E-ISSN:2456-3110

Review Article

Bronchial asthma

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 2 March
Publisherwww.maharshicharaka.in

Narrative review to unravel the link between symptoms and components of pathogenesis (Samprapti Ghatak) of Tamak Swasa (bronchial asthma)

Mali V.1*, Mali P.2
DOI:

1* Vaishali Mali, Assistant Professor, Department of Samhita-Siddhant, Ch. Brahm Prakash Ayurved Charak Sansthan, Khera Dabar, Najafgarh, New Delhi, India.

2 Pavankumar Namdeo Mali, Chief Medical Officer (NFSG), Directorate of Ayush, Department of Health & Family Welfare, Government of NCT of Delhi, New Delhi, India.

Tamak Swasa is a disorder of Pranavaha Srotas. It highly correlates with the clinical picture of bronchial asthma. The non-recognition of Tamak Swasa in the early stages may lead to worsening of symptoms, frequent attacks of Swasa, and decreased quality of life. It is highly essential to recognize the underlining pathology and related Samprapti Ghataka (components of pathogenesis) based on clinical signs and symptoms of asthma. This understanding helps a physician to choose the most appropriate therapeutic approach. This review aims to explain the underlying pathology of symptoms of Tamak Swasa. A literature search was performed referring Bruhatrayee, Laghutrayee, and all other available classical texts of Ayurveda. Published articles were referred to using PubMed and google scholar search. This review analyzed that Vegavastha (exacerbation) and Avegavastha are important milestones of treatment. Identification of involvement of Vata and or Kapha Dosha, Aavaranajanya Samprapti (obstructed pathology), types of Srotodushti (Srotasas are the channels of transportation), deteriorated status of Jatharagni and functionality of Apan Vayu (a subtype of Vata Dosha) found to be vital components of pathogenesis linked with the major symptoms responsible for the manifestation of serious exacerbation stage of Tamak Swasa.

Keywords: Samprapti, Lakshan, Ayurved, components of pathogenesis, bronchial asthma

Corresponding Author How to Cite this Article To Browse
Vaishali Mali, Assistant Professor, Department of Samhita-Siddhant, Ch. Brahm Prakash Ayurved Charak Sansthan, Khera Dabar, Najafgarh, New Delhi, India.
Email: 		Vaishali Mali, Pavankumar Namdeo Mali, Narrative review to unravel the link between symptoms and components of pathogenesis (Samprapti Ghatak) of Tamak Swasa (bronchial asthma). J Ayu Int Med Sci. 2022;7(2):44-51.
Available From
https://jaims.in/jaims/article/view/1650

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-02-05 2022-02-07 2022-02-14 2022-02-21 2022-02-27
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 18%

© 2022by Vaishali Mali, Pavankumar Namdeo Maliand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Hetu, Ling, and Aushadhi are Trisutras of Ayurved.[1] These factors play an important role in the diagnosis and treatment of any disease. Symptoms are more important in the diagnosis of disease. The disease is mentioned as Lakshan Samucchaya i.e., group of symptoms. Every symptom is the repercussion of the underlying pathology of the disease. Underlying pathogenesis starts from the indulgence of Nidana (causative factors) and it goes on till the appearance of Lakshnas (symptoms). For treatment purpose, it is essential to find out this underlying pathology based on symptoms. ‘Samprapti Vighatanam Eva Chikitsa’ Treatment based on Samprapti Vighatan gives complete relief from disease and it never reappears as long as Hetu-Sevan (exposure to etiological factors) is restricted.

Darshan (inspection), Sparshana (palpation and percussion by touching), and Prashna (interrogation) are used as a tool for assessment of patient whereas Nidan Panchak is used as a tool for assessment and to diagnose the disease. While mentioning Nidan Panchak (five stages to evaluate disease), general pathogenesis (Samanya Samprapti) of disease is mentioned in classics along with symptoms, but in practice, it is observed that patient may not be having all symptoms of disease mentioned in classics. In this condition, it is very essential to identify the signs and symptoms of the patient and confirm the underlying pathogenesis accordingly. It will provide us a complete picture of the disease status of patient. Here an attempt is made to illustrate the underlying pathology of every symptom of Tamak Swasa mentioned in classics.

Material and Methods

Ayurveda classics like Bruhatrayee and Laghutrayee were referred. Electronic search engines like Google Scholar, PubMed were also searched for relevant data. Collected data was then analyzed to tress the underlining pathogenesis for the related symptoms.

Discussion

Ancient classics have described the Tamak Swasa (bronchial asthma) as a type of Swasa disease. After an explanation of general manifestation of Swasa, Acharya Charak

has described the pathogenesis and symptomatology of Tamak Swasa separately. Symptoms of Tamak Swasa find a correlation with bronchial asthma in allopathic medicine. They are discussed below to explore the underlying pathogenesis.

Greeva Shirascha Sangrihya (stiffness in the neck and head)

This symptom appears due to Vataprakopa. Sankocha is appeared due to vitiated Vata.[2] It may also be due to Snayugata Vata causing spasm of neck muscle, manifested as Griva and Shirasosangrihya.[3]

Stiffness in the neck and head is observed during acute exacerbation of bronchial asthma. In this stage, patients are suffering from severe dyspnea. To compensate for increased demand additional muscles of respiration are working. Here neck muscle e.g., sternocleidomastoid gets contracted to lead to stiffness of the neck and head region. McFadden et al in their study revealed that consistent retraction of the sternocleidomastoid muscle is an important sign to identify the severe impairment of pulmonary function.[4] 

Peenasam Karoti (rhinorrhea)

Vitiated Vata when enters the Pranavaha Srotas (channels carrying prana), deranges the Kapha situated in the Urahsthan (chest region). This aggravated Kapha results in Peenasa. A survey study conducted by Ohta K et. al observed severe rhinitis as one of the major factors associated with asthma exacerbations.[5]

Ghurghurakam (Kanthe Ghurghurak Shabdam-Chakrapani) (wheeze)

It appears due to the vitiated Kapha, which obstructs normal flow of Vayu. This symptom appears due to Srotorodha (obstruction of airways) and it is produced during breathing. Sometimes vitiated Vata due to Srotosankoch (bronchospasm) leads to narrowing of channels, which produces wheezing sound.

Wheezing may result from localized or diffuse airway narrowing or obstruction from the level of the larynx to the small bronchi. The airway narrowing may be caused by bronchoconstriction, mucosal edema, external compression, or tenacious secretions.[6] Wheezing is observed as a major symptom of an asthma attack.[7]


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Ativ Tivra Vegam Swasa (Exceedingly severe attack afflicts the Prana and enhances severity)

Tamaka Swasa has been described as a disease occurring in Vegavastha (paroxysmal attack). This is "Pratyatma Lakshana" (cardinal symptom) of Tamak Swasa. Word Tivra’ is used to express more distress during respiration. Spasm of smooth muscle and mucus plug formation in airway obstructs airway. Due to this obstruction, less amount of Prana Vayu enters the body. To compensate for the required amount of Prana, rate of respiration is markedly increased which is explained as Ativa Tivra Swasa.

Pratamyati Ativegat Kaasate Sanniruddhyate (During severe coughing, patient faints repeatedly)

The patient gets repeated attacks of fainting during continuous coughing which if continue for a longer period causes distress to the patient. Many theories have proposed to explain the probable mechanism behind the loss of consciousness following cough: various consequences of the marked elevation of intrathoracic pressures induced by coughing: diminished cardiac output causing decreased systemic blood pressure and, consequently, cerebral hypoperfusion; neurally mediated reflex vasodepressor-bradycardia response to cough are some of them.[8]        

Shlesma Mucchyamane Bhrisam Bhavati Dukham / Shlesma Vimokshante Muhurtam Sukham (The patient finds it difficult to expectorate the phlegm and feels relieved for nearly an hour after expectoration)

‘Stheevana’ is the function of PranaVayu.[9] In Tamaka Swasa, vitiated Kapha obstructs the natural course of Vayu leading to aggravation due to Avarana. Further Ruksh Guna of Vayu changes the nature of Kapha and it becomes sticky, hence cannot expel easily.[10] This Avaranjanya Vayu tries to expel this Kapha, which induces pain. This symptom also differs according to underlying pathogenesis. If underlying Samprapti has a dominance of Kapha, Kapha will be vitiated from the beginning due to its etiological factors. Vitiated Kapha further obstructs the natural course of Vayu. This results in the expulsion of a large amount of Kapha after little coughing and the patient gets relief after expectoration.[11] In another pathogenesis dominance of Vata is observed and Kapha is in a normal state. Vitiated Vata causes vitiation of Kapha Dosha. This aggravated Kapha

causes Avarana of Vata (obstructing Vata Dosha). In such cases, there will be vigorous coughing leading to less or no expectoration and the condition becomes very painful.

Udvansate Kanthah (hoarseness of voice)

Due to intense coughing and Vata Prakopa, dryness occurs in mouth and irritation in throat region results in hoarseness of voice.

Krucchrat Shaknoti Bhashitum (speaks with difficulty)

‘Vakpravritti’ (speech) is the main function of Udana Vayu.[12] In Swasa, vitiated Kapha in Urasthana obstructs the natural course of Udana Vayu leading to Avaranajanya Karmahani (deterioration of natural functions due to obstruction), which results in difficulty in talking (Krucchrat Bhasitam).

While mentioning symptoms of Kaphavrita Udana,[13] Vakaswar-Graha (dysarthria) is mentioned which explains the role of Udana Vayu in the pathogenesis. Intense coughing and breathlessness result in hoarseness of voice and the patient feels difficulty in talking. Tenacious mucous coated in the throat including vocal cord leads to difficulty in speaking.

Shayane Swasa Piditam / Na Cha Api Nidra Labhate (does not get proper sleep, and on lying down suffers from dyspnea):

During exacerbation of asthma, ventilation of air in alveoli reduced in lying down posture. Lungs are not fully expanded; diaphragm moves in upward direction rather abdominal pressure is created on it. Hence surface area available for ventilation is also reduced and secretions obstruct the airways leading to dyspnea and cough. Due to cough and dyspnea person doesn’t get proper sleep.

In patients with asthma, dyspnea is caused by airway obstruction. Antonelli A. et. al have observed that dyspnea increased with the severity of obstruction, mostly because of inspiratory effort and chest tightness. The trigger for chest tightness in asthma could be either chemical or mechanical. The inspiratory effort is found to be originated from an increase in motor command to inspiratory muscles working at increased lung volumes because of dynamic hyperinflation.[14]

Lougheed and O'Donnell found that dyspnea and lung hyperinflation are increased during induced bronchoconstriction.[15]


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Shayane Parshva Graha (on lying down suffers from dyspnea as flanks are afflicted by Vayu):

Acharya Sushruta while describing Parshvshula explains that Vata gets obstructed due to Kapha, manifesting Parshvashula[16] (intercostal pain), Graha (stiffness), and Shula (severe pain). Vata is obstructed due to Avarana of Kapha, which leads to Parshvshula / Graha.

Asino Labhate Saukhyam Shayanah Swasa Piditah (feels comfortable in the seating position, on lying down suffers from dyspnea)

During an asthmatic attack, the patient prefers a seating posture to any other position. Sleeping posture aggravates the exacerbation state. In seating posture diaphragm is lowered hence secretions do not obstruct the airways completely. There will be more space for gaseous exchange.

Hence patient gets relief while seated. This condition is referred to as orthopnoea usually reported in the cases of status asthmaticus.

Ushnam Abhinandati (likes hot things)

The predominance of Kapha is there in the Samprapti with or without the involvement of Vata Dosha. Both the Doshas are having Sheeta Guna. Ushna Guna, which is opposite to Sheeta Guna, pacifies Vata and Kapha Dosha.

So, patients of Tamaka Swasa like warm articles such as tea, coffee, hot water, etc.

Ucchritaksha (face holding upward/bloated eyes)

When proper oxygenation is hampered due to obstruction in the airways, there may be gasping for air to meet the oxygen demand. The patient holds the face upward to facilitate straitening of the airways.

Hence, he keeps his eyes open as he is in apprehension.

Lalate Sweda (sweat on the forehead)  

This clinical feature of asthmatic attack indicates exertion due to rapid respiration. Acharya Sushruta instead of Lalate Sweda mentions only Sweda,[17] which generally indicates the perspiration of whole body.

Lalate Sweda is due to extra efforts taken to meet oxygen demand. Lalate Sweda is also indicated in symptoms of Ardha Shakti Vyayama.[18]

Bhrusham Aratimana (severe restlessness)

During the attack of Tamak Swasa, the patient cannot perform respiration properly as he is under great distress. This causes excess mental restlessness.

Vishushkasyata (dryness of the mouth)

Due to rapid breathing sometimes, patient tries to get maximum amount of air through the mouth leading to dryness of mouth. Due to rapid breathing heat loss is also more through respiration. Acharya Sushruta mentioned Trita (thrust) as Lakshana of Tamaka Swasa.

Muhurmuhu Swasa (Gasping Type of Respiration)

To fulfill the oxygen demand, the respiratory rate is increased. The patient may have a gasping type of respiration; this is a grave condition that may occur in the terminal stage of the disease.

Hypoxia alters the respiratory network. Peña F has studied the neuronal network properties underlying the generation of gasping.

The pre-Bötzinger complex (preBötC) is a cluster of interneurons in the ventral respiratory group of the medulla of the brainstem. This complex is essential for the generation of the respiratory rhythm in mammals.

During severe hypoxia, the network properties within the PreBötC are reconfigured whereby the network no longer generates eupnoea but instead generates a new rhythm, named gasping. Such reconfiguration includes changes in synaptic and intrinsic properties triggered by hypoxia itself, as well as the influence of different neuromodulators released during hypoxia. Gasping has been considered an important arousal mechanism that triggers autoresuscitation.[19]

Muhu Cha Eva Avadhamyate (stir up)

मुहुश्चैवावधम्यते इति क्षणं क्षणं श्वसनेन वायुनाऽवधम्यते | Chakrapani

The body moves along with respiration during an attack. Due to starvation of air, patient tries to inhale a large amount of air inside. For this purpose, the trunk is raised, and during expiration, it is lowered. Acharya Gangadhara explained this phenomenon as the movement of a person traveling on an elephant.


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Meghambu - Sheet Prakvate Shlesmalai Cha Abhivardhate (aggravating factors)

The predominance of Kapha and Vata Dosha is observed in Tamaka Swasa. Vata and Kapha aggravating factors further worsen the condition of Swasa.

Meghambu: While explaining the seasonal impact on body physiology, Chakrapani opines that a cloudy atmosphere leads to an aggravation of Kapha and Vata Dosha, which are the prime Doshas in the etiopathogenesis of Swasa.[20]

Sheeta: Being an inherent property of Dosha it aggravates Kapha and Vata Dosha.

Prag Vata: Directly acts as Preraka Nidana (stimulating cause) for Swasa.

The research findings have substantiated the importance of cold weather as a trigger in the pathogenesis of rhinitis, and the development of asthma. Cold air hyperpnea provokes bronchoconstriction in asthmatic subjects. Cold air hyperventilation also provokes coughing in susceptible people.[21,22] A study has demonstrated that a few hours of exposure to cold air increases the number of inflammatory cells (granulocytes and macrophages) in the lungs.[23]

Another study has revealed the mechanism of cold air effect concluded that the long-term exposure to cold exposure induces airways alterations, increased prevalence of airway hyperresponsiveness, increase in airway fluid osmolarity following hyperpnoea, increase in bronchoalveolar lavage fluid granulocytes, loss of ciliated epithelium, thickening of the lamina propria with increased concentrations of inflammatory cells.[24]

It is also reported that cold damp air causes more symptoms than cold dry air in asthmatic patients. Along with cold air, other meteorological variables like humidity, visibility, cloud cover, air pressure, wind speed, and others in combinations are referred to as “synoptic air masses”, known to influence morbidity conditions like asthma.[25]

Essential component of pathogenesis (Samprapti Ghataka)

The components involved in the pathogenesis of Tamak Swasa and mentioned in various classics are comprehended in the below-given table 1.

Table 1: Components of Pathogenesis of Tamak Swasa highlighted in classics   

Dosha Vata-Prana Vayu (involves predominantly), followed by Udana, Samana and Apana Vayu[26]
Kapha- Kledaka and Avalambaka Kapha
Dushya Udaka, Rasa Dhatu, Rakta Dhatu
Agni Status of Jatharagni - Mandagni, Vishamagni Dhatvagni - Rasa Dhatvagnimandya
Srotasa Pranavaha[28], Udakavaha [29], Annavaha [30]
Udbhavasthana Pittasthana[31], Aamashaya [32]
Vyaktisthana Urah, Phupphusa (lungs), Pranavaha Srotas
Srotodusti Sanga, Vimarg-gamana and Atipravritti
Rogamarga Abhyantara

The role of every component of pathogenesis (Samprapti Ghatak) to manifest Tamak Swasa is discussed below-

Udbhavasthana and Vyaktishtan (site of origin and manifestation): Aamashaya and Pranavaha Srotasa are mainly involved in the pathogenesis, Embryological development also indicates that both lungs and the stomach develops from one bud and are later divided into two compartments. Both the organs are having the same parasympathetic stimulus hence both are interrelated.

Dosha: Vata and Kapha Dosha are involved in pathogenesis. Among subtypes of Vata Dosha, Prana Vayu is dominant followed by Udana, Samana, and Apana Vayu. Acharya Vagbhata opined that vitiation of Prana Vayu leads to development of Swasa.[26] The respiration process, which is under the control of Prana Vayu, gets disturbed in Swasa. Udana Vayu is situated around Nabhi (umbilicus) and Urah Pradesha, which gets associated with prana Vayu. Samana Vayu is mainly related to the balance of fluid parts in body i.e., Udakavaha Strotas as well as it plays a major role in the deterioration of Jatharagni.

Dushya: Udaka, Rasa, and Rakta are primarily involved in pathogenesis. Udaka mainly relates to the fluid part of the body. Hridaya is the second organ involved which is the root of Rasavaha Srotosa. Site of manifestation, Phupphusa (lungs) is an organ evolved from Raktaphena[27] (froth of Rakta Dhatu) (Shonit Phena Prabhavah Phuphusah I)

Srotasa: Pranavaha Srotasa is a primary component of pathogenesis of Tamaka Swasa.[28] Chakrapani has mentioned


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the involvement of Pranavaha and Udakavaha Srotasa in Swasa.[29] Acharya Vagbhata has also mentioned the involvement of Prana, Anna, and Udakavaha Srotasa.[30] Thus, Prana, Anna, and Udakavaha Srotasa are to be considered in the pathogenesis of Swasa disease.

Srotodushti: Sanga, Atipravritti and Vimargagamana are the types of Srotodushti responsible for manifestation of Tamaka Swasa. Vitiated Vayu moving in reverse direction pervades the Pranavaha Srotasa. Vayu gets obstructed by Kapha in its course which further vitiates Prana Vayu resulting in Atipravritti and Vimarg Gamana.

Agni: In the initial stage, Agnimandya is one of the fundamental causes for vitiation of Doshas which leads to formation of Aam. Udbhavasthan of Swasa is Amashaya. Hence the status of Jathragni is pivotal in controlling the disease. Vitiation of Vata and Kapha Dosha in a later stage further deteriorates the status of Jatharagni.

The above discussed symptomatology of the disease is initially classified based on Vegavastha (exacerbation) and Avegavastha. Specific symptoms appear only during Vegavastha. Stiffness in the neck and head, sweat on the forehead, severe dyspnea, repeated fainting, difficulty in speech, ceasing of breath, upward holding of face, dryness of the mouth, severe restlessness these symptoms are predominantly observed during exacerbation. Sroto-Sankocha (obstruction of the airway) caused due to vitiation of Vata Dosha, vitiation of Kapha obstructing the functioning of Vayu, an increase of Abhishyandi Guna results in excess oozing from walls of Srotosas are the probable factors responsible for exacerbation.

Conclusion

Thus, it can be said that Tamak Swasa though manifest in Pranavah Srotas, originates in Amashaya. Knowledge of underlining pathology for specific symptoms helps physician to finalize the treatment protocol more precisely.  Knowledge of Vegavastha and Avegavastha has utmost importance because treatment modalities will differ during the stage of Vegavastha (exacerbation). Agni Deepan, Kapha Shaman, Vatanuloman, Bruhan and Shaman therapies need to be adopted as per the different stages of the disease.

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