中医临床病证 哮病

中医临床病证哮病第1页/共99页ContentsTerminologyEtiologyMechanismManifestationTCMDiagnosisDifferentiationTherapyTCMFormulaeOthers

病名病因病机症候四诊辨证治则方药其他第2页/共99页Terminology

病名第3页/共99页医说2000年前内经针灸资生经1180年

医学正传1224年丹溪心法1481年

1515年第4页/共99页01.《内经∙素问∙阴阳别论篇》提到“喘鸣”。古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。

Ifyindominatesinteriorlyandyangintrudesexteriorlyexteriorly,thesoulsweatingfailstobestoredandthedisordersdevelopsalloverthebody,startingwithlungdamagedwhichwillleadtowheezingwithstridor.主第5页/共99页02.南宋嘉定(1220)王执中《针灸资生经》最早提出“哮喘”之名。

古文：因与人治哮喘，只缪（刺）肺腧，不缪他穴。

AcupointFeishumorethanothersisneedledtotreatasthma.03.南宋张杲《医说∙卷四》提到“齁喘”。古文：因食盐虾过多，遂得齁喘之疾。

Takingtoomuchsaltyfishwillleadtoasthmaduetofish(Houchuan).第6页/共99页第7页/共99页04.元朱丹溪首创“哮喘”病名，《丹溪心法》设独立篇名《哮喘十四》；另设《喘十五》；自此喘与哮分别叙述。

It’sthefirsttimetogivename“asthma”tothisdisorderusedasthetitleofonechapterandthentodiscusswheezingsyndromeanddyspneasyndromeseparately.第8页/共99页06.明朝秦景明在《症因脉治•卷二哮病论》提出“哮病”之病名。古文：哮病内伤痰饮，外感风寒，合而成。

英文：Wheezingsyndromeiscausedbybothinteriorphlegm-retentionandexteriorwind-cold.第9页/共99页第10页/共99页05.明虞抟《医学正传∙哮喘》区别哮与喘。古文：哮以声响言，喘以气息言。

Wediagnoseasthmaespeciallyfromit’ssound,anddiagnosegaspingfromit’sbreath.第11页/共99页Terminology喘：panting喘鸣：stridor喘证：gaspingsyndrome哮证：wheezingsyndrome哮喘：asthma第12页/共99页Etiology病因第13页/共99页01《内经∙素问∙阴阳别论篇》认识到内外因素影响脏功能(尤其是肺)是哮病的主要病机。古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。Ifyindominatesinteriorlyandyangintrudesexteriorly,thesoulsweatingfailstobestoredandthedisordersdevelopsalloverthebody,startingwithlungdamagedandleadingtostridorandwheezing.第14页/共99页02《内经·素问·太阴阳明论》提出外(风)邪致哮说。古文：犯贼风虚邪者，

…阳受之则入六腑…

入六腑则身热，不时卧，上为喘呼。Itproposedthetheorythatexogenousevilcancausetheillness,“Whenthebodyisinfectedbyoccultevilwind,…yangsixFU-organsareaffectedifyangisinvolved,…thenthepatienthasafeverandfailstosleepflat,leadingtowhoopingupward.第15页/共99页03《黄帝内经·灵枢·邪气藏府病形》提出外感“寒邪”之认识。古文：两寒相感，中外皆伤，故气逆而上。

Whentwokindsofcoldmeet,bothinteriorandexteriorofthebodyareimpaired,resultinginqiascendingreversely.

第16页/共99页04元朱丹溪《丹溪心法·喘十五》述及情志、饮食、体弱等多种病因。古文：六淫七情之所感伤，饱食动作，脏气不和，呼吸之息，不得宣畅而为喘急。亦有脾肾俱虚，体弱之人，皆能发喘。Damagedbysixclimaticexopathogensandsevenemotionsaswellasactionafterfullstomach,thevisceralqiwillbedisharmonizedresultinginobstructiverespirationandrapidgasping.Anybodywhosespleenandkidneyaredeficientcandevelopgaspingsyndrome.第17页/共99页04:Damagedbysixclimaticexopathogensandsevenemotionsaswellasactionafterfullstomach,thevisceralqiwillbedisharmonizedresultinginobstructiverespirationandrapidgasping.Anybodywhosespleenandkidneyaredeficientcandevelopgaspingsyndrome.第18页/共99页05明秦景明《症因脉治∙喘》指出体虚之病因。古文：气虚喘逆之因，或本元素虚，或大病后，大劳后，失于调养，元气大伤。Thecauseofwheezingconverselywithqideficiencyisduetofailureofrecoveryleadingtodamagingprimordialqiafterseverediseaseorexhaustion.第19页/共99页病因总结winddietcoldmotionmorbidoverstrain第20页/共99页2000年前中国古代医学对于哮喘的病因记载已经相当完整第21页/共99页2000年前《内经·素问·太阴阳明论》提出风邪致哮说:犯贼风虚邪者,阳受之则入六腑,入六腑则身热，不时卧，上为喘呼。1938年西方撰此词古希腊医学认为此病与风相关。相似何其乃尔第22页/共99页Mechanism病机第23页/共99页01《黄帝内经·灵枢·本藏第四十七》最早提到肺与本病的特殊关系古文：肺高则上气肩息咳。Ifthelungisinsuperiorposition,thepatientwillgaspandcoughwithraisedshoulder.

第24页/共99页02《黄帝内经•素问•至真要大论篇第七十四》提出水饮之内因可上犯于肺引发本病。古文：饮发于中，咳喘有声。Whenthefluidretentionoccursinsidethebody,itwillcausecoughandwheezingwithstridor.第25页/共99页03隋巢元方550-630在《诸病源候论卷十四·咳嗽病诸候》最早指出痰饮与本病的关系。古文：其胸膈痰饮多者，嗽则气动于痰，上搏喉咽之间，痰气相击，随嗽动息，呼呷有声，谓之呷嗽。Ifthereistoomuchphlegmabovethediaphragminthechest,theqivibratesupwardwiththephlegminthethroatwhenthephlegmandqistrugglemutuallyworseningwiththecoughingandwheezing,accompaniedbythesound,whichiscalledasXiasou(stridor).第26页/共99页

Ifthereistoomuchphlegm

abovethediaphragminthechest,theqivibratesupwardwiththephlegminthethroatwhenthephlegmandqistrugglemutuallyworseningwiththecoughingandwheezing,accompaniedbythesound,whichiscalledasxiasou(stridor).第27页/共99页04东汉张仲景在《金匮要略∙痰饮咳嗽病脉证治第十二》中，将哮证归为“伏饮”证。古文：膈上病痰，满喘咳吐，发则寒热，背痛腰疼，目泣自出，其人振振身膶剧，必有伏饮。Withdiseasedphlegmabovediaphragm,thepatientwillhaveheavypantingwithcoughandvomiting,andthendevelopfever,lowerbackache,spontaneoustearingandbodyshiveringduringattack,whichisrootedinconcealedfluidretentioninsidebody.第28页/共99页哮病的三饮

水饮-痰饮-伏饮水电解质失衡免疫反应第29页/共99页05明戴思恭1324-1405《秘传证治要诀及类方•哮喘》明确提出本病的“宿根”之说。古文：喘气之病，哮吼如水鸡之声，牵引胸背，气不得息，坐卧不安。此为嗽而气喘，或宿有此根，遇寒暄则发，一时暴感。Thediseaseofgaspingsyndromeiswhoopingwithfrog-likesoundandraisingthechestandshouldersleadingtodyspneaandfailingtositandsleep.Itischaracterizedbycoughaccompaniedbygaspingorfundamentalillnesswhichwillrecurincaseofcoldparoxysmally.第30页/共99页06清李用粹《正治汇补∙哮病》全面阐明哮病病机。古文：哮即痰喘之久而常发者，因内有壅塞之气，外有非时之感，膈有胶固之痰，三者相合闭拒气道，搏击有声，发为哮病。Itsummedupthethreelinksofasthma:“Asthmaislong-termwheezingwithphlegmhavingfrequentrecurrencebecausethereisinteriorqiobstruction,inductionofexogenousfactorsandtenaciousphlegmabovethediaphragm,threeofwhichmeettogethertoobstructairway,fightingmutuallywithstridor,calledasasthma.第31页/共99页太复杂失去中医特色

第32页/共99页MechanismTrilogyinducedfactorsFluidretentionPhlegmr.

RootConcealedr.

第33页/共99页Manifestation症候第34页/共99页01巢元芳《诸病源候论•卷之十四•气病诸侯》最早描述“水鸡之鸣”，犹如西医之喉鸣。古文：肺病令人上气，兼胸膈痰满，气行壅滞,喘息不调,致咽喉有声,如水鸡之鸣也。

Lungdiseasemakesqiascendwithchestfullofphlegmandqistagnation,causingabnormalbreathingandnoisysoundinthethroatlikethesoundoffrog.第35页/共99页02《黄帝内经•素问•逆调论篇第三十四》已经记载本病的端坐呼吸。古文：不得卧而息有音。Thepatientcan’tsleepflatandwheezingwithstridor.第36页/共99页03《黄帝内经•灵枢•五阅五使第三十七》已经提到呼吸衰竭时出现的鼻翼扇动。古文：肺病者，喘息鼻张。Apersonwiththepulmonarydiseasewillwheezewithnasalflaring.第37页/共99页04明李中梓1588-1655在《医宗必读•卷九》(1637成)记载呼气性呼吸困难之表现。古文：哮者与喘相类，但不似喘开口出气之多，而有呀呷之音。Asthmaandwheezingaresimilar，butasthmadoesnotbreatheasmuchaswheezing，andhaveit’ssoundlike“yaxia”第38页/共99页第39页/共99页第40页/共99页古代中医早已完整记载哮喘的临床表现第41页/共99页TCMDiagnosis四诊第42页/共99页（一）望诊01唐朝王焘670-755在《外台秘要卷九•久咳坐卧不得方》（752年撰成）准确描述哮证大作症候。古文：久患气嗽，发时奔喘，坐卧不得，并喉里呀声，气欲绝。Itrecordstheparoxysmalmanifestationsofseverewheezinganddyspneasyndrome:“Thepatientwithlong-termcoughingandwheezinghasheavywheezing,failstositandsleepwithstridorinthethroatandevenandisgoingtobesuffocatedduetodyspnea.第43页/共99页02明王肯堂1549-1613《证治准绳∙喘》描述哮证发作症候，与西医呼衰表现一致。古文：喘者，促促气急，喝喝息数，张口抬肩，摇身撷肚。Thepatientwithasthmaisoutofbreath,wheezingrapidlywithstridor,openingmouthandshruggingshoulder,aswellasshakingbodyandabdomengoingforward.第44页/共99页第45页/共99页03清汪宏在《望诊遵经•卷二诊唇气色条目》(撰于1875年)述及哮喘之望诊。古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。Ifthepatienthasblackstasis,bulgingeyesandupwardbreathing,asthmawouldbediagnosed.第46页/共99页03清汪宏在《望诊遵经•卷二诊唇气色条目》(撰于1875年)述及哮喘之望诊。古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。Ifthepatienthasbluishcolortothelips,bulgingeyesandupwardbreathing,asthmawouldbediagnosed.第47页/共99页风寒犯肺症状:主证加咳痰稀白,表寒证,口不渴。舌象:舌淡苔薄白而滑第48页/共99页痰热遏肺症状：主证加咳嗽痰黄稠，咽干，口渴喜冷饮，尿赤，便结或发热。舌脉：舌红苔黄腻第49页/共99页（二）问诊03清何梦瑶在《医碥·喘哮》指出哮与饮食的关系。古文：得之食味酸咸太过，幼时多食盐醋，往往成此疾，俗谓之盐哮。Wheezingsyndromeiscausedbytoomuchacidandsaltinthedietduringchildhood,itisreferredtosaltywheezingsyndrome.第50页/共99页（二）问诊04南宋张杲撰在《医说·卷四》(1224刊)记载“鱼腥哮

fish-asthma”。古文：因食盐虾过多，遂得齁喘之疾。Takingtoomuchsaltyfishwillleadtoasthmaduetofish(Houchuan).第51页/共99页（二）问诊05南宋许叔微1079-1154在《普济本事方•卷一》（撰于1132年）中已经认识到本证具有遗传性。古文：此病有苦而至终身者，亦有母子相传者。

Thepatientcansufferfromthisallhislifewhichcanalsobeinheritedfrommothertoson.第52页/共99页（三）闻诊06明朝虞抟1438-1517在《医学正传•卷之二•哮喘》（撰于1515年）提出“哮”与“喘”之别古文：夫喘促喉中如水鸡声者，谓之哮；气促而连属不能以息者，谓之喘。

Itiscalledasthmaforthepatientiswheezingwithfrog-likesoundinthethroatanditiscalledgaspingsyndromeforthepatientispantingwithacceleratedandpantingrespiration.第53页/共99页（四）切诊07《黄帝内经•素问•通评虚实篇第二十八》中首次提到用脉象判断哮病的预后古文：乳子中风热，喘鸣肩息者，脉实大也。缓则生，急着死。TheInfantilepatientsufferingfromwheezingsyndromewithstridorandraisedshoulderhasalargeandexcesspulse.Hewillliveonwithrelaxedpulsebutdiewithswiftpulse.第54页/共99页Manifestations喉鸣一般呼吸衰竭gaspingfeverorthopneawheezingcoughraisedshoulderwhoopingpantingNasalflareXiasouExpiratoryd.Shivering齁喘bruiseliptearingstridordyspneabulgingeyes第55页/共99页（四）切诊08唐王焘《外台秘要∙上气喉中水鸡鸣方》记载脉诊诊断本病。古文：脉浮咳逆，咽喉中水鸡鸣，喘息不通，呼吸欲死。Thepatienthasfloatingpulse,badcoughandupwellingqiwithfrog-likesoundsinthethroat,gaspingbecauseofobstructionofairwaysandevenfeelingtodie.第56页/共99页TCMDifferentiation辨证第57页/共99页01明虞抟1438-1517《医学正传∙哮喘》(1515年成）提出“哮”与“喘”之别古文：大抵哮以声响名，喘以气息言。Wediagnoseasthmaespciallyfromit’ssound,anddiagnosewheesingfromit’sbreath.第58页/共99页02元朝朱丹溪1281-1358《丹溪心法·卷二·哮喘十五》提出虚实辨证。古文：实喘气实肺盛，虚喘由肾虚。Theexcessivewheezingsyndromeduetoexcessivelungqianddeficienctwheezingsyndromeduetokidneydeficiency.肺盛肾虚第59页/共99页03明张景岳《景岳全书·杂证》归纳虚实两证。古文：实喘者有邪，邪气实也；

虚喘者无邪，元气虚也。Excessivegaspingsyndromehasevilqiinwhichevilqiisexcessiveanddeficientgaspingsyndromehasnoevilinwhichvitalqiisdeficient.第60页/共99页05清林佩琴《类证治裁卷之二∙哮症论治》提出哮喘有冷哮、热哮两大证候。古文：遇风寒而发者为冷哮为实，伤暑热而哮者为热哮为虚，其盐哮、酒哮、糖哮，皆虚哮也……。Coldasthmaistheexcessiveonecausedbycoldwindwhilethehotasthmaistheefficientcausedbysummerheatandasthmainducedbysalt,wineandsugararealldeficientone.第61页/共99页06明王肯堂在《证治准绳·第二册·诸气门··哮》(撰于1608年)中对寒哮作进一步辨证。古文：哮喘遇冷则发者有二证∶其一属中外皆寒，……。其二属寒包热，……。

译文：Wheezingsyndromeinducedbycoldhastwosubtypes:Onebelongstocoldwheezingsyndromewithbothinteriorandexteriorcold,theotherbelongstotheonewithexteriorcoldwrappingheat.第62页/共99页实证虚证实喘气实肺盛虚喘由肾虚实喘者有邪虚喘者无邪新病多实久病多虚遇风寒而发者暑热而哮者冷哮热哮哮病虚实辨证-明清佳第63页/共99页TreatmentPrincipal治则第64页/共99页01元朝朱丹溪（1281-1358）在《丹溪心法∙卷二∙哮喘十五》提出治疗“已发”与“未发”之别。古文：凡久喘之症，未发宜扶正气为主，已发用攻邪为主。Forthepatientwithlong-termdisease,vitalqihastobestrengthenedforpre-paroxysmswhileevilqihastobeeliminatedforparoxysm.

第65页/共99页02明张景岳《景岳全书∙杂证谟∙卷之十九明集•喘促》仔细分析哮证的治疗方法。古文：扶正气者，须辩阴阳，阴虚者补其阴，阳虚者补其阳。攻邪气者，须分微甚，或散其风，或温其寒，或清其痰火。Theyin-yangdifferentiationhastobemadeinthecaseofstrengtheningvitalQi,forwhichyinhastobereplenishedfortheyin-deficientwhileyanghastobereplenishedfortheyang-deficient.Thecarefuldifferentiationhastobemadeinthecaseofeliminatingevil,inwhichthewindhastobedispelled,thecoldbewarmedorthefirebecleared.第66页/共99页Theyin-yangdifferentiationhastobemadeinthecaseofstrengtheningvitalQi,forwhichyinhastobereplenishedfortheyin-deficientwhileyanghastobereplenishedfortheyang-deficient.Thecarefuldifferentiationhastobemadeinthecaseofeliminatingevil,inwhichthewindhastobedispelled,thecoldbewarmedorthefirebecleared.第67页/共99页03元朱丹溪(1281-1358)《丹溪心法·哮喘十四》之治法为后世所宗。古文：哮喘必用薄滋味，专主于痰，宜大吐。Theplainfoodmustberecommendedtothepatientwithasthma,forwhomtheemeticagentsisusedtoresolvethephlegmspecifically.第68页/共99页04清林佩琴《类证治裁卷二∙哮症论治》(撰于1773年)提出外感内伤两种治法。古文：喘由外感者治肺，内伤者治肾。Gaspingsyndromecausedbyexogenousfactorshouldbetreatedwithfocusingonlung,whilebyinternaldamage,onkidney.第69页/共99页PrincipleofTreatment凡久喘之症,未发宜扶正气为主,已发用攻邪为主。扶正气者,须辩阴阳,阴虚者补其阴,阳虚者补其阳。攻邪气者,须分微甚,或散其风,或温其寒,或清其痰火。喘由外感者治肺,内伤者治肾。大凡治哮病,宜忌燥药:亦不宜纯用凉药。第70页/共99页PrincipleofTreatment(背诵)Forthepatientwithlong-termdisease,vitalqihastobestrengthenedforpre-paroxysmswhileevilqihastobeeliminatedforparoxysm.

扶正气者,须辩阴阳,阴虚者补其阴,阳虚者补其阳。攻邪气者,须分微甚,或散其风,或温其寒,或清其痰火。喘由外感者治肺,内伤者治肾。大凡治哮病,宜忌燥药:亦不宜纯用凉药。第71页/共99页TCMFormulae方药第72页/共99页（一）发作期：治寒哮01张仲景《金匮要略·肺痿肺痈咳嗽上气病脉证并治第七》(撰于3世纪初)记载的射干麻黄汤为治疗哮病(寒哮大作)的祖方。古文：咳而上气，喉中水鸡声，射干麻黄汤主之。Ifthepatienthascoughwithupwellingqiandstridorafrog-likesoundinthroat,SheganMahuangdecoctionshouldbeusedasmainformula.第73页/共99页（一）发作期：治寒哮02东汉张仲景在《伤寒论·卷第三·辨太阳病脉证并治中第六》提出以小青龙汤治喘。古文：伤寒，心下有水气，咳而微喘，发热不渴。……小青龙汤主之。Ifthereispathogenicwaterfluidbelowheart,coughandlittlegaspingandfeverwithoutthirstyduetodamagedcold,MinorBlueDragonDecoctionisused.第74页/共99页（一）发作期：治寒哮03东汉张仲景在《伤寒论》中记载治喘之方。古文：喘家作，桂枝加厚朴杏子佳。

Whenthepatienthasanattackofwheezingwiththisprevioushistory,itisbettertogivehimGuizhiplusHoupuandXingzi.第75页/共99页（二）发作期：治热哮01明龚廷贤在《寿世保元·卷三·哮吼》用千金定喘汤治热哮。古文：千金定喘汤治哮吼如神。QianjinDingchuandecoctioniseffectiveinthetreatmentofwheezingwithstirdor.第76页/共99页（二）发作期：治热哮02清林佩琴在《类证治裁卷二∙哮症论治》(撰于1773)中提出治热哮之方。古文：热哮当暑月火盛痰喘者，桑白皮汤，或白虎汤加芩、枳、瓜蒌霜。Whenwheezingsyndromeattacksinsummerwithexuberantfireandphlegm-gasping,SangbaipiDecoctionorBaihuDecoctionplusPowderofBaicalSkullcap,OrangeFruit,andSnakegourdFruitisused.第77页/共99页（二）发作期：治热哮03清吴瑭《温病条辨∙寒湿》麻杏石甘汤治疗热饮。古文：喘咳患促，吐稀涎，脉洪效，右大于左，喉哑，是为热饮，麻杏石甘汤主之Ifthepatienthascoughandwheezingwiththinsalivaandhoarsevoice,whosepulseisrapidlysurgingwiththerightbiggerthantheleft,thediseaseisduetoheatfluidwhichshouldbetreatedwithMahuangXingrenGancao.第78页/共99页（三）缓解期01张仲景在《金匮要略∙肺痿肺痈咳嗽上气病脉证并治第七》（撰于3世纪初）记载麦门冬汤。古文：大逆上气，咽喉不利，止逆下气，麦门冬汤主之。Whenqiisascendingreverselyandthethroatisconstricted,Maimendongdecoctionisusedtocontrolreverseqi.第79页/共99页（四）喘脱01唐王焘670-755在《外台秘要》(撰于752年)用人参之治喘脱。古文：“疗咳上气，喘息便欲绝，以人参末之，日五次。Totreatcoughandupwardqisoastoresolvewheezingandgasping,ginsengpowdercouldbeusedfivetimesaday.第80页/共99页方药小结寒哮大发祖方射干麻黄汤寒哮微喘小青龙汤喘作桂枝加厚朴杏子热哮千金定喘汤热饮麻杏石甘汤缓解期麦门冬汤MinorBlueDragonDecoction第81页/共99页Acupuncture&Moxibustion针灸第82页/共99页（一）实证：宜针。01南宋王执中《针灸资生经》(撰于1180-1195)古文：凡有哮喘者，为按肺俞，无不酸痛，皆为缪刺肺俞，令灸而愈。Anypatientwithwheezingsyndromefeelsachewhenpressingacupointoffeishu,whichiscontraypunctureonFeishuandcouldbecuredwithmoxibustiononit.(CanonofPromotingHealthwithAcupunctureandMoxibustion).第83页/共99页（一）实证：宜针。02明杨继洲1522-1619《针灸大成》(1601)古文：哮吼嗽喘：俞府、天突、膻中、肺俞、三里、中脘(主要)WheezingSyndromewithcroup:Shufu,Tiantu,Danzhong,Feishu,SanliandZhongwanareused.第84页/共99页（二）虚证：宜灸01明朝高武《针灸聚英》（刊于1529年）古文：喘，灸中府、云门、天府、华盖、肺俞。Moxibustionisappliedinacupointsofzhongfu,yunmen,tianfu,huagaiandfeishuareselectedtotreatgaspingsyndrome.第85页/共99页总结第86页/共99页了解第87页/共99页DiagnosticTerms喘证：gaspingsyndrome哮证：wheezingsyndrome哮喘：asthma掌握第88页/共99页MechanismTrilogyinducedfactorsFluidretentionPhlegmr.

RootConcealedr.

第89页/共99页Manifestations喉鸣一般呼吸衰竭gaspingfeverorthopneawheezingcoughraisedshoulderwhoopingpantingNasalflareXiasouExpiratoryd.Shiveringstridorbruiseliptearingdyspneabulgingeyes掌握第90页/共99页方药小结寒哮大发祖方射干麻黄汤寒哮微喘MinorBlueDragonDecoction喘作桂枝加厚朴杏子热哮千金定喘汤热饮麻杏石甘汤缓解期麦门冬汤第91页/共99页病案分析

杨某，男，20岁，工人。常发作性喉间哮鸣气急6年，入夏即发。最近哮喘又作，喘息抬肩，喉中痰鸣如锯，不能平卧，痰黄粘稠，咳吐不利，口渴喜冷饮，胸闷、心悸，疲乏无力，舌红，两侧糜烂，舌苔薄白，脉象细数。第92页/共99页CaseBriefMr.Yang,20-year-old,worker,hasparoxysmalwheezingwithstridorandshortnessofbreath