Management of the Diseases of Respiratory System
Prof. Muralidhar Sharma
Based on the lecture available at–Management of the Diseases of Respiratory System
These are my clinical experiences while dealing with different varieties of diseases in clinical practice. It is not a complete description of all diseases but I have picked up a few of those conditions which are significant, important, and which may have a significant outlook on dealing with the different varieties of the diseases as such.
It is a very commonly seen troublesome condition also often translated as the surgical condition. Incidence of surgery is quite common but most of the time surgery is not necessary. Surgery is necessary for only a few conditions. It can be effectively managed without surgery if you have a thorough clinical assessment. Brodsky’s classification for grading tonsillitis is based upon its diameter.( needs original ref)
|Degree of Tonsils Blockage||The ratio of Tonsils in the Oropharynx|
|Degree 0||Tonsils in the Fossa|
|Degree 1||Tonsils occupy less than 25% of the Oropharynx|
|Degree 2||Tonsils occupy from 25 to 50% of the Oropharynx|
|Degree 3||Tonsils occupy50 to75% of the Oropharynx|
|Degree 4||Tonsils occupy more than 75% of the Oropharynx|
- Image : Tonsillitis
When the tonsils get enlarged and occupy up to 75% or more of the oropharynx then it is degree 4. Air passage gets blocked and virtually there is no space for air to move in. In such conditions, there is no fun to use any non-interventional treatment. Very obviously that degree 4 condition is an absolute indication for surgery irrespective of the system or medicines we use. In earlier conditions as per the norms followed in contemporary surgery, in earlier conditions like ‘degree 2’which consists of more than25 % enlargement, surgery is indicated.But this condition doesn’t require surgical removal and can be managed by Ayurvedic medicine.
Sushruta has very clearly described all the four categories of swellings present in the throat with the typical names Kanthashundi, Tundekeri, Adhrusha,and Kacchapa. Kacchapa is a condition having a huge size and considered incurable (Asadhya) that is similar to ‘Degree 4’ mentioned by Brodsky’s classification. While the rest of the degrees of tonsillitis have to be managed as Kapha Raktaj or Kapha Pittjaj Vyadhi.
कूर्मोत्सन्नोऽवेदनोऽशीघ्रजन्माऽरक्तोज्ञेयःकच्छपःश्लेष्मणास्यात् |( Su.Ni16/41,42)
In chronic tonsillitis where a patient may not have other symptoms except repeated occurrences of febrile condition and somewhat pain in the throat but may not be in respiratory distress then such condition can be effectively managed by using Mritunjaya Rasa, TriphalaGuggulu, Amrutarishta but the duration of treatment may have to be prolonged. It’s not a critical condition.
The issue of tonsillectomy helping the patient, in the long run, is very controversial. Contemporary surgeons have different opinions about the long-term benefits of tonsillectomy. Some people say tonsillectomy helps the patient but in reality, it does not help the patient. As long as tonsils are placed in their position,the respiratory tract remained protected. Tonsils are also named ‘Policemen or Gatekeepers’ of the respiratory tract. Tonsils help to minimize infection entering the lower respiratory tract. Therefore the incidences of infection of the lower respiratory tract infection tend to increase after the tonsillectomy. The majority of the patient comes with complications they may have undergone tonsillectomy earlier.
The protocol suggested for acute management of tonsillitis is Centour’s criteria. (add ref) This is the universal guideline. Here I have done a few modifications to this guideline.
Centour criteria are considered for the assessment of tonsillitis and its scoring.
- If body temperature > 38 C degree Celsius- score 1
- The presence of a cough suggests the involvement of the trachea. The absence of a cough is a positive sign of tonsillitis -score 1
- Visible anterior swollen tonsils- score 1
- The presence of exudate -watery discharge- score 1
If the total score is <3 then contemporary medicine suggests symptomatic treatment andno need forantibiotics.
Mritunjaya Rasa, Triphala Guggulu, Gandhak Rasayan, Amritarishta
- For more discharge –Gandhak Rasayan
- For lesser discharge along with only a swelling –Triphala Guggulu
The modification would be that instead of what is mentioned as symptomatic treatment; we will have ‘Ayurvedic curative management’. Along with this advantage,the recurrence rate is significantly lower and patients can recognize it. In patients with a long history of repeated tonsillitis and managed either with Mritunjaya Rasa, or Triphala Guggulu, usually during the next one or two episodes, the interval between the consequences itself gradually increased, and at once said you will have patients with the symptom-free conditions.
Many times the swelling may continue to be visible but that does not need surgical intervention. I would prefer Mritunjay Rasa, Triphala Guggulu, or Gandhak Rasayan depending upon the issue. If there is more discharge then I prefer Gandhak Rasayan. If there is a lesser discharge, and only swelling is present then the choice is Triphala Guggulu.
But at the same time, there is one of the significant risks of tonsillitis is rheumatism. Patients developing rheumatism as a consequence of tonsillitis is one of the significant issues which we cannot mitigate and that fact has to be there. Hence my guideline during practice is if the patient continues to be febrile and the score is more than three, then definitely I would have a total leukocyte count done. If the patient is febrile for a week or more than a week and the tonsils are enlarged, I would have an ASO titer test done. ASO titer is one of the investigations which we will have to do. If the ASO titer is negative and if the total leucocyte count is less than 16,000, then again we can manage it with our medicines only like Mritunjay Rasa, Triphala Guggulu, or Gandhak Rasayan. The same treatment would be enough. But if the total leucocyte count is more than 16,000, ASO titer is positive and the patient has tachycardia then I do not generally continue with our medicines. I recommend the use of antibiotic choices, either you can prescribe it or you can refer the patient to the others. So antibiotic use may be necessary. In my case, I do admit the patient to our hospital and administers the antibiotics and usually, it’s a penicillin derivative. Possibly that’s the limit for Ayurvedic treatment when the patient has tachycardia and ASO titer is positive. Continuing with our treatment may not be ethically justified because you have a risk of the progressive development of cardiac pathology. But at the same time, for patients who have been treated as acute status with antibiotics, there is no need for prophylactic antibiotics. The other norm which is usually practiced in contemporary practices, is prophylactic antibiotic where long-acting penicillin is given once in three weeks or once in four weeks and is usually given for a lifelong, such kind of practice is not necessary. Such patients who are on penicillin prophylaxis can be very effectively managed with our drugs like Mritunjay Rasa, Triphala Guggulu, etc. By using this treatment we can prevent cardiac complicationswhich may occur. In the acute stage when the patient is febrile and total leucocyte count tends to be higheris one of the limits where probably this condition cannot be managed through Ayurvedic treatment. In bacterial tonsillitis whatever we have discussed in terms of size and scaling, grading is an issue. In acute conditions follow the Centour’s criteria and depending upon the ASO titeryou have to take the decision.
- Joint pain
- Fleeting pain
Every patient coming to you with the swelling and pain in the throat is not tonsillitis. This is another very frequently committed error.If you can see the incidents, particularly in our area the majority of the patients are not bacterial tonsillitis. They are viral tonsillitis. Making up the difference between viral tonsillitis and bacterial tonsillitis is one of the clicks of the practice.The majority of even contemporary medicine practitioners also may fail.
It’s very easy and simple. If you look at the throat in the provided image it’s only a generalized inflammation and we do not see the clear cut borders, reddish color seen, not many exudates,the surface is smooth then such condition is always viral.The patient may have a fever, but the fever usually is not very high. , it is moderate fever.The patient would have nasal discharge and a cough. It’s not the tonsil that is inflamed, the nearby area, like the uvula also is inflamed. So if you see the whole area as reddish, it’s not bacterial tonsillitis where you do not have to worry about all those issues which we have discussed. Whatever we have discussed now is about bacterial tonsillitis, but in viral tonsillitis, this doesn’t require all that issue. It’s relatively simpler and most of the time it is self-limiting.
Very often viral tonsillitis is induced after you had some cool substance after food. Ice cream is the commonest cause of viral tonsillitis. Consumption ofice cream is the commonest cause of viral tonsillitis. Contemporary medicine also knows that, a sudden change in the temperature in the environment breaks the safety barrier on the surface of the body, and that it still would be inviting inflammatory pathologies. But of course, this is not regularly used in the lifestyle. Usually, immediately after the food, you’ll have ice creams. Ice creams are safer in cold seasons when the temperature raises differences lesser. Ice creams are used foods in the Western country where the environmental temperature also is close to that zero or nearby and there it’s not going to harm because the impact of the temperature is lesser.When you take ice cream in the hot season, when the environmental temperature is more you are invited for pathology because the temperature gradient is more. Usually, when it’s hot, everyone prefers cold drinks, my recommendation is even if it is a hot climate take warm drinks.Once you try this and then you know about it, the advantages can be seen. You try ice cream in winter and warm drinks in summer. You’ll know the difference. These facts are not established in textbooks. It’s not mentioned in the text box but it’s a well-known fact and can be observed, and used in your life.
If you have identified viral tonsillitis, management is very easy. The usual same treatment which we use in other common upper respiratory disorders like Mritunjay Rasa, Triphala Guggulu, etc. It is also true that even if you do not give any medicines, it will subside in one or two weeks provided you do not have further onslaught with such irritant objects, the lifestylewould be enough.But the same may not be true in bacterial tonsillitis.
- Image Viral Tonsillitis
- Smooth surface
- Nasal discharge
- Moderate fever
- Total count within in normal limits
Bacterial tonsillitis can be easily identified where the swelling is having a very clear cut clearidentification. The surface is rough very characteristically. The uvula is not involved and the absence of the cough is one of the important clinical signs. Most of the clinicians failed to make up that difference.The relatively high fever and presence of the lymph nodesare characteristic features of bacterial tonsillitis. It may be possible to palpate the lymph nodes.
In bacterial tonsillitis whatever we have discussed in terms of that size and scaling, grading has to be considered.In acute conditions the same issue which we have discussed already,the Centaur’s criteria and depending upon the ASO titeryou have to take the decision.
- Image Bacterial tonsillitis
- Limited area
- Rough surface
- High fever
- Lymph nodes
- Total count raised
- ASO Titre