Lecture Note: “Management of the Diseases of Respiratory System” (Part-3) by Prof. Muralidhara Sharma

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Management of the Diseases of Respiratory System
(Part-3)

Prof. Muralidhar Sharma
Based on the lecture available at–Management of the Diseases of Respiratory System

In the same category of patients, they may present with more Piita or Vata AnubandhSymptoms.In that conditions, you will have more crepitation, and sputum would be more. Naturally, the clinical symptoms will be more when the patient has food consumption, food aggravates it. Often the symptom also could be related to the posture, very often once the patient lays down at night the symptom will be more. During daytime and the erect posture, comparatively, symptoms are lesser because you will have more exudates which is increased along with dense fibrous tissue formation. Dense fibrous tissue formation, as you see in the right lower lobe is one of the samples that could be a sign of the Vatanubandhi or

 Pittanubandhi Kasa Lakshan which is another category of bronchitis.

तमकःकफकासेतुस्याच्चेत्पित्तानुबन्धजः|

पित्तकासक्रियांतत्रयथावस्थंप्रयोजयेत्|| Ch. Chi. 18/131

Now this categorization of bronchitis is our domain that the contemporary sense doesn’t have. In that condition, the treatment would be along with the Mritunjay Rasa, and Makaradwaja may be needed. I prefer it because it is always a prolonged condition, treatment would be more prolonged. The outcome would be rather slow and you may not see the recovery quite early. So you have to keep the patient prepared psychologically that you need to have prolonged treatment. My advice is you have to take the medicine for at least one month, not less than one month. These are the conditions where again, modern medicine often fails and the majority of the patients coming to Ayurveda practitioners after two or three weeks of other treatment are usually of this category.

Makaradwaja along with Laghu Sootshekhar Mishran is my preference which gives better results. Of course, it’s not only that Makaradwaj aand Laghu Soot Shekhar Mishran, it could be any other drug which you prefer, but that should be having more Tikshna Guna and more Kaphghna Gunas would be the choice of the treatment. Treatment has to begin prolonged, either three weeks or one month is the minimum duration of the treatment. Don’t expect the result in the early phase that’s one.

Bronchitis
Symptoms:

More than 1 week

Expectoration thinner and more

Crepitations

Inspiratory rhonchi [Local]

Dyspnoea

Treatment

Mrityunjaya Rasa

Makaradwaja 1gm for 3 weeks

LaghusootShekharMishrna25 gm

Madhuyasti 5 gm for

Somasava3 weeks/ one month 

Recurrent bronchitis

यदास्रोतांसिसंरुध्यमारुतःकफपूर्वकः|

विष्वग्व्रजतिसंरुद्धस्तदाश्वासान्करोतिसः||Ch .Chi 17/45

I am using certain  words which are not technically perfect. Technically perfect word in that condition will be chronic bronchitis. But I will not reserve that word because there is another interface that we can see in the clinical condition. This is not mentioned in the textbooks. So I take all the liberty to go beyond the textbooks from that point of view. I use the word recurrent bronchitis, textbooks don’t mention this word. It is a sort of interface between chronic bronchitis and acute bronchitis. To make a diagnosis of chronic bronchitis symptoms should persist for six months. But I have plenty of patients who do not fit into the definition of chronic bronchitis including six months duration. But otherwise, they have all the symptoms of chronic bronchitis and I use the word recurrent bronchitis for such a category of patients. So whether it’s perfect from the technical point of view that’s a debated issue. But I think I take the liberty to do that. In that condition,n there a is repeated history of cough and fever. Occasional rhonchi and crepitation the one the important auscultatory signs. Development of the fibrous bands at the right lower lobe in the given image would be one of the important features. Basic management would be the same. Once the patient’s acute symptoms are resolved, to prevent further recurrenceKumariAsavais a treatment for the residual Aama.  I do notpreferghuSootshekharMishrana.  KumariAsava along with MritunjayRasa, andArogyavardhini can effectively prolongthe interval of the attacks and after the prolonged duration of the treatment, the attacks can be subsided. Another important benefit would be patients practicing yoga at this stage, particularly pranayama also helps significantly. Practicing yoga, particularly Pranayam is another kind of recommendation which can be given and where you can see significant results. Yoga also gives the results not the other way. But in such conditions, the changes can be seen in short duration and a significant result can be seen.

Recurrent bronchitis

Sign and symptoms:

Repeated episodes of cough fever

Breathlessness

Crepitations with rhonchi

Expectoration – more yellowish

Treatment:

Shvasakuthara rasa

Arogyavardhini

Makaradwaja

LaghusootshekharMishrana1 month

Madhuyashti1 month

Somasava               1 month

KumariAsava after the episode

Bronchiectasis  -Kshataja Kasa

 It is an area where a good number of patients come to Ayurveda clinicians, usually when the patients would havea history of symptoms for very long duration, years together. For most of the events, contemporary science fails to have a satisfactory treatment. The ultimate treatment would be lobectomy which involvesthe lobeneeding to be removed. Till the removal of lobe virtually the patient would not have a complete recovery. Systemic complications of the infective pathology would be significantly seen in such patients.  It’s big chunk of patients who at least visit to the Ayurvedic doctor once. Most of the times, bronchiectasis patients would have seen many doctors and they would have usually have a very thick file. So lots of medicines would be given and their condition will be quite pitiable. So such people are characteristic of bronchiectasis cases. Interestingly the number of such patients is increasing, whether the number of patient is really increasing in the society, or whether the number of patients coming to Ayurvedic doctors is increasing. I don’t have such a significant or verifiable data to provide answer of this question. But possibly it could be like the number of patients are increasing in the society. This is only my hypothesis and I’m not sure about the data. But such patients are another of the problem and I consider that as the KshatajKasa.

इदानींक्षतकासस्यनिदानादिनिरूपयति – – – –

—————————————————-|

युद्धाद्यैःसाहसैस्तैस्तैःसेवितैरयथाबलम्||

उरस्यन्तःक्षतेवायुःपित्तेनानुगतोबली|

कुपितःकुरुतेकासंकफंतेनसशोणितम्||

पीतंश्यावंचशुष्कंचग्रथितंकुथितंबहु|

ष्ठीवेत्कण्ठेनरुजताविभिन्नेनेवचोरसा||

सूचीभिरिवतीक्ष्णाभिस्तुद्यमानेनशूलिना|

पर्वभेदज्वरश्वासतृष्णावैस्वर्यकम्पवान्||

पारावतइवाकूजन्पार्श्वशूलीततोऽस्यच|

क्रमाद्वीर्यंरुचिःपक्ताबलंवर्णश्चहीयते||

क्षीणस्यसासृङ्मूत्रत्वंस्याच्चपृष्ठकटीग्रहः|A.H. Ni 3/27 -31

 The typical presentation of the sputum is purulent, pus like. One of the important clinical sign will be postural drainage, like the sputum presenting in a specific position being more. Patient often say like when I lay down on the left side it is more or somebody patients says that sputum is more when laid on the right side or so on. Therefore expectoration quantity related to the position is one of the important key signs for making the diagnosis. When you take the history, if a patient says that the sputum is more in specific position, then definitely you have case of bronchiectasis.

 X -rays show the typical bee hive like appearance that is the characteristic feature. Sushruta has mentioned that patient would have pigeon like sound. When you auscultate the sound is very typical, though often named as rhonchi we don’t have technical term different from rhonchi. But this sound is very typical consisting of coarse crepitation and rhonchi similar to sound of pigeon.In all that patients of bronchiectasis one of the important issue is to rule out underlying pathologies. Significantly in chronic rheumatoid arthritis developing bronchiectasis is very common, also many of collagen issue disorder could be coexisting.  Presence of such underlying pathology makes the issue more complicated from Ayurvedic treatment point of view. Cystic fibrosis particularly in children is common in bronchiectasis conditions. HIV is also a common cause seen in bronchiectasis conditions. So before we take the steps, it’s important to rule out these conditions and this can be done only by other detailed history or required investigations.

 So in case of bronchiectasis, you have to have a more detailed history workup. It’s not simply about the cough and the respiratory symptoms. You have to take the history of other treatment taken earlier and the incidences. When the patient would have an underlying pathology naturally the outcome would be poor.

My treatment in that condition would be Mrityunjaya Rasa, Suvarnamalini Vasantha with Laghsoota Mishrana and Pushkaramoolasava/Vasakasava. Suvarnamalini Vasantha is given at the lower dose, one gram per week. Pushkaramoolasava is preferred when the patient has pain as symptom. Vasakasava is preferred when patient having more sputum. Pushkaramool asava or Vasakasava could be used alternately as per the clinical presentation. But the treatment has to be given for prolonged period. I have patients who are being treated for 10 years and patients are in a satisfactory level.

Underlying conditions to be ruled out:

Rheumatoid arthritis

Cystic fibrosis

HIV

Effective palliative measures

Mrityunjaya Rasa

Suvarnamalinivasantha 1 gm

LaghsootaMishrana25gm      ¼ tsfTDS

Pushkaramoolasava / Vasakasava

 ‘Virechan is given when the patient is physically fit, it would help in significant resolution of the symptoms. I don’t say bronchiectasis patient can be completely cured. A complete cure in the case of bronchiectasis might not be possible, but patient can be effectively managed in more satisfactory level than any other contemporary methods of treatment.

Patient can sustain for 10-15 years or more and having normal life is possible with our medicines. But only thing is you have to identify that clearly and educate the patient about the possibilities. In bronchiectasis another important aspect of the management would be the postural drainage. It could be the Bhastrika Pranayama or if the patient has difficulty the simple education about the technique for bringing up the sputum every morning would be another useful practice. (refer image no 13Airway clearance technique –Bhastrika)

Image:Airway clearance technique -Bhastrika

In case of the bronchitis steam inhalation helps but in case of the bronchiectasis the steam inhalation doesn’t help. I don’t say steam inhalation harms, but steam inhalation doesn’t help much. But it’s a postural drainage where it’s only holding the breath and then forcing the breath out. So something like ‘Bhastrika Pranayam’ or if you do that methodical ‘Bhastrika Pranayam’ also would be significantly useful. This postural expectoration has a more value than other medical treatment. Most of the times physicians may not have time to educate a population about this issue. But once you have educated the patient about this, patient can identify the advantage and then he/she make a deal every day. Patient has to do this exercise every day in the morning, immediate after getting up from the bed for five times. It will be quite significantly helpful in such condition.

Pneumonia

Infective pathology is the basis for the development of Pneumonia. We are now having that sequence of the infection traveling through the respiratory tract. This is one of the condition where the infection has gone through the respiratory tract directly into the lungs. The clinical features are where the patient would have a typical one week of dry cough. There will be tachypnea, the respiratory rate is increased and fever is more. Second week there will be productive resolving phase, so you will have typical course.

 Usually as per standard protocol, pneumonia is considered three weeks disease. So at the end of three weeks, either the patient is resolved or the disease is a resolved.  Now a days the fatal complications associated with pneumonia become significantly lesser so it’s not categorized as a fatal disease. But few years earlier, pneumonia was considered as one of the fatal disease conditions and that’s the issue like if three weeks is the usual period considered.

Pneumonia

 The clinical features for the same are described in Vagbhat among a variation of the Vataj Kasa.

अधुनावातकासस्यनिदानादिनिर्देशार्थमाह –

कुपितोवातलैर्वातःशुष्कोरःकण्ठवक्क्रताम्||२२||

हृत्पार्श्वोरःशिरःशूलंमोहक्षोभस्वरक्षयान्

करोतिशुष्कंकासंचमहावेगरुजास्वनम्||२३||

सोऽङ्गहर्षीकफंशुष्कंकृच्छ्रान्मुक्त्वाऽल्पतांव्रजेत्|A.H Ni 3/22,23

In a condition when a person consumes Vatal Ahara and Vata Prakop (aggravation) has occurred, initially there would be high degree of fever but at the same time dry cough would be also present. High degree fever and dry cough are the characteristic clinical sign of evolving pneumonia, initial phase of consolidation in the first week. One of other sign that could be present is after consumption food patient would have resolving symptoms. This symptom issimilar to symptom that may be present in Tracheitis. Definitely it is not Tracheitis, there is possibility of confusion with Tracheitis simply if you depend upon the clinical symptoms. Auscultation sound provides very characteristic feature of bronchial breathing at the concerned area. Because of involvement of pleura there is always localized pain over chest cage.

Signs and symptoms:

High fever

Chest Pain

Tachypnea

Dry cough first week

Productive second week

Bronchial breathing

Crepitation

Raised Leucocyte count

In case the pneumonia if the patient has a sever clinical manifestation, if there is a underlying pathology, leucocyte count is more than 17,000 I prefer antibiotic treatment. Usually patient come to Ayurveda clinician in second week, because in the first week fever is higher. Also many of patient prefers other sorts of treatment. Very interestingly, what I have observed is patients who are taking Ayurvedic medicines for all usual respiratory tract infections, they do not develop pneumonia. Particularly in paediatric patients, incidence of pneumonia is almost nil. Whereas if you see the incidence of pneumonia in the other category of people, incidence is quite higher. This could be one of the area where we may have objective study, to show the differences. But this difference is visible, it can made out.  My hypothesis is those who do not take repeated antibiotics, they may have a lesser chance of developing pneumonia. It’s not proved with objective evidence, but its worth of trial.

If the total count is less than 16,000 my management will be same treatment .

Treatment:

Mrityunjaya Rasa first week ,Lakshminarayana Rasa  second  week

Makaradwaja

Laghusootshekharmishrna

Amritarishta / Somasava /Vasakarishta

Antibiotic therapy needed

Total leucocyte count more than 16000

Children

Co existing diseases

Non resolving pneumonia

 My management would remain same treatment. I don’t make much of difference because it is Vataja Kasa variety except the duration of treatment. But at the same time there is serious issue of non-resolving pneumonia, it is also a problem for contemporary pulmonologist. Pneumonia which fails to get resolve in three weeks is always something like underlying bomb. So there may be some serious pathology and it should be investigated thoroughly. You may need bronchoscopy, cytology and so on. If there is provision of infrastructure for investigation then get it done otherwise refer patient to higher centre.

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