Management of the Diseases of Respiratory System
Prof. Muralidhar Sharma
Based on the lecture available at–Management of the Diseases of Respiratory System
Management of respiratory disorders
The condition often comes across with that respiratory diseases will be the pleural effusion. Pleural effusions of different varieties have been described by Sushruta. The typical conditions described are Kaphapurna Koshtha (Hydrothorax), Lohitpurna Koshtha (Hemothorax), and Vatapurna koshtha (Pneumothorax) are mentioned while describing Marmaviddha Lakshana. Pyothorax(presence of Pus) has been mentioned while describing Urokshata Vyadhi. All these varieties of effusions described by Sushruta are considered incurable conditions. Treatment advice by Sushruta would not be useful, so the other detailed approach is needed. Identification of pleural effusion is one of the important issues. A simple clinical examination of auscultation and examination of respiratory movements would be enough; a plain X-ray also could be confirmatory. After confirming a diagnosis of pleural effusion it’s mandatory that it has to be aspirated and then confirm the cause. Earlier, there was a general guideline like 75% of the effusions are tubercular and you may start with anti-tubercular treatment. Nowadays this kind of guideline is removed. The present protocol is once we have a case of pleural effusion, it needs to be aspirated and the natural origin of the effusion has to be identified. It could be tubercular, pyogenic, or tumour pathology. The transudative pathology or systemic pathologies like cardiac conditions also can present with pleural effusion. All those issues are about the identification of the underlying cause and your management will be accordingly. Pleural effusion requires a more sophisticated setup than the usual OPD clinical setup where you need to go for investigation. Many symptomatic conditions like pain and distress can be supported with Gokshuradi Guggulu, Punarnava Mandura, and Pushkaramoolasava. Even in malignant effusion patients would have some relief with the use of this management. Aspiration of fluid is also needed. Pleural effusion can’t be managed at OPD level conditions. You need a setup where it can be handled methodically. Therefore, if required refer the patient to such a clinical setup for further management
Diagnostic and curative tapping
कर्मणा चाप्युरस्येन वक्षो यस्य विदारितम् |
तस्योरसि क्षते रक्तं पूयः श्लेष्मा च गच्छति ||
कासमानश्छर्दयेच्च पीतरक्तासितारुणम् |
सन्तप्तवक्षाः सोऽत्यर्थं दूयनात्परिताम्यति ||दुर्गन्धवदनोच्छ्वासो भिन्नवर्णस्वरो नरः |Su. U 41/24,25,26 )
Hydrothorax, Haemothorax Pneumothorax
सत्त्वरजस्तमसामधिष्ठानं हृदयं, तत्रापि सद्य एव मरणं; स्तनयोरधस्ताद्  द्व्यङ्गुलमुभयतः स्तनमूले, तत्र कफपूर्णकोष्ठतया (कासश्वासाभ्यां  ) म्रियते; स्तनचूचुकयोरूर्ध्वं द्व्यङ्गुलमुभयतः  स्तनरोहितौ  , तत्र लोहितपूर्णकोष्ठतया कासश्वासाभ्यां च म्रियते; अंसकूटयोरधस्तात् पार्श्वोपरिभागयोरपलापौ नाम, तत्र रक्तेन पूयभावं गतेन मरणं; उभयत्रोरसो नाड्यौ वातवहे अपस्तम्भौ नाम, तत्र वातपूर्णकोष्ठतया कासश्वासाभ्यां च मरणम्; एवमेतान्युदरोरसोर्द्वादश मर्माणि व्याख्यातानि ||Su.Sha 6/25
Other conditions may mimic symptoms of respiratory pathology but have underlying pathological conditions among them one is the pericardial effusion. The incidences of pericardial effusion are raising comparatively in the last 10-15 years of my practice carrier. In old age patients particularly Diabetic patients it is more. The exact reason behind it is unknown. Possibly it could be due to an overload of medicines. If a patient particularly a diabetic patient complains of heaviness chest patient needs to be investigated. We can make out a diagnosis of pericardial effusion with the help of auscultation. If you missed it is better to investigate either with echocardiography or an X-ray chest. Echocardiography is a better investigation. Diabetic patients crossing age above 50 years, having a sense of compression in the chest, not atypical pain in the chest then it is better to have echocardiography. The typical description of clinical symptoms mentioned by Vagbhat is patient would feel as if there is a stone inside.
श्लेष्मणा हृदयं स्तब्धं भारिकं साश्मगर्भवत्||
कासाग्निसादनिष्ठीवनिद्रालस्यारुचिज्वराः|A.H Ni 5/42
A more detailed evaluation is needed in this condition. You may need some experts to help with that condition at that time because echocardiography usually it’s beyond your reach. The usual prescription given by modern medicine is ‘Dytor’ having diuretic action. My advice would be not to discontinue this medication. Over the pre-existing medicine that is given earlier, my prescription would be Prabhakara Vati, Punarnava Mandura, and Punarnavasava. Though it is not a cure for pericardial effusion still it could provide some additional advantages over the basic treatment. Once the patient has absolute clinical proof of a resolution then we may stop the medication. If pericardial effusions occur in diabetic patients, then treatment can be discontinued. But if the patient has chronic hypertension and cardiomegaly then it is not advisable to stop the medication. According to the patient’s specifications, you have to make decisions.
Pulmonary hypertension is often seen in patients with a history of cardiac intervention. Typically, the intensity of symptoms may look milder, a patient may not have typical standard symptoms of pulmonary hypertension. A typical patient with pulmonary hypertension is severely breathless and can be easily identifiable. But a pattern of disease is now changing. The presentation would be subdued but after investigation, you will get significant pulmonary hypertension. So there is some change in the total pattern of presentation of the disease. In earlier days’ patients with pulmonary hypertension would be categorized as an acute emergency. These days’ pulmonary hypertension conditions are not an acute emergency. Patients would be presenting with a large amount of watery sputum and nocturnal dyspnoea. If a patient needs two or more pillows at night time, probably indicates cardiac involvement and pulmonary hypertension that needs to be investigated thoroughly. We can provide supportive management in this condition because there will be some or other coexisting pathology. A thorough analysis and standard classification of pathologies and defining management would be comparatively difficult. The supportive management includes the same medication as that for pleural effusion. The important thing is not to miss these conditions to develop a fineness of clinical approach.
Congestive Cardiac Failure:
हृदयस्य रसादीनां धातूनां चोपशोषणौ||
तस्मात् साधारणावेतौ मतौ परमदुर्जयौ|
मिथ्योपचरितौ क्रुद्धौ हत आशीविषाविव|| Ch. Chi. 17/8,9
Charak has mentioned that it is impossible to treat this condition. This description shows that it is not possible to manage this condition only with Ayurvedic treatment but identification of CCF is an important issue. Patients with CCF can be definitely helped by Ayurvedic treatment along with other contemporary treatments. If a patient has tachycardia and basal crepitation, then suspect CCF. Oedema would also occur, but it would be a relatively later sign. Identification of congestive cardiac failure before the onset of oedema is a plus point.
Congestive Cardiac Failure
Carcinoma of the lung is the most misleading condition among all tumor pathology. There is no standard clinical presentation of pulmonary carcinoma. The two important categories of lung carcinoma are small-cell lung carcinoma and non-small-cell carcinoma. The incidence of small cell lung cancer is more in smokers. Clinical symptoms are given below.
The maximum incidence of symptoms is chest pain and not the cough or hemoptysis. Usually, it is a general impression that the patient would have cough and expectoration but it is seen only in 8% of patients. The old-aged patient tends to lose weight and have some occasional chest pain not related to exercise, not typical of cardiac chest pain then it is better to investigate thoroughly. Investigations may include chest Xray, MRI scans, and bronchoscopy. Carcinoma of the lung is not our domain to provide treatment. We can give supportive treatment that includes Arogya vardhini and Kumari Asava
Old age, smoking, chest pain not related to exercise
Carry home points
- Ayurveda has a significant advantage in selective patients
- Clinical diagnosis and prediction of course are crucial.
- Lifestyle modifications can produce a huge difference in the outcome