太陰肺濕熱瘟?。ü跔畈《拘苑窝祝┓乐沃改?英文精簡(jiǎn)版）

吳雄志

1天津南開(kāi)醫(yī)院，中國(guó) 天津，300060。

These guidelines use coronavirus disease 2019(COVID-19) as an example for the prevention and treatments of damp-heat in Tai Yin lung disease.

Damp-heat disease is dominated by exudative inflammation, with pathological features such as tissue inflammatory exudation and edema and frequent sequelae fibrosis.

These symptoms caused by COVID-19 are considered damp-heat disease.

The location and characteristics of dampness of this disease are as follows:

· Damp-heat is caused by either the spleen and stomach or the liver and gallbladder. The spleen is the source of dampness production. Owing to the correspondence of their internal and outer environment, people with spleen deficiency are prone to producing dampness. The Shao Yang San Jiao channel is the fluid passage of the body. It is responsible for water metabolism. “Above the Shao Yang channel, Fire Qi is the dominant Qi”； hence,it is easier for the Shao Yang channel to convert dampness into heat or directly convert pathogens into heat. Therefore, this disease is mostly treated from Tai Yin and Shao Yang. Liver damage is also common in clinical practice. Fever accompanied by significant fatigue and aversion to oily food is a prominent indication of Shao Yang disease. Others include bitter taste in the mouth, throat discomfort,red eyes, wiry pulse, and swelling of both sides of the tongue.

· Dampness can easily permeate the San Jiao.It could manifest cough when it disturbs the upper body. It can cause diarrhea, vomiting, and abdominal distension in the middle Jiao, whereas it can cause dysuria and kidney damage in the lower Jiao.

· Damp-heat can manifest externally and cause internal damage, such as externally manifested skin rashes, internally manifested myocardial damage, and even shock and coma.

· Yang Ming disease often manifests heat and excess whereas Tai Yin disease often manifests dampness and deficiency.

The course of treatment for this disease is as follows:

· Heat is not relieved after sweating. Although the patient sweats after taking a medicine (or sweats without taking a medicine), the fever subsides and the symptoms are relieved, which does not mean that the condition is completely relieved. However,many patients will have recurrent fever, which is characterized by a pulse that has not completely returned to normal during the remission period. The body temperature is not completely normal and the tongue coating is not cleared.

· Patients with regular fever (with obvious fever in the afternoon) can take a medicine one more time at about 30 minutes to 1 hour before the fever.For example, if the fever is obvious after noon, take Yinchai Xiaodu Dan once, because the heat is in the Yang Ming channel owing to the fever time. Chailing decoction is often used before noon, and the heat is relatively common in the Tai Yang channel.

· For severe condition, take the medicine once every 4 hours, and for very severe cases, take the medicine once every 3 hours. At the same time, we need to care for the spleen and stomach, which is responsible for the genuine Qi.

· In general, the course of disease is approximately 14 days. Patients with mild symptoms can be completely relieved in a few days. Even after the symptoms are relieved, it is recommended to continue taking the medicine for 14 days.

1 In the early stage

1.1 Classification and staging

Commonly seen:

· Early stage. It should be noted that the early and middle stages do not completely depend on the time of onset. Some patients stay in the early stage(mostly mild) for a long time, some at the onset of the middle stage (more severe), and some die quickly(critically severe).

· When spleen deficiency is obvious, the patients will manifest more damp symptoms than heat symptoms. If the patient’s tongue looks pale from the middle to the root, it is caused by spleen deficiency or Yang deficiency. When the body temperature is not high or the fever is reduced after taking a medication,you can touch the toes to diagnose whether there is Yang deficiency. In severe cases, the temperature of the toes can be low even when there is a fever. The teeth marks on the edge of the tongue also denote spleen deficiency, which needs to be distinguished from those with swollen edge of the tongue (a manifestation of liver stagnation). If the teeth marks and swollen edge are not easy to distinguish, you can look for cheek marks inside.

· Mild patients. It should be noted that sometimes the symptoms do not match the seriousness of this disease, that is, we cannot define the seriousness based on the symptoms. It is mainly based on the tongue and pulse manifestations or the chest X-ray/computed tomography (CT) examination of modern medicine.

In this stage, cold dampness is easily diagnosed in these patients.

The reasons are:

· When someone has deficient spleen, it is easier to produce dampness inside the body. It is easy to attract dampness pathogen because of the correspondence of the external and internal environment. A pale tongue with teeth mark is commonly seen in these patients.

· When the patient has dampness, the tongue generally has a white coating. Some white coating will cover the tongue body. When the person has heat inside the body, we can see the redness at the bottom of the tongue, which can be easily neglected during the diagnosis.

· At the beginning of dampness transforming into the heat, there will be a slight yellow coating on top of the white coating, which is easy to neglect.In this situation, we need to ask about the person’s bowel movement. If he is constipated, then purging method can be applied. The yellow coating will be gone once the constipation is resolved. If the person is not constipated, it is possibly caused by the inflammation, which caused the heat.

· When the person has immune dysfunction,the symptoms can manifest as heat but the tongue coating is not yellow.

· During inflammation, it takes several hours to 1 or 2 days for white blood cells to become pus cells. If there is excessive heat, tongue coating should be dry； however, if there is dampness, wet coating will cover the dryness, but the body of the tongue should look granular.

· Cold dampness generally manifests a relatively slow pulse. Damp-heat causes a rapid pulse. A slight rapid pulse can be seen in cases without fever.

· Some patients manifest a pale tongue with white greasy coating. However, as soon as warming herbs are applied, the pulse becomes rapid, and the tongue coating turns into yellow covering the white coating. In this case, we know it is damp-heat disease. Because it is cold dampness, warming herbs are not going to convert the dampness into heat. Only if it is already damp-heat disease will the warming herbs produce more heat. Lizhong decoction is a formula to treat cold dampness.

· Even though the pandemic disease has its clear pathogenic organisms, which in essence is damp-heat disease, it will not always manifest damp-heat. Cold dampness symptoms can be seen in some patients. Because dampness is a Yin pathogen and heat is a Yang pathogen, different clinical manifestations will appear, based on whether the constitution is hot or cold, when it invades individual constitutions. Therefore, the prescription should be adjusted according to the cold or hot constitution, but the prescription should still be based on damp-heat treatment.

In summary, this pandemic disease should not be diagnosed as cold damp disease.

Some patients will have dry cough or cough with scanty phlegm. This will be easily mistaken as Yin deficiency. The scanty phlegm is caused by the disease being located in the lung interstitium and alveoli, which makes the phlegm difficult to cough out. This is different from the inflammation of the trachea and bronchi. Therefore, the disease cannot be diagnosed as Yin deficiency. Even though there is not much phlegm to be seen, dampness is still the cause.

1.2 Treatment

1.2.1 Formula

The formula 1 Chai Ling decoction modification is 24 grams of Chaihu(Bupleuri Radix), 9 grams of Huangqin(Scutellariae Radix), 9 grams of Guizhi(Cinnamomi Ramulus), 9 grams of Baizhu(Atracylodis Macrocephalae Rhizoma), 10 grams of Fuling(Poria), 10 grams of Zhuling(Polyporus),9 grams of Zexie(Alismatis Rhizoma), 5 grams of Gancao(Glycyrrhizae Radix et Rhizoma), 30 grams of Shishangbai(Selaginellae Herba), and 30 grams of Lianqiao(Forsythiae Fructus).

1.2.2 Prescription analysis

According to ShangHan Lun, Wuling San treats vomiting, diarrhea, cough, and fever. Xiaochaihu decoction can be used to release the fever caused by catching a cold. It also regulates the water passages of the San Jiao (triple burner)； “when the upper Jiao is unblocked； healthy fluid is able to descend； when the stomach Qi is harmonized, the disease can be resolved after the body sweats.”

Shishangbai(Selaginellae Herba) is specialized in treating lung infections.

Gancao(Glycyrrhizae Radix et Rhizoma)resolves toxicity. The glycyrrhizin in Gancao(Glycyrrhizae Radix et Rhizoma) is equivalent to anti-inflammatory glucocorticoid.

If cold dampness syndrome appears when catching a cold, Jing Yue Quan Shu mentioned that Qiang Huo can be added to Wu Ling San. In my experience, Lianqiao(Forsythiae Fructus) can be added to Wu Ling San if damp-heat syndrome appears during an external pathogen invasion.

Besides resolving the exterior, Lianqiao(Forsythiae Fructus) can stop vomiting (e.g.,Ganlu Xiaodu Dan), cool the blood (e.g., Qingying decoction), and clear the heart (e.g., Qinggong decoction) and liver (e.g., Mahuang Lianqiao Chixiaodou decoction).

Severe damp-heat can cause acute liver damage.

The pandemic disease can affect the blood phase straight away, which is evidenced by a prickly tongue coating. Therefore, Lianqiao (Forsythiae Fructus)will be heavily used in the prescription.

For early stage, it is important not to use Huangqi (Astragali Radix), Renshen(Ginseng Radix et Rhizoma), and other Qi tonifying herbs, because these herbs will make the symptoms worse. This is why Renshen(Ginseng Radix et Rhizoma) is removed from Xiaochaihudecoction.

For patients with weak constitution, add 9-15 grams of Gancao(Glycyrrhizae Radix et Rhizoma).For severely weak individuals, add 15-30 grams of Taizishen(Pseudostellariae Radix) (watch the patient"s reaction cautiously, because this can easily knock the body system off balance).

The cytolytic infection owing to spleen deficiency requires Renshen(Ginseng Radix et Rhizoma) and Huangqi (Astragali Radix)； otherwise,it is difficult to remove the pathogen. However, this disease is a noncytolytic infection, which is mainly immunologically damaged. Western medicine usually uses anti-inflammatory and anticytokine therapy for this disease. When Renshen(Ginseng Radix et Rhizoma) and Huangqi (Astragali Radix) are used,the immune reaction is strengthened, which can cause more infection. Therefore, the practitioner should be cautious； these extra herbs should be avoided for those who do not have an in-depth research on traditional Chinese medicine (TCM) febrile disease and western medicine epidemiology.

For patients with severe vomiting and diarrhea,add 9 grams of Jiangbanxia(Pinelliae Rhizoma Praeparatum Cum Zingibere et Alumine) and 1 tbs of fresh ginger juice. Ginger juice can help dissolve dampness and causes less heat than ginger slices. Thus, it is more commonly used to treat febrile diseases. If Xiaochaihudecoction is used in this condition, it is better to replace Shengjiang(Zingiberis Rhizoma Recens) with ginger juice.

For women during their menstrual cycle or patients with blood deficiency, add 9 grams of Danggui (Angelicae Sinensis Radix). Danggui(Angelicae Sinensis Radix) can activate blood circulation and nourish the blood, with antiinflammatory effects during the blood phase. This formula does not contain Dazao(Jujubae Fructus)because it adds too much dampness.

For diarrhea or for those with red complexion,add 30 grams of Gegen(Puerariae Lobatae Radix)(the idea of Gegen Qinlian decoction).

For patients with thick, powdery tongue coating,add 3-6 grams of Caoguo(Tsaoko Fructus). Caoguo(Tsaoko Fructus) specializes in treating white, thick tongue coating (thickened filiform papillae). For patients with abdominal distension, add 9 grams of Houpo (Magnoline Officinalis Cortex). Binglang(Arecae Semen) can be used for even more severe distension (bowel motions should be normal).

1.3 Disease outcome

The most common outcome is damp stagnation transforming into heat, which is equivalent to entering the so-called inflammatory storm period(often turning severe) in modern medicine or secondary bacterial infection.

The methods to diagnose whether dampness has transformed into heat are as follows: First, look at the tongue coating； the coating is yellow over the top of the white. Second, look at the texture of the tongue, and lift up the tongue； the bottom of the tongue will be red or prickly. Third, feel the radial artery pulse； an irritated pulse indicates presence of heat. An irritated pulse is not restricted in the pulse rapidity. Beginners can count the pulse rate.Refer to the following: Spleen deficiency pulse is slow, the basic pulse can be estimated at 70 beats/min, and a Yang deficiency pulse is estimated at 60 beats/min. If the body temperature increases by 1℃, then pulse rate will increase by 10 beats/min.Note that body temperature immediately affects the pulse. Estimate whether the increase in pulse is proportional to the increase in body temperature,and determine the degree of heat or whether there is internal heat. Fourth, check if there is a secondary bacterial infection. Throat pain is clinically common；the tonsils will be swollen or suppurative. Blood tests will reveal elevated white blood cell or increased absolute value of neutrophils. Because this disease can cause lymphopenia, an increase in the percentage of neutrophils is not enough to indicate bacterial infection.

When it is unclear whether there is heat, you can remove Guizhi(Cinnamomi Ramulus) or reduce Guizhi(Cinnamomi Ramulus) to 3-6 grams or replace Guizhi (Cinnamomi Ramulus) with Rougui(Cinnamomi Cortex). The formulas for the middle stage are more stable and safer, whereas the formulas for the early stage can dissolve heat quickly. If the identification of heat is unclear, beginners of TCM can use middle stage formulas. However, formulas for the early stage are more suitable for spleen deficiency constitution. If you use middle stage prescriptions,you should pay attention to adding Chenpi(Citri Retiiculatae Pericarpium) and Cangzhu(Atractylodis Rhizoma) to protect the spleen and stomach.

There are 2 ways to deal with severe heat(external heat, internal heat, or damp stagnation heat).

2 Middle stage

2.1 Classification and staging

Commonly seen:

· For patients with chronic internal heat, the initial onset of disease tends to directly develop into the middle stage.

· Patients with chronic stagnant dampness can develop heat toxicity； for such patients, their constitution generally has more dampness than heat.

· For patients with severe infections, the symptoms do not match the disease severity. It is important to closely monitor the pulse and tongue patterns, or modern medical X-ray, and/or CT scans should be used.

For pandemic disease without fever, one must pay attention to the pulse:

· For patients with low grade fever or without fever, it is important to check whether there is an irritated pulse. For inexperienced doctors, it is critical to monitor the pulse rate. Generally speaking, if there is fever, the pulse rate will increase. Therefore, when there is no fever or the fever is not severe but there is an increase in pulse rate, there is a danger of a cytokine storm.

· To diagnose dampness, one should pay attention to 3 points: (1) Is the pulse thready? (2) Is the pulse moderate? A moderate pulse can indicate an occurrence of pandemic disease the in Tai Yin spleen,for example, enteric typhoid in western medicine. It is rare for pandemic disease in Tai Yin lung to occur.(3) Is the pulse smooth? For beginners, they can feel whether the pulse beating under the fingers is clear or not. Some of the unsmooth pulse can indicate dampness.

In clinic, many of the manifestations of dampness and heat are in contradiction, which is because dampness is a Yin pathogen, whereas the heat is a Yang pathogen.

· Pulse with heat condition will generally manifest as forceful, big, and rapid. Pulse with damp condition will generally manifest as thready, feeble,and moderate (forceful-feeble, big-thready, and rapidmoderate are in contradiction). However, the patients’tongue coating will be thick greasy and yellow or red/crimson sublingually. All these symptoms indicate that dampness and heat exist simultaneously.

· Tongue assessment can also be complicated.The patient who has more dampness than heat generally will have spleen deficiency with pale tongue. The patient who has more heat than dampness will manifest red tongue. The key is to observe the tip of the tongue and its coating. If the patient has hidden heat, it is necessary to look at the sublingual area.

· Sometimes dampness and Yin deficiency can be complicated. Generally speaking, damp-heat disease can also manifest a thready pulse, but will not combine with a weak pulse. If the patient has thready and weak pulse at the same time, it indicates Yin deficiency, and blood deficiency.

· A prickly tongue can also be confused with spleen deficiency. Assessment of the tongue tip can make the diagnosis easier. If the prickle is profuse but not red, it indicates genuine Qi deficiency.Because this type of patient has a weakened immune system, this condition is more likely fatal when cytotoxic infection occurs. Although for noncytotoxic(i.e., cytolytic) viral infection, sudden death is less likely to happen in this type of patient. However,the condition is prone to prolong its course； some patients will die from secondary bacterial infection and some are prone to sequelae fibrosis after the acute phase. Some can become chronic, depending on whether the disease itself will become chronic.

2.2 Treatment

2.2.1 Formula

Yinchai Xiaodu Dan: 24 grams of Chaihu(Bupleuri Radix), 9 grams of Huangqin(Scutellariae Radix), 30 grams of Jinyinhua (Lonicerae Japonicae Flos), 30 grams of Lianqiao (Forsythiae Fructus),9 grams of Changpu(Acori Tatarinowii Rhizoma),9 grams of Yujin (Curcumae Radix), 9 grams of Huoxiang(Pogostemonis Herba), 9 grams of Peilan(Eupatorii Herba), 30 grams ofYinchen(Artemisiae Scopariae Herba), 6 grams of Baidoukou(Amomi Fructus Rotundus), 9 grams of Danggui (Angelicae Sinensis Radix), 9 grams ofDanpi(Moutan Cortex),30-60 grams of Yi Ren, 30 grams of Shishangbai(Selaginellae Herba), and 5 grams of Gancao(Glycyrrhizae Radix et Rhizoma).

2.2.2 Prescription analysis

Chaihu(Bupleuri Radix) paired with Huangqin(Scutellariae Radix) is used to expel the external coldness and fever. This pairing is from Xiaochaihu decoction. This formula is also used to regulate fluid metabolism because the San Jiao Channel is also a Shao Yang channel. “When the upper Jiao is smooth,body fluid can move normally； there will be recovery after thorough perspiration because the stomach Qi is harmonized.”

Jinyinhua(Lonicerae Japonicae Flos) paired with Lianqiao(Forsythiae Fructus) is used to expel the external pathogens. Changpu(Acori Tatarinowii Rhizoma) and Yujin (Curcumae Radix) are combined to prevent shock, tremors, and convulsion.

Huoxiang(Pogostemonis Herba) paired with Peilan(Eupatorii Herba) harmonizes the middle Jiao.For patients with sticky phlegm or sweet taste in the mouth, add 20-30 grams of Peilan(Eupatorii Herba),because Peilan(Eupatorii Herba) is a specific herb to inhibit mucus secretion. It can reduce a large amount of mucus exuded from lung inflammation and prevent the formation of phlegm clots.

Yinchen(Artemisiae Scopariae Herba) with Baidoukou(Amomi Fructus Rotundus)can resolve damp-heat in the Triple Burner. Danggui(Angelicae Sinensis Radix) with Danpi(Moutan Cortex) can help clear blood. For patients with constipation, add Zicao(Arnebiae Radix). Yiyiren(Coicis Semen)supports the removal of damp-heat and is antiviral.Shishangbai(Selaginellae Herba) specifically treats lung infection. Gancao(Glycyrrhizae Radix et Rhizoma) is used to detox. Glycyrrhizinate in Gancao(Glycyrrhizae Radix et Rhizoma) has a similar function as glucocorticoid and has a good antiinflammatory effect.

Chaihu(Bupleuri Radix) is good for fever.Jinyinhua(Lonicerae Japonicae Flos) has a good effect on severe throat pain. Peilan(Eupatorii Herba)helps the digestive symptoms. The most powerful pairing of herbs in Yinchai Xiaodu Dan are Chaihu(Bupleuri Radix) and Huangqin (Scutellariae Radixfor fever, Jinyinhua(Lonicerae Japonicae Flos) and Lianqiao(Forsythiae Fructus) for external pathogens,and Peilan(Eupatorii Herba) and Huoxiang(Pogostemonis Herba) for harmonizing the stomach.

2.2.3 Modification

For continuous fever, remove Chaihu(Bupleuri Radix) to prevent further Yin damage.For Yin deficiency, add 15 grams of Shengdihuang(Rehmanniae Radix).

Vomiting and diarrhea are more likely to appear with Yin damage in patients with consistent fever. In the early stage of Yin damage in damp-heat disease,tongue assessment should be applied. If there is a fine crack in the tongue coating that is not congenital,then there will be Yin damage.

There are 4 methods to help this situation:

First, remove Chaihu(Bupleuri Radix) and add Shengdihuang (Rehmanniae Radix) to nourish Yin.Otherwise, the damp-heat cannot be easily resolved.

Add Xuanshen(Scrophulariae Radix) to nourish Yin. Xuanshen(Scrophulariae Radix) paired with 30 grams of Danggui(Angelicae Sinensis Radix)has a good anti-inflammatory effect. However, it is not recommended to use when a patient is in shock because Xuanshen(Scrophulariae Radix) and Danggui(Angelicae Sinensis Radix) can enlarge blood vessels, which further reduces blood pressure.

Another one is adding 30～50 grams of Lugen(Phragmitis Rhizoma). Lugen(Phragmitis Rhizoma)can drain dampness, is antiviral, nourishes Yin,relieves coughing, reduces fever, and can help resolve the tongue coating because it contains vitamin B.

If there is Yin damage combined with fever,Zhimu(Anemarrhenae Rhizoma) is good to protect the adrenal cortex. Because the consistent fever can exhaust the adrenal cortex, it causes circadian rhythm disorders. It not only prevents fever from damaging Yin but also helps nourish Yin.

For severe dampness, add 30 grams of Danzhuye(Lophatheri Herba) and 30 grams of Lugen(Phragmitis Rhizoma). For severe fever, add 30 grams of Daqingye(Isatidis Folium), combined with 6-9 grams of Chenpi(Citri Retiiculatae Pericarpium) to prevent stomach damage.

You should avoid using a big dosage of Daqingye(Isatidis Folium) because it could cause stomachache, diarrhea, or poor appetite if someone already has spleen deficiency； 15 grams can be applied. To prevent these symptoms, 8 grams of Chenpi(Citri Retiiculatae Pericarpium) or 8 grams of Cangzhu(Atractylodis Rhizoma) can be used to regulate Daqingye(Isatidis Folium).

2.3 Outcome

The first outcome is the emergence of serious illness and the transition to critical illness. The second outcome is relief after medication. The third outcome is spleen deficiency and dampness,which manifests after remission of damp stagnation transforming into heat. The clinical manifestations are the tongue coating turning white, the tongue body turning pale, and fever subsiding after taking a medication. In this stage, the early stage formula mentioned earlier can be used. Guizhi(Cinnamomi Ramulus) in formulas can be replaced with 3 grams of Rougui(Cinnamomi Cortex), or you can take 1 gram of Rougui(Cinnamomi Cortex) as a powder.Meanwhile, heat-clearing medications such as Huashi(Talcum) and Hanshuishi (Calcitum,Gypsum Rubrum)can be added to the formula. If the heat flares after the medication, middle stage prescription can be used.

The fourth outcome is damp and heat lingers.Dampness is a Yin pathogen, which requires warming method to transform. For patients with obvious spleen deficiency, the early prescription can be used if the midterm prescription is not effective in removing dampness. Guizhi(Cinnamomi Ramulus)in formulas can be replaced with 3 grams of Rougui(Cinnamomi Cortex) or can take 1 gram of Rougui(Cinnamomi Cortex) as a powder. Meanwhile, heatclearing medications such as Huashi(Talcum) and Hanshuishi (Calcitum,Gypsum Rubrum) can be added to the formula, while closely observing the inflammatory reaction.

3 Severe illnesses

The disease often manifests as 2 types: (1) the outbreak type, which is severe from the outset. It is mainly seen in people with severe fever, rapid progress of the disease, sudden death, and death of internal pericardium even within a few minutes. (2)The ordinary type, in which the early progress is slow, but the fever will manifest and the condition will change rapidly once the severe stage is reached.Urgent treatment is needed. This type is often neglected because of the stability in the early stage,causing severe illness.

Clinically, it can be seen as cardiopulmonary and renal failure, which can be combined with liver injury, gastrointestinal failure, and coagulation disorders. It needs immediate emergency treatment.

The symptoms of the disease and the remission of the disease are often not parallel in the epidemic.Look at the extreme period, and look at the tongue coating which represents that Yang Ming is hot. For patients who are not progressing to an outbreak, the severe stage usually occurs in approximately 10 days.If there are no severe extreme clinical manifestations in 14 days, the patient is relatively safe.

To judge the severe stage, one should look at the body of the tongue. A large number of prickles on the tongue mean pathogens have entered the blood phase and the blood circulation quickens. Second is to feel the pulse； if the pulse is wiry and sharp,the patient can go into febrile convulsion. Tongue coating is also helpful for judging the condition of the disease. In patients with severe dampness,the tongue coat is white and thick as if coated with powder. For patients with severe heat, the tongue can exhibit a yellow, thick, and dry coating, or there can be a peeled coating, which indicates that the disease period is longer and some of these patients are likely to become critically ill.

As for those with dark purple tongue, if it is not caused by blood stasis in the body, it is caused by an infection that causes a hypercoagulable state, but the progress is often not particularly quick. Tai Yin lung damp-heat disease quickly manifests a purple and dark tongue and low blood oxygen saturation must be ruled out. This is an indication of severe lung disease and should be distinguished from heat that causes blood stasis. Blood stasis owing to extreme heat can cause bleeding. Add 30 grams of Qiancao(Rubiae Radix et Rhizoma) and 9 grams of Zicao(Arnebiae Radix)； 15 grams of Guanzhong(Osmundae Rhizoma) can be used directly. Shenxi Dan can also be used directly.

Cough, sputum, fever, and dyspnea combined with tongue and pulse assessment is a powerful basis for judging the progress of the disease compared with other gastrointestinal symptoms. If you have difficulty breathing, you should try to monitor the blood oxygen saturation and immediately take a chest X-ray or CT to confirm the lung’s condition. Severe breathing difficulties require rapid first aid.

In severe cases, adding 9 grams of Mahuang(Ephedrae Herba) can prevent shock. Depending on the blood pressure, the dosage can reach 30-40 grams； you can use Maxing Shigan decoction,Maxing Yigan decoction, and Mahuang Lianqiao Chixiaodou decoction. The latter is also effective for liver damage caused by viral infection. Ephedrine is an adrenaline-like drug. Mahuang Shengma decoction is a representative prescription of TCM to treat critically ill infections. The treatment of critically ill infections by this prescription requires addition and subtraction based on syndrome differentiation. The characteristics of Chailing decoction are based on the treatment of Shao Yang and Tai Yang (Tai Yang channel treatment is to expel external dampness,whereas Shao Yang channel treatment is to prevent the sickness from transforming into fire). Yinchai Shaodu Dan treats 3 Yang channels simultaneously.Mahuang Shengma decoction aims at severe stage and the 6 channels are combined within the treatment.

Renshen(Ginseng Radix et Rhizoma), Fuzi(Aconiti Lateralis Radix Praeparaia), Yuzhu(Polygonati Odorati Rhizoma), and Shen fu injection have anti-heart failure effects and can be used as appropriate. Banbianlian (Lobeliae Chinensis Herba)is mainly for central respiratory failure, which is not effective for this disease, especially for those with irritability and convulsions.

Glycyrrhizin is similar to glucocorticoids. If there are no other anti-inflammatory drugs, 30 grams of Gancao(Glycyrrhizae Radix et Rhizoma) can be used to replace glucocorticoids. It has a strong antiinflammatory effect. It needs to be combined with Chenpi(Citri Retiiculatae Pericarpium), Fuling(Poria), and other diuretic herbs to antagonize the side effects of Gancao(Glycyrrhizae Radix et Rhizoma).

Changpu(Acori Tatarinowii Rhizoma)and Yujin (Curcumae Radix) have an effect on preventing severe diseases and can prevent coma and convulsions. “When the external heat sinks,the internal collaterals are closed,” and the early manifestation is often chest tightness. For those who are unconscious or convulsed, the traditional first aid method is to use the “Three Treasures” of Chinese medicine. Patients with damp-heat and Yin damage can use the modified Baihe Dihuang decoction(Bai He (Lilii Bulbus), Shengdihuang (Rehmanniae Radix), Zhu Ye (Lophathatheri Herba), Shigao(Gypsum Fibrosum), and Danpi(Moutan Cortex)). To help revive the unconscious patient, Huashi(Talcum)and Gancao(Glycyrrhizae Radix et Rhizoma) can be added.

Once there is pathogenic fluid retention, there will be pericardial or pleural effusion； hence, take 30 grams of Jiang Nan Juan Bai immediately.

Chantui (Cicadae Periostracum) has the effect of stimulating the synthesis of interferon and has a strong antiviral effect. It is seen in Shengjiang San,but you must be careful about severe cases. Its use is not recommended for severe inflammation. The dosage can reach 30-40 grams. It is not recommended for those who have no in-depth research on TCM febrile disease and western medicine infectious disease.

4 Sequelae

The sequela of this disease is mostly pulmonary fibrosis, and the prescription is Yuke decoction seen in Wu Men’s clinical prescriptions (Xiangfu(Cyperi Rhizoma), Xuanfuhua (Inulae Flos), Yiyiren(Coicis Semen), Taoren (Persicae Semen), Danggui(Angelicae Sinensis Radix), Wugong(Scolopendra),Sanqi (Notoginseng Radix et Rhizoma), and Baijiezi (Sinapis Semen)). Shancigu (Cremastrae Pseudobulbus), Shanglu (Phytolaccae Radix),Zaojiaoci (Gleditsiae Spina), etc., can be added for modification and the side effects of each medication should be noted. For obvious emphysema, take Taiyi Xisui Gao for 3 consecutive years. It can be seen in the Wu Men,s prescription.

5 Prevention and regulation

5.1 Prevention

Pay attention to ventilation, avoid going to crowded places, avoid contact with infected patients,avoid fatigue, wash your hands frequently, and wear masks. It is important to note that epidemics are powerful infectious diseases. In this case,the immunity of a normal human body is often insufficient to prevent epidemic diseases. Infectious diseases are sometimes not entirely treatable, and it is especially important to avoid close contact.

TCM commonly includes Qigong and meditation, incense (including wearing sachets), and miasma (taking antipandemic herbs, such as Xiaojin Dan inThe Inner Canon of Huangdi). You can use the formulas mentioned in this guideline.

You can also rub the sole of the foot (Yong Quan (Kid1), 81 times) and the arch of the foot (Ran Gu (Kid2), 81 times), or press it for 5-10 minutes.

In addition, it should be noted that some patients are still infectious with the virus for up to 14 days after recovery, and one should be careful when in contact with them. It is possible that individual patients may carry the disease for life.

The key is to feel the pulse. When the disease is cured, the clinical symptoms, and imaging manifestations disappear. If the pulse is still agitated at the deep or middle depth, then the patient could still be infectious.

5.2 Regulation:

· Food and nutrition: rice porridge can nurse patients back to health, eat more vegetarian dishes,it is very important to keep the bowel movement smooth, and avoid fatty and sweet food and cold drinks.

· Avoid excessive labor that includes excessive physical activities, overthinking, and sexual activity.Try to avoid sex for 14 days after recovery.

6 Instructions for use of the guide

6.1 Essentials of differentiation and treatment

It is crucial to grasp the core pathogenesis for disease differentiation and treatment. The more syndrome types, the farther away from the essence of the pandemic. For pandemics, it is ideal to use 1 herb for 1 disease. If you cannot use 1 herb for 1 disease,try to have 1 formula for 1 disease. If you do not know how to use the formula for the disease, at least address the core pathogenesis to determine the core syndrome type. Clinically, various factors will cause a variety of concurrent syndromes and changes；although many situations will affect the prognosis, it does not reflect the nature of the disease. Although relieving the syndromes formed by symptoms and signs is important, the TCM treatment for pandemic pathogens and key pathologies are more important.The core pathogenesis for the same infectious disease is relatively constant, because the organism for the same infectious disease is unique.

6.2 Prognosis

Severe pandemic often presents a contradiction between symptom relief and disease progression,that is, the changes of syndrome, and disease are not synchronized. Therefore, the change of the tongue and pulse is sometimes more important than the clinical symptoms.

6.3 Integration of Chinese and western medicine

For the prevention and treatment of the pandemics, it is recommended to combine modern medicine with the theoretical basis of traditional medicine. Modern infectious diseases and intensive care medicine can cooperate with traditional medicine, especially in terms of vaccination,isolation, disinfection, protection, supportive treatment, and first aid.