Shwasa Roga (COPD) Written by Kapil Thakur

Shwasa Roga(COPD)

In normal terminology “Shwasa” word means respiration. Sanskrit origin of the word ‘Shwasa’ derives its root from “Shwasa Jivane” meaning the existence of life through ‘Prana Vayu’. Shwasa - Swas+‘Ghanj’ Pratyaya. ‘Shwasa’ is derived from ‘Shwasa’ dhatu by applying ‘Ghanj’ pratyaya which denotes ‘to respire or to take breath’ or normal respiration. The word ‘Shwasa’ also gives entity in which individual breathe with difficulty and with increased respiratory rate. In Hemachandra commentary the word “Svasitam” is also termed as ‘Prana’ in physiological conditions.
Shwasa Pranane + ‘Lyut’ Pratyay
In Amarkosha 20 synonyms of ‘Vayu’ have been given. (13/3/117)
In Vachaspatyam the word ‘Shwasa’ is derived from the root word ‘Shwasa’ dhatu by applying ‘Ghanj’ pratyaya’. Shwasa-Swas+ ‘lyut’ Pratyaya
According to Halayudhakosha, the word Shwasa is derived from ‘Swas’ dhatu by applying ‘Lyut’ pratyaya which means inspiration and both phases of respiration.

Definition of Shwasa

From the above description it is clear that ‘Shwasa’ word is used to describe normal physiology of respiration as well as pathological states. The abnormal, rapid, or difficult breathing when present as a cardinal feature of a disease is called ‘Shwasa roga’.

According to Sanskrit Hindi Shabdakosha, “bhooyo-bhooyo swasiti yasmin roge sah shwasa” i.e. which points towards a pathological condition having rapid respiration.5

In Madhava Nidana this term has been described to the condition in which the patient, “breaths again and again”, i.e. exaggerated respiration with rapidity and difficulty.

“Shwasastu bhastrika aadhamana sam vatordhava gamita” (Madhukoshakar on Ma.Ni.12) i.e. due to the upward motion of the air, respiration resembles with the “blowing of a furnance” this is according to Acharya Vijayrakshita in Madhu Kosha commentary on Madhava Nidana.

So on the basis of above description it can be summarised that when Prana Vayu get vitiated and becomes defiled, get obstructed by Kapha and moves in opposite direction i.e. upwards and unable to perform normal functions, this condition is termed as Shwasa roga

Shwasa Kriya

Physiology of respiration (shwasa kriya) is available in Ayurvedic and Sanskrit literature. In ‘Bhagavatgita’ it is mentioned that ‘Prana and Apana’ moves through nasika (Bha. 5/2). In ‘Yajurveda’ (Yaj 15/12), it is mentioned that air in the form of ‘Prana and Apana’ enters the Nasika, sometimes Udana has been mentioned in the place of Apana.

• Prana - Going in
• Udana - Going Out

In some Ayurvedic texts the word ‘Prana’ has been used for inspiration and ‘Udana’ for expiration. In ‘Atharvaveda’ (Kand II) it is mentioned that some portion of air remains in body at the end of expiration, as it cannot be expelled out.At the time of respiration the sound produced is termed as ‘Hansa’.Respiration takes place during day and night without any interval.(Atharva veda Kand II)

Acharya Sharangdhara has mentioned the process of respiration in detail in Purvakhand chapter 7.Hrdaya (heart) is the seat of chetana (life, soul) and also of ojas (essence of the dhatus) Siras and Dhamanis (veins and arteries) arise from the nabhi spread throughout the body and supply air to the dhatus (tissues) constantly. The ‘Prana Vayu’ located near the nabhi moves upward to the hrdaya (heart) and comes out of the throat to drink the Visnupadamrta (nectar of atmosphere i.e. oxygen) and having part taken, it moves quickly inside to enliven the entire body and kindle the gastric fire (digestive power). Because of their combination of Vayu (air) and Sarira (body), Ayu (life) is existing when they get separated in course of time pancatwa (death) supervenes. No animal is immortal in this world, death is unavoidable whereas diseases can be avoided.

Definition of COPD

Chronic obstructive pulmonary disease (COPD) has been defined by the Global Initiative for Chronic obstructive lung disease (GOLD) as "a disease state characterized by airflow limitation that is not fully reversible".

COPD includes emphysema, an anatomically defined condition characterized by destruction and enlargement of the lung alveoli, chronic bronchitis is a clinically defined condition with chronic cough and phlegm and small airways disease, a condition in which small bronchioles are narrowed.

GOLD estimates suggest that COPD will rise from the sixth to the third most common cause of death worldwide by 2020.
(Harrison's internal medicine -16th edition 2005)

The terms "chronic obstructive airways disease" (COAD) and "chronic obstructive lung disease" (COLD) have been variously used to describe "airway obstruction" occuring mainly in smokers or ex- smokers.

Chronic bronchitis is defined on the basis of the history as:
* Cough productive of sputum on most days for at least three months of the year for more than one year.
Emphysema on the other hand is defined pathologically as:
* Dilatation and destruction of the lung tissue distal to the terminal bronchioles. (Kumar and Clark Clinical Med. 4th Edn.2005)

By "British Thoracic Society" Chronic bronchitis has been classified into three forms ‘simple bronchitis’, defined as hyper secretion of mucus, chronic or recurrent ‘mucopurulent bronchitis’ in the presence of persistent or intermittent mucopurulent sputum, and ‘chronic obstructive bronchitis’ when chronic sputum production is associated with airflow obstruction. The use of the term ‘chronic obstructive bronchitis’ arose from the ‘British hypothesis' that persistent recurrent infection, and thus chronic sputum production, resulted in damage to the airways and hence airways obstruction. The guidelines published by the "American Thoracic Society" (ATS) define COPD as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema, the airflow obstruction is generally progressive, may be accompanied by airway reactivity and may be partially reversible .The "European Respiratory Society" (ERS) has adopted a similar definition : “a disorder characterized by reduced maximum expiratory flow and slow forced emptying of the lungs, features which do not change markedly over several months”. The definition adopted by the BTS is similar a slowly progressive disorder characterized by airways obstruction (reduced FEV1 and FEV1/FVC ratio), which does not change markedly over several months.

The term chronic obstructive pulmonary disease (COPD) has gradually displaced “chronic bronchitis” and “emphysema” as a label for the type of airways obstruction seen predominantly in smokers and exsmokers. (Oxford Textbook of Med. 1st Edn. 2000)

Chronic bronchitis and emphysema, which are two distinct pathologic conditions, share similar symptoms and frequently coexist. Patients with either or, more commonly, both conditions are usually classified as having ‘chronic obstructive lung disease’ or ‘chronic obstructive pulmonary disease’ (COPD).
(Drazen Gill, Cecil, Textbook of Med. 21st Edn. 2000)

Clinical manifestations

Symptoms

• A productive cough is usually present, associated with a thick or "sticky" sputum varying widely in quantity copious amounts of purulent sputum, coupled with cough
• Cough with production of sputum, wheeze and breathlessness following many years of smoker's cough.
• Exertional dyspnoea
• Dyspnoea at rest
• Morning headache may indicate onset of significant carbondioxide retention.
• Weight loss, anorexia (advanced disease), may occur due to hypermetabolism and decreased caloric intake.
• Chest pain may occur due to underlying heart disorder or gastro esophageal reflex.
• Chest tightness during excerbations of breathlessness.
• Anxiety, depression and sleep disturbances are common.
• Recurrent bronchial infections.
• Smoker's cough with the production of small amounts (usually < 60ml) of mucoid sputum, often occuring predominantly in the morning for many years.
• Severe orthopnoea.
• Hemoptysis in association with purulent sputum may be due to inflammation or infection.
• Psychiatric morbidity, particularly depression, is common.
• Impaired sleep quality in advanced COPD.

Physical Signs

Physical signs in the patients with COPD are not specific to the disease and depends on degree of air flow limitation and pulmonary overinflation:

• In mild disease there are no signs except wheezing throughout the chest.
• There are no clinical findings in the earlier stages (diagnosis depends on spirometery).

With progression - sign of hyperinflation occurs like -

• Barrel shaped chest.
• Low positions of the laryngeal prominance.
• Loss of cardiac dullness and lowering of hepatic dullness.
• Increased frequency of breathing.
• Use of accessory muscles while respiration.
• Loss of the normal outward movement of abdomen during inspiration.
• Wheeze, particularly in the second half of expiration.

At the most advanced stage

• Pursed lip breathing.
• Cyanosis
• In drawing of the lateral rib cage (Hoover's sign) on inspiration.
• Ankle odema
• Variable degree of tachypnoea.
• Prolonged forced expiratory time (>5 sec.)
• Flapping tremors (indicating hypercapnia)
• Use of accessory muscles of respiration, particularly sternomastoids.

In later stages of disease

• Barrel shaped chest, with Kyphosis (Increased A.P. diameter)
• Horizontal ribs
• Prominence of sternal angle and a wide subcostal angle.
• Widening of xiphisternal angle and abdominal protuberance occur.
• Rise in jugular venous pressure (J.V.P.) may be seen on expiration.

Treatment of Shwasa Roga

Ayurveda believes that the treatment in short is to eliminate all possible causes of the disease.The primary approach of treatment for “shwasa roga” had been described by Charakaa in Chikitsa Sthana chapter 17/70

The treatment is divided into two groups

• Samsodhan chikitsa
• Samshamanaa chikitsa

“This division can be derived on the basis of body constitution i.e. strong and weak built person and on the basis of dosha predominance”.

Thus the three major treatment modalities mentioned in text for Shwasa Roga are :

• Nidana Parivarjana
• Sodhana Chikitsa
• Shamanaa Chikitsa

1. Nidana Parivarjana includes following measures :

• Follow dietetic code to avoid formation of Ama.
• Avoid Vataprokapaka and Kapha prakopaka Ahara and Vihara.
• Avoidance of Raja, Dhuma, Vayu.
• Follow Ritucharya.
• Daily used of Pratimarsa Nasya.
• Avoid all Nidan (causes) mentioned in Nidana of Shwasa Roga.

2. Samsodhan Therapy :
Charakaa has discribed Samsodhan therapy in chapter 17 (70-76)

• Snehana and Swedana : The patient afflicted with shwasa roga should be first anoited with ( Abhyanga) Til tail associated with Saindhav lavana on the chest, and back, then Nadi Sweda or Prastar Sweda (hot bed sudation) or Sankra Sweda (mixed sudation). The fomentation therapy renders the adhered Kapha dissolved in the channel of circulation and softened thereby. These therapies also cause downward movement of Vayu. “As the snow melts over the creepers in the mountain range, on account of the hot rays of the sun, so does the stable Kapha in the body gets dissolved on account of the heat generated by these fomentation therapies”.(Ca. Ci. 17/73)
• Vamana Karma : After proper Snehana and Swedana Karma, the patient should be given prepared rice (with snigdha dravyas) or curds so that kapha dosha may increase in quantity when, as the result of this diet the kapha is increased in the patient, he should be administered an emetic compound of long pepper, rock salt and honey, taking care to see that such an emetic is not antagonistic Aggrevated kapha plays an important role in the pathogenesis of shwasa roga. The patient gets relief after the vitiated kapha is eliminated. When the channels of circulations are made clear (free from impediments) then Vayu moves at ease without any obstruction. This type of therapy is more useful where shwasa is associated with kasa (cough) and swar bhanga (hoarseness of voice)
• Virechana karma : Virechana with Vata Kapha Nasak Dravya should be given specially in Tamaka Shwasa.Virechana in Tamaka shwasa is indicated due to the fact that the Udbhav Sthana of Tamaka Shwasa is Adho amasaya which is considered to be a place of Pittasthana and in Pitta, virechana is considered to be the most suitable therapy. It seems that Charakaa might have this point of view when he wrote “tamke tu Virechanam” if this is not done, it may lead to Pitta Virddhi and ultimately may give rise to ‘pratamaka shwasa’.
• Dhumra Panam : If inspite of oleation, fomentation and vamana karma, the residual dosa still remains adhered to the channels, then, this should be eliminated by the administration of ‘dhumra panam’ (smoking therapy with medicated cigarette). The common drugs for this purpose are Haridra, Yav, Erandamoola, pipal, laksha, Manahsila, devdaru, Jatamansi, tej patra.
• Nasya Karma : Nasya karma has also been indicated in cases of tamaka shwasa, and a number of drugs have been mentioned for Nasya karma.

3. Shamana Chikitsa (Palliative treatment)
Shamana therapy includes :

• Vata kapha nasaka Ausadha, anna, panna,
• Usna Ausadha, anna, panna.
• Vatanulomaka Ausadha, anna, panna.

i.e. ingredients which cause alleviation (Shamana) of vayu and kapha, which are hot in potency, which causes downward movement of vayu (Vatanulomana) are useful as medicines, drinks and food preparations for the patient suffering hiccup and “shwasa roga”.

The therapy which alleviates Vayu is generally nourishing (brmhana). Applying such therapy may produce some adverse effects, but such adverse effects are minimal, and moreover patient will gain strength by the nourishing therapy as a result of which he can easily overcome these adverse effects.

It is only the alleviation (shamana) therapy which is absolutely free from these adverse effects, and such category of therapy should be preferred for the treatment of shwasa roga.

Management of different conditions of patients :(Ca. Ci. 17/89)

Charaka has advised a brief line of treatment of Shwasa roga in the above verse.
If Kapha is predominant and the patient has strength, then he should be given wholesome food, and be administered emetic and purgation therapies, dhuma, leha (linctus) for the alleviation of dosas (sanshamanaa)
If vayu is aggrevated, if the patient is weak, and if the patient is either an infant or old, then he or she should be administered vayu alleviating drugs, and nourishing recipes prepared of ghrta, vegetable soup, meat soup.

Single drugs for Shwasa roga :
Charakaa has described “Swashara Mahakasaya” Sushruta described “Surasadigana” (Su. 38/18-19) and “Dasamulagana” (Su. 38/66-72) for the treatment of Shwasa Roga.
Some commonly used single drugs for Shwasa Roga are :

• Ankol Beej
• Marich
• Shweta Kushmand
• Kantakari
• Kaiwach
• Vasa
• Arka
• Soma
• Dhatura
• Madhuyasti
• Malla (White Arsenic)
• Kulathi
• Abhraka (Mica)
• Draksa
• Manahsila (Arsenic Rubrum)
• Punarnava
• Bharangi
• Amla
• Haridra
• Godanti (Gypsum)

Compound preparation for Shwasa Roga
Rasa Preparations :

• Shwasa Kuthar Rasa
• Shwasa Chintamani
• Shwasa Bhairav Rasa
• Chandramrt Rasa
• Mahalaxmi Vilasa Rasa
• Laxmi Vilasa Rasa
• Basant Malti Rasa
• Nardiya Laxmi Vilasa Rasa

Vati Preparations :

• Vijaya Vati
• Mrganka Vatika (Brhat)
• Bhagottara Gutika

Churana Preparations :

• Sitopaladi
• Talishadi
• Jiwantiyadi
• Haridradi
• Indra Varunakadi Churna
• Satyadi Churna.
• Sringyadi Churna (especially for children)
• Kantakari, Amalaki, Hingu (half) (to be taken with Madhu)

Ksar Prayoga

• Aswagandha Kshar with honey and ghrt
• Ksar of fish sclaes.
• Apamarg ksar
• Yavaksar
• Arka Ksar and Arka Lavana
• Ksar of Kurr Pankh.

Yoga preparations :

• Soma yoga (Rasa sindoor and Soma churan)
• Swargika yoga
• Maha Katphaladi yoga
• Nidigdhikadi yoga
• Madhukadi yoga

Kwatha Preparations :

• Kulathyadi kwatha
• Vasadi kwatha
• Dasamula kwatha
• Bharangi nagar kwatha
• Amrtadi kwatha

Ghrta prayoga :

• Srngi Gur Ghrt
• Purana Ghrt
• Dashmul Ghrt
• Tejovatyadi Ghrt
• Manahshiladi Ghrt
• Dadhika Ghrt
• Vasa Ghrt
• Dhanwantari Ghrt
• Hisradya Ghrt

Asava/Arista :

• Kanakasav
• Dasamularisha
• Draksarista
• Pathadya Asava

Gura :

• Bharangi
• Kulttha
• Gur and Katu taila (in equal quantity)
• Bharangi Sarkara

Avaleha :

• Gur Avaleha
• Haridradi Leha
• Bharangyadi leha
• Ksudra Avaleha
• Bharangi Haritaki Avaleha
• Draksa harityadi Avaleha
• Kharjuradya Avaleha
• Vasaharitaki Avaleha
• Vasavaleha Kantkari Avaleha
• Chyavanpras Avaleha.
• Tamelya Avaleha (Siddh Bhaisajya Ratnawali)