Hongmei Li ShuSen Li

A case study of an ICU severe patient’s experience with the application of pulse-respiration ratio

Patient: Female, 72 years old. Fall down and be unconscious for 1 week.

Medical History: The patient developed symptoms on 2/28/2023, presenting with respiratory distress and chest pain due to a lung infection, which progressed to acute respiratory failure and led to hospitalization. Upon admission, the patient had a pulse rate of 97 beats per minute and a respiratory rate of 15 breaths per minute. According to the patient’s family, the patient had been using a tracheal tube at home for over five years. With treatment, the patient’s condition improved. On 3/5/2023, the patient was found collapsed on the ground with a right frontal head injury. The tracheal tube was beside the bed, and the patient was unconscious. Immediate PCR testing and cardiopulmonary resuscitation were performed. The patient was subsequently transferred to the ICU. In the ICU, the patient received cardiac monitoring, tracheal intubation, nasogastric tube placement, and urinary catheterization. The patient stayed in the ICU for 10 days.

The patient’s family requested traditional Chinese acupuncture treatment. The attending Western physician invited consultation with a traditional Chinese medicine (TCM) practitioner.

Past Medical History: The patient had a history of hypertension, coronary artery disease, chronic kidney disease, ovarian cancer (10 years post-surgery), uterine cancer, type 2 diabetes, COVID-19 sequelae, and tracheostomy (7 years ago).

Western Medical Diagnoses:

1.Hypoxic brain injury with cerebral edema

2.Acute encephalopathy

3.Rib fractures

4.Acute hypoxic hypercapnic respiratory failure

5.Pneumonia

6.Coronary artery atherosclerosis

7.Chronic kidney disease

8.COVID-19 sequelae

9.Bilateral flaccid paralysis of the upper limbs

The patient’s family requested TCM acupuncture treatment. The attending physician of Western medicine invites a TCM doctor for consultation .

Initial Consultation：3/15/2023: The patient was unconscious, with closed eyes, a sluggish pupillary light reflex. Other superficial reflexes were present. The jaw was tightly closed, and the patient was unresponsive to questions.

The patient had a sutured wound on her right frontal area and wore a cervical collar. She had bilateral flaccid paralysis of the upper extremities, but the extremities were warm, with no edema. The patient had an endotracheal tube, nasogastric tube, and urinary catheter in place. Pulse: 110 beats/min, stringy and rapid; the tongue coating cannot be seen as the teeth are tightly closed. Blood pressure: 135/50mmHg; Respiration: 31 times/min, cardiac monitoring was in place.

MRI Findings:

1.Cerebral edema

2.Spinal cord edema at C5-C6

3.Left 4th-6th rib fractures; right 4th-5th rib fractures

TCM Diagnosis:

1.Closed wind stroke, Zang-Fu disharmony

2.Syncope

3.Acute respiratory failure

4.Blood stasis and Qi stagnation

5.Traumatic rib fractures

6.Lung and kidney deficiency

7.Heart and spleen deficiency

8.Concretions and agglomerations

Initial Acupuncture Treatment:

1. 12 jing-well point acupuncture therapy;

2. Jiao’s scalp acupuncture;

3. Lu’s jumping needle; Shuigou (GV 26), Zhongchong (PC 9): used to refresh the brain; Wailaogong (Extra point on dorsum of hand opposite PC 8), Yongquan (KD 1) is used to clear the heart and reduce adverse events;

Hegu (LI 4), Taichong (LV 3): used to regulate Qi and blood.

One acupuncture treatment per day, 5 days as a course of treatment.

Patient’s Response: After the Master Lu jumping needle treatment the patient’s limbs experienced twitching. Following acupuncture treatment, the patient was able to open her eyes, blink, respond to her daughter’s call, open her mouth to show her tongue coating, and move her feet, though she could not answer questions.

03/22/2023: Hemodialysis was performed.

03/25/2023: After taking the first An Gong Niuhuang Pill, the patient’s blood pressure increased, particularly systolic pressure. However, the pulse-respiration ratio was 3.4.

03/26/2023: The patient was able to yawn but not consciously. Her tongue coating was white and greasy, and her pulse was weak. How should the pulse be analyzed? The pulse-respiration ratio was 78/27 = 2.8.

03/31/2023: Under the guidance of Professor Li Shusen, acupuncture was administered at Tianzhu (BL 10), Dazhu (BL 11), Zhongchong (PC 9), and Yongquan (KD 1) using a balanced reinforcing-reducing method. Needles were retained for 20 minutes, with treatments administered every other day.

04/01/2023: Pulse-respiration ratio: 82/18 = 4.6. Can we consider that the patient’s condition has improved? The patient is still not fully conscious, with reactive pupils and shallow reflexes. However, she cannot respond to questions.

04/03/2023: As planned, the patient was stably transferred out of the ICU. Upon transfer, the patient’s pulse-respiration ratio was 4.3, indicating a stable condition. However, the prognosis is still not optimistic, and close observation and treatment are still needed.

The following is the pulse ratio recorded by the application of pulsation technique:

Explanation of Pulse-Respiration Ratio Technique:

This technique was developed by Professor Li Shusen. One calculates the ratio between pulse rate and respiratory rate as the pulse divided by the respiration, which equals the Pulse-Respiration Ratio.

Diagnostic Pulse-Respiration Ratio Categories

1.Pulse-Respiration Ratio of less than 4:Qi Deficiency or Cold Syndrome.

Treatment: Xiaojian Zhong Tang-tonifying method. For “Qi Deficiency” in any disease, build the qi of the middle burner. For men, use Huangqi (Astragalus) to build the central qi; for women, use Danggui (Angelica Sinensis) to build the central qi. Imbalance of “Heart Governs Blood, Lungs Govern Qi” functions results in Qi Deficiency.

2. Pulse-Respiration Ratio 4-5: Neutral State (Ping Ren). While this is “balanced”, it is no “healthy”. This is ostensibly a person blanched between an excess and a deficiency, although there is a disease present, one should follow the rules to treat it, one must balance and harmonize the mix of vacuity and repletion. Xiao Jian Zhong Tang and Da Chai Hu Tang are the governing formulas. Acupuncture should be used to regulate the channel system.

Acupuncture Treatment: When there is shortness of breath and Neutral State, the disease mechanism is in the area under Tianshu (ST 25), and one should employ points on the six channels of the leg for its treatment.

3.Pulse-Respiration Ratio > 5: Restless Pulse-This indicates an excess or heat syndrome. Treatment: The governing formula is Dachaihu Tang.

Acupuncture: Drain Yang meridians, tonify Yin meridians. Yang Qi is floating outwards, and Yin is unable to restrain Yang.

Acupuncture treatment: Restless Pulse patterns occur in the area above Tianshu (BL 25); select points from the six hand channel. Points used: Drain Erjian (LI 2), supplement Yuji (LU 10), and drain Zhigou (SJ 6). Stomach qi is the foundation of human beings, regardless of breathlessness, restless pulse, or an even presentation, regulating stomach qi is the first priority.

Discussion

1.The patient was in critical condition. Based on the recorded Pulse-Respiration Ratio, the patient’s condition changed continuously from admission to discharge. When admitted to the hospital due to infection of community pneumonia with fever, rapid heartbeat and pulse, and dyspnea, a pulse-to-breath ratio of 6.6 is considered restless pulse; After treatment, the Pulse-Respiration Ratio improved to 5.3 (Neutral State). Following a fall and subsequent ICU admission, the patient’s Pulse-Respiration Ratio ranged between 3.0 and 4.0 (Qi Deficiency). With combined Western and Chinese medicine treatment, the Pulse-Respiration Ratio shifted to 4.5 (Neutral State). Can we consider this as an improvement? It is evident that the patient was in a coma, emphasizing that Neutral State does not necessarily equate to health. The condition may have included a mixture of cold and heat, indicating a critical situation. This case highlights the challenges in diagnosis and treatment.

2.Because the patient was unconscious, the medicinal An Gong Niuhuang Wan was administered via gastric tube. Blood pressure increased, and the Pulse-Respiration Ratio decreased to 3.4. After one week, the Pulse-Respiration Ratio ranged from 4.1 to 4.6. Can we infer that the patient’s consciousness improved following the administration of An Gong Niuhuang Wan?

3.The Pulse-Respiration Ratio provides a reference for assessing the patient’s condition. Similar to the use of MRI and ECG in Western medicine diagnosis, clinical treatment should consider the patient’s individual situation for optimal results. This patient demonstrated strong vitality and benefited from both Western medicine and the unique efficacy of traditional Chinese medicine.

4.Professor Li Shusen’s teaching emphasizes the importance of the Pulse-Respiration Ratio in Changsangjun Pulse Diagnosis, and he proposes treatments for the three presentations of Qi Deficiency, Neutral State, and Restless Pulse. Through observation of this case, it is believed that this technique can provide significant clinical guidance.

NOTE: Chang Sang Jun, mentioned above, was a legendary doctor of the Warring States period who was the teacher of Bian Que, who is the reputed author of the Nan Jing.

Author information:

Hongmei Li Senior acupuncturist Cedars-Sinai Medical Center ，Los Angeles, CA.

ShuSen Li Founder of Chang Sang Jun Pulse Method， Academic Advisor of Swiss Chinese Medicine Association