[Update March 22: I see that Josh Farkas at the Internet Book of Critical Care has similarly staged the illness, if less finely than TCM academics might: “Early” Infection, Pulmonary Phase, Hyperinflammation Phase. I cannot vouch for his credentials, but it appears pretty well done. And what specifically caught my attention was the section on the pulmonary failure aspect of Covid-19. It’s “not the typical ARDS”-- Acute Respiratory Distress Syndrome-- he writes, and questions to himself and to us all whether it’s alveolar collapse (atelectasis) or if the aveoli are simply “drowning.” “If it’s the latter,” the author(s) write, “there’s not much we can do.” Why this caught my attention is that the entire point of the reporting I’ve shared below is to make the case that, “Yes, there most definitely is something we can do.” Or at least there might be. We’ll just need to broaden our thinking-- and be open to expertises other than our own. If you’re brave or concerned or twisted enough to read it all, you’ll see why people are kind of terrified: if you’re fated for Phase II it apparently can come without warning and you may quickly become a candidate for intubation. Here’s their text: "Despite being stable for several days during Stage I, as patients enter Stage II they may abruptly deteriorate (often with worsening hypoxemic respiratory failure).  Patients often present to the hospital at this point.  They may progress rapidly to ARDS, requiring intubation." (I would say that, yet again, this very generous woman who shares her story below makes this point quite clearly: address the lung fluid issue way before you think you need to!) At this stage, the immune response really seems to kick into high gear. People talk of the “cytokine storm,” but I have not read any first hand accounts of this. The authors report that this Hyperinflammatory Phase is characterized by "progressive disseminated intravascular coagulation and multi-organ failure.]

Here’s the original post:

It’s the report of one doctor on the front lines in China. And yes, she has a conflict of interest in that she is a practitioner of Traditional Chinese Medicine. She reports on her weeks of treating sick people there, alongside physicians administering more familiar pharmaceuticals. What she observed to be key to recovery, though, might be unfamiliar to most Westerners.

"Today, I want to share my experience treating thirty Covid-19 patients from the beginning to the end with you. I treated every single patient from admission to discharge, and I hope my experience can provide some insights for you. One of the similarities of these 30 patients is that the time of onset of their illness is relatively close. Admission date for all of these patients was February 4 and 5. Through my observations of the course of their illness, I hope to provide a small clinical group study. 

Pharmaceuticals and Herbal Combinations Used During Treatment Period

As this is an Integrative TCM and Western medicine hospital, our approach to the Covid-19 virus, was to utilize both types of medicine. The Western medicine route offered oral antiviral drugs such as Tamiflu* and Arbidol. The critically ill patients were given supportive therapy. IV fluids were strictly monitored. If they were still able to eat, we generally did not administer fluids, as we felt they were getting enough. From the Chinese medical perspective, we had to make a differential diagnosis before prescribing herbs. {see addendum at the end of this for specific formulas] Integrative therapy seemed like it would provide better results. Furthermore, this provided the rare opportunity to fully embrace the essence of the Shang Han Lun. I knew then that my understanding of Covid-19 was deepening, and that it would leave a lasting impression on me. 

Most patients received the oral antiviral medications, oseltamivir* (Tamiflu) and umifenovir (Arbidol). Some also required IV fluids.

Throughout the entire treatment process, regardless of which formula was used, Ma Huang (Herba Ephedrae) was found to be an essential adjunct to treatment. Initially, there was a great deal of dispute regarding the use of Ma Huang (Herba Ephedrae), but those debates were quickly put to rest when we saw how effective it was.

When Covid-19 started around mid-January, I began to receive many calls daily from patients. While my colleagues and I analyzed their x-rays, we did not pay too much attention to the gravity of the illness, until we were actively working with patients.

What I noticed was that while many patients were experiencing symptomatic relief, their CT scans were showing the progression of the disease. It showed the worsening of lung conditions as the white area in the scan continued to show expansion. Surprisingly, the patients’ sleep, appetite, energy level, etc. were, by and large, improving. At first, I was baffled and tried to explore possible explanations for this phenomenon. 

Initially, there was a great deal of dispute regarding the use of Ma Huang (Herba Ephedrae), but those debates were quickly put to rest when we saw how effective it was.

What my patients reported was that once they expectorated the sputum, their respiration felt much more open. This was especially the case for patients with a dry cough, for the 30 patients I was overseeing. They all experienced the same thing: difficult inhalation, but normal exhalation. So, with that in mind, I insisted on using Ma Huang (Herba Ephedrae) for all my patients from that time forward.

Throughout the entire treatment period from February 4 through February 20, most of the critically ill patients became mild cases and most mild cases were released out of the hospital with this integrative approach to care. From this, we learned that Ma Huang (Herba Ephedrae) was pivotal in achieving exceptional results for these 30 patients.

Following this experience, I now highly recommend the use of Chinese herbs to treat Covid-19, in all of its stages. Though the use of herbs is non-invasive with relatively mild side effects, it is not only effective to treat mild and mid-stages of this illness, it can also help prevent patients from moving into the more critical stages of this disease. However, I cannot stress the importance of achieving accurate diagnosis and regularly updated herbal prescriptions for the particular stage of illness. 

On The Importance of Continuing “Phlegm Transforming” Herbs Throughout the Course of Treatment

I also recognized a similar pattern among all my patients. All the patients had a worsening of symptoms around 1/31, the last one being 2/2. Most patients had their CT scans on 2/2 or 2/3. What I discovered was that on 2/8, the CT results all appeared to be more severe.

• However, despite CT results being more severe on 2/8, the patients’ subjective symptoms were all improving

• 3/2- 3/12-13, all patients’ CT results showed absorption

• I concluded that the peak of Covid-19 is roughly at days 7-8, which coincides with the presentation of other types of viral pneumonia.

I asked many experts about why patients improve before their CT scans show improvement. Many of them agree that the CT results seem to improve after the patients’ subjective feeling is better. Hence, I conclude that the CT results lag behind patient presentation.

My personal feeling is that even though the patient experiences relief from cough, fever, nausea, etc, the retained phlegm in the lungs has not been addressed. Most patients present with high fever so most doctors would focus on reducing the fever without addressing the phlegm.

Furthermore, my ward primarily used TCM treatment, whereas others may strictly use Western medicine. I noticed that some patients, when admitted, had very few symptoms. However, after 3-4 days, they would start to develop dyspnea and respiratory obstruction. After discovering this pattern, I urged my colleagues to start using phlegm eliminating herbs even before the patient starts to show symptoms. Five of the herbs that I used the most were Zi Su Zi (Fructus Perillae), Jie Zi (Semen Sinapis), Jiang Can (Bombyx Batryticatus), Cang Zhu (Rhizoma Atractylodis) and finally Ma Huang (Herba Ephedrae). Ma Huang (Herba Ephedrae) was something that I used throughout the entire course of the treatment. It’s a key herb that must NOT be left out. Most of our patients were using Ma Huang (Herba Ephedrae) from February 8 - 20.

[Ma Huang aka Herba Ephedra, is not currently reliably obtainable in the U.S. due to abuses in purported weight loss and body building products in the 1990’s, although there are a handful of Chinese (and possibly Korean-- in Fort Lee, NJ, in Flushing, Queens, in Koreatown, LA) herbal pharmacies who have successfully requested exemption from the ban.]

This group of patients, especially the 15 who were released on 2/25 showed complete absorption without leaving a trace.

After discovering this pattern, I urged my colleagues to start using “Phlegm Transforming” herbs even before the patient start to show symptoms. 

On 2/18, I read a pathology report about Covid-19, and one doctor pointed out that fibrosis develops in the lung, mucus secretions, pulmonary edema, hyaline membrane formation, and more. My understanding is that there is a presence of these secretion or mucus, and it is what we consider to be damp-phlegm in Chinese medicine. So, what we learned is that it is vital for recovery to dispel this phlegm in order to avoid further complications and burden on the lungs. 

Ma Huang (Herba Ephedrae) Dosage and Formulas

Some of you may ask what dose of Ma Huang (Herba Ephedrae) is most appropriate. To be honest, I was not very confident about the dosing at first. My colleague suggested using around 10 grams of Ma Huang (Herba Ephedrae), 15-20 grams of Gui Zhi (Ramulus Cinnamomi), 15-20 grams of Ku Xing Ren (Semen Armeniacae Amarum) and 10 grams of Gan Cao (Radix et Rhizoma Glycyrrhizae).

Before prescribing Ma Huang Tang (Ephedra Decoction) and Ma Huang Fu Zi Xi Xin Tang (Ephedra, Asarum, and Prepared Aconite Decoction) to the patients, we doctors drank these formulas for 3 full days first. What I noticed is that even though these formulas normally dispel the exterior by inducing sweating, neither I nor my colleagues had any sweating after we drank the formula. We used up to 30g of Ma Huang (Herba Ephedrae) and 45g of Gui Zhi (Ramulus Cinnamomi). The three of us did not experience any sweating nor did we notice any discomfort or side effects. Therefore, we decided to use the same formulas on our patients. 

[Asarum, like Ephedra, is not available in the U.S. unless, I suppose, you are growing your own.]

The (Potential) Significance of Ma Huang (Herba Ephedrae) In This Epidemic

In my opinion, the two greatest benefits of Ma Huang (Herba Ephedrae) for treatment of this epidemic are: FIRST - it opens the ENTIRE chest cavity; SECOND - it opens the water passageway up above the lungs, by increasing urine output, leading to the dissipating accumulated fluids and dampness from the Lungs. Case after case, I saw patients increase urine output, without experiencing thirst. Furthermore, they expressed feeling lighter and more energetic. Hence, I gained much more confidence in prescribing Ma Huang (Herba Ephedrae) as time went on. 

Case after case, I saw patients increase urine output, without experiencing thirst. They reported feeling lighter and more energetic. In time, I gained much more confidence in prescribing Ma Huang (Herba Ephedrae). 

Out of the 30 patients, only 4 were elderly and critically ill. For those who averaged over 60 years of age, I would add some Dang Shen (Radix Codonopsis) and Huang Qi (Radix Astragali) to their formula. For the rest of the patients, I didn’t add tonics. All patients seemed to respond well to the Ma Huang (Herba Ephedrae) based formulas. 

Thank you for reading about my thoughts, observations, and process in regard to these 30 Covid-19 patients."

Edited down and wordsmithed a tiny bit (mostly to remove some of the more outlandish TCM way of thinking) from the original by Chen Juan, Huang Di, Wang Shi Qi, Cai Xiang Compiled and Translated by John K. Chen, Pharm.D., PhD., OMD, LAc

* They used what they had, did what they knew, surely, at the time, but it has since been pretty much agreed that Tamiflu (ostalmevir) has little to no activity against this Covid-19 (aka Sars-CoV-2) virus. Similarly, some clinical guidelines now warn against giving IV fluids because of potential problems down the road. For me, it’s even more fascinating to imagine a potential role for ephedra here, as its recognized actions in Traditional Chinese Medicine are not only to “ventilate” the lungs but also to address upper body edema by promoting urination. (Tested in school, we had to memorize that Ma Huang entered the Lung and Urinary Bladder “meridians,”) and that it was "acrid, warm and slightly bitter." For the former indication, it is traditionally combined with dried ginger root (Gan Jiang) and asarum (Xi Xin); for the latter, white atractylodis rhizome (Bai Zhu), but also more commonly within a larger six to twelve ingredient formula. There are exceptions to this range, however, as one might expect. The Qing Fei Pai Du San formula I am keeping in my fridge, just because, you know, you never know, contains 21 different herbs: Ephedra, cinnamon twig, Tuckahoe fungus, fresh ginger, asarum, pogostemi (aka patchouli!), licorice root, alismata rhizome, bupleurum root, lycopi (whole plant), dioscorea rhizome, apricot pit kernel, polyporus fungus, scute root, coltsfoot flower, aurantus fruit, gypsum, atractylodis rhizome, pinellia rhizome, belamcandae rhizome, aged citrus peel.

Mike Barr, a long ago Poz Senior Contributing Editor and founding member of and scribe for the Treatment Action Group (TAG), is a functional medicine practitioner, acupuncturist and herbalist in NYC. Reach out to him here.