Hindawi Evidence-Based Complementary and Alternative Medicine Volume 2021, Article ID 5565562, 21 pages https://doi.org/10.1155/2021/5565562

Research Article The Clinical Efficiency and the Mechanism of Sanzi Yangqin Decoction for Chronic Obstructive Pulmonary Disease

Mengqi Wang ,1,2 Wenwen Gu ,2 Fuguang Kui ,2 Fan Gao ,2 Yuji Niu ,2 Wenwen Li ,2 Yaru Zhang ,2 Lijuan Guo ,2 Shengnan Geng ,1 and Gangjun Du 1,2

1School of Pharmacy and Chemical Engineering, Zhengzhou University of Industry Technology, Xinzheng, Henan Province 451150, China 2Institute of Pharmacy, Pharmaceutical College of Henan University, Jinming District, Kaifeng, Henan Province 475004, China

Correspondence should be addressed to Shengnan Geng; [email protected] and Gangjun Du; [email protected]

Received 21 January 2021; Revised 24 April 2021; Accepted 27 May 2021; Published 11 June 2021

Academic Editor: Xue-Rui Wang

Copyright © 2021 Mengqi Wang et al. .is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

.is work is carried out to evaluate the clinical efficacy of Sanzi Yangqin decoction (SZYQD) treating chronic obstructive pulmonary disease (COPD) and to analyze its mechanism. .e clinical efficacy of SZYQD treating COPD was evaluated by meta- analysis, and its mechanism was analyzed by network pharmacology. Molecular docking validation of the main active compounds and the core targets was performed by AutoDock vina software. A cigarette smoke (CS) and LPS-induced COPD model in ICR mice was constructed to confirm the effects of luteolin on COPD. Results showed that SZYQD has a greater benefit on the total effect (OR � 3.85, 95% CI [3.07, 4.83], P � 1) in the trial group compared with the control group. .e percentage of forced expiratory volume in one second (FEV1%) (MD � 0.5, 95% CI [0.41, 0.59], P < 0.00001) and first seconds breathing volume percentage of forced vital capacity (FEV1%/FVC) were improved (MD � 5.97, 95% CI [3.23, 8.71], P < 0.00001). .ere are 27 compounds in SZYQD targeting 104 disease targets related to COPD. PPI network analysis indicated that EGFR, MMP9, PTGS2, MMP2, APP, and ERBB2 may be the core targets for the treatment of COPD. Molecular docking demonstrated that luteolin in SZYQD showed the strongest binding activity to core targets. Experimental results revealed that the expression of COPD-related targets in lung tissue was significantly increased in the COPD group and was improved in the luteolin group. Our data indicated that SZYQD has a curative effect on COPD and luteolin is a candidate compound for COPD treatment by regulating EGFR, MMP9, PTGS2, MMP2, APP, and ERBB2.

1. Introduction Despite vast improvements in the treatment of COPD, patients still suffer from cough with sputum production, Chronic obstructive pulmonary disease (COPD), caused dyspnea, wheezing, and chest tightness. .erefore, seeking mainly by cigarette smoking, is characterized by chronic other effective treatments has always remained a continuing airway inflammation and persistent airflow limitation and is problem for COPD. the fourth leading cause of death in the world [1]. A recent Traditional Chinese Medicine (TCM) has defended study identified that there are about 100 million patients Chinese people’s health for thousands of years ago. TCM with COPD in China, which not only have a heavy social and plays a significant role in remodeling the airway and re- economic burden but also seriously affect their quality of life ducing airway hyperresponsiveness in COPD [6]. Among [2]. .e treatment of COPD has made enormous progress in them, Sanzi Yangqin decoction (SZYQD) is a commonly the past. Inhalation of long-acting bronchodilators or glu- used multiherb TCM with a satisfactory efficacy, such as cocorticoids is the primary treatment for COPD, which has antitussive, expectorant, and antiasthmatic [7]. .is formula been confirmed to have beneficial effects in reducing ex- was first described in Han’s Medicine .eory, which is acerbation rates and boosting health conditions [3–5]. composed of white mustard, radish, and perilla seed [8–10]. 2 Evidence-Based Complementary and Alternative Medicine

White mustard seed is the dry mature seed of Sinapis alba 2.3. Data Extraction. Two independent reviewers searched L. of the cruciferous plant. It has the pharmacological effects the literature according to the titles and abstracts and the of antitussive, expectorant, antiasthmatic, anti-inflamma- established strategy, then extracted data from the included tory, and analgesic effects [11, 12]. It is commonly used in studies, performed duplicate checking, and compared the the treatment of pneumonia and bronchial asthma [13]. results carefully. Disagreements were resolved by a third Radish seed is the dry mature seed of Raphanus sativus L., investigator to avoid bias. .e name of the first author and which contains alkaloids, glucosinolates, isothiocyanates, year of publication were extracted for identification in our flavonoids, volatile oil, fatty oil, protein, polysaccharides, etc. analysis. [14]. It has the effect of eliminating bloating, reducing Qi, and resolving phlegm [15]. Perilla seed is the dry ripe fruit of 2.4. Quality Assessment. We assessed the quality of the Perilla frutescens L. Britt. Its leaves, stems, and fruits can be literature according to the Cochrane Collaboration’s Bias used as medicine. It has the function of reducing gas and risk assessment tool. .e main assessment areas are as eliminating phlegm, relieving asthma, and moistening the follows: random sequence generation, allocation conceal- intestines [16]. However, its efficacy has not been com- ment, the blinding method for patients/researchers and prehensively and systematically evaluated. .erefore, this outcomes assessors, incomplete outcome data, selective paper will use meta-analysis to evaluate the efficacy of reporting, and other sources of bias. .e results were judged SZYQD on COPD through the study of a large number of as “low risk”, “high risk”, and “unclear”. clinical data. Currently, network pharmacology analysis has been widely used to evaluate the interactions between proteins and molecules in biological systems to study the 2.5. Screening of Active Compounds and Targets. .e main mechanisms of TCM [17, 18], which provides a new and chemical compounds of white mustard, radish, and perilla powerful method for these multitarget drugs. .e combi- seed in SZYQD were retrieved from TCM Systems Phar- nation of classical pharmacology and systems pharmacology macology Database (TCMSP, https://tcmspw. com/ analysis may provide a better strategy for identifying new tcmspsearch.php) [19], which were mainly filtered by inte- therapeutic uses and mechanisms for TCM. .erefore, this grating oral bioavailability (OB) > 30% and drug-likeness study will also perform network pharmacology and animal (DL) > 0.15. .e targets of the active compounds in SZYQD experiments to elucidate the mechanism of SZYQD on were obtained from the TCMSP database, PubChem database COPD. A workflow of the study is summarized as shown in (https://pubchem.ncbi.nlm.nih.gov/), and STITCH (http:// Figure 1. stitch.embl.de/) [20]. GeneCards Database (https://www. genecards.org/) and .erapeutic Target Database (TTD, 2. Materials and Methods https://db.idrblab.org/ttd/) were used to collect the thera- peutic targets related to COPD. COPD-related targets and 2.1. Literature Search. We systematically searched the drug targets were mapped in Venny 2.1.0 to select the Cochrane Library, PubMed, Web of Science, Embase, and common targets. In order to explicit the interaction between CNKI from 2005 to 2020 for eligible articles and included the potential disease targets of SZYQD, the PPI networks were them in the meta-analysis. .e keywords that were used constructed from STRING [21] (https://string-db.org/). .e are as follows: Sanzi Yangqin tang, Sanzi Yangqin de- limited species was “Homo sapiens”, and the minimum coction, SZYQD, chronic obstructive pulmonary disease, confidence score was ≥0.700. .e core targets were screen and COPD. Besides, we also performed other searches and with the network analyzer plugin in Cytoscape 3.7.2. checked reference lists of relevant reviews and eligible randomized controlled trials to ensure a comprehensive 2.6. Gene Ontology and KEGG Pathway Enrichment. In search. order to elucidate the action mechanisms of SZYQD on COPD, DAVID 6.8 (https://david.ncifcrf.gov/) [22] was used to analyze GO biological processes and KEGG path- 2.2. Inclusion and Exclusion Criteria. .e inclusion criteria ways. GO biological processes and KEGG pathways with P were as follows: (1) randomized, clinical trial; (2) control value < 0.05 and Count >7 were employed. Gene set en- group for routine western medicine treatment and experi- richment analyses were performed by using the OmicShare mental group for SZYQD based on other medicines or tools (http://www.omicshare.com/tools/), which visualized SZYQD alone; (3) basis of disease diagnosis being no- the enrichment analysis results. menclature and diagnostic criteria for COPD; (4) clinical efficacy, lung function index of FEV1% and FEV1%/FVC, and blood gas analysis index of the PaO2 and PaCO2 as 2.7. Network Construction and Analysis. To facilitate the outcome indicators; and (5) conforming to the ethical and visualization of multiple-target effects of SZYQD and COPD moral treatment standard. Meanwhile, exclusion criteria interrelation, compound-target, disease-target-compound, include the following: (1) nonrandomized trials; (2) ex- and compound-target-pathway networks were constructed periments on animals; (3) review; (4) no clear diagnostic by Cytoscape 3.7.2. In these networks, we used nodes to criteria or not meeting inclusion criteria; (5) lack of required stand for the components, compounds, targets, and diseases, data for meta-analysis; (6) the sample size being less than 40; and the edges between the two nodes represented their and (7) no complete evaluation of efficacy. interaction. Evidence-Based Complementary and Alternative Medicine 3

Compound-target-disease network

Core targets Compound-target network Sanzi Yangqin decoction TCMSP Common targets database

SWITCH Genecards Target of active Disease All compounds OB and DL PubChem COPD-related TTD Active compounds compounds relating screening database targets database

COPD

LPS

Clinical efficacy GO analysis Compound-target-pathway network Molecular docking Experimental validation Mata-analysis (Autodock vina) Figure 1: .e flow chart of this whole analysis for this study.

2.8. Molecular Docking Verification. Molecular docking was Zhangzhongjing Pharmacy (Zhengzhou, China). Ix53 carried out between the top 6-degree value of active com- inverted fluorescence microscope and Cx31 upright mi- pounds in the disease-compound-target network and the top croscope were purchased from OLYMPUS company, Japan. 6-degree value of the target genes in the PPI network. .e G: BOX multifunctional gel imaging system was purchased mol2 format structure files of chemical compounds were from Syngene, UK. .e animal respiratory metabolic obtained from the TCMSP database, and the crystal struc- measurement system was obtained from Sable Systems tures of core targets from the RCSB Protein Data Bank (PDB, International, United States. http://www.pdb.org/) were collected. .e processed crystal structures of core targets and structures of active compounds were imported into AutoDock vina software [23] for mo- 2.10. Animals. Seven-week-old female ICR mice were ob- lecular docking. tained from Henan Provincial Medical Laboratory Animal Center. All mice were housed in individually ventilated cages (lights on 7: 00 AM to 7: 00 PM). Animals were fed standard 2.9. Materials. Antibodies against α-SMA (1 :1000), TGF-β1 rodent chow and water. All animal procedures were ap- (1 :1000), EGBB2 (1 :1000), MMP2 (1 :1000), MMP9 (1 :1000), proved by the Animal Experimentation Ethics Committee of PTGS2 (1 :1000), APP (1 : 500), EGFR (1 :1000), and β-actin (1 : Henan University (permission number HUSAM 2016-288), 1000), as well as HRP goat anti-mouse antibody (1 :10000) and and all procedures were performed in strict accordance with FITC goat anti-mouse antibody (1 :1000), were obtained from the Guide for the Care and Use of Laboratory Animals and BD Pharmingen. Sanhua cigarette was provided by Hunan the Regulation of Animal Protection Committee to mini- Tobacco (Changsha, China). LPS (lipopolysaccharide) was mize suffering and injury. Animals were euthanized via purchased from Sigma Chemical Co. (St. Louis, MO, United carbon dioxide overdose based on experimental need. States). Reactive Oxygen Species Assay Kit (ROS, DCFH-DA) Standard rodent chow was purchased from Henan Pro- and DAPI were obtained from Beijing Solarbio Technology vincial Medical Laboratory Animal Center (Zhengzhou, Co., Ltd. (Beijing, China). Mice quantitative ELISA kits, IL-6 China), under License No. SCXK (YU) 2015–0005, Certif- (M6000 B) and TGF-β(MB100 B), were obtained from R&D icate No. 41000100002406. Systems (Minnesota, USA). Luteolin (purity > 98% via HPLC, batch number: L107328) was purchased from Lianshuo Biotechnology Co., 2.11. CS and LPS-Induced COPD Model. .e animals were Ltd. (Shanghai, China). Dexamethasone Tablets (75 mg/ divided into six groups (n � 10/group): group one, control tablet, batch number: 191067) were purchased from group; group two, CS + LPS group; group three, CS + LPS/ 4 Evidence-Based Complementary and Alternative Medicine dexamethasone group (positive control; 1 mg/kg body effect models were used. Funnel plots were used to identify weight); and groups four to six, CS + LPS/luteolin group (5, potential publication bias. .e data were statistically ana- 10, 20 mg/kg body weight). .e COPD mice model was lyzed using GraphPad Prism, Version 5.0 (San Diego, CA, established where mice received an intraperitoneal injection USA), and presented as the mean ± SD. .e differences of LPS (750 ng/kg solved in 50 μL saline) once weekly for 6 between the two groups were evaluated using a t-test. A P weeks. .e next day after LPS injection, the mice were value of less than 0.05 was considered statistically significant. exposed to cigarette smoke (2 cigarettes each hour, 1 hour each time, twice a day, and 6 days per week) in a whole-body 3. Results exposure system (30 cm × 40 cm × 60 cm’s chamber) for 6 weeks. Following the first LPS injection, treated mice re- 3.1. Search Results and Quality Assessment. .e search ceived therapeutic drugs via intragastric administration once process is shown in Figure 2. All databases generated 112 daily for 6 weeks. Food and water were provided ad libitum potentially relevant studies in the initial search. Among during the study. .e health of the mice was monitored them, 77 studies were excluded due to irrelevant content or daily, and body weights were measured weekly. Lung not up to inclusion criteria after reading the titles and ab- function was analyzed weekly by tidal volume using the stracts. 35 studies were subsequently selected for the final animal respiratory metabolic measurement system. One analysis. A total of 3730 patients from 35 included studies week after the last CS exposure, mice were sacrificed under containing 1847 control groups and 1883 treatment groups anesthesia with pentobarbital sodium (90 mg/kg), and a part were included in this meta-analysis. .e detailed data of each lung was preserved in 10% buffered formalin and extracted from these included articles are listed in Table 1. routinely embedded in paraffin. Lung sections were stained Quality assessment of 35 available studies was performed by with hematoxylin and eosin (H&E), and the pathological using the Risk Assessment Tool of the Cochrane Library. .e score was determined as previously reported [24]. risk of inclusion literature is shown in Figure 3.

2.12. Broncho Alveolar Lavage Fluid (BALF) Collection and 3.2. Clinical Efficacy, Lung Function, and Blood Gas Analysis. Analysis. .e BALF collection was carried out as described All 35 studies, including a total of 3730 patients, reported the [25]. Briefly, 1 mL 1 × PBS was injected and withdrawn total effect of SZYQD on COPD. Due to the low hetero- intratracheally three times. .e centrifuged inflammatory geneity (I2 � 0%), we used a fixed-effect model to analyze the cells (white cells, neutrophils, and lymphocytes) in collected results. Compared with the control group, the clinical BALF were resuspended and counted via a hemocytometer. symptoms in COPD patients were improved (OR � 3.85, .e supernatants were kept at −80°C before the evaluation of 95% CI [3.07, 4.83], P � 1, Figure 4(a)) in the trial group. 11 IL-6, TGF-β cytokines, and ROS using ELISA kits following of the 35 trials used FEV1% to evaluate the effect of SZYQD the manufacturer’s specification. in COPD patients. A random-effect model was used to analyze the results. .e effect size of the 11 trials showed that SZYQD could significantly improve the FEV1% (MD � 0.5, 2.13. Immunofluorescence Staining. Lung tissue sections 2 were treated with blocked with 5% BSA for 30 min at room 95% CI [0.41, 0.59], P < 0.00001, I � 96%, Figure 4(b)). 15 of temperature and incubated with anti-EGBB2, anti-MMP2, the 35 trials used the FEV1%/FVC to assess the improve- anti-MMP9, anti-PTGS2, anti-APP, anti-EGFR, and sec- ment in lung function. .e effect size of the six trials showed that SZYQD could significantly improve the FEV1%/FVC ondary antibody (FITC goat anti-mouse IgG). .en, the 2 sections were fixed with antifluorescence quencher, ob- (MD � 5.97, 95% CI [3.23, 8.71], P < 0.00001, I � 99%, served, and photographed under the fluorescence micro- Figure 4(c)). PaO2 and PaCO2 were used to assess the improvement of blood gas, and a random-effect model was scope. Fluorescence intensity was quantified using ImageJ 2 software (NIH, Bethesda, MD, USA). used to analyze the results (I � 91%, 93%). .e meta- analysis showed that compared with the control group, PaO2 was heightened (MD � 6.37, 95% CI [2.38, 10.36], 2.14. Western Blot Analysis. Proteins were extracted and P < 0.00001, Figure 4(d)), but PaCO2 was decreased separated via 12% sodium dodecyl sulfate-polyacrylamide (MD � −1.78, 95% CI [−2.68, −0.89], P < 0.00001, gel electrophoresis, electroblotted onto nitrocellulose Figure 4(e)) in the trial group. membranes, and probed with antibodies against α-SMA, TGF-β1, EGBB2, MMP2, MMP9, PTGS2, APP, EGFR, and β-actin. Band density was quantified using ImageJ software 3.3. Publication Bias. Funnel plots were made to evaluate and normalized to the corresponding control group. publication bias. .e result indicated that there is no clear bias in the total effect (Figure 4(f)). 2.15. Statistical Analyses. Statistical analyses in the meta- analysis were performed using RevMan 5.3. .e SMD and 3.4. Screening of Active Compounds and Targets in Sanzi corresponding 95% CI were calculated to evaluate the effect Yangqin Decoction. .e compounds of white mustard, of SZYQD on COPD. .e heterogeneity was calculated radish, and perilla seed in SZYQD were retrieved from using I2 statistics. If high heterogeneity (I2 > 50%) was ob- TcmSPTM. According to the standard of OB ≥ 30%, served, random-effect models were applied; otherwise, fixed- DL > 0.15. A total of 27 active compounds were obtained for Evidence-Based Complementary and Alternative Medicine 5

Records identified through database searching Additional records identified from the Cochrane Library, PubMed, Web of through other sources (N = 0) Science, Embase, and CNKI (N = 112) Identification

Records identified through database searching (N = 112)

49 records excluded Not relevant (N = 5) Screening Records screened (N = 112) Studies out of the topic (N = 11) The sample size is less than 40 (N = 33)

28 records excluded Multiple publication (N = 5) Full-text articles No full-text (N = 6) Eligibility assessed for eligibility Not RCT (N = 9) (N = 63) Efficacy evaluation is incomplete (N = 8)

Studies included in quantitative synthesis N Included ( = 35)

Figure 2: Flow diagram of the study selection process. Search strategy and flow chart of the screened, excluded, and analyzed articles.

SZYQD, including three compounds in white mustard seed, 3.6. Network Analysis. Compound-target network (C-T six compounds in radish seed, and eighteen compounds in network) was constructed via Cytoscape 3.7.2. .e nodes perilla seed (shown in Supplementary File 1). We performed represent compounds and targets. .e edges represent their target fishing on the 27 active compounds based on data- interactions (Figure 8(a)). .e C-T network embodies 604 bases and collected 1019 drug targets, among which there nodes and 2650 interaction relationships. To explore the were 203 in white mustard seed, 290 in radish seed, and 526 relationships between COPD, their associated targets, and in perilla seed (shown in Supplementary File 2). 290 COPD- the corresponding compounds, we further established a related targets were found in different databases, 599 drug disease-target-compound network (D-T-C network). As targets and 290 COPD-related targets were mapped in shown in Figure 8(b), the D-T-C network consists of 138 Venny 2.1.0, and 104 common targets were obtained (Fig- nodes and 632 interaction relationships, and the degree ure 5). PPI network data were imported into Cytoscape 3.7.2, value of active compounds was analyzed (shown in Sup- which covered 71 nodes and 316 interaction lines, and the plementary File 1). Sinoacutine, exceparl M-OL, phthalic average degree value was 12.9 (Figure 6(a)). 6 core targets, acid, butyl isohexyl ester, luteolin, beta-sitosterol, and including EGFR, MMP9, PTGS2, MMP2, APP, and ERBB2, stigmasterol may be the main active compounds of SZYQD. were selected according to the descending order of degree To further characterize the molecular mechanism of SZYQD value (Figure 6(b)). .ese targets were associated with the on COPD, a compound-target-pathway network (C-T-P development of COPD and its complications. network) was performed based on active compounds, tar- gets, and their corresponding signal pathways. .erefore, 35 signal pathways were selected in the treatment of COPD by 3.5. GO and KEGG Enrichment Analysis. 104 predicted SZYQD, constructing the C-T-P network (Figure 8(c)). .ey targets were mapped to the DAVID database to systemat- interact with 190 nodes and 512 interaction relationships. ically analyze their GO and KEGG pathway enrichment. 37 GO biological processes and 35 KEGG pathways were ob- tained. GO biological processes showed that these predicted 3.7. Active Compounds and Core TargetsDocking Verification. targets have a very strong correlation with physiological .e crystal structures of EGFR (5y9t), MMP9 (5th9), MMP2 mechanisms, such as serotonin receptor signaling pathway, (3ayu), APP (3ktm), ERBB2 (3wlw), and PTGS2 (5kir) were protein autophosphorylation, positive regulation of MAP obtained from the RCSB Protein Data Bank (PDB). .e kinase activity, and release of sequestered calcium ion into crystal structure of each protein was selected based on the the cytosol. .e main pathways were the cancer pathway, best resolution available. .e active compounds of SZYQD, calcium signaling pathway, PI3K-Akt signaling pathway, such as sinoacutine, exceparl M-OL, phthalic acid, butyl and Ras signaling pathway. Besides, GO biological processes isohexyl ester, luteolin, beta-sitosterol, and stigmasterol, and the KEGG pathway visualized the enrichment analysis were docked with the targets of EGFR, MMP9, PTGS2, results via the OmicShare tools (Figures 7(a) and 7(b)). MMP2, APP, and ERBB2. .e results showed that 6 Evidence-Based Complementary and Alternative Medicine

Table 1: .e characteristics of all included studies. Drug Author and reference Year Total sample Control/treatment Period of treatment (days) Evaluation standard CT Cui et al. [26] 2017 100 50/50 7 d 1 2 ① Deng and Ceng [27] 2017 102 51/51 — 1 2 ① Deng and Tan [28] 2020 80 40/40 84 d 1 2 ①②③ Gong and Shen [29] 2014 88 44/44 14 d 1 2 ①④ He et al. [30] 2018 94 47/47 10 d 1 2 ①②③ Huang [31] 2019 94 47/47 14 d 1 2 ①②③ Hui [32] 2019 90 45/45 7 d 1 2 ①③ Lai et al. [33] 2017 80 40/40 14 d 1 2 ① Li [34] 2014 88 44/44 14 d 1 2 ① Li et al. [35] 2019 180 90/90 7 d 1 2 ①③ Li [36] 2020 97 48/49 12 d 1 2 ① Li et al. [37] 2013 112 56/56 28 d 1 2 ①③ Li et al. [38] 2018 150 75/75 15 d 1 2 ① Liu [39] 2015 84 42/42 — 1 2 ① Liu [40] 2019 80 40/40 12 d 1 2 ① Lu and Wang [41] 2018 160 80/80 30 d 1 2 ①④⑤ Lu [42] 2019 80 40/40 14 d 1 2 ①②③ Lv et al. [43] 2011 100 50/50 14 d 1 2 ① Pang [44] 2019 82 41/41 7 d 1 2 ① Tian et al. [45] 2005 99 49/50 30 d 1 2 ① Wang [46] 2019 96 48/48 90 d 1 2 ①②③ Wang et al. [47] 2020 84 42/42 14d 1 2 ①②③⑤ Wu [48] 2018 252 126/126 — 1 2 ① Xu [49] 2020 80 40/40 14 d 1 2 ① Yan [50] 2018 80 40/40 15 d 1 2 ①④⑤ Yang [51] 2011 160 72/88 14 d 1 2 ① Yang and Shi [52] 2014 86 40/46 14 d 1 2 ①②③④⑤ Yang [53] 2020 80 40/40 90 d 1 2 ①③ Yuan et al. [54] 2014 127 63/64 14 d 1 2 ①②③ Zhang [55] 2016 100 50/50 15 d 1 2 ①②③ Zhang [56] 2011 80 40/40 30 d 1 2 ① Zhang et al. [57] 2013 120 62/58 7 d 1 2 ①④⑤ Zhang [14] 2018 80 38/42 7 d 1 2 ① Zhang and Fang [58] 2006 85 37/48 28 d 1 2 ①②③ Zhou and Huang [59] 2017 160 80/80 30 d 1 2 ② Note. 1: routine western medicine treatment (including oxygen absorption, anti-infection, phlegm reduction, bronchial dilator, and glucocorticoid.); 2: Sanzi Yangqin decoction based on other medicine or Sanzi Yangqin decoction alone. ① Clinical efficacy. ② FEV1%. ③ FEV1%/FVC. ④ PaO2. ⑤ PaCO2. sinoacutine, exceparl M-OL, phthalic acid, butyl isohexyl dexamethasone and luteolin group (tidal volume in the lung ester, luteolin, beta-sitosterol, and stigmasterol had a good function decreased more than 20% among mice). .e CS binding ability with EGFR, MMP9, PTGS2, MMP2, APP, and LPS group exhibited enlarged alveolar space and thinner and ERBB2 (docking score > 4.25) (Table 2). In particular, alveolar septum and destroyed alveolar wall compared with luteolin showed the strongest binding activity with EGFR, the control group. However, luteolin treatment dose-de- MMP9, PTGS2, MMP2, APP, and ERBB2 (docking pendently alleviated CS and LPS-induced lung pathologic score > 7). Next, a pharmacology experiment was designed changes compared with CS and LPS group (Figures 10(b)– to validate the effect of luteolin on COPD induced by CS and 10(d)). LPS. PyMol software was used to display the interaction of the ligand with the receptor-binding site. Beta-sitosterol and EGFR, exceparl M-OL and MMP2, luteolin and MMP9, and 3.9. Effects of Luteolin on Inflammatory Cells, Cytokine Levels, sinoacutine and APP were selected for visualization with and ROS in BALF of Mice with COPD. To evaluate the effects PyMol software (Figure 9). of luteolin on inflammatory cells, cytokine levels, and ROS in BALF, the percentage of inflammatory cells (white blood cells, neutrophils, and lymphocytes), concentrations of cy- 3.8. Effects of Luteolin on Lung Function and Alveolar Ar- tokines (IL-6, TGF-β), and ROS were detected. As shown in chitecture in Mice with COPD. .e tidal volume (TV) was Figures 11(a)–11(c), the percentage of white blood cells, used for detecting lung function. As shown in Figure 10(a), neutrophils, and lymphocytes and the concentration of IL-6 tidal volume was significantly decreased in the CS and LPS and TGF-β (Figures 11(d) and 11(e)) in the BALF were group compared with the control group but increased in significantly increased in CS and LPS group compared with Evidence-Based Complementary and Alternative Medicine 7

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

0255075 100 (%)

Low risk of bias

Unclear risk of bias

High risk of bias

(a) ZHOU RW 2017 RW ZHOU 2006 SJ ZHANG 2018 QB ZHANG MIN 2013 ZHANG LJ 2011 ZHANG 2016 JING ZHANG YF 2014 YUAN ZX 2020 YUAN XL 2014 YANG SQ 2011 YANG BZ 2018 YAN XU JN 2020 2018 WU NAN FU 2020 WANG CH 2019 WANG 2009 QING TIANG YF 2019 PANG 2011 YM LV ZM 2019 LV CX 2018 LU LIU XS 2019 2015 LIU MQ 2018 LI TAO LI SQ 2013 2020 LI SHUANG 2019 LI QUAN LI GH 2014 LAI YU 2017 HUI SZ 2019 WEI 2019 HUANG HE ML 2018 PQ 2014 GONG XJ 2020 DENG 2017 QF DENG CUI CF 2017

+ ? ? ? ? ? ? ? + ? ? ? + ? ? ? ? ? ? ? + ? ? ? ? ? ? ? + + ? ? ? ? ? Random sequence generation (selection bias)

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? + ? ? Allocation concealment (selection bias)

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Blinding of participants personnel (performance bias)

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Blinding of outcome assessment (detection bias)

+ ? ? ? ? + ? ? ? ? ? ? ? ? + + + + ? + + + + ? ? + ? + ? ? + + ? + + Incomplete outcome data (attrition bias)

? ? ? + ? ? ? ? + ? ? ? ? ? ? + ? + + + ? ? ? + ? ? ? ? + + + ? ? + ? Selective reporting (reporting bias)

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? + ? ? ? ? ? ? ? ? ? + ? ? Other bias

(b)

Figure 3: Quality assessment of 35 available studies. (a) Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies. (b) Risk of bias summary: review authors’ judgments about each risk of bias item for each included study. the control group. However, treatment with luteolin sig- growth factor (TGF)-β is a well-known fibrogenic mediator nificantly decreased the percentage of white blood cells, involved in COPD. .e expression of α-SMA and TGF-β1 in neutrophils, and lymphocytes and the concentration of IL-6 the lung was determined by western blot (Figures 12(a) and and TGF-β in the BALF compared with CS and LPS group. 12(b)). Elevated expression of α-SMA and TGF-β1 was In addition, ROS was also significantly increased in the CS observed in the CS and LPS group compared to the controls. and LPS group compared with the control group but de- However, the administration of luteolin markedly inhibited creased in the luteolin group (Figure 11(f)). the expression of α-SMA and TGF-β1 in the luteolin group compared with CS and LPS group.

3.10. Effects of Luteolin on the Expressions of α-SMA and TGF- β1 in Mice with COPD. Resident lung fibroblasts are acti- 3.11. Effects of Luteolin on COPD-Related Targets. vated in chronic airway inflammation, accompanied by Western blot analyses were performed to evaluate COPD- increased expression of α-smooth muscle actin (α-SMA), related targets (EGFR, MMP9, PTGS2, MMP2, APP, and leading to irreversible airflow limitation. Transforming ERBB2) involved in the therapeutic effects of luteolin on 8 Evidence-Based Complementary and Alternative Medicine

Experimental Control Weight Odds ratio Odds ratio Experimental Control Weight Mean difference Mean difference Study or subgroup Study or subgroup Events Total Events Total (%) M-H, fixed, 95% CI M-H, fixed, 95% CI Mean SD Total Mean SD Total (%) IV, random, 95% CI IV, random, 95% CI CUI CF 2017 49 50 42 50 1.0 9.33 [1.12, 77.70] DENG XJ 2020 3.72 1.12 40 2.19 0.78 40 3.6 1.53 [1.11, 1.95] DENG CF 2017 50 51 42 51 1.0 10.71 [1.30, 88.05] HE ML 2018 2.29 0.58 47 1.6 0.33 47 9.2 0.69 [0.60, 0.88] DENG XJ 2020 39 40 31 40 0.9 11.32 [1.36, 94.25] HUANG WEI 2019 1.89 0.06 47 1.64 0.02 48 15.1 0.25 [0.23, 0.27] GONG PQ 2014 41 44 35 44 2.8 3.51 [0.88, 14.00] LU ZM 2019 4.09 0.69 40 3.64 0.15 40 8.2 0.63 [0.41, 0.85] HE ML 2018 44 47 35 47 2.7 4.48 [1.16, 17.29] WANG CH 2019 1.65 0.61 48 1.49 0.55 48 7.7 0.16[−0.07, 0.39] HUANG WEI 2019 45 47 39 47 1.9 4.62 [0.92, 23.04] WANG FU 2020 2.39 1.78 42 2.04 1.72 42 1.4 0.35 [–0.40, 1.10] HUI SZ 2019 42 45 38 45 2.9 2.58 [0.62, 40.69] YANG ZX 2020 2.9 0.4 40 2.3 0.5 40 8.9 0.60 [0.40, 0.80] LAI YU 2017 36 40 26 40 3.0 4.85 [1.43, 16.42] YUAN YF 2014 1.84 0.42 65 1.59 0.41 63 11.1 0.25 [0.11, 0.39] LI GH 2014 41 44 35 44 2.8 3.51 [0.88, 14.00] ZHANG JING 2016 1.62 0.4 50 0.35 0.39 50 10.6 1.27 [1.12, 1.42] LI QUAN 2019 81 90 70 90 0.1 2.57 [1.10, 6.01] ZHANG SJ 2006 1.86 0.47 48 1.62 0.45 37 9.0 0.24 [0.04, 0.44] LI SHUANG 2020 45 50 39 60 4.5 2.54 [0.81, 7.94] ZHOU RW 2017 1.89 0.06 80 1.64 0.02 80 15.1 0.25 [0.24, 0.26] LI SQ 2013 47 49 41 48 2.0 4.01 [0.79,20.40] LI TAO 2018 53 58 44 56 2.7 4.82 [1.28,18.16] Total (95% CI) 547 533 100.0 0.50 [0.41, 0.59] LIU MQ 2015 70 75 58 75 4.3 4.75 [1.67, 13.52] LIU XS 2019 40 42 34 42 1.9 4.71 [0.94, 23.67] 2 2 f P I2 LU CX 2018 78 80 74 80 2.1 3.15 [0.62, 16.17] Heterogeneity: tau = 0.01; chi = 243.81, d = 10 ( < 0.00001); = 96% LU ZM 2019 38 40 31 40 1.8 5.52 [1.11, 27.43] Test for overall effect Z = 10.65 (P < 0.00001) LV YM 2011 48 50 42 50 1.9 4.57 [0.92, 22.73] –1 –0.5 0 0.5 1 PANG YF 2019 40 41 35 41 1.0 6.86 [0.79, 58.76] TIANG QING 2009 46 50 38 49 3.5 3.33 [0.98, 11.30] Favours Favours WANG CH 2019 40 40 35 40 4.2 3.19 [1.04, 9.03] (experimental) (control) WANG FU 2020 42 42 39 42 0.5 7.53 [0.38, 150.47] WU NAN 2018 117 126 105 126 8.7 2.80 [1.14, 5.93] XU JN 2020 39 40 35 40 1.0 5.57 [0.82, 50.03] YAN BZ 2018 38 40 32 40 1.8 4.75 [0.94, 23.98] YANG SQ 2011 81 88 58 72 5.3 2.79 [1.06, 7.35] YANG XL 2014 42 46 30 40 3.2 3.50 [1.00, 12.22] YANG ZX 2020 39 40 32 40 0.8 9.75 [1.16, 82.11] YUAN YF 2014 61 64 51 63 2.8 4.78 [1.28, 17.89] ZHANG JING 2016 46 50 38 50 3.5 3.63 [1.08, 12.18] ZHANG LJ 2011 33 40 25 40 5.1 2.83 [1.00, 7.98] ZHANG MIN 2013 57 50 50 62 1.0 13.60 [1.72, 100.96] ZHANG QB 2018 40 42 32 39 1.8 3.75 [0.71, 19.85] ZHANG SJ 2006 46 48 35 37 1.9 1.31 [0.18, 9.80] ZHOU RW 2017 75 80 68 80 4.9 2.65 [0.89, 7.90] Total (95% CI) 1883 1847 100.0 3.85 [3.07, 4.83] Total events 1772 1493 Heterogeneity: chi2 = 11.44, df = 34 (P = 1.00); I2 = 0% Test for overall effect Z = 11.70 (P = 0.00001) 0.02 0.1 1 10 50 Favours Favours (experimental) (control) (a) (b)

Experimental Control Weight Mean difference Mean difference Experimental Control Weight Mean difference Mean difference Study or subgroup Study or subgroup Mean SD Total Mean SD Total (%) IV, random, 95% CI IV, random, 95% CI Mean SD Total Mean SD Total (%) IV, random, 95% CI IV, random, 95% CI DENG XJ 2020 89.72 1.34 40 78.13 1.67 40 7.2 11.59 [10.93, 12.25] GONG PQ 2014 76.82 12.57 44 73.59 10.9 44 17.7 3.23 [–1.69, 8.15] HE ML 2018 64.83 7.26 47 54.1 5.22 47 6.8 10.73 [8.17, 13.29] LU CX 2018 12.25 1.35 80 10.27 1.43 80 24.0 1.98 [1.55, 2.41] HUANG WEI 2019 66.26 3.41 47 60.05 2.87 46 7.1 6.21 [4.93, 7.49] YAN BZ 2018 69.75 6.37 40 61.49 6.52 40 21.5 8.26 [5.44, 11.08] HUI SZ 2019 67.6 7.6 45 61.4 8.5 45 6.5 6.20 [2.87, 9.53] YANG XL 2014 58.4 6.94 46 54.88 5.98 40 21.7 3.52 [0.79, 6.25] LI QUAN 2019 67.8 5.2 90 61.8 5.5 90 7.1 6.00 [4.44, 7.56] ZHANG MIN 2013 105.32 16.65 58 86.91 18.37 62 15.1 18.41[12.14, 24.68] LI SQ 2013 79.37 15.96 49 73.55 16.03 48 5.2 5.82 [–0.55, 12.19] Total (95% CI) 268 266 100.0 6.37 [2.38, 10.36] LU ZM 2019 78.68 15.9 40 62.39 10.26 40 5.4 16.26 [10.40, 22.12] 2 2 2 WANG CH 2019 59.46 12.92 48 55.07 11.64 48 5.9 4.39 [–0.53, 9.31] Heterogeneity: tau = 17.18; chi = 45.42, df = 4 (P < 0.00001); I = 91% –10 –5 0 5 10 WANG FU 2020 0.76 0.19 42 0.65 0.13 42 7.2 0.11 [0.04, 0.18] Test for Overall effect: Z = 3.13 (P = 0.002) YANG XL 2014 62.3 4.48 46 59.98 5.62 40 6.9 2.32[0.15, 4.49] Favours Favours YANG ZX 2020 91.4 2.2 40 82.8 2 40 7.2 8.60 [7.68, 9.52] (experimental) (control) YUAN YF 2014 64.79 9.21 65 60.92 8.53 63 6.6 3.87 [0.80, 6.94] ZHANG JING 2016 68.05 1.38 50 69.64 1.54 50 7.2 –1.59 [–2.16, –1.02] ZHANG SJ 2006 64.8 9.34 48 59.93 8.78 37 6.3 4.87 [1.00, 8.74] ZHOU RW 2017 66.26 3.41 80 60.05 2.87 80 7.2 6.21 [5.23, 7.19] Total (95% CI) 777 756 100.0 5.97 [3.23, 8.71] Heterogeneity: tau2 = 27.01; chi2 = 1890.91 df =14 (P < 0.00001); I2 = 99% Test for Overall effect: Z = 4.27 (P < 0.0001) –20 –10 0 10 20 Favours Favours (experimental) (control) (c) (d)

Experimental Control Weight Mean difference Mean difference 0 Study or subgroup Mean SD Total Mean SD Total (%) IV, random, 95% CI IV, random, 95% CI LU CX 2018 6.68 0.52 80 7.25 0.85 80 40.5 –0.57 [–0.79, –0.35] WANG FU 2020 6.81 0.42 42 8.15 0.39 42 40.9 –1.34 [1.51, –1.17] YAN BZ 2018 45.37 4.56 40 53.41 5.62 40 11.5 –5.04 [–7.28, –2.80] 0.5 YANG XL 2014 55.45 8.98 46 60.35 8.21 40 5.3 –3.90 [–7.53, –0.27] ZHANG MIN 2013 43.23 18.25 58 55.47 18.77 62 1.8 –12.24 [–18.86, –5.62] Total (95% CI) 266 264 100.0 −1.78 [−2.68, −0.89] 1 Heterogeneity: tau2 = 0.50; chi2 = 54.75, df = 4 (P < 0.00001); I2 = 93% Test for overall effect Z = 3.90 (P < 0.0001) –20 –10 0 10 20 (log[OR]) SE

Favours Favours 1.5 (experimental) (control)

2 0.02 0.1 1 10 50 OR (e) (f)

Figure 4: Sanzi Yangqin decoction has a curative effect on COPD. (a) Comparison of total effect between the experimental group and the control group for COPD. (b, c) Forest plot analyzing lung function of COPD patients with SZYQD: FEV1; FEV1/FVC%. (d, e) Forest plot analyzing blood gas of COPD patients with Sanzi Yangqin decoction: PaO2; PaCO2. (f) Funnel plot analyzing the bias of the total effect in the treatment of COPD by Sanzi Yangqin decoction.

Drug targets

COPD targets

495 104 186

Figure 5: Venn diagram of drug-disease intersection targets. .e 290 targets of COPD were mapped to the 599 targets of SZYQD to screen out the 104 common targets. Evidence-Based Complementary and Alternative Medicine 9

CTSD 9 CHRM5 9 CHRM3 9 S1PR1 10 PRKCD 10 PRKCA 10 NR3C1 10 HTR1A 10 ELANE 10 KIT 11 HTR2C 11 HTR2A 11 DRD2 11 CYP3A4 11 IGF1R 12 CHRM1 12 CCR5 12 TACR1 13 ADAM17 13 ADRB2 14 MAPK14 15 HIF1A 15 MDM2 17 KDR 17 ERBB2 19 PTGS2 20 MMP2 22 MMP9 26 APP 27 EGFR 32

0 5 1015202530 (a)

(b)

Figure 6: .e PPI network constructed by the STRING database and Cytoscape 3.7.2. (a) .e number of nodes in the protein interaction network (Top 30). (b) Core targets of Sanzi Yangqin decoction for the treatment of COPD. .e top 6 targets as SZYQD’s main therapeutic targets, such as EGFR, MMP9, PTGS2, MMP2, APP, and ERBB2, were associated with the development of COPD.

COPD. Outcomes presented showed a significant increase immunofluorescence revealed that the expression of in the expression of COPD-related targets in the CS and COPD-related targets in lung tissue was significantly LPS group compared with the control group. However, increased in the CS and LPS group compared with the luteolin treatment markedly inhibited the expression of control group, but luteolin decreased the expression of COPD-related targets compared with the CS and LPS COPD-related targets compared with the CS and LPS group (Figures 13(a) and 13(b)). Similarly, group (Figures 13(c) and 13(d)). 10 Evidence-Based Complementary and Alternative Medicine

Top 36 of pathway enrichment Top 35 of pathway enrichment

GO:0007155~cell adhesion hsa04010:MAPK signaling pathway GO:0006915~apoptotic process hsa05202:Transcriptional misregulation in cancer GO:00045944~positive regulation of transcription hsa04068:FoxO signaling pathway GO:0006508~proteolysis hsa04921:Oxytocin signaling pathway GO:0035556~intracellular signal transduction hsa04062:Chemokine signaling pathway GO:0016477~cell migration hsa05161:Hepatitis B GO:0001934~positive regulation of protein phosphorylation hsa04670:Leukocyte transendothelial migration GO:0043066~negative regulation of apoptotic process hsa04919:Tyroid hormone signaling pathway GO:0048015~phosphatidylinositol–mediated signaling hsa04810:Regulation of actin cytoskeleton GO:0008283~cell proliferation hsa04725:Cholinergic synapse Genenumber Genenumber GO:0007169~transmembrane receptor protein tyrosin hsa05231:choline metabolism in cancer GO:0030335~positive regulation of cell migration 10 hsa04270:Vascular smooth muscle contraction 10 GO:0006874~cellular calcium ion homeostasis 15 hsa04370:VEGF signaling pathway 15 GO:0001525~angiogenesis hsa05218:Melanoma GO:0007166~cell surface receptor signaling pathway 20 hsa04151:PI3K–Akt signaling pathway 20 GO:0032496~response to lipopolysaccharide 25 hsa04012:ErbB signaling pathway 25 GO:0010628~positive regulation of gene expression hsa04014:Ras signaling pathway GO:0030168~platelet activation hsa05219:Bladder cancer GO:0022617~extracellular matrix disassembly Pvalue Pvalue Pathway Pathway hsa05223:Non–small cell lung cancer GO:0070374~positive regulation of ERK1 and ERK2 cascade hsa04066:HIF–1 signaling pathway GO:0006954~inflammatory response 0.020 hsa04540:Gap junction GO:0008284~positive regulation of cell proliferation 0.0075 0.015 hsa04015:Rap1 signaling pathway GO:0007193~adenylate cyclase~inhibiting G– GO:0007187~G–protein coupled receptor signaling pathway 0.010 hsa04510:Focal adhesion 0.0050 GO:0007200~phospholipase C–activating hsa04750:Infammatory mediator regulation of TRP channels 0.005 0.0025 GO:0007268~chemical synaptic transmission hsa04071:Sphingolipid signaling pathway GO:0009636~response to toxic substance hsa04024:cAMP signaling pathway GO:0007165~signal transduction hsa05206:MicroRNAs in cancer GO:0006468~protein phosphorylation hsa05215:Prostate cancer GO:0018105~peptidyl–serine phosphorylation hsa05214:Glioma GO:0018108~peptidyl–tyrosine phosphorylation hsa05230:Central carbon metabolism in cancer GO:0051209~release of sequestered calcium ion into cytosol hsa05205:Proteoglycans in cancer GO:0043406~positive regulation of MAP kinase activity hsa05200:Pathways in cancer GO:0046777~protein autophosphorylation hsa04020:Calcium signaling pathway GO:0007210~serotonin receptor signaling pathway hsa04080:Neuroactive ligand–receptor interaction GO:0042493~response to drug hsa04726:Serotonergic synapse

0.0 0.2 0.4 0.6 0.05 0.10 0.15 0.20

Richfactor Richfactor (a) (b)

Figure 7: Gene enrichment analyses performed by DAVID and visualized by OmicShare. (a) GO biological process. .e results showed that vital targets have a very strong correlation with physiological mechanisms, such as the serotonin receptor signaling pathway, protein autophosphorylation, positive regulation of MAP kinase activity, and release of sequestered calcium ion into the cytosol. (b) KEGG enrichment analysis. .e main pathways were the cancer pathway, calcium signaling pathway, PI3K-Akt signaling pathway, and Ras signaling pathway. .e vertical axis is the pathname and the horizontal axis is the Rich Factor value. .e larger the P value, the higher the channel enrichment; the size of the point indicates the number of enriched targets; the color of the dots is red to green and the value is from small to large.

4. Discussion perspective, which has become a powerful tool in elucidating complex and holistic mechanisms of TCM [64, 65]. Hence, TCM has focused on the treatment of COPD for thousands we used network pharmacology to elucidate the mechanisms of years [60]. Large-scale clinical trials have confirmed that of multiple-target components in traditional Chinese TCM has made progress in controlling COPD [61, 62]. medicine. In this study, 27 active components of SZYQD However, a considerable number of TCM studies exhibit were screened through network pharmacology, among defects. For example, on the one hand, the clinical efficacy which 6 compounds, including beta-sitosterol, exceparl evaluation is incomplete or lacks a large amount of clinical M-OL, luteolin, phthalic acid, butyl isohexyl ester, sinoa- data support, the intervention time is limited, the sample size cutine, and stigmasterol, may be the key compounds of is small, and the indices of efficacy evaluation lack empirical SZYQD. Pharmacological studies have shown that β-sitos- validity. Considering the aforementioned problem, we terol performs anti-inflammatory activity by attenuating conducted a meta-analysis. Meta-analysis aims to increase edema in the rat model [66]. Exceparl M-OL has a certain the credibility of conclusions and solve the inconsistencies of effect on the treatment of chronic inflammatory diseases research results by increasing the sample and conducting a [18]. Luteolin effectively prevented LPS-induced changes in systematic, objective, and quantitative comprehensive blood gas parameters and histopathology, activation of analysis of multiple research results [63]. .erefore, in this neutrophils, and infiltration of white blood cells and neu- article, we selected high-quality studies published in the past trophils into the lung [67, 68]. Phthalic acid and butyl to evaluate the effects of TCM interventions on disease isohexyl ester exert protective actions against lung injury progression of COPD through meta-analysis and collected and are used to treat COPD airway hyperreactivity [19]. the current evidence on the total effect of SZYQD on COPD Sinoacutine inhibits the proliferation of lung cancer cells, in 3730 individuals from 35 studies. .e result showed that which may be related to the inhibition of PI3K/Akt and SZYQD has a curative effect on COPD. MAPK/ERK pathways [69]. Stigmasterol suppresses airway On the other hand, in a large number of TCM have inflammation by inhibiting allergen-induced immuno- complex compounds, the active compounds are not clear in globulin E-mediated responses [70]. .ese compounds have clinical and pharmacological studies, the specific targets a good correlation with the treatment of COPD. Disease- have not fully been identified, and the mechanism of action target-compound network and PPI network analysis showed has not been effectively elaborated. Network pharmacology that EGFR, MMP9, PTGS2, MMP2, APP, and ERBB2 may illustrates the intricate interactions among genes, proteins, be the core targets of SZYQD in the treatment of COPD, and metabolites related to diseases and drugs from a network which were mainly involved in cancer in the pathway, Evidence-Based Complementary and Alternative Medicine 11

Component Compound Target (a)

Disease Component Target Compound (b)

Component Target Compound Pathway (c)

Figure 8: C-Tnetwork, D-T-C network, and C-T-P network: (a) a compound-target network, and nodes represent component, compounds, and targets; (b) a disease-target-compound network, red nodes represent the drug-disease intersection targets, green nodes represent the compounds, yellow nodes represent the components, while the pink nodes represent disease, and disease is linked with compounds and targets; (c) a compound-target-pathway network, red nodes represent the drug-disease intersection targets, green nodes represent the compounds, yellow nodes represent the components, while purple nodes represent the pathways. And then, each edge symbolizes the interaction between them. 12 Evidence-Based Complementary and Alternative Medicine

Table 2: Molecular docking of main active compounds of SZYQD and core targets. Target name PDB ID Compound Energy (kcal/mol) EGFR 5y9t Beta-sitosterol −5.28 EGFR 5y9t Exceparl M-OL −5.24 EGFR 5y9t Luteolin −7.16 EGFR 5y9t Phthalic acid, butyl isohexyl ester −5.19 EGFR 5y9t Sinoacutine −5.26 EGFR 5y9t Stigmasterol −6.27 MMP9 5th9 Beta-sitosterol −5.28 MMP9 5th9 Exceparl M-OL −6.00 MMP9 5th9 Luteolin −8.4 MMP9 5th9 Phthalic acid, butyl isohexyl ester −5.84 MMP9 5th9 Sinoacutine −5.82 MMP9 5th9 Stigmasterol −6.02 MMP2 3ayu Beta-sitosterol −5.12 MMP2 3ayu Exceparl M-OL −5.48 MMP2 3ayu Luteolin −7.21 MMP2 3ayu Phthalic acid, butyl isohexyl ester −6.24 MMP2 3ayu Sinoacutine −5.82 MMP2 3ayu Stigmasterol −6.25 APP 3ktm Beta-sitosterol −5.23 APP 3ktm Exceparl M-OL −5.71 APP 3ktm Luteolin −7.00 APP 3ktm Phthalic acid, butyl isohexyl ester −5.30 APP 3ktm Sinoacutine −6.77 APP 3ktm Stigmasterol −5.34 ERBB2 3wlw Beta-sitosterol −5.87 ERBB2 3wlw Exceparl M-OL −5.53 ERBB2 3wlw Luteolin −7.10 ERBB2 3wlw Phthalic acid, butyl isohexyl ester −5.33 ERBB2 3wlw Sinoacutine −5.02 ERBB2 3wlw Stigmasterol −5.68 PTGS2 5kir Beta-sitosterol −6.12 PTGS2 5kir Exceparl M-OL −5.89 PTGS2 5kir Luteolin −7.50 PTGS2 5kir Phthalic acid, butyl isohexyl ester −5.35 PTGS2 5kir Sinoacutine −5.21 PTGS2 5kir Stigmasterol −6.82 Note. Docking scores of main active compounds of SZYQD in the disease-compound-target network and the top 6-degree value of the target genes in the PPI network. .e lower the energy of binding with receptors is, the greater the possibility of action is. calcium signaling pathway, PI3K-Akt signaling pathway, [73]. Liu et al. [74] studied that luteolin may be an effective and Ras signaling pathway. To further verify the key com- candidate for the treatment of HgCl2-induced lung injury by pounds of SZYQD treating COPD, we carried out molecular preventing NF-κB activation and activating AKT/Nrf2 docking between six compounds and the core targets, and pathway. A study also showed that luteolin attenuates the results showed that six compounds had a good binding neutrophilic oxidative stress and inflammatory arthritis by activity to these core targets. In particular, luteolin showed inhibiting Raf1 activity [68]. the strongest binding activity with EGFR, MMP9, PTGS2, Although luteolin has a broad application prospect in MMP2, APP, and ERBB2. the treatment of lung diseases, inflammation, and oxi- Luteolin, an active flavonoid compound isolated from dative stress process, there are few reports about its Lonicera japonica, is widely distributed in the plant king- treatment of COPD. .us, we used CS and LPS to establish dom. Preclinical studies have shown that this flavone pos- a COPD mice model, exploring the effects of luteolin on sesses a variety of pharmacological activities, including COPD induced by CS and LPS. Results presented a re- antioxidant, anti-inflammatory, antimicrobial, and anti- duction of tidal volume and lung injury under CS and LPS cancer activities [71]. Recently, luteolin has been found to stimulation; meanwhile, treatment with luteolin promi- alleviate bronchoconstriction and airway hyperreactivity in nently improved this condition. Additionally, we found ovalbumin sensitized mice [72]. It can also decrease in- that the increase in the number of inflammatory cells in flammatory reactions in lung tissue of treated mice [72]. A the BAL fluid after CS and LPS stimulation was signifi- study in the lipopolysaccharide (LPS) model of Ali suggested cantly attenuated by luteolin. Luteolin also reduced the that luteolin blocked the AKT/NF-κB pathway, conse- production of IL-6, TGF-β, ROS, and histological signs of quently suppressing the inflammatory mediator expression pulmonary fibrosis including such as α-SMA and TGF-β1. Evidence-Based Complementary and Alternative Medicine 13

(a) (b)

(c) (d)

Figure 9: Pattern diagram of molecular docking. (a) Beta-sitosterol and EGFR. (b) Exceparl M-OL and MMP2. (c) Luteolin and MMP9. (d) Sinoacutine and APP.

0.4

0.3 b bbbb c b b aa bb c b bb 0.2 aaa cc c b bb aaaaaa cc cc 0.1 0.10

0.05 Tidal volume (ml/min) volume Tidal 0.00 123456 123456 123456 123456 123456 123456 Week

Control CS + LPS + luteolin (5mg/kg) CS + LPS CS + LPS + luteolin (10mg/kg) CS + LPS + dexamethasone CS + LPS + luteolin (20mg/kg) (a) Figure 10: Continued. 14 Evidence-Based Complementary and Alternative Medicine

Control CS + LPS CS + LPS + CS + LPS + luteolin CS + LPS + luteolin CS + LPS + luteolin dexamethasone (5mg/kg) (10mg/kg) (20mg/kg) (b)

Control CS + LPS CS + LPS + CS + LPS + luteolin CS + LPS + luteolin CS + LPS + luteolin dexamethasone (5mg/kg) (10mg/kg) (20mg/kg) (c) 60

40 c bb bbb bbb bbb 20 lung injury area (%) area injury lung

0

CS + LPS CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) (d)

Figure 10: Effects of luteolin on lung function and alveolar architecture in mice with COPD. (a) Tidal volume (TV) in lung function. (b) .e whole lung in the naked eye. (c) HE staining of lung tissues. (d) .e area of involved lesions in HE staining. .e data presents mean ± SD (n � 7), the experiments were repeated 3 times, and statistical significance was determined by a t-test. aaP < 0.01, aaaP < 0.001 vs control; bP < 0.05, bbP < 0.01, bbbP < 0.001 vs CS + LPS group; cP < 0.05, ccP < 0.01 vs dexamethasone.

10 25 aa aaa cc

8 20 b b c bb bb 6 15 bb bbb bbb 4 10 Neutrophils (%) Neutrophils White blood cell (%) White 2 5

0 0

Control Control CS + LPS CS + LPS CS + LPS + dexamethasone CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) CS + LPS + luteolin (20mg/kg) (a) (b) Figure 11: Continued. Evidence-Based Complementary and Alternative Medicine 15

15 800 aaa cc b c aaa 600 c bb 10 b bbb bbb bb 400 bbb bbb 5 Lymphocyte (%) Lymphocyte 200 BALF IL-6 level (pg/ml) level IL-6 BALF

0 0

Control Control CS + LPS CS + LPS CS + LPS + dexamethasone CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) CS + LPS + luteolin (20mg/kg) (c) (d) 1000 90 aa 80 cc c 800 b 70 bb 60 600 bb 50 40 400 Absorption 30 200 20 level (pg/mg) β level TGF- BALF 10 0 0 450 500 550 600 Control CS + LPS Wavelength (nm) CS + LPS + dexamethasone Control CS + LPS + luteolin (5mg/kg) CS + LPS CS + LPS + luteolin (10mg/kg) CS + LPS + dexamethasone CS + LPS + luteolin (20mg/kg) CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) (e) (f)

Figure 11: Effects of luteolin on inflammatory cells, cytokine levels, and ROS in BALF of mice with COPD. (a) .e percentage of white blood cells in BALF. (b) .e percentage of neutrophil lymphocytes in BALF. (c) .e percentage of lymphocytes in BALF. (d) IL-6 level in BALF. (e) TGF-β level in BALF. (f) ROS level in BALF. Data were expressed as mean ± SD (n � 7), the experiments were repeated 3 times, and statistical significance was determined by a t-test. aaP < 0.01, aaaP < 0.001 vs control; bP < 0.05, bbP < 0.01, bbbP < 0.001 vs CS + LPS group; cP < 0.05, ccP < 0.01 vs dexamethasone.

Our study also revealed that the protein expressions of a rough direction, substantial experimental data are COPD-related targets such as EGFR, MMP9, PTGS2, necessary for verification. Luteolin is a candidate com- MMP2, APP, and ERBB2 in lung tissue were significantly pound for COPD treatment by regulating EGFR, MMP9, increased in the COPD group and were prevented in the PTGS2, MMP2, APP, and ERBB2 through a preliminary luteolin group. Although network pharmacology provides decomposition experiment. 16 Evidence-Based Complementary and Alternative Medicine

CS + LPS –+++++ 2.5 Dexamethasone (mg/kg) ––1––– 2.0 aaa aaa c Luteolin (mg/kg) – – – 5 10 20 c 1.5 c b bb bb bb bbb bbb bbb α-SMA 1.0 bbb 0.5 TGF-β1

Relative protein expression 0.0 β-Actin α-SMA TGF-β1

Control CS + LPS CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) (a) (b)

Figure 12: Effects of luteolin on the expressions of α-SMA and TGF-β1 in the lung. (a) Protein extracted from the lung was reacted with anti-α-SMA and anti-TGF-β1 by Western blot. (b) .e relative protein expressions of α-SMA and TGF-β1. .e data presents mean ± SD (n � 7), the experiments were repeated 3 times, and statistical significance was determined by a t-test. aaaP < 0.001 vs control; bP < 0.05, bbP < 0.01, bbbP < 0.001 vs CS + LPS group; cP < 0.05 vs dexamethasone.

CS + LPS –+++++ Dexamethasone (mg/kg) – –1––– Luteolin (mg/kg) – ––51020 ERBB2

MMP2

PTGS2

MMP9

EGFR

APP

β-Actin

(a) Figure 13: Continued. Evidence-Based Complementary and Alternative Medicine 17

3

aaa 2 ccc aa aa aa cc aa b cc aa cc b b c cc c b b c bb bb b b bb bb bb bbb bbb bbb bbb 1 bbb bbb bb bb Relative protein expression protein Relative

0 ERBB2 MMP2 PTGS2 MMP9 EGFR APP Control CS + LPS CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) (b) CS + LPS

Control CS + LPS Dexamethasone Luteolin (5mg/kg) Luteolin (10mg/kg) Luteolin (20mg/kg)

ERBB2

MMP2

PTGS2

MMP9

EGFR

APP

(c) Figure 13: Continued. 18 Evidence-Based Complementary and Alternative Medicine

250

aaa 200 aaa aaa aa aa aa cc cc cc cc cc cc cc bb bb c b 150 bbb bb c b c b c c b bb c bb bbbbb bbb bb bbb bbb bb bb bbb bbb bb bb 100 bb Fluorescence intensity Fluorescence

50

0 ERBB2 MMP2 PTGS2 MMP9 EGFR APP Control CS + LPS CS + LPS + dexamethasone CS + LPS + luteolin (5mg/kg) CS + LPS + luteolin (10mg/kg) CS + LPS + luteolin (20mg/kg) (d)

Figure 13: Effects of luteolin on COPD-related targets. (a) Core target-associated markers examined by western blot. (b) .e relative protein expressions of core targets. (c) Core target-associated markers examined by immunofluorescence; (d) Fluorescence intensity of core targets. Data were expressed as mean ± SD (n � 7), the experiments were repeated 3 times, and statistical significance was determined by a t-test. aaP < 0.01, aaaP < 0.001 vs control; bP < 0.05, bbP < 0.01, bbbP < 0.001 vs CS + LPS group; cP < 0.05, ccP < 0.01, cccP < 0.001 vs dexamethasone.

5. Conclusion Acknowledgments SZYQD has a curative effect on COPD, and its mechanism is .is study was supported by the Joint Foundation of the related to 27 compounds, 104 targets, and 35 pathways. National Natural Science Foundation of China and Henan Meanwhile, luteolin is a candidate compound for COPD Province of China (No. U200410711) and Henan Youth treatment by regulating EGFR, MMP9, PTGS2, MMP2, Natural Science Foundation (No. 212300410109). APP, and ERBB2. .e strategy of integrating classical pharmacology with systems pharmacology analysis has the Supplementary Materials potential to provide a better strategy for the understanding of the TCM mechanism. Supplementary File 1: information of 27 active compounds of Sanzi Yangqin decoction and degree value of corre- Data Availability sponding compounds. Supplementary File 2: a component- compound-target network of white mustard seed (A), radish All data used to support the findings of this study are in- seed (B), and perilla seed (C). .e red nodes represent the cluded within the article. targets, the green nodes represent the compounds, while the yellow nodes represent the components and those com- Conflicts of Interest pounds are linked with the corresponding targets. (Sup- plementary Materials) .e authors declare no conflicts of interest. References Authors’ Contributions [1] A. Neumeier and R. Keith, “Clinical guideline highlights for Mengqi Wang and Gangjun Du conceived and designed the the hospitalist: the GOLD and NICE guidelines for the experiments. Mengqi Wang, Wenwen Gu, Fuguang Kui, Fan management of COPD,” Journal of Hospital Medicine, vol. 15, no. 4, pp. 240-241, 2020. Gao, Yuji Niu, Wenwen Li, Yaru Zhang, Lijuan Guo, and [2] E. Birnie, H. S. Virk, J. Savelkoel et al., “Global burden of Shengnan Geng performed the experiments. Mengqi Wang, melioidosis in 2015: a systematic review and data synthesis,” Gangjun Du, and Shengnan Geng analyzed the data. Le Lancet Infectious Diseases, vol. 19, no. 8, pp. 892–902, Shengnan Geng and Gangjun Du contributed reagents/ 2019. materials/analysis tools. Mengqi Wang and Gangjun Du [3] C. Karner and C. J. Cates, “Combination inhaled steroid and wrote the paper and plotted the results. long-acting beta(2)-agonist in addition to tiotropium versus Evidence-Based Complementary and Alternative Medicine 19

tiotropium or combination alone for chronic obstructive [19] J. Ru, P. Li, J. Wang et al., “TCMSP: a database of systems pulmonary disease,” Le Cochrane Database of Systematic pharmacology for drug discovery from herbal medicines,” Reviews, vol. 3, Article ID CD008532, 2011. Journal of Cheminformatics, vol. 6, no. 1, p. 13, 2014. [4] U. Maqsood, T. N. Ho, K. Palmer et al., “Once daily long- [20] M. Kuhn, D. Szklarczyk, A. Franceschini, C. Von Mering, acting beta2-agonists and long-acting muscarinic antagonists L. J. Jensen, and P. Bork, “Stitch 3: zooming in on protein- in a combined inhaler versus placebo for chronic obstructive chemical interactions,” Nucleic Acids Research, vol. 40, pulmonary disease,” Le Cochrane Database of Systematic pp. D876–D880, 2012. Reviews, vol. 3, no. 3, Article ID CD012930, 2019. [21] D. Szklarczyk, J. H. Morris, H. Cook et al., “.e STRING [5] H. Ni, S. Moe, Z. Soe, K. T. Myint, and K. N. Viswanathan, database in 2017: quality-controlled protein-protein associ- “Combined aclidinium bromide and long-acting beta2-ago- ation networks, made broadly accessible,” Nucleic Acids Re- nist for chronic obstructive pulmonary disease (COPD),” Le search, vol. 45, no. 1, pp. D362–D368, 2017. Cochrane Database of Systematic Reviews, vol. 12, no. 12, [22] D. W. Huang, B. T. Sherman, and R. A. Lempicki, “Systematic Article ID CD011594, 2018. and integrative analysis of large gene lists using DAVID [6] S. Guo, Z. Sun, E. Liu et al., “Effect of bufei granule on stable bioinformatics resources,” Nature Protocols, vol. 4, no. 1, chronic obstructive pulmonary disease: a randomized, double pp. 44–57, 2009. blinded, placebo-controlled, and multicenter clinical study,” [23] Z. Wang, H. Sun, X. Yao et al., “Comprehensive evaluation of Journal of Traditional Chinese Medicine, vol. 34, no. 4, ten docking programs on a diverse set of protein-ligand pp. 437–444, 2014. complexes: the prediction accuracy of sampling power and [7] H. J. Fu, N. N. Qu, and C. Zhao, “A review on the treatment of scoring power,” Physical Chemistry Chemical Physics, vol. 18, respiratory diseases with Sanzi Yangqin decoction,” Chinese no. 18, pp. 12964–12975, 2016. Traditional Medicine Emergency, vol. 27, no. 1, pp. 182–185, [24] Z. Li, Y. Lin, S. Zhang et al., “Emodin regulates neutrophil 2018. phenotypes to prevent hypercoagulation and lung carcino- [8] B. M. Feng, D. Zhou, L. X. Duan et al., “A quantitative dose- genesis,” Journal of Translational Medicine, vol.17, no. 1, p. 90, effect relationship study of the antiasthmatic action of Sanzi 2019. Yangqin decoction,” Journal of Dalian University, vol. 32, [25] J. Chen, X. Yang, W. Zhang et al., “.erapeutic effects of pp. 56–58+66, 2006. resveratrol in a mouse model of LPS and cigarette smoke- [9] M. Q. Yang, N. Kong, and J. Zhang, “Advances in the induced COPD,” Inflammation, vol. 39, no. 6, pp. 1949–1959, treatment of bronchial asthma,” Xinjiang Journal of Tradi- 2016. tional Chinese Medicine Pharmacology, vol. 37, pp. 100-101, [26] C. Cui, M. Deng, and C. H. Zheng, “Clinical effect of Zhisou 2019. powder and Sanzi Yangqin decoction in the treatment of [10] L. X. Duan, Study on the Material Basis of Sanzi Yangqin children with acute bronchitis,” Shenzhen Journal of Inte- Decoction and its Flavor Medicine Raphani, Shenyang Phar- grated Traditional Chinese and Western Medicine, vol. 27, maceutical University, Shenyang, China, 2007. no. 12, pp. 52-53, 2017. [11] Z. J. Yu, Chemical Constituents and Antitussive Activity of [27] Q. F. Deng and R. Z. Ceng, “Observation on the curative effect Sinapis Alba L, Shenyang Pharmaceutical University, She- of Sanzi Yangqin decoction combined with Erchen decoction nyang, China, 2005. in the treatment of acute exacerbation of chronic obstructive [12] Z. H. Liu, J. F. Shen, Y. L. Sheng et al., “Application progress of white mustard seed in the treatment of asthma,” Health for pulmonary disease,” Journal of Practical Chinese Medicine, All, vol. 22, p. 220+294, 2018. vol. 33, no. 3, pp. 1366-1367, 2017. [13] N. Li, Y. L. Liu, M. Hua et al., “Acupoint application of [28] X. J. Deng and Y. J. Tan, “Clinical observation of Linggan Mustard Seed applying in asthmatic Guinea pigs through Wuwei Jiangxin decoction combined with Sanzi Yangqin downregulation of TGFβ/MAPK/MMPs pathway to protect decoction in the treatment of asthma-chronic obstructive airway epithelial barrier,” Chinese Archives of Traditional pulmonary disease overlap syndrome,” Chinese Community Chinese Medicine, vol. 35, no. 6, pp. 1416–1419, 2017. Physician, vol. 36, no. 16, pp. 88-89, 2020. [14] Q. B. Zhang, “.erapeutic effect of Sanzi Yangqin decoction [29] P. Q. Gong and Y. L. Shen, “Clinical observation of Jianpi- and Erchen decoction on phlegm-dampness-lung type huatanzhike decoction on acute exacerbation of chronic asthma,” Clinical Research of Traditional Chinese Medicine, obstructive pulmonary disease with syndrome of phlegm vol. 10, no. 32, pp. 17–19, 2018. accumulation in Lung,” Chinese Traditional Medicine Emer- [15] Z. H. Zhao, Y. Li, D. Q. Ji et al., “Research progress in chemical gency, vol. 23, no. 1, pp. 32-33+53, 2014. composition and pharmacological effects of raphani semen,” [30] M. L. He, Y. M. Xie, Z. G. Lu et al., “Study on the therapeutic Food and Drugs, vol. 19, no. 2, pp. 147–151, 2017. effect of Erchen decoction combined with Sanzi Yangqin [16] L. Wu, “Effects of Zisuzi decoction on expression of TNF-α, decoction on 47 patients with chronic cough of phlegm interleukin-8 and interleukin-1β in asthmatic mice,” Shanxi dampness accumulation type,” Contemporary Medicine Re- Traditional Chinese Medicine, vol. 40, no. 2, pp. 152–155, 2019. view, vol. 16, no. 18, pp. 129–131, 2018. [17] L. Huang, Q. Lv, F. Liu, T. Shi, and C. Wen, “A systems [31] W. Huang, “Clinical observation on Suzi Jiangqi decoction biology-based investigation into the pharmacological mech- and Sanzi Yangqin decoction in the treatment of acute ex- anisms of sheng-ma-bie-jia-tang acting on systemic lupus acerbation chronic obstructive pulmonary disease,” Modern erythematosus by multi-level data integration,” Scientific Distance Education of Chinese Medicine, vol. 17, no. 9, Reports, vol. 5, no. 1, p. 16401, 2015. pp. 63-64, 2019. [18] L. Wang, G.-B. Zhou, P. Liu et al., “Dissection of mechanisms [32] S. Z. Hui, “.erapeutic effect of acute exacerbation of chronic of Chinese medicinal formula Realgar-Indigo naturalis as an obstructive pulmonary disease,” China Continuing Medical effective treatment for promyelocytic leukemia,” Proceedings Education, vol. 11, no. 15, pp. 143–145, 2019. of the National Academy of Sciences, vol. 105, no. 12, [33] Y. Lai, K. Sun, X. J. Ma et al., “Clinical study of modified Sanzi pp. 4826–4831, 2008. Yangqin decoction on hypertension caused by sleep apnea 20 Evidence-Based Complementary and Alternative Medicine

hypopnea syndrome,” Hebei Journal of Traditional Chinese World Traditional Chinese Medicine, vol. 15, no. 10, Medicine, vol. 32, no. 3, pp. 19–21, 2017. pp. 1458–1461, 2020. [34] G. H. Li, “Feizhang decoction in the treatment of 44 cases of [48] N. Wu, “.erapeutic effect of Erchen decoction combined chronic obstructive pulmonary disease with acute exacerba- with Sanzi Yangqin decoction on pulmonary heart disease tion of phlegm and lung accumulation,” Zhejiang Journal of with heart failure,” Systematic Medicine, vol. 3, no. 24, Traditional Chinese Medicine, vol. 49, no. 2, p. 103, 2014. pp. 152–154, 2018. [35] Q. Li, Y. M. Du, and F. Wang, “Clinical efficacy of Kuanxiong [49] J. N. Xu, “Clinical observation of Erchen decoction combined Liqi decoction combined with Sanzi Yangqin decoction in the with Sanzi Yangqin decoction in the treatment of senile treatment of elderly patients with acute exacerbation of pneumonia,” Journal of Mathematical Medicine, vol. 33, no. 6, chronic obstructive pulmonary disease,” Chinese Journal of pp. 874–876, 2020. Gerontology, vol. 39, no. 5, pp. 1093–1095, 2019. [50] B. Z. Yan, “Clinical observation of Shenmai acupuncture [36] S. Li, “Clinical efficacy of Erchen decoction and Sanzi Yangqin combined with Sanzi Yangqin decoction in the treatment of decoction in the treatment of acute exacerbation of COPD chronic pulmonary heart disease,” Clinical Practice of Inte- (phlegm dampness obstructing lung syndrome),” Chinese grated Traditional Chinese and Western Medicine, vol. 18, Journal of Metallurgical Industry Medicine, vol. 37, no. 2, no. 2, pp. 10-11, 2018. pp. 148–150, 2020. [51] S. Q. Yang, “Observation on the therapeutic effect of Suzi [37] S. Q. Li, L. Y. Fan, S. S. Guo et al., “A study of the mechanism Jiangqi decoction and Sanzi Yangqin decoction on phlegm- of Jiangqi Huoxue therapy in the treatment of stable chronic turbidity chronic obstructive pulmonary disease,” Chinese obstructive pulmonary disease by improving airway inflam- Journal of Clinical Medicine, vol. 23, no. 3, pp. 231-232, 2011. mation,” Modern Journal of Integrated Chinese and Western [52] X. L. Yang and J. Shi, “Treatment of 46 cases of acute ex- Medicine, vol. 22, no. 22, pp. 2398–2400, 2013. acerbation of chronic obstructive pulmonary disease by [38] T. Li, S. J. Wang, and L. Gao, “Clinical analysis of Xiao- adding Erchen decoction and Sanzi Yangqin decoction,” qinglong decoction combined with Sanzi Yangqin decoction Shaanxi Traditional Chinese Medicine, vol. 35, no. 9, in the treatment of chronic bronchitis,” Journal of Modern pp. 1154-1155, 2014. Medicine and Health Research, vol. 2, no. 17, pp. 159–161, [53] Z. X. Yang, “Effect of Sanzi Yangqin decoction on TCM 2018. syndrome score and lung function in patients with bronchial [39] M. Q. Liu, “Analysis of the curative effect of Sanzi Yangqin asthma,” Shanxi Journal of Medicine, vol. 49, no. 7, decoction and Erchen decoction on asthma syndrome of pp. 866–868, 2020. phlegm dampness accumulation type,” Massage and Reha- [54] Y. F. Yuan, G. L. Jin, J. Z. Zhang, and G. D. Song, “.erapeutic bilitation Medicine, vol. 6, no. 11, pp. 76-77, 2015. effect of Sijunzi decoction and Sanzi Yangqin decoction on 65 [40] X. S. Liu, “Erchen decoction combined with Sanzi Yangqin cases of chronic obstructive pulmonary disease,” Inner decoction in the treatment of acute exacerbation of COPD,” Mongolia Journal of Traditional Chinese Medicine, vol. 33, Inner Mongolia Traditional Chinese Medicine, vol. 38, no. 7, no. 28, pp. 14-15, 2014. pp. 64-65, 2019. [55] J. Zhang, “Effect of Buzhong Na Shen Sanzi decoction on [41] C. X. Lu and D. C. Wang, “Clinical observation of Tingli remission stage of chronic obstructive pulmonary disease,” Dazao Xiefei decoction combined with Sanzi Yangqin de- Shi Zhen Chinese Medicine, vol. 27, no. 6, pp. 1434–1436, 2016. coction in the treatment of pulmonary heart disease,” [56] L. J. Zhang, “Clinical efficacy of Suzi Jiangqi decoction GuangMing Traditional Chinese Medicine, vol. 33, no. 5, combined with Sanzi Yangqin decoction in the treatment of pp. 609–611, 2018. chronic obstructive pulmonary disease,” New Chinese Med- [42] Z. M. Lu, “Analysis of the application effect of Erchen de- icine, vol. 43, no. 2, pp. 31-32, 2011. coction and Sanzi Yangqin decoction in the treatment of acute [57] M. Zhang, Y. Wu, L. L. Qi, and X. G. Zhou, “Clinical study of exacerbation of chronic obstructive pulmonary disease,” combined traditional Chinese and western medicine in the Chinese and Foreign Medical Research, vol. 17, no. 10, treatment of 58 cases with phlegm-obstructed lung syndrome pp. 71-72, 2019. during acute onset of chronic obstructive pulmonary disease,” [43] Y. M. Lv, A. Liguli, and X. H. Hu, “50 cases of acute exac- Jiangsu Journal of Traditional Chinese Medicine, vol. 45, no. 3, erbation of chronic obstructive pulmonary disease treated by pp. 28-29, 2013. Integrated Chinese and Western Medicine,” Henan Tradi- [58] S. J. Zhang and C. Q. Fang, “.erapeutic effect of Erchen tional Chinese Medicine, vol. 31, no. 11, pp. 1290-1291, 2011. decoction and Sanzi Yangqin decoction on 48 cases of chronic [44] Y. F. Pang, “Efficacy evaluation of Erchen Decoction com- obstructive pulmonary disease,” New Chinese Medicine, bined with Sanzi Yangqin decoction in ventilator-associated vol. 10, no. 10, pp. 24-25, 2006. pneumonia,” Northern Pharmacy, vol. 16, no. 6, pp. 159-160, [59] R. W. Zhou and G. Q. Huang, “Efficacy of Suzi Jiangqi de- 2019. coction combined with Sanzi Yangqin decoction in the [45] Q. Tian, B. Ding, and M. Ma, “Clinical observation on 50 cases treatment of phlegm-turbidity chronic obstructive pulmonary of COPD in stable stage treated with Yifei decoction,” Modern disease,” Sichuan Traditional Chinese Medicine, vol. 35, no. 12, Clinical Medicine, vol. 5, pp. 339-340, 2005. pp. 71–73, 2017. [46] Z. H. Wang, C. Fan, D. Li, W. Wang, and S. L. Lu, “Ob- [60] Y. Zeng, Y. Li, H. Wei et al., “.e effects and safety of Chinese servation on the curative effect of Sanzi Yangqin decoction oral herbal paste on stable chronic obstructive pulmonary combined with tiotropium bromide powder inhalation in the disease: a systematic review and meta-analysis of randomized treatment of stable COPD,” Guangxi Traditional Chinese controlled trials,” Evidence-Based Complementary and Al- Medicine, vol. 42, no. 2, pp. 14–16, 2019. ternative Medicine, vol. 2020, Article ID 5867086, 16 pages, [47] F. Wang, Q. N. Ceng, and Z. Y. Fu, “Modified Sanzi Yangqin 2020. decoction and Maxing Ganshi decoction in the treatment of [61] F.-S. Li, Y.-L. Zhang, Z. Li et al., “Randomized, double-blind, phlegm-heat obstructing lung syndrome of patients with placebo-controlled superiority trial of the Yiqigubiao pill for acute exacerbation of chronic obstructive pulmonary disease,” the treatment of patients with chronic obstructive pulmonary Evidence-Based Complementary and Alternative Medicine 21

disease at a stable stage,” Experimental and Lerapeutic Medicine, vol. 12, no. 4, pp. 2477–2488, 2016. [62] M. Wang, J. Li, S. Li, and Y. Xie, “Effects of comprehensive therapy based on traditional Chinese medicine patterns on older patients with chronic obstructive pulmonary disease: a subgroup analysis from a four-center, randomized, controlled study,” Frontiers of Medicine, vol. 8, no. 3, pp. 368–375, 2014. [63] D. Lin, J. Xia, and S. Wan, “Climate warming and biomass accumulation of terrestrial plants: a meta-analysis,” New Phytologist, vol. 188, no. 1, pp. 187–198, 2010. [64] D. C. Hao and P. G. Xiao, “Network pharmacology: a Rosetta Stone for traditional Chinese medicine,” Drug Development Research, vol. 75, no. 5, pp. 299–312, 2014. [65] S. Lee, “Systems Biology - a pivotal research methodology for understanding the mechanisms of traditional medicine,” Journal of Pharmacopuncture, vol. 18, no. 3, pp. 11–18, 2015. [66] A. Navarro, B. De Las Heras, and A. Villar, “Anti-inflam- matory and immunomodulating properties of a sterol fraction from Sideritis foetens Clem,” Biological and Pharmaceutical Bulletin, vol. 24, no. 5, pp. 470–473, 2001. [67] M.-Y. Kuo, M.-F. Liao, F.-L. Chen et al., “Luteolin attenuates the pulmonary inflammatory response involves abilities of antioxidation and inhibition of MAPK and NFκB pathways in mice with endotoxin-induced acute lung injury,” Food and Chemical Toxicology, vol. 49, no. 10, pp. 2660–2666, 2011. [68] S.-C. Yang, P.-J. Chen, S.-H. Chang et al., “Luteolin attenuates neutrophilic oxidative stress and inflammatory arthritis by inhibiting Raf1 activity,” Biochemical Pharmacology, vol. 154, pp. 384–396, 2018. [69] Y. Hong, J. Yang, X. Shen et al., “Sinomenine hydrochloride enhancement of the inhibitory effects of anti-transferrin re- ceptor antibody-dependent on the COX-2 pathway in human hepatoma cells,” Cancer Immunology, Immunotherapy, vol. 62, no. 3, pp. 447–454, 2013. [70] A. O. Antwi, D. D. Obiri, and N. Osafo, “Stigmasterol modulates allergic airway inflammation in Guinea pig model of ovalbumin-induced asthma,” Mediators of Inflammation, vol. 2017, Article ID 2953930, 13 pages, 2017. [71] M. Lopez-Lazaro, “Distribution and biological activities of the flavonoid luteolin,” Mini-Reviews in Medicinal Chemistry, vol. 9, no. 1, pp. 31–59, 2009. [72] M. Das, A. Ram, and B. Ghosh, “Luteolin alleviates bron- choconstriction and airway hyperreactivity in ovalbumin sensitized mice,” Inflammation research: official journal of the European Histamine Research Society, vol. 52, no. 3, pp. 101–106, 2003. [73] Y. C. Li, C. H. Yeh, M. L. Yang, and Y. H. Kuan, “Luteolin suppresses inflammatory mediator expression by blocking the Akt/NF-κB pathway in acute lung injury induced by lipo- polysaccharide in mice,” Evidence-Based Complementary and Alternative Medicine, vol. 2012, Article ID 383608, 17 pages, 2012. [74] B. Y. Liu, H. X. Yu, R. Q. Baiyun et al., “Protective effects of dietary luteolin against mercuric chloride-induced lung injury in mice: involvement of AKT/Nrf2 and NF-κB pathways,” Food and Chemical Toxicology, vol. 113, pp. 296–302, 2003.