Management of the Diseases of Respiratory System
(Part-4)
Prof. Muralidhar Sharma
Based on the lecture available at–Management of the Diseases of Respiratory System
Chronic obstructive and restrictive lung disorder
Chronic patients with respiratory obstructions usually known by the word Asthma patient. Asthma is misleading word. All the patients who have their chronic breathlessness conditions, irrespective of the cause primarily of two categories, obstructive or restrictive. Pulmonologist manage on the same lens. Now what I’m talking is from the pulmonologist management point of view. Underlying diseases are many, that’s another issue but your approach to the management would be whether there is an obstruction to air passage or whether there is reduced capacity of expansion of lungs, ventilation is reduced or not. This can be assessed with help of spirometry by Pulmonologist. But I can identify these situations without spirometry. If you can observe the patient keenly then we will try to demonstrate with some examples. In both the conditions, clinical symptom will be a persistent breathlessness and breathlessness which aggravates after exercise. So clinical symptoms will be similar in case of both obstructive and restrictive pathologies.
Very interesting Charaka has clearly mentioned these differences. Charaka has categorised these two conditions while describing Urdhva Shwas.
दीर्घंश्वसितियस्तूर्ध्वंनचप्रत्याहरत्यधः|
श्लेष्मावृतमुखस्रोताःक्रुद्धगन्धवहार्दितः||
ऊर्ध्वदृष्टिर्विपश्यंश्चविभ्रान्ताक्षइतस्ततः|
प्रमुह्यन्वेदनार्तश्चशुष्कास्योऽरतिपीडितः||
ऊर्ध्वश्वासेप्रकुपिते [ह्यधःश्वासोनिरुध्यते|
मुह्यतस्ताम्यतश्चोर्ध्वंश्वासस्तस्यैवहन्त्यसून्||Ch. Chi 17/49-51
इत्यूर्ध्वश्वासः|
‘Shleshmavrutamukh srotas’ means obstructive phenomenon, while ‘Urdhwa Shwase Prakupite Hi Adhah Shwase Nirudhyate’ means expiration is maintained but inspiratory efforts are lesser than expiratory, the typical feature of restrictive phenomenon. Thus Charak has clearly defined the two differences hence we have an authenticity to deal with that condition. You may have to use certain sophisticated technologies occasionally and a keen observation would be enough. Obstructive conditions are usually categorized as chronic bronchitis, emphysema, cystic fibrosis, and so on. Whereas restrictive it could be interstitial lung disorders, obesity, Scoliosis, and so on. You may have different underlying pathology. The primary difference between these two conditions is illustrated with help of a graph. (Image of graph no17)
Image Graph depicting obstructive and restrictive pattern
In typical obstructive pathology, the inspiration is low intensity and expiration is prolonged. In the graph, normal breathing is represented in green color. If you keenly observed the patient the difference can be made out easily. In normal patient inspiration and expiration is smoother. In a patient with obstructive pathology, inspiration starts earlier and the total rate of breathing is enhanced.
In a restrictive pathology, a patient would have found it difficult to start the inspiration. He always tries to open his mouth. In obstructive pathology, a patient would find it difficult to expire and bends forward. Spirometry is not necessary in every case. If a patient can afford spirometry then get it done. Graph and results obtained after spirometry would be sufficient enough to make a difference between obstructive and restrictive pattern. Knowing the difference about underlying pathology would have another advantage, still we can manage the condition effectively without knowing it
Interstitial lung disorder [Restrictive lung disease]:
Among the restrictive conditions most common variety of the restrictive conditions which we see is the interstitial lung disorders. Incidence of the interstitial lung disorders have increasing rapidly now. It’s well known that the pollution is one of the important causes and also lack of exercise and obesity. Many of the persons, even of younger age are having restrictive pathology. Initial identification of the restrictive lesions at the beginning itself is one of the crucial issue.In the beginning, they may not have the other obvious clinical signs. There might be any significant cough or expectoration. It could be that only when they do the rigorous exercise. When they climb up the stairs, they will have the dyspnoea and in that condition you may not have obvious clinical signs that could be the beginning of interstitial lung disorders. Once the interstitial lung disease become established then all the obvious clinical signs will be present.
Person who do pranayama regularly and if you have identified person in initial stages ofinterstitial lung disorders you can 100% assure about prevention of further progression of disease.
None of medical treatment neither Ayurveda nor contemporary medicine treatment would be as effective as a regular Pranayama if you have identified the patient in the initial stages of the interstitial pathology. But later, once diseases has become established, it could also have a marginal benefit and you may need medical management and so on. So identification at that crucial stage would be very crucial for at least ourselves will be beneficial, whether it’s for the patients or not. Once the patient has the clinical symptoms, it’s obviously the clinical signs would be crepitation with reduced breath sounds.Charak considered it as Kshudra Shwas.
रूक्षायासोद्भवःकोष्ठेक्षुद्रोवातउदीरयन्|
क्षुद्रश्वासोनसोऽत्यर्थंदुःखेनाङ्गप्रबाधकः||Ch .Chi.17/65
Important issue Shwasand Kasa are considered as ‘Amashay Samudhbhav’. In general notion, Avipathikara Choorna and Godanti are considered as treatment for gastrointestinal disorder. But my prescription would be Avipathikara Choornaalong with Mritunjay Rasa and Arogyavardhini. As discussed before Pranayam is very useful. Another useful therapy which can definitely help in this condition is ‘Virechan’ but it should be done in physically fit patient. Textually ‘Vamana’ is the suggested treatment but I generally avoid it. Patient may not tolerate it well. I always have some reservation, patient may not tolerate it well. I prefer ‘Virechan’ and outputs are significantly good and patient can be better managed than contemporary system. I don’t say again, interstitial lung disorder can be completely cured, but that’s one of the issues. I give more preference to Pranayam, respiratory exercise, Virchan and lifestyle management than medical management though medicine would be also a part of management.
Interstitial lung disorder [Restrictive lung disease]
Key points:
Exercise intolerance
Dry Cough
Repeated episodes
Crepitations with reduced inspiratory sounds
Systemic signs –Club fingers Scleroderma
Treatment:
Shvasakuthara
Arogyavardhini
Pippalyasava /Draksharishta
Avipathikarachoorna
Godanti
Pranayama helps significantly
Virechana is useful
Interstitial lung disorders can be a quite severe degrees where the total lung area available is lesser. In that condition. It’s a typical Shwasa and I prefer Shwaskutahr, Arogyavardhini along with the usual treatment Makardhwaja .In very chronic conditions when there is significant fibrosis typical chronic bronchitis, where all the lung volume is reduced significantly, it can be managed with Bruhanchikitsa like Chyavanprasha could be helpful. While in minor conditionVirechanwould be more beneficial.Virechan andChyavanprashacan be used alternatively. These are conditions where you have to continue treatment for years together or lifelong.
Sever degree ILD
Treatment suggested for sever ILD
Shvasakuthara Rasa
Arogyavardhini
Pushkaramoolasava
Makaradwaja
Laghusootshekhar Mishrana
ChyavanaPrasha
Virechana
Emphysema
Emphysema, which is often effective of chronic conditions and incidence of the emphysematous conditions are more. Very interestingly, the air locked is described by Vagbhat as the Vata that is stagnated at chest region and produces a disease. This is also called as AmashaySamudhbhavVyadhi.
कफोपरुद्धगमनःपवनोविष्वगास्थितः|
प्राणोदकान्नवाहीनिदुष्टःस्रोतांसिदूषयन्||
उरःस्थःकुरुतेश्वासमामाशयसमुद्भवम्|A.H.Ni 4/3
Emphysema means locked air located in chest region. Though the language is different, similar words has been used by Vagbhatand he clearly classified it as one of variety of Shwas. Characteristic clinical features areshortness of breath, recurrent episodes and typical emphysematous breathing. Auscultation would help be helpful. There will be lesser gap between inspiration and expiatory sounds. Intensity of the inspiratory sounds become reduced, duration of the inspiratory sounds become reduced and that would be the very characteristic of emphysema. Virtually there is no curative management on contemporary system side. They are managing it with bronchodilators and regular use of inhalers. Patients of emphysema also would be moving around the world and they may visit Ayurveda practioner some or other day to take treatment. The treatment span may vary from a month to year. Alternate cycles of visit to modern medicine physician and Ayurveda practioner would be commonly observed in case of emphysema patient. In such patients who tend to move keeping the patients for years together that would be an achievement. I can assure that patient of emphysema can be retained under my treatment for long duration with satisfactory relief. Treatment would remain same, Avipattikar and I prefer Draksharishta because it is sign of Dhatukshaya. Makardhwaja is also prescribed.
Emphysema
Key points
Short breath
Auscultatory findings
Recurrent episodes
Treatment:
Shvasakuthara
Punarnavamandora
Makaradwaja
Sitopaladi
Draksharishta
Avipathikarachoorna
Virechana
Pulmonary tuberculosis:
Identification of pulmonary tuberculosis is comparatively easier. We have to follow national health guidelines. These restrictions are now becoming rigid. Once you have diagnosed a case of tuberculosis with clinical signs and positive sputum then it should be reported. National guideline programme provides restrictions and even the legal implication. It’s not simply an ethical guideline. If a practitioner fails to report tuberculosis patient then he is punishable. He/she can be punished though the quantum of punishment is not yet defined. Probably in next session quantum of punishment also would be defined in new bill. In Madhya Pradesh it has been already started and bill has been introduced in assembly. Physician who fails to report tuberculosis would be punished for three months imprisonment.
So it’s not the question of whether you can treat tuberculosis or not. The issue is because we are living in a situation where it is absolutely necessary to report. If you report the patient under the ‘Nikshay’ website, patient will have a direct benefit. After reporting a case of tuberculosis patient’s account will be immediately credit with 2000 rupees. Patient will be guided to daily monitory treatment.Even before diagnosing a tuberculosis patient when you refer a patient for sputum test and if the test would be positive then laboratory must need to report it. In case of tuberculosis Ayurvedic management has definitive supportive role, I would limit it as supportive management. Many of those symptomatic management of complication of ant tubercular treatment can be effectively managed with Arogyavardhini and KumariAsava. Symptoms of pulmonary complication cannot be managed effectively with ayurvedic treatment but other symptoms like malise debility etc can be managed. Makardwaja, LaghusootshekharMishrna can help in cough and sputum also. Rasayan therapy like ChyavanPrasha may be useful. Multidrug resistant tuberculosis is another area where Ayurveda can intervene. As per current guidelines multidrug resistant tuberculosis needs to be reported. Virtually there is no solution and patient would be loaded with too many of drugs. In that condition Ayurvedic management can make change in the outcome. I consider it as DhatugatVishamjwarand my prescription would be Laxminarayan Rasa, Arogyavardhini, Abhrakbhasma, MakardhwajaandSitopaladi.
When you use Abhrakbhasma, Makardhwajacost of treatment would be higher but there may not be huge number of patients. Many of patient would visit Ayurveda physician when they know that they have multidrug resistant tuberculosis, that’s one of sensitive area and we should be careful about it.
सगात्रशूलज्वरदाहमोहान्प्राणक्षयंचोपलभेतकासी|
शुष्यन्विनिष्ठीवतिदुर्बलस्तुप्रक्षीणमांसोरुधिरंसपूयम्||
ससर्वलिङ्गंभृशदुश्चिकित्स्यंचिकित्सितज्ञाःक्षयजंवदन्ति|Su . U. 52/12,13
Pulmonary Tuberculosis
Key points
Chronic history
Low grade fever
Thick expectoration
Emaciation
Bronchial breathing
Cavernous breathing
Diabetes, HIV etc
Supportive treatment in tuberculosis
Arogyavardhini
Kumariasava / Draksharishta
Makaradwaja
Lsmishrana
Rasayana therapy – Chyavanaprasha
Treatment: Multidrug resistant Tuberculosis
Lakshminarayana Rasa
Arogyavardhini
Makaradwaja
Abhraka Bhasma
Sitopaladi
Vasakarishta /Draksharishta
