens under acute release of histamines on some people is the throat actually locks up and you can't breathe so if you're allergic to bees or if you're like my poor nephew who's allergic to everything if he leads a if he eats a walnut he actually needs an EpiPen you know because his throat starts to swell up and shut so this was described as throat wind wind because it comes on quickly and throat because that's the location of the sort of acute change in the body so um there's also a we have some menitis stuff here also um for our purposes unless you specialize in acute care and specialize in anaphylaxis and inpatient situations or emergency rooms um I don't think you need to know this except to be familiar with the phrase throat wind and then it points to some sort of acute respiratory issue maybe anaphylaxis or some sort of you know intense infection that closes up your throat so diptheria is one of the things that could be in this as well dryness invading the lung is an acute condition and we can actually have certain things that um are external signs and symptoms so you can have chills and fever with that you know and it can either slant a little bit more towards heat or slant a little bit more towards cold and if the state of the organ looks a little bit dry then we say this is now lung dryness you know and if it persists it becomes lung in deficiency um and that hinging point between lung dryness and lung y deficiency is a little tricky it honestly is because we're going to have thirst we're going to have a dry tongue um the moment that you start to show Yin deficient heat symptoms is kind of the time where we would think that it's sort of flipped so that would be a little bit more um textbook dryness but we can have blood streak flame with lungin deficiency as well so for instance um pulmonary tuberculosis or consumption you know it used to be called consumption in the old days and if you ever watch Victorian dramas there's always like some like you know wasting person that's like weak and coughing into a handkerchief and they see the blood on the handkerchief and every's like oh they have the consumption and that that's lung Yin deficiency and it's often marked by a lot long-term low-grade fever so both of them can have blood stream fleem you have both lung dryness and lung Yin deficiency because the lung is this delicate biscuits that loathes dryness right so as soon as dryness gets into it it starts to really mess it up very quickly is lung dryness excess or deficiency lung dryness as an exterior Invasion as an excess condition um once it hits the inside you kind of you kind of have to look and see are they showing more excess signs or deficiency signs and you know once it's on the inside it's really up to what uh excess or deficiency is what's showing in the tongue and pulse what's showing in the other signs of symptoms um and I think for the exterior condition with still in the exterior level we would look for fever and chills in some proportion acute onset and seasonality and then we'd probably call it Autumn dryness exterior invasion of autumn dryness yeah clinically you know it it's it's rare to find uh the exterior stage of that cough of that cough usually you see sort of the more chronic one where he's actually gotten into the song already you know