Case Report
A 10-year-old girl presented in the Outpatient Department (OPD) with complaints of breathlessness, cough, and sneezing, especially early in the morning on and off since, she was five years old. She had been taking allopathic medicines in the form of nebulisation, steroids, and inhalers, specifically rota caps (100 mcg) twice a day. Her symptoms were aggravated during the winter season.
Additionally, the patient reported a decreased appetite on/off from 4-5 days and generalised weakness in the last 3-4 days. No significant illnesses were noted. The patient came for Ayurvedic treatment and was subsequently admitted to the Inpatient Department (IPD).
The written informed birth history revealed significant preterm delivery at around 30 weeks of gestational age due to maternal hypertension, with a normal vaginal delivery. The birth weight was 1.00 kg, cry immediately after birth. She was born to a couple in a second-degree consanguineous marriage, with the father undergoing treatment for asthma. The patient had a history of a 20-day stay in the Neonatal Intensive Care Unit (NICU) due to respiratory distress and extremely low birth weight.
According to her developmental history, every developmental milestones were achieved at the appropriate ages. The personal history reveals poor appetite with a mixed diet; bowel movements occurred once or twice a day, urination occurred about 6-7 times a day, and she experienced sound sleep. She expressed a preference for fast food, chocolates, and packaged foods, while disliking milk and dairy products.
In terms of past medical history, the patient experienced recurrent respiratory tract infections and had been admitted for the same issue. She had been receiving allopathic medications, including nebulisation, steroids, and inhalers (specifically rota caps 100 mcg twice a day), but despite this treatment, she continued to experience recurrence and exacerbations. This led to a discontinuation of therapy due to dependency on these drugs and nebulisation for quick relief, prompting her to seek natural and safer alternatives.
On general examination, the patient appeared ill, with a Body Mass Index (BMI) of 16.4. She had a coated tongue, normal eyes, a height of 121 cm, and a weight of 24 kg. Her respiration rate was 26 breaths per minute, and her blood pressure was 110/70 mmHg. A systemic examination of the respiratory system revealed rhonchi and crepitations. The patient was oriented to time, place, and person, and other systemic examination parameters were within normal limits.
The case was diagnosed as Tamaka Shwasa, or bronchial asthma, based on clinical signs and symptoms such as difficulty in breathing (Shwasa Krichhrata), cough (Kasa), sputum (Kaphanistivan), wheezing (Ghurghurukam), frequency of Shwasa vega, and cold (Pinasa), as mentioned in [Table/Fig-1] [1].
| Symptoms | Grade 0 | Grade 1 | Grade 2 | Grade 3 |
|---|
| Shwasa krichhrata | There is no evidence of Shwasakrichhrata | Slight Shwasakrichhrata after intense work | Shwasakrichhrata during slight exercise such as walking | Shwasakrichhrata even at rest |
| Kasa | No Kasa | Kasavega sometimes | Troublesome | Very troublesome |
| Pinasa | No Pinasa | Along with the attack | Very regularly, even without an attack. | Always persisting |
| Parshvashula | No | Along with the attack | Very regularly, even without an attack | Always |
| Ghurghurukam (Wheezing) | No wheeze during auscultation | Frequently wheezing over a few lobes of the lungs | Mild wheezing in several lobes of the lungs | Moderate wheezing throughout in few lobes of the lungs |
| Kapha Nishthivana | No Kaphanishthivan | Occasional Kaphanishthivan | Very often Kaphanishthivan | Always Kaphanishthivan |
| Frequency of Shwasa Vega | No attack for 7 days | 1 attack over 7 days | >1 attacks over 7 days | Daily attacks for 7 days |
| Anidra | Sound sleep | Uninterrupted late sleep | Sleep interrupted in the late night and early morning | Disturbed sleep |
Treatment: The treatment protocol adopted in the first session included Deepana, Mridu Rechana, and Langhana, along with Kapha-hara ahara and anti-helminthics. The internal administration of medicine for the first session is as follows:
Agnitundi Vati (250 mg) at a dosage of 125 mg twice daily (after food) with lukewarm water for five days.
Krimi kuthar Rasa (125 mg) at a dosage of 250 mg twice daily (before food) with lukewarm water for five days.
Triphala Kwath 5 mL twice daily (after food) with water for five days.
Shirisharishta 5 mL (after food) with water for five days.
Avipattikar Churna 1 teaspoon at bedtime with warm water.
Dosages were calculated based on Young’s formula.
Plan for Virechana:
Day 1 and Day 2: Saindhav+Trikatu+Hingwastak churna Deepana Pachana for two days.
After Deepana Pachana, Snehapan was given for next three days.
Day 3: 30 mL Koshna Til Taila (Luke Warm Til Taila)
Day 4: 40 mL Koshna Til Taila
Day 5: 60 mL Koshna Til Taila
Day 6: Snehana,Swedana
Day 7: Snehana, Swedan, Mrudu Virechan- Avipattikar churna+Manuka=Kwath 50 mL with Castor oil 20 mL+Ushnodak 100 mL and Vega: 4-6 vegas with semi-loose consistency.
Day 8 and Day 9: Sansarjan Karma
Vardhaman Pippali Rasayana: Raw Pippali (Piper longum Linn) was used in the Vardhamana Krama. On day 1, one Pippali was boiled with water; on day 2, two Pippalis were boiled, and on day 3, three Pippalis were boiled until the water evaporated. For the following three days, the dose was reduced from three to one in decreasing order. This process was carried out for a total of six days. After that, one Pippali was continued daily for the next 10 days.
On discharge, the medications prescribed were as follows: Shwasananda Gutika 125 mg tablet twice daily (BD), Talisadi Churna 1 gram BD, Abhrak Bhasma 100 mg BD, Godanti Bhasma 100 mg BD, Tankan Bhasma 50 mg BD, Trikatu Churna 300 mg BD, and Triphala Churna 500 mg BD. These medications were mixed together and given with honey and Dashmool Kwath 10 mL BD. The above treatment was continued for a total of 20 days.
After the first course of treatment, the child’s appetite improved significantly. Additionally, the symptoms of breathlessness, wheezing, and the frequency of attacks were greatly reduced. The patient was advised to engage in exercises, such as inflating balloons and practicing Pranayama at home.
Pathya (Recommended practices): Pranayama, meditation, yoga, garlic, ginger, turmeric, black pepper, lukewarm water, and honey during the treatment duration and follow-up.
Apathya (Avoid): Consumption of heavy and cold foods, such as fried foods, fish, sweets, preserved foods, curd, chilled water, intense physical activity, repression of instinctive desires, exposure to a chilly environment, stress, smoke, fumes, and other similar factors.
For the second session, the internal medications prescribed were Gopichandanadi Vati 250 mg BD (after food) with lukewarm water, Hinguvachadi Vati ½ teaspoon five times daily (after food) with lukewarm water, and a syrup containing Yashtimadhu, Vasa, Kantakari, and Tulsi, 5 mL BD (after food).
The procedures advised during the second session included Utsadan for 20 minutes with Dashmool Taila and Vacha Churna for seven days, and Nadiswedana for 15 minutes with Dashmool Kashaya and Bala Churna for seven days. Upon discharge after the second session, the medications included Chyawanprash 1 teaspoon BD for one month and Pranayama, specifically Ustrasana.
After the second course of treatment, there was further improvement in the child’s appetite, as well as a reduction in breathlessness, wheezing, and the frequency of attacks. The patient was advised to take Kaphahar aahara and to continue exercises such as inflating balloons.
Before and after the course of treatment, the severity of symptoms was noted and the details are given in [Table/Fig-2].
Symptomatic severity across different stages of treatment.
| Symptoms | Before treatment | After 1st sitting | After 2nd sitting |
|---|
| Shwasa krichhrata | 3 | 1 | 1 |
| Kasa | 3 | 1 | 0 |
| Pinasa | 1 | 0 | 0 |
| Parshvashula | 1 | 0 | 0 |
| Ghurghurukam (Wheezing) | 3 | 1 | 0 |
| Kapha Nishthivana | 3 | 1 | 0 |
| Frequency of Shwasa Vega | 3 | 1 | 0 |
| Anidra | 2 | 0 | 0 |
This table illustrates the effectiveness of Ayurvedic treatment in reducing the intensity of Tamaka Shwasa symptoms, showing a notable improvement in the patient’s condition following the two treatment sessions.
Investigations: The patient’s Complete Blood Count (CBC) parameters significantly improved after receiving Ayurvedic treatment [Table/Fig-3]. The White Blood Cells (WBC) count decreased from 13,400/cmm to 9,600/cmm, and the eosinophil proportion decreased from 13% to 7%. Both of these findings are noteworthy, indicating a reduction in inflammation and allergic reactions. Overall, the patient’s haematological health was positively affected by the treatment, as evidenced by other metrics that stayed within normal ranges.
CBC report before and after the treatment.
| Test description | Before treatment | After treatment | Normal range |
|---|
| Haemoglobin (gm) | 11.40 | 11.60 | (11-16 gm.%) |
| RBC Count (millions/cmm) | 4.48 | 4.56 | (3.5-5.5 millions/cmm) |
| Haematocrit (HCT/PCV) | 38.6 | 39.2 | (37-47%) |
| MCV (fL) | 82.6 | 85.6 | (80-100 fl.) |
| MCH (Pg) | 28.6 | 30.6 | (27-32 Pg.) |
| MCHC (%) | 32.6 | 33.6 | (32-36%) |
| Platelet count (*103/cmm) | 262 | 292 | (150-300)*103/cmm. |
| WBC count (cmm) | 13400 | 9600 | (4,500-11,000/cmm.) |
| Neutrophils (%) | 66 | 64 | (40-70%) |
| Eosinophils (%) | 13 | 07 | (0-6%) |
| Basophils (%) | 00 | 00 | (0-1%) |
| Lymphocytes (%) | 20 | 28 | (20-50%) |
| Monocytes (%) | 01 | 01 | (2-10%) |
| WBC morphology | As above | Nil | |
| RBC morphology | Nil | Nil | |
| Platelets on smear | Adequate on smear | Adequate on smear | |
HCT/PCV: Haematocrit/packed cell volume; MCH: Mean corpuscualr haemoglobin; MCHC: Mean corpuscular haemoglobin concentration
Follow-up and outcome: Follow-up assessments were conducted every 20 days to monitor the clinical results of the therapy and to assess any adverse reactions to the medication in the child. However, no adverse effects were found from any medicine or procedure. The post-treatment follow-up was also satisfactory, and the parents expressed their happiness at being able to discontinue repeated nebulisation and steroidal therapy.
Discussion
Dosha vitiation and Srotorodha (obstruction of channels) are among the main causative factors for Tamaka Shwasa, which further leads to the manifestation of disease symptoms primarily associated with Vata and Kapha doshas. The treatment principles of Ayurveda emphasises to remove the obstruction of channels and pacify the aggravated doshas. This can be achieved by selecting suitable drugs that possess properties like Vata-Kapha hara, Ushna, and Vatanulomana.
The traditional use of Shirisha bark in the treatment of inflammatory disorders includes its decoction, which has antihistaminic and bronchial asthma preventive properties. Therefore, it was being used in present case study [2,3]. The Pittasthana (stomach) is considered the origin of Shwasa Roga origin. Therefore, to curb exacerbated Pitta Dosha vitiation, Virechana Karma was conducted to facilitate Apunarbhava treatment instead of suppressing the dosha.
Tamketu Virechanam was also mentioned by Acharya Charaka. It is recommended to perform Mridu Virechana if, Vata Dosha is still connected to other Doshas [4]. In patients with Shvasa Roga, Virechana Karma helps balance the Vata Dosha, which is linked to Kapha. In present case, the patient is from the paediatric group; so here Mridu Virechana has been given [5]. As a result, Virechana aids in preserving Pitta Dosha at a normal level by increasing appetite and promoting a feeling of lightness and freshness.
In respiratory disorders such as Shwasa (asthma) and Kasa (cough), mucous and sticky secretions obstruct the passage. To clear the blocked passages, castor oil is utilised [6]. Vardhamana pippaliprayoga is mentioned by Yogaratnakara as a treatment for Shwasa (dyspnoea), Kasa (cough), and Jwara (fever) [7]. It is also recommended in chronic obstructive pulmonary disease as a Rasayana [8]. In clinical trials for the treatment of Shwasa Roga, a formulation containing Abhraka Bhasma has been found to be both safe and efficacious [9]. Abhraka Bhasma is also used in patients with asthma and low immunity, particularly those with srotorodha [10]. Godanti Bhasma is beneficial for curing cough and dyspnea due to its Vata-kaphahara action [11]. Tankana is utilised in Shwasa and Kasa because it exhibits Kshara characteristics, which facilitate the absorption of mucus and secretions [12]. Vasa is recommended for conditions including Rajayakshma (tuberculosis) and Shwasa [13]. Vasicine and vasicinone, two bitter alkaloids found in the plant, possess bronchodilating properties. Few studies have demonstrated that vasicinone is 6-10 times more effective than aminophylline in cases of bronchial asthma [14]. The allopathic medicines that were earlier used by the patient are suggested for use in emergency condition. Pranayama also plays a very important role in the management of Tamaka shwasa, as it helps to increase lung tidal volume and strength [15].
Conclusion(s)
The clinical features of Tamaka Shwasa, as described in Ayurvedic classics, are identical to those of bronchial asthma. It is clear that a combination of shaman and Virecana Karma, a form of laxative therapy, is a suitable option for treating Tamaka Shwasa. No side effects were observed in the present study. In the nutshell, recurrence was reduced, appetite increased, and strength also increased.
HCT/PCV: Haematocrit/packed cell volume; MCH: Mean corpuscualr haemoglobin; MCHC: Mean corpuscular haemoglobin concentration
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