Tamaka shvasa kantakari-kb


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Tamaka shvasa kantakari-kb

  2. 2. DEPARTMENT OF POST - GRADUATE STUDIES IN KAUMARABHRITYA SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA & HOSPITAL HASSAN - 573 201 Certificate This is to certify that the Dissertation entitled “Role of Virechana and Kantakaryavaleha in the Management of TamakaShvasa in Children” is the bonafide record of research work conducted by “Rahul Patil” under my direct supervision and guidance as a partial fulfillment for the award of the degree of M.D. in Ayurveda - Kaumarabhritya. The candidate has fulfilled all the requirements of ordinances laid down in the prospectus of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka for the award of Degree of Ayurveda Vachaspathi (MD Ayu.) in Kaumarabhritya. I am fully satisfied with his work and recommend this dissertation to be forwarded for adjudication.Date: Guide :Place: HASSAN Dr. SHAILAJA U. H.O.D. & PROESSOR Dept. of P. G. Studies in Kaumarabhritya, S D M College of Ayurveda & Hospital, Hassan
  3. 3. DEPARTMENT OF POST GRADUATE STUDIES IN KAUAMARABHRITYA SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA & HOSPITAL HASSAN – 573 201 (Affiliated to R.G.U.H.S, Karnataka, Bangalore) ENDORSEMENT BY THE HOD AND HEAD OF THE INSTITUTION This is to certify that the Dissertation entitled “Role ofVirechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children” is the bonafide record of research workconducted by “Rahul Patil” under the guidance of Dr.Shailaja U,H.O.D. and professor, Dept. of P. G. Studies In Kaumarabhritya, S D MCollege of Ayurveda, Hassan.Dr. Shailaja U. Dr. Prasanna N. Rao.Prof.& H.O.D. PrincipalDept. of P. G. Studies in Kaumarabhritya S D M College of Ayurveda & Hospital,S D M College of Ayurveda & Hospital, HassanHassan Prof. Gurdip Singh Director, Post Graduate Studies S D M College of Ayurveda & Hospital, HassanDate:Place: HASSAN
  4. 4. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled “Role of Virechanaand Kantakaryavaleha in the Management of TamakaShvasa inChildren”is a bonafide and genuine research work carried out by me under theguidance of Dr. Shailaja.U, M.D. (Ay.), Ph.D., Professor and H.O.D., Dept. of P. G.Studies in Kaumarabhritya, S D M College of Ayurveda and Hospital, Hassan.Date: Signature of the candidatePlace: Hassan Rahul Patil
  5. 5. COPYRIGHT DECLARATION BY THE CANDIDATEI hereby declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate thisdissertation/ thesis in print or electronic format for academic/research purpose.Date: Signature of the candidatePlace: Hassan Rahul Patil © Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. ACKNOWLEDGEMENTMy gratitude, which is the mother of all virtues and most capital of all duties, has allthere order and diligence to all those who graciously involved in this venture ofmine. There is much greatness of mind in acknowledging a good turn, as in doing it.I humbly, seek this opportunity to bow my head to the feet of almighty LordDhanwantari for showering their blessings and empowering me to this eventfuloutcome without any impediments.Words are not enough to express my gratitude and indebt to the sacrifices of mybeloved and respected parents Mr. Jagdish Patil and Smt. Shobha who are the causefor me to take this noble profession and shape me into what I am today.I pay my respectful salutations to his Holiness Poojya Shri Veerendra Heggadeji,founder father of SDMCA&H, Hassan and fountainhead of educational movements,for his divine blessings in disguise and who has been kind enough to provide me anopportunity to study and render my service in this esteemed institution.My vocabulary falls short of suitable words to express my recondite sense ofindebtedness to my compassionate teacher Prof. Prasanna N. Rao, Principal, whohas been guiding force and instrumental in all the proceedings of my postgraduatestudy and stood as an excellent encouraging stanchion in all strides in accomplishingthis meticulous effort.It is beyond the reach of my language to inscribe the profound respect and devotiontowards affectionate Prof. Gurdip Singh. Director, P.G. Board of Studies, for his
  7. 7. constant support, timely guidance and valuable suggestions to get this work donesuccessfully. The words are inadequate to express with profound reverence my heartiestgratitude and indebtedness to my guide Dr. Shailaja U H.O.D. Dept ofKaumarabhritya for her untiring help, close and constant attention with constructiveand valuable suggestions at every steps of this work. I am extremely grateful to Dr. Srinidhi K Acharya Asst. professor, Dept. ofKaumarabhritya, for his constant support and guidance during my thesis work.I am very much thankful to my colleagues Dr. Shwetha, Dr.Aarthi, Dr.Praveen,Dr.Prasad my seniors and junior for their support and encouragement throughoutthe research work. I am also thankful to Dr.Ramya, Dr.Drishya, Dr.Sunil, Dr.Ketan,Dr. Maheshwar, Dr. Jyotirmoy, Dr. Gautam & my all classmates for their kindsupport.I express my deep sense of gratitude to my brother Mr. Bhushan Patil forsupporting, blessing and praying for my success in life. Rahul Patil
  8. 8. LIST OF ABBREVIATIONSKa.Sa.- Kashyapa SamhitaCha. - Charaka SamhitaSu. - Sushruta SamhitaA.S. - Astanga SamhitaA.H. - Astanga HridayaB.P. - Bhava PrakashY.R. - Yoga RatnakaraM.N. - Madhava NidanaG.N. - Gada NigrahaC.D. - ChakradattaSha.Sa - Sharangadhara SamhitaSu. - SutrasthanaSha - Shareera SthanaNi - Nidana SthanaChi - Chikitsa SthanaI - Indriya SthanaKa - Kalpa SthanaSi - Siddi SthanaU - Uttara tantraKhi - Khila SthanaAEC - Absolute cosinophitea count
  9. 9. TC - Total CountDC - Differential countESR - Erythrocyte Sedimentation ratePEFR - Peak Expiratory Flow RateT.B. - Text BookT.S. - Tamaka ShwasaS.C. - Shringyadi ChoornaE.I.A. - Exercise induced asthmaH.I.A. - Hyperventilation induced asthmaLTD4 - Leukotrine D4PAF - Platelate activating factorPGD2 - Prostaglandin D2UTRI - Upper Respiratory Tract InfectionRSV - Respiratory Syncytial VirusNB - Note beforeJ.M. - Jamnagar I.P.G.T.& R.A. Gujarat Ayurveda UniversityA.D. - Ahmedabad, Govt. Ayurvedic College, Gujarat Ayurvedic UniversityB.U. - Varanasi, Faculty of Ayurveda, IMS., Banaras Hindu UniversityL.K. - Lucknow, State Ayurvedic College, University of LucknowJ.P. - National Institute of Ayurveda, Rajasthan UniversityU.D. - Udaipur M.M.M Government Ayurvedic Colege, Rajasthan UniversityT.R. - Trivendrum, Govt. Ayurvedic College, Kerala University, Thiruvananthapuram
  10. 10. H.Y. - Hyderabad, Government Ayurvedic College, HyderabadB.L. - Bangalore, Govt. College of Indian MedicineM.Y. - Mysore, Govt. College of Indian MedicineR.P. - Raipur, Govt. Ayurvedic College, Pt. Ravishankar University, Raipur.G.W. - Gwaliar, Government Ayurvedic College, Jiwaji University, GwaliarP.U - Puri Government Ayurvedic CollegeC.A. - Calcutta, Post Graduate Centre, University of CalcuttaP.L. - Patiala Government Ayurvedic CollegeP.N.T - Pune Tilak Ayurveda Mahavidyalaya, Poona University Astanga Ayurveda Mahavidyala, Poona UniversityN.D. - Nanded Govt. Ayu. Mahavidyalaya, Dr. Babu Saheb Ambedkar Marathwada VidyapithN.G. - Government Ayurvedic College, Nagpur.N.S. - Shri. Ayurveda Mahavidyala, NagpurB.M. - K.G. Mittal Punarvasu Ayurveda Mahavidyala, Bombay.
  12. 12. LIST OF TABLESSr. no Content Page No.No 1 Nidana of Shvasa 04No 2 samprapti of Tamakashwasa 20No 3 Poorvaropa of Shvasa 22No 4 Roopa of Tamaka Shvasa 23No 5 Differencial Diagnosis of Extrinsic and intrinsic Asthma 30No 6 Vyavacchedaka Nidana of Tamakashvasa 33No 7 Sapeksha Nidana of Shvasa 34No 8 Assessment of Severity of Asthma 35No 9 List of Shamanoushadhi for Shvasa 45No 10 Pathya and Apathya for Shvasa 49No 11 Age wise Distribution 79No 12 Sex wise Distribution 79No 13 Religion wise Distribution 79No 14 Education Status 80No 15 Age of onset 80No 16 Aggravating factors 80No 17 Incidence of associated disorders 81No 18 family history of Asthma 81No 19 Dietary Habit-wise distribution 81No 20 Prakruti wise distribution 82
  13. 13. No 21 Sara wise distribution 82No 22 Samhanana wise distribution 82No 23 Satwa wise distribution 83No 24 Pramana wise distribution 83No 25 Vyayama Shakti wise distribution 83No 26 Showing Ahara Shakti of Tamaka Shvasa patients 84No 27 Showing of Agni of Tamaka Shvasa patient 84No 28 Showing Nature of kosta 84No 29 Effect of Kantakaryavaleha after Virechana on Dyspnoea 85No 30 Effect of Kantakaryavaleha after Virechana on Wheezing 86No 31 Effect of Kantakaryavaleha with Virechana on Cough 86No 32 Effect of Kantakaryavaleha with Virechana on Sputum 86No 33 Effect of Kantakaryavaleha with Virechana on Sneezing 87 Effect of Kantakaryavaleha with Virechana on CommonNo 34 87 Cold Effect of Kantakaryavaleha with Virechana on Day TimeNo 35 87 Asthama Effect of Kantakaryavaleha with Virechana on Night TimeNo 36 88 AsthamaNo 37 Effect of Kantakaryavaleha with Virechana on Discomfort 88 Effect of Kantakaryavaleha with Virechana on Tightness ofNo 38 88 ChestNo 39 Effect of Kantakaryavaleha with Virechana on Chest Pain 89 Effect of Kantakaryavaleha with Virechana on Loss ofNo 40 89 SleepNo 41 Effect of Kantakaryavaleha after Virechana on PEFR 89 Effect of Kantakaryavaleha with Virechana on Impact onNo 42 90 ActivityNo 43 Effect of Kantakaryavaleha with Virechana on Palpitation 90
  14. 14. Effect of Kantakaryavaleha with Virechana on the MeanNo 44 90 Respiratory Rate Effect of Kantakaryavaleha with Virechana on FrequencyNo 45 91 of Attack Effect of Kantakaryavaleha with Virechana on Duration ofNo 46 91 SymptomsNo 47 Effect of Kantakaryavaleha on Dyspnoea 92No 48 Effect of Kantakaryavaleha on Wheezing 92No 49 Effect of Kantakaryavaleha on Cough 92No 50 Effect of Kantakaryavaleha on Sputum 93No 51 Effect of Kantakaryavaleha on Sneezing 93No 52 Effect of Kantakaryavaleha on Common Cold 93No 53 Effect of Kantakaryavaleha on Day Time Asthama 95No 54 Effect of Kantakaryavaleha on Night Time Asthama 95No 55 Effect of Kantakaryavaleha on Discomfort 95No 56 Effect of Kantakaryavaleha on Tightness of Chest 96No 57 Effect of Kantakaryavaleha on Chest Pain 96No 58 Effect of Kantakaryavaleha on Loss of Sleep 96No 59 Effect of Kantakaryavaleha on PEFR 98No 60 Effect of Kantakaryavaleha on Impact on Activity 98No 61 Effect of Kantakaryavaleha on Palpitation 98No 62 Effect of Kantakaryavaleha on the Mean Respiratory Rate 99No 63 Effect of Kantakaryavaleha on Frequency of Attack 99No 64 Effect of Kantakaryavaleha on Duration of Symptoms 99No 65 comparison of effect of treatment 101
  15. 15. LIST OF GRAPHSGraphs Content Page No.No 01 Effect of therapies on Dyspnoea 94No 02 Effect of therapies on Wheezing 94No 03 Effect of therapies on Cough 94No 04 Effect of therapies on Sputum 94No 05 Effect of therapies on Sneezing 94No 06 Effect of therapies on Common Cold 94No 07 Effect of therapies on Day Time Asthama 97No 08 Effect of therapies on Night Time Asthama 97No 09 Effect of therapies on Discomfort 97No 10 Effect of therapies on Tightness of Chest 97No 11 Effect of therapies on Chest Pain 97No 12 Effect of therapies on Loss of Sleep 97No 13 Effect of therapies on PEFR 100No 14 Effect of therapies on Impact on Activity 100No 15 Effect of therapies on Palpitation 100No 16 Effect of therapies on the Mean Respiratory Rate 100No 17 Effect of therapies on Frequency of Attack 100No 18 Effect of therapies on Duration of Symptoms 100No 19 comparison of effect of treatment 102
  16. 16. List of Diagrams – Drugs which are used in studyNo 01 KantakariNo 02 GuduchiNo 03 ChitrakaNo 04 MustaNo 05 Maricha 73No 06 KarkatasringiNo 07 RasnaNo 08 SathiNo 09 KantakaryavalehaNo 10 TrivritNo 11 VidangaNo 12 PippaliNo 13 Moorchita Ghrita 74No 14 HaritakiNo 15 BibhitakiNo 16 Amalaki
  17. 17. Introduction INTRODUCTION Tamaka Shvasa is one among the five varieties of Shvasa explained in almost .all the classics of Ayurveda, which is analogous with bronchial asthma mentioned inmodern medicine. Since centuries TAMAka Shvasa remained to be a challenging andunremitting disease. In both sexes it may occur at any age. Tamaka Shvasa is one ofthe chronic diseases of children, which causes a lot of worries to the patients as wellas parents. It affects school attendance, play works, school performance, day to dayactivities and growth of the child. Bronchial asthma in children is a worldwide problem having an incidence rateof 10-15% in boys and 7-10% in girls. In general population, about 80% of childrenbegin to have symptoms before the age of 4-5 years and 10% starts wheezing for thefirst time in the later childhood. Thus asthma is a chronic respiratory disease inchildren which is increasing day by day due to the mode of life, dietetic changes,pollution environmental variations and various stimuli like dust, cold air, smoke,pollens, house dust mite, viral respiratory track infections etc. Childhood asthma ishighly variable and may differ from patient to patient, so needs much attention andcare. The younger asthmatic child is often very troubled by cough especially atnight rather than flank wheezing. So the diagnosis is often given as bronchitis orspastic bronchitis rather than asthma. Chronic nocturnal cough is one of thesymptoms of asthma children. The older children with asthma, typically has episodicattacks of wheezing and breathlessness, usually worst at night or early morning andare often accompanied by cough, but little or no sputum production. The attacks areseparated by symptoms free interval and duration attach varies from patient to patient. Page 1Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  18. 18. Introduction The nature of attacks of asthma and the pattern of recurrence variesconsiderably from child to child and this has an importance on treatment. Virechana is explained as best treatment in Tamakashvasa i.e. TamaketuVirechanam. As the disease in Pittasthana Samudbhava, Virechana may help a lot.Caraka explains that according to disease, Bheshaja should be used in reduced dosageand in mild form for children. Adopting the same principles, Mridu Virechana withTrivrutta can be administered to children, which does not cause much discomfort tothem.2a Generally it is seen in practice that only Virechana may not cure the diseaseand some Shamana Yoga has to be given. Bhavaprakasha has indicatedKantakaryavaleha to manage Shvasa Raga. Moreover the medicine is palatable &sweet in taste, hence can be administered to children easily.3 In the present clinical study patients were divided into 2 groups. Total 60patients were completed the clinical study with 15 patients in each group. Group Apatients were admitted in S.D.M. C.A & H Hassan and Virechana therapyadministered followed by Kantakaryavaleha for Shamana Chikitsa. In groups Bpatients only Kantakaryavaleha was administered. The study was planned under following headings. 1. Literary review 2. Drug review 3. Clinical study 4. Discussion 5. Summary and conclusionIn the present clinical study Virechana followed by Kantakaryavaleha as a ShamanaChikitsa provided better relief in relieving the symptoms of Tamaka Shvasa. Page 2Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  19. 19. Literary Review REVIEW OF LITERATURETamaka Shvasa is one of the five varites of Shvasa Roga, explained in almost all theclassics of Ayurveda.NiruktiThe term „Tamaka-Shvasa‟ consists of two words „Tamaka‟ and „Shvasa‟.„Tamyati tamuglanou kwip anunasikasya iti deerghahai Shvasagati pratibandhakaDoshaha’.1The word „Tamaka‟ is derived from the dhatu (root) „Tamu – glanau’ with ‘kvip’pratyaya (syllable). It means to choke, be suffocated, darkness.1„Tamyati iti Tamaka’ Tama eva Tamaka’ i.e. where Tama occurs is Tamaka.2Tama means –Darkness 2a The word „Shvasa‟ is derived from the dhatu „shvas‟ with „ghai‟ pratyaya.„Shvasti iti Shvasah‟ it means to – breathe, by which the respiratory movements takeplace.3 The term Tamakashvasa is formed by Karmadharaya Samasa as “Tamakaschaasau Shvasascha Tamaka Shvasaha” It means difficulty in breathing, which mainlyoccurs during night time.Paribhasha Sushruta defined Tamaka Shvasa as “Visheshad durdine tamyeti shwasha saTamako matah”.4 The attack of Shvasa with Tamapravesha occurs specially during Durdina. Nocommentator has mentioned the meaning of the word Durdina. Acharya Carakaexplained that Tamaka Shvasa gets aggravated when one is exposed to cloudyatmosphere, cold water, cold weather, and wind blowing from eastern direction, Page 3Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  20. 20. Literary ReviewKapha aggravating food and regimen.5 Hence the above conditions can be correlatedwith durdina. Vijayarakshita the commentator of MadhavaNidana explained in Shvasa Rogathe expired air produces sound similar to the sound of blow of blacksmith.6NIDANA PANCHAKATamaka Shvasa is one of the diseases where Nidana Parivarjana and SampratiVighatana play an important role.NIDANAThe term Nidana refers to all the factors, which causes initiation and progress of thedisease. Various etiological factors can be studied under 4 conventioanal headings aslisted in Table-1. Table-1 AAhara sambandhi Nidana of Shvasa Mentioned in Ayurvedic Texts A. M. G. Nidana C.S S.S A.S Y.R B.P H N N A. Ahara Sambandhi Sheetapana + + + + + + + + Sheeta Ashana + + - - + + + + Guru Bhojana + + - - + + + + Abhishyandi Bhojana + + - - + + + + Rooksha Bhojana + + - - + + + + Vidahi ahara + + - - + + + + Vistambi ahara + + - - + + + + Adhyashana + + - - + + + + Shleshmala ahara + - - - - - - - Jalaja Mamsa + - - - - - - - Anoopa Mamsa + - - - - - - - Ama Ksheera + - - - - - - - Shaluka + - - - - - - - Dadhi + - - - - - - - Masha + - - - - - - - Nishpava + - - - - - - - VishAmashana + + - - - - - - Puinyaka + - - - - - - - Tila Taila + - - - - - - - Pista padartha + - - - - - - - Amla padartha - + - - - - - - Page 4Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  21. 21. Literary Review Table 1 BVihara sambandhi Nidana of Shvasa Mentioned in Ayurvedic Texts A. M. G.Nidanas C.S S.S A.S Y.R B.P H N NB.Vihara SambadndhiVata Sevana + + + + + + + +Raja Sevana + + + + + + + +Dhomma Sevana + + + + + + + +VyayAma + + + + + + + +Vegadharana + + - - - - + +Sheeta Sthana - + - - + + + +Sheeta snana - + - - + + + +Sheetashana - - - - + + - -Atapa Sevana + + - - - - - -Bhara vahana - + - - + + + +AdwagAmana + - - - - - - +Abhishyandi upachara + - - - - - - -Dwandwa Sevana + - - - - - - - Table 1 CAvastha sambandhi Nidana of Shvasa Mentioned in Ayurvedic Texts A. M. G.Nidana C.S S.S A.S Y.R B.P H N NC.Vyadhi/Avastha sambadhi NidanaPratishyaya + + - - - - - -Kasa - + + + + - - -Jwara + - + + + + + -Chardi + - + + + - - -Kshata kshaya + - - - - - - -Atisara + - + + + + + -Vishoochika + - - - - - - -Vibandha + - - - - - - -Dourbalya + - - - - - - -Udavartha + - - - - - - -Raktapitta + - - - - - - -Anaha + - - - - - - -Pandu + - + + + - - -Rookshata + - - - - - - -Apstarpana + + - - + + + -Shuddi Atiyoga Page 5Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  22. 22. Literary Review Table 1 DAgantu karaka Nidana of Shvasa Mentioned in Ayurvedic Texts A. M. G. Nidana C.S S.S A.S Y.R B.P H N N D. Agantu Karaka Marmaghata + + + + + - - - Visha + - + + + - - - Kantorasa Pratighata + - - - - - - - Acharya Caraka explains that the child feeding on Atisnigdha breast milksuffers from Tamaka Shvasa. Chakrapani commeting on the Nidanas of Shvasa hadgrouped them into Vata Prakopaka gana and Kapha Prakopaka gana, 15, which can bestudied as fallows:VATA PRAKOPAKA NIDANA Sheetapana, sheetasnana, sheeta Vata and similar Nidanas causes sheetaGunavriddhi of Vata, which may in term causes the Kshobha and Sankocha in the Srotas. Ativyayama, Adhvagamana, Bharavahana and Atapa Sevana may cause DhatuKshaya as well as Vata Prakopa.KAPHA PRAKOPAKA NIDANA SheetaSthana, Sheetasana, Sheetasnana, Sheeta Vata etc causes increase inSheeta Guna of Kapha resulting in KaphaVruddhii. Dadhi, Masha etc are Guru andPicchila in nature so excessive consumption of these food materials causes KaphaVriddhii. Vishamashana, Adhyashana and Abhishyandhi Bhojana cause Agnimandyawith resultant production of Ama. The Ama having similar Gunas of Kapha causesKapha Vriddhii. Page 6Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  23. 23. Literary Review Asatmya in our classics has been defined as “Shareerena saha yat athmatamvikritha roopatham na yathi that. Ethena yadupayuktam prakrita roopopaghathakambahavathi that Asatmyami”16 i.e. which doesn‟t suit to the body constitution. Raja andDhooma are well known to produce Tamaka Shvasa symptoms especially in children.These can be taken as pollen grains, smoke, dust particles, animal danders, featherwool and fungal spores.NIDANARTHAKARA ROGAS Acharya Gangadhara in the context of Shvasa Nidana has commented that thediseases like jvara, Kasa, Pratishyaya, Pandu, Kshatakshaya, Raktapitta, Udavarta,Visoochika, Visha etc. cause Shvasa.17 According to Sushruta Apasthamba,Sthanamoola, and Sthanarohita Marma18 and according to Vagbhata Siramarma,Vishalyagna Marma Viddha causes Shvasa.19 Out of these pratishyaya and kasa areknown to produce Tamaka Shvasa. It is explained that Pratishyaya is Nidanarthakasa Roga for Kasa and if Kasa isnot treated properly then it leads to Shvasa i.e. “Kasa Vruddhya Bhaveta Shvasah”.20PITTASTHANA DUSTIKARAKA NIDANA Acharya Caraka has explained Shvasa as Pitta Sthana Samudbava Vyadhi. 21Vagbhata and Cakrapani have explained it as Amashaya Samydbhava Vyadhi. 22 Alletiological factors including Agnimandyakaraka and Amotpadaka Nidanas may begrouped under this heading. These factors affect PittaSthana, which may result inAgnimandya and Ama formation. It is explained that „Rogah sarve api mandagnow‟i.e. all the diseases are produced by Mandagni. Agnimandya and Ama have a definiterole in initiation and severity of Tamaka Shvasa. Page 7Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  24. 24. Literary ReviewKHAVAIGUNYA KARAKA NIDANAS Acharya Sushruta had explained that the vitiated Doshas while traveling allover body, settles where there is Khavaigunya and produces Vyadhi there.23 ThusKhavaigunya in Pranavaha Srotas may occur due to many factors which causesvitiation of Doshas. Thus Khavaigunya in Pranavaha Srotas may occur directly due toAgantu Karanas like Raja, Dhooma, SheetaVata Sevana etc. It is also explained thatPratishyaya & Kasa are Nidanarthakara Rogas for Tamaka Shvasa. ThusKhavaigunyakaraka Nidanas are important factors which are responsible for TamakaShvasa. This Khavaigunya may be compared to bronchial hyperreactivity or airwayhyperresponsiveness.PROBABLE CAUSE FOR RECURRENCE OF TAMAKA SHVASA Caraka explains that, even if a disease is cured, it may reoccur by minor formof etiological factors, 24 which is true especially in case of Tamaka Shvasa. AcharyaCaraka also explained that when a person becomes weak due to earlier diseases andthe channels for the manifestation of the disease (here Pranavaha Srotas) becomesvulnerable for the same disease.25 Cakrapani commenting on the word „margeekrute‟ told that„Vyadhipratibandhakataya margasadrushikrute‟ i.e. person may not become resistantto that Vyadhi.25a Caraka substantiated his statement by giving a simily that, after themain fire is extinguished, a small quantity of fire is enough to flare up the same. This principle can be applied in Tamaka Shvasa also. Because once the childgets Tamaka Shvasa (asthma), the Pranavaha Srotas (airways) is vulnerable for thesame disease, whenever the child is exposed to Nidanas i.e. etiological factors. Thiscan be compared to bronchial hyper-reactivity or airway hyperresponsiveness. In Page 8Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  25. 25. Literary Reviewmost of the cases bronchial hyperreactivity in association with triggering factors, willbe the main cause for childhood asthma.ETILOGOY OF ASTHMAAsthma is a complex disorder involving autonomic, immunologic, infectious,endocrine and psychologic factors in varying degrees in different individuals. Thusasthma is a result of multifactorial inheritance.ALLERGY Airway inflammation related to allergic processes is of fundamentalimportance in asthma especially in childhood asthma. Here the problem is to detectthe specific allergens for a particular individual in the initiation and persistance ofasthma.INHALED ALLERGENS Most of the allergens that initiate asthma are inhaled allergens like pollengrains, animal hairs, dander, feathers, dandruff, dust and smoke etc. Inhalation ofthese allergens in the hypersensitive children leads to a biphasic response (early andlate reactions) ultimately causing bronchoconstriction.26FOOD ALLERGY (INGESTED ALLERGY) Foods that have the highest potential to cause IgE mediated sensitivity arefish, shellfish, peanuts, various nuts and seeds, egg, cow‟s milk, soya, wheat and corn. Children with IgA deficiency have higher levels of antibodies to cow milkproteins and of immune complexes containing milk antigens than do normal controls.Cow milk allergy can contribute to gastro-intestinal reflux, especially associated with Page 9Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  26. 26. Literary Reviewdiarrhoea or atopic dermatitis. Children with gastro-esophageal reflux and atopichistory are more succeptible for asthma.27 Salfites can cause bronchoconstriction in some asthAmatic patients and severelife threatening airway obstruction in few.28 Food additives like dyes (coloring agent) e.g. tartazine, flavouring agents(MSG) and preservatives like metabilsulfite can induce bronchoconstriciton inasthmatic children.28 Various foods or food preparations, which can cause allergy, are listedbelow.29DIETARY SOURCES OF COW MILKButter fried foods ChocolatesBiscuits CookiesBread Cream SaucesButter Cream SoupsCakes CustardCandy Fish fried in batterCereals GraviesYogurt Ice-creamCheeseDIETERY SOURCES OF EGGBaked goods Egg noodlesBaking mixes Ice creamBatters OmelettesBreakfast cereals SoupsCake flours Malted cocoa drinksCandy CookiesCreamy fillings Custard Page 10Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  27. 27. Literary ReviewVIRAL INFECTIONS One of the important factors that triggers childhood asthma are viral infectionsof respiratory tract with respiratory syncytial virus (RSV), parainfluenza virus,influenza virus, and rhino virus. Probably viral infections damage the mucosal surfaceand causes shedding of epithelium leading to mucosal oedema and more mucussecretion.30 One study reveals that viral infections accounts for some 80-85% of asthmaexacerbation in children aged 9-11yrs (Johson et.al.1995).31DIURNAL AND SEASONAL FACTORS Children usually suffer from frequent nocturnal attacks and they will berelatively well without symptoms during daytime.Exercise The commonest problem encountered in asthma management is exercise-induced asthma. Because children are naturally for more active physically than adultsand they often take part in play works or competitive physical activities. The severityof asthma depends upon climate of air breathed and exercise induced asthma (EIA) isless where the air is warm and humid. EIA is seen less common after intermittentexercise such as occurs in most group games as compared with continuous runningfor 6-8 minutes. There fore swimming is best exercise for asthmatic children, as itdoesn‟t cause EIA because the air that the child breathes is relatively humid. Physical exercise is seen as having four effects on the asthmatic person.32 It causes hyperventilation with consequent cooling and drying of bronchialmucous and intern liberates bronchoconstricting mediators such as LTD4. Page 11Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  28. 28. Literary ReviewSMOKING AND POLLUTION In a child with hyper-reactive airways, environmental pollution especiallytobacco smoke can increase the incidence of lower respiratory tract disease andprovokes attacks of asthma. It is interesting to note that the study of Targer et.al.1993; Stick et.al.1996,demonstrated that in infants of mothers who smoke during pregnancy, had reducedresting lung function and increased bronchial reactivity. A study revealed thatdampness in the house was significantly associated with incidence and severity ofasthma. (Williamson et.al.1997) 33PSYCHOLOGICAL FACTORS Emotional factors can trigger symptoms in many asthmatic children.34Emotional stress operates through vagus, initiating bronchial smooth muscles tocontract.35 In these cases control over asthma is poor.ENDOCRINE FACTORS Asthma may worsen in relation to menses especially in pre-menstrual period.In some girls symptoms of asthma reduces after puberty. Thyrotoxicosis increases theseverity of asthma but the pathophysiology is yet unknown.34DRUGS: Drugs such as aspirin, NSAID, tartarazine, -receptor antagonists, andmetabilsulphites can trigger an asthmatic attack. Page 12Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  29. 29. Literary ReviewGASTRO-OESOPHAGEAL REFLUX It has been recognised that gastro-oesophageal reflux can produce an increasein bronchial reactivity (Wilson et.al, 1985; Vincent et.al. 1997) and may beresponsible for the very severe attacks of nocturnal asthma which occurs in somechildren. This can be supported by the study reported that, in some infants antirefluxtreatment has been accompanied by an improvement in lung function. (Eid et. al.1994) In severe asthmatic children having severe and alarming nocturnalexacerbations, the possibility of reflux should be investigated.36CONTRIBUTING FACTORSBronchial hyper-reactivity /Khavaigunyata Bronchial hyper-responsiveness manifests itself as bronchoconstrictionfollowing exercise, on natural exposure to strong odours on irritant fumes such assulphur dioxide, tobacco smoke or cold air.37 This may be compared to Kha-vaigunya explained by Acharya Sushruta. Thevitiated Dosha‟s while moving all over the body settles where the khavaigunya ispresent and produces Vyadhi there.31 When the airway is hyper-reactive (ie whenKhavaigunyata is present in Pranavaha Srotas) various known and unknown stimuli(vitiated Dosha‟s settled in Pranavaha Srotas) cause bronchoconstriction(Shvasakrichrata).GENETIC FACTOR It is acceptable that we cannot give answers for the questions like:- 1. Why the asthmatic airways are hyper-reactive. 2. Whether this is present since birth or acquired. Page 13Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  30. 30. Literary Review 3. Why it seems to disappear during later childhood or puberty in most children as they „grow out‟ of their asthma. Study reported that there was a relatively high incidence of atopy and bronchialhyper-reactivity amongst the totally healthy relatives of asthmatic children andwheezy infant. A child with one affected parent has about a 25% risk of havingasthma; the risk increases to about 50% of both parents are asthmatic.39 It seems thateven in genetically predisposed children also some environmental factor(s) is neededto activate them.PRECIPITATING FACTORS IN ASTHMA /VYANJAKA NIDANA Respiratory symptoms in asthma may be precipitated or exacerbated byvarious factors although in many cases, no precipitating factors may be recognized. Other triggering factors which may produce wheezing are water over scalp orinside nose, irritation of nasal mucous, sweets, some fruits like grapes etc. ice colditems, non stop speech, loud prolonged laughing, exposure to cold air, closed andcrowed places & violent air flow (window seat while travelling). 40SAMPRAPTI The study of Samprapti helps in understanding how the disease has beenmanifested after Nidana Sevana. Thus Samprapti deals with all the pathologicalprocesses, which are responsible for clinical signs and symptoms of the disease. InAyurveda, much importance has been given for Samprapti Vighatana i.e. breaking thepathological process. Because Chikitsa is mainly to disintegrate the Samprapti(pathology) i.e. Samprapti Vighatana meva Chikitsa41 Page 14Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  31. 31. Literary Review Acharya Caraka explains that if the child is feeding on Atisnigdha breast milk,his body channels (Srotas) are constantly smeared with aggrevated Kapha and thechills gets Tamaka Shvasa etc diseases.42 In the Charaka Samhita Chikitsa Sthana, Samprapti of Shvasa has been dealtin three occasions. 1. Common Samprapti of Hikka and Shvasa. 2. Vishista Samprapti of Shvasa. 3. Samprapti of Tamaka Shvasa. I. Common Samprapti of Hikka and Shvasa It is explained that the (vitiated) Vata enters the Pranavaha Srotas (channelscarrying the vital breath) and this vitiated Vata affecting the Kapha which is situatedin Uras (chest) produces Hikka and Shvasa.43From the above explanation we can point out the Acharya Caraka‟s views as 1. Srotas affected is Pranavaha Srotas. 2. Vata and Kapha are primly involved Dosha‟s. II. Vishista Samprapti of Shvasa This Samprapti is common for all 5 types of Shvasa. Acharya Carakaexplained that the Kapha along with Vata obstructs the Srotas. This obstructed Vatatrying to overcome the obstruction moves in all directions resulting in Shvasa.44 Here the term “Kapha purvaka” is commented by Cakrapani as „Kaphapradhana ie predominance of Kapha.45 Gangadhar opines it to be Kapha samyukta i.e.along with Kapha.46 Page 15Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  32. 32. Literary Review The term ‘Vishwagwrajati’ is commented by Cakrapani as ‘Sarvagwrajati’ i.e.moves in all direction.45 (inside the Pranavaha Srotas). But Gangadhara opines it to be“Sarva shareera gacchati i.e. moves all over the body.46 Arunadatta commenting onthe same uses the term “Urasthagagrahanam” i.e. it should be considered as Uras.After observing the above explaination Gangadhar commentory seems to beunacceptable and Cakrapani and Arunadatta opinions hold good. Acharya Sushruta explains that the vitiated Prana Vata gets Urdhwagati andcombines with Kapha and produces Shvasa.48 Dalhana on the above verse commentsthat Tamaka Shvasa is Kaphaprdhana Vyadhi.49 Acharya Vagbhata explained that the Vata, which is obstructed by Kapha,moves all over. This viatiated Vata further vitiates Prana, Udaka & Annavaha Srotasand produces Shvasa in Uras which is considered as Amashaya samudbhavaVyadhi.50 Madhukoshakara has the same opinion as Cakrapani regarding the VishistaSamprapti of Shvasa. Also he had explained as Pranavaha Sroto Avarodha is due toKaphavritha Vata.51 Vagbhata has mentioned the Samprapti of Caraka in different words but hehas considered the affliction of Annavaha and Udakavaha Srotas along withPranavaha Srotas.52 Even Cakrapani has considered the involvement of Annavaha andUdakavaha Srotas53, but Gangadhar has clearly ruled out the involvement of Srotasother than Pranavaha Srotas.54 Page 16Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  33. 33. Literary ReviewIII. Samprapti of Tamaka Shvasa This Samprapti is explained for Tamaka Shvasa only because it is acontinuation of the previous Samprapti as it states “Pratilomam yada Vata”. The Vata in Pratiloma Gati enters the Pranavaha Srotas and causes agitation ofKapha and then enters Greeva and Shiras resulting in Greeva and Shirograha andstimulates phlegm to cause peenasa (Coryza). Thus the obstructed Vata produces thesigns & symptoms of Tamakashvasa.55SAMPRAPTI GHATAKADosha: Vata – PranaVata, UdanaVataKapha: Avalanbhaka KaphaDushya: RasaAgni: Jatharagni, rasadhatvagniAma: JataragnimandhyajanyaSrotas: PranavahaSrotodusti: Sanga – AtipravrittiUdbhava Sthana: PittaSthana / AmashayaAdhistana: UrasSanchara Sthana: Pranavaha SrotasVyakta Sthana: UrasRogamarga: Abhyantara Due to multifactorial origin of Tamaka Shvasa, the Samprapti may differ frompatient to patient and varies according to the etiological factors. Thus commonSamprapti of Tamakashvasa can‟t be drawn due to its complexity. Eventhough, the Page 17Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  34. 34. Literary ReviewSamprapti of Tamakashvasa with regards to Kriyakalas can be studied in general asfallow in two stages.STAGE 1 In this stage physiological derangement takes place due to exposure toetiological factors (Nidanas). It occurs in first three phases of Kriyakalas i.e.Sanchaya, Prakopa and Prasara. The important manifestations are as fallows: 1. Vata Prakopa occurs due to Vata Vardhaka Nidana Sevana. 2. Kapha Prakopa occurs due to Kaphakara Nidana Sevana. 3. Pitta Sthana Dusti may occur due to Agnimandyakaraka and Amotpadaka Nidanas. 4. The vitiated Doshas circulates all over the body. 5. Sthanika Doshas may be directly vitiated due to direct affliction of Pranavaha Srotas due to Nidanas like Raja, Dhooma Sheeta Vayu etc. Though the role of Kapha is predominant in obstruction of Pranavaha Srotas but itis also motivated by Vata Dosha.STAGE 2 In this stage physiological abnormality leads to the pathologicalmanifestations and then circulation to all over the body. This stage includes threephases corresponding to the changes that take place in the last three phases ofKriyakalas i.e. Sthana Sansraya, Vyakta and Bheda.STHANA SAMSRAYA In this stage, the Doshas, which are already aggrevated and circulatingthroughout the body, settles in (Uras) Pranavaha Srotas where Khavaigunya is Page 18Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  35. 35. Literary Reviewpresent. Here Khavaigunya may be present since birth (Beeja Dosha, Prakriti) orresulted due to aggrevated Doshas. Poorva Roopas will appear at this stage.VYAKTI The basic pathology is due to vitiation of Kapha and Vata in the PranavahaSrotas. Due to Kapha vitiation, excess Kapha Udeerana takes place, resulting inobstruction of Vata marga in the Pranavaha Srotas. Acharya Caraka has given thesimily to explain this as, „when the flowing water is obstructed, first it collects andbreaks the obstruction leading to exceess flow of water suddenly,56 in the same way ifthe free flowing Vata is obstructed by Kapha then it vitiates and causes damage to theSrotas‟. The obstructed Vata moves in all direction.BEDHAVASTHA If proper treatment is not done in the above stage, the pathological processesalready going on may worsen and Lakshanas may be produced according topredominance of Doshas. If Vata is predominant Vatadhika, Kaphadhika if Kaphapredominate and if Pittanubandha is there praTamaka Lakshanas will be produced. Ifneglected or due to improper or inadequate treatment, the Pranavaha Srotas andSrotomoola may be affected resulting into complications in due course of time. Page 19Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  36. 36. Literary Review Table No. 2 Showing schematic representation of samprapti of TamakashwasaPATHOLOGY OF ASTHMA It is now clearly established that the airway inflammation is the basicpathology in all types of asthma. Airway epithelium damage is another characteristicabnormality, which is not found in other diseases of airways. Pathology of extrinsicand intrinsic asthma is different. Therefore these are separately explained below. Page 20Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  37. 37. Literary ReviewPathology of Extrinsic Asthma or Allergic Asthma It is a type I hypersensitivity reaction. The basic sequence of events inpathogenesis of type I hypersensitivity begins with the initial exposure of antigen(also called as allergen). The allergen stimulates IgE production by B cells. Once IgEis bound to the surface of mast cells the individual is primed to develop type Ihypersensitivity. Re exposure to the same antigen results in fixing of the antigen tocell bound IgE, initiating a series of reactions which lead to the release of severalpowerful mediators that are responsible for the clinical features of type Ihypersensitivity.57 All allergens causes bronchoconstricition, mucosal edema, and mucussecretion, which ultimately result in airway obstruction58 and variety of chemotaxic,vasoactive and spasmogenic compounds take part in the pathogenesis of extrinsicasthma.59PATHOLOGY OF INTRINSIC ASTHMA In intrinsic or non-atopic asthma the mechanism of bronchial inflammationand hyper responsiveness is less understood. In this type of asthma, perhaps there is a hereditary or acquired over activityof the cholinergic (constrictor) response or reduced activity of the 2-adrenergic(bronchodilator) pathway. But in majority of cases triggering mechanism is non-immune in intrinsic asthma. Page 21Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  38. 38. Literary ReviewPOORVA ROOPA Poorva roopa denotes the symptoms that manifest before the actual or mainsymptoms occur. They are manifested during the stage of DoshadushyaSammurchana. The poorva roopa of Shvasa collected from different texts are presented inTable-3. Table-3 Poorvaropa of Shvasa According to Ayurvedic Major TextsNidanas C.S S.S A.S A.H Y.R B.P M.N G.NAnaha + + + + + + + +Hridaya Peedana + + + + + + + +Parshwa shoola + + + + - - - -Asya Vairasya - + - - + + + +Shankha Bhedha - - + + + + + +Pranasya Vilomata + - + + - - - -Shoola (udara) - - - - + + + +Admana - - - - + + + +Bhaktadwesha - + - - - - - -Aruchi - + - - - - - -ROOPA The symptom of a disease or the characteristic manifestations, which appearsduring the course of a disease, is known as Roopa. Acharya Kashyapa explains that ifthe child, who has hot breath from chest, is to be considered for having Shvasa. Page 22Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  39. 39. Literary Review Table-4 Roopa of Tamaka Shvasa According to the Major TextsPranavaha Srotosambandhi C.S S.S A.S A.H Y.R B.P M.N G.NLakshanaGurguruka (Wheezing) + + + + + + + +Shvasakrichrata (Dyspnea) + + + + + + + +Kasa (Cough) + + + + + + + +Prana peedana(Discomfort in chest) + - + + + + + +Peenas/ Pratishyaya (Coryza) + + + + + + + +Ateeva teevra Vegam chaShvasam (Increased rate of + - + + + + + +respiration)MuhuShvasa (Gets frequentattacks of dyspnea) + + + + + + + +Kantodhwansa(Throat irritation) + - + + + + + +Pramoham kasamanas-Cha(Fainting during excessive + - + + + + + +cough)Krichrat shaknote bhashitam(Difficulty in speaking) + - - - + + + +Shayanasya Shvasa peedita(Dyspnea increases in lying down + + + + + + + +posture)Pranavaha Srotosambandhi C.S S.S A.S A.H Y.R B.P M.N G.NLakshanasAseena Labhate Soukhyam + + + + + + + +(comfortable in sitting position)Parshwe tasyavagrahnatishayanasya sameeranah + - + + + + + +(Discomfart in sides of chest inlying down posture)Shleshmanam Amuchyamanebrusham bhavathi dukitha (Distress + + + + + + + +increases when unable toexpectorate)Tasyeva vimokshantemuhurtham labhate sukham + + + + + + + +(Gets relief after expectoration) Page 23Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  40. 40. Literary ReviewMeghambusheeta pragvataishleshmalaisch abhivardhate + - + + + + + +(Attacks gets aggravatedduring cloudy weather afterconsuming cold water,exposure to cold air, easternwind and when resorts Kaphaaggravating food and regimen)17.Ghoshen mahat - + - - - - - -Sarvadaihika Lakshanas C.S S.S A.S A.H Y.R B.P M.N G.NBrushAmatiman + - + + + + + +(Maximum distress)Sushkasyata + - + + + + + +(Dryness of mouth)Latatena swidyata + + + + + + + +(Sweating in forehead)Uchritaksha (wide opened eyes) + - + + + + + +Sannirudhyati (Immobilised) + - - - + + + +Na labhate nidra + - - - + + + +(Distrubed sleep)parshwa peeda - - + + - - - -(Pain in the sides of chest)Pratamyati + + + + + + + +(Loss of consciousness)Ushna abhinandana + - + + + + + +(Likes to take hot things)rishna (Thirst) - + + + - - - -Vamathu (Vomiting) - + - - - - - -Vepatu (Tremours) - - + + - - -Aruchi (Tastelessness) - + + + - - - -Trastyate (Frightened) - - - - - - - -Annadvit (aversion to food) - + - - - - - -CLINICAL FEATURES OF TAMAKA SHVASA/ASTHMA Common signs and symptoms include bouts of cough especially more innight, dyspnea, tachypnea wheezing and use of accessory muscles of respiration. Page 24Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  41. 41. Literary Review Ghurghuruka (wheezing) is due to Pranavaha sroto avarodha by Kapha.60Excess Kapha Udeerana (secretion) takes place resulting in Sroto Avarodha. PittaSthana Dustikaraka Nidanas may cause Agnimandya and Ama which in tern doesRasa Dusti. This results in Kapha Vriddhi in Pranavaha Srotas. As Sroto Avarodha isone of the Rasa Dustipradoshaja Roga61 and Sashabdhata is an important Lakshana ofPranavaha Sroto Dusti, 62 it ultimately produces Gurguruka Shabda Shvasa Krichrata (dyspnea) is due to Pranavaha Sroto Sankocha andAvarodha. Due to Vatakara Nidanas Vata Prakopa takes place in Pranavaha Srotas,and being obstructed by Kapha, it further vitiated and moves in all directions.Sankocha has been explained as one of the Lakshana of vitiated Vata63 thus vitiatedVata causes the Pranavaha Sroto Sankocha leading to Shvasakrichrata. Peenasa and Kasa are important symptoms especially in children. Theobstructed Vata moving in Pratiloma Gati causes Greeva and Shiragraha andproduces peenasa.then child gets bouts of cough (Kasa) and faintig occurs whenfrequency of cough is increased (Pramoham Kasamanascha). Many children having no symptoms during day time, often gets up in themiddle of the night or early morning with either a classical wheezing (Nocturnaldyspnea) or a severe bout of cough (Nocturnal cough). Frequency and severity ofcough increases gradually along with wheezing. It is sometimes difficult for theparents to accept that the nocturnal cough is a manifestation of asthma. Child may bepresented with only cough without wheezing or wheezing without cough. But theyounger asthmatic child is often troublesome due to nocturnal cough rather thandyspnea. Page 25Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  42. 42. Literary Review Ateeva Teevra Vega64 Shvasa i.e. increased rate of respiration may indicatethe severity of Vata vitiation. Murda (head) is main seat for Prana Vata65 and uras forUdana Vata.66 Impairement in the functions of Prana Vata and Udana Vata may leadto Ateeva Teevra Vega Shvasam. Here it is also important to recall that Atisristamand Kupita are Pranavaha Sroto Dusti Lakshana.67 When the lungs become overinflated, the stretch receptors activate an appropriatefeedback response that „switches off‟ the inspiratory ramp and thus stops furtherinspiration. This is called the Hering-Breuer inflation reflex. This reflex alsoincreases the rate of respiration.68 Krichrat shaknoti bhashitam69 i.e. difficulty in speaking may be due toinvolvement of Udana Vata. Vak Pravritti is one of the important fuction of UdanaVata66 and vitiation of Udana Vata may cause difficulty in speaking. Due to increasedrate of respiration and expiratory difficulty child will be having difficulty in speaking. Parshve tasyagrahnati i.e. discomfort in the sides of chest may be due to excessand laborious work of respiration especially intercostal muscles. Pramoham kasmanascha71 i.e. fainting during excessive cough might be due tosevere bronchoconstriction (which is not able to generate wheezing sound) andhypoxia. This leads to less oxygen supply to brain which causes fainting in children. Prana peedana64 is due to respiratory distress/ discomfort in the chest because ofShvasakrichrata. When airway is obstructed by mucus plug, the child gets maximum distress(brushAmatiman72). The distress increases when the child is unable to expectorate it Page 26Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  43. 43. Literary Review(shleshmanam amuchyAmane brusham bhavati dukhita73) and gets relief afterexpectoration of sputum (tasyeva vimokshante muhurtam labhate sukham73). Abdominal pain (udara shoola) is common particularly in younger children.Vomiting (Vamathu80) is common which may give temporary relief of symptoms.Children can‟t expectorate sputum, instead they swallow it. During vomiting due tocontraction of diaphragm and intercostal muscles, the intrathoracic pressure increaseswhich may help in expulsion of sputum from airways. By Ushnopachara Kapha gets liquefied causing its easy expectoration and thepatient thus likes to take ushnopachara (ushnabhinandana70). Aruchi78 (tastelessness), annadvit81 (aversion to food) and Vamathu (vomiting)may be due to involvement of Annavaha Srotas along with Pranavaha Srotas. Tamaka Shvasa gets aggrevated during cloudy atmosphere, cold weather, afterexposure to cold air, eastern wind and Kapha aggrevating food & regimen.74 All thesefactors may act as precipitating factors for attacks of asthma. Na labhate nidra75 i.e. unable to get sleep is due to Pranavaha Sroto Avarodhaand difficulty in breathing. Usually in younger children sleep is disturbed bynocturnal cough rather than wheezing and in older children cough with frankwheezing disturbs the sleep. With severe airway obstruction, child has difficulty in walking (sannirudyate71) oreven talking (Krichrat shaknoti bhashitam75), child may assume a hunched overtripod like sitting position that makes it easier to breathe (Aseena Labhate sukham70).Because sleeping in supine position increases dyspnea (Shayansya Shvasa peedita76). Page 27Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  44. 44. Literary ReviewMany children complain both inspiratory and expiratory difficulty. In severe casesthere will be respiratory distress (brushAmatiman) and child may sweat profusely(lalatena swidyate77). Low-grade fever (Jvara) may develop due to infection orenormous work of breathing. Suskasyata76 and trishna78 indicates involvement of udakavaha Srotas. Duringsevere attack, child may get thirst due to excess water loss through evoparation fromlungs and low intake of foods & fluids during attacks. Pratamyati71 (loss of consciousness), uchritaksha76 (wide opened eye),brushAmartiman (distress), vepatu79 (tremors) and sannirudyati (immobilised) etcsigns and symptoms indicates the severity of disease and the child in this conditionneeds urgent and immediate prompt treatment. A barrel shaped chest deformity is a sign of chronic unremitting airwayobstruction of severe asthma.UPASHAYA AND ANUPASHAYAA judicious application of Aushadhi, Ahara and Vihara, when produces relief in thesymptoms that is called as Upashatya when it aggravates the symptoms it is calledanupashaya. It is a trial and error treatment. 82 In Tamaka Shvasa, the Upashaya and Anuashaya have been explained whilementioning the Lakshanas of the disease. These are as fallows.Upashaya: 1. Tamaka Shvasa patients always desire for warm substances and surroundings.70 2. Respiratory distress will be relieved in sitting posture.70 (Tripod posture) Page 28Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  45. 45. Literary ReviewAnupashaya:1. Respiratory distress increases in lying down posture.832. Shvasakrichrata & kasa with expectoration will be aggravated during cloudyweather, cold season, intake of cold substances cold weather especially eastern wind,durdina and night or early morning.74VARIANTS OF TAMAKA SHVASA In Ayurveda Tamaka Shvasa has not been classified. On the basis of PittaDosha association two variants have been explained viz. Pratamaka and Sansamaka. 1. Pratamaka If Tamaka Shvasa is associated with Jvara and Moorcha then it is called asPraTamaka. It occurs due to Udavarta, Raja Sevana, Ajeerna, Klinnakaya andVegadharana.84 2. SantamakaIn this patient complaints of darkness around him and feels as if sinking in darkness.It aggravates severely in Tama ie darkness (or night) and subsides bySheetopachara.85 Acharya Gangadhara opines that these two are not bhedhas of Tamaka Shvasarather are stages of the same.86 In modern science asthma is mainly classified into 3 types. 1) Extrinsic or allergic (or atopic) asthma 2) Intrinsic asthma 3) Mixed variety Page 29Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  46. 46. Literary ReviewThe differences between extrinsic and intrinsic asthma are shown in Table-5. Table-5 Differencial Diagnosis of Extrinsic and intrinsic AsthmaExtrinsic IntrinsicImmune reaction type I Non immune abnormal autonomic regulationshypersensitivity of airwaysFamily history of hypersensitivity No family history of hypersensitivityis commonUsually starts in childhood Starts in adult lifeProceeded by infantile eczema and No evidence of atopyhypersensitivity of foodPredisposition to form IgE IgE antibodies may be found but no particularantibodies predispositionRecognizable allergens like pollen No recognizable allergensdandruff, house dust mite etcAttacks often diminish in later Attacks increases in severity as years passyearsChronic bronchitis seldom Associated with nasal polyp‟s chronicdevelops bronchitisEmphysema unusual Emphysema commonly developsNo drug sensitivity Drug sensitivity may develop (aspirin, penicillin etc)Increased levels of IgE found in Normal level of IgE in serumserumPositive response to skin Negative response to skin provocation testprovocation testLABORATORY INVESTIGATION Only on the basis of laboratory investigations it is very difficult to establishthe diagnosis of asthma. Following are the laboratory findings. 1) Blood eosinophilia more than 250-400 cells/mm is usual. 2) Eosiniophilia is seen in the sputum sample. 3) Asthmatic sputum is grossly tenacious, rubbery & whitish. 4) Serum protein and immunoglobulin concentrations are generally normal in asthma; expect that IgE levels may be increased.87 Page 30Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  47. 47. Literary ReviewBronchial Reactivity Testing Tests of bronchial reactivity can be a major importance in making thediagnosis, when the diagnosis is uncertain and evaluating the severity of asthma.Bronchial provocation by inhalation has now been widely performed in children usingeither methacholine or histamine as the challenge. Children with asthma generallyrespond abnormally to exercise, methacholine and adenosine 5- monophasphate(AMP) challenges while those with other types of chronic lung disease often respondabnormally to methacholine but not to exercise or AMP (Avital.et.al.1995). This maybe helpful in differential diagnosis of the child with chronic airway obstruction. Whenthe baseline pulmonary function is abnormal, instead of methacholine provocationtesting, response to bronchodilator therapy is more appropriate.Exercise Testing Running for 1-2 minutes causes bronchodilation but prolonged running causesbronchoconstrion in children suffering from asthma.Chest Radiograph If the child is presented with acute severe asthma, chest radiograph isnecessary to exclude the other possible diagnosis or complications such as atelactesisor pneumonia or mediastenal emphysema. Lung markings are commonly increased inasthma. During exacerbations if the child is presented with fever, tachypnea>60beats/min, tachycardia 160beats/min, localised rales or wheezing or decreasedbreath sounds or suspected for pneumothorax, in these conditions chest radiograph isnecessary. Page 31Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  48. 48. Literary ReviewImmunological Tests Skin testing or the measurement of specific IgE levels is of limited value inmost children with asthma. If a strong reaction is obtained to a specific allergen, it isonly significant when the child has a history of wheezing on contact with the allergen.Determination of specific IgE with these testing is useful in identifying theenvironmental allergens. But Shapiro and Anderson 1998 reported that none of theseunconventional tests (in vitro allergy diagnostic tests) have been shown to be of anyreal diagnostic value.Pulmonary Function Testing Testing of lung function useful for management of asthma and in theevaluation of children in whom asthma is suspected. Above 6yrs aged children canundergo spirometry and in younger children peak flow meter is helpful. If the PEFRor FEV, measured before and after aerosol therapy shows a 10% increase then it isstrongly suggestive of asthma. PEFR can be measured at home 2-3 times/day with themini Wright peak flow meter that provides an objective evidence for degree of airwayobstruction. Diurnal variability more than 30% indicates increased bronchialresponsiveness and worsening of asthma with increased susceptibility to airwayobstruction. Page 32Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  49. 49. Literary Review Table-6 Vyavacchedaka Nidana of Tamakashvasa Tamaka Maha Urdhwa Chinna KshudraSymptoms Shvasa Shvasa Shvasa Shvasa Shvasa Deergam Rooksha Ateeva UchaihiShva Shvasati Shvasati ayasodbh Shvasa teevra sati UrdwamShva vichinnam ava Vega sati Shvasa Matta Shabda Gururaka _ _ _ Vrishabhavat PranastaConcious- Pramoha Gyanavignan Pramoha Murcha _ ness a UchaihiShvas Vibrantaloch Viplutaksha Uchritaksh ati Netra an & Raktaikaloch _ a &Vibrantaks Vivrataksha ana ha No Parshwa Shoola _ Vedanartha Marmacheda indriya Shoola vyatha Krichrat Vak Shaknoti Vishirnavak _ Pralapana _ Bhashitam Vishuskasy Pari Asya _ Shuskasya _ a shuskasya Latata Sweda _ _ _ _ sweda Precipitat ed by BaddaMiscellane Anaha, vyayAma mutra _ Arati ous vivarna & ahara varcha no much distressSadhyasadh Yapya/sad Asadhya Asadhya Asadhya Sadhya ata hya Page 33Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  50. 50. Literary Review Table-7 Sapeksha Nidana of ShvasaSymptoms Tamaka Shvasa Kshataja Kasa RajayakshmaShvasa Swasa with teevra One of the One of the Vega is the symptoms symptoms of partyathma Lakshana ekadasha roopa rajayakshmaKasa Present Initially dry Present Piohila, visra,Steevana Kruchra steevana Rakthayuktha bahala, naritha, swetha, peetha varna rasa steevana, some times raktha yuktaJvara Absent Present PresentDhatu shoshana A late feature Late feature PresentShabda Ghurguraka ParaVata - koojanaShoola Parshva shoola Vedana in kanta Parshvashoola shira pradesha shoolaSadhya Yapya Yapya Sarva roopayuktha is asadhyaNidana Kapha and Vata Kshata on uras Vegavarodha, vardaka Nidanas or dhatukshaya, sahasa marmaghata or vishAmashan Nidanarthakara RogasDIAGNOSIS Recurrent episodes of coughing and wheezing especially, if aggravated ortriggered by exercise, viral infection or inhaled allergens are highly suggestive ofasthma. Persistent cough without wheezing is also suggestive of asthma in children,which may be erroneously diagnosed as „allergic cough‟, or „allergic bronchitis‟ or„wheezy bronchitis‟ or „chronic bronchitis‟. Pulmonary function testing before andafter administration of methacholine or a bronchodilator or before and after exercisemay help to establish the diagnosis of asthma.87 Page 34Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  51. 51. Literary Review Table-8Assessment of Severity of Asthma in Children88Based on Mild Moderate SevereFrequency/Month <One episode >One episode 4 episodesDuration of Symptoms Brief for hours Prolonged Almost continuous 2-3daysActivities-Eating - Normal - Solids - Liquids-Sleep disturbance - Nil - At times - Frequent-Playing - Able - Restricted - Not able-School absenteeism - Nil - Occasional - FrequentHospitalisation Rare Occasional FrequentPEFR 60-80% 40-60% Predicted 40% PredictedChest x-ray Normal Hyperairation EmphysemaUPADRAVA OF TAMAKASHVASA Trishna has been mentioned as the upadrava of Shvasa and this type ofTrishna is called as Aupasargika Trishna.89 No reference is available regarding theother Upadrava of Tamaka Shvasa.ARISHTA LAKSHANA Arista Lakshanas occurs just before death indicating the fatal prognosis of thepatient. Arista Lakshanas of Tamakashvasa have not been explained in any classics.Arista Lakshanas of Shvasa have been explained in the classics, which are as follow: 1. Patient presenting with deegra and hriswa niShvasa.90 2. Passage of grathita mootra and pureesha associated with agnisada.91 3. Shvasa complicated with atisara, jwara, Hikka, chardi, medrashotha and andashotha.92 4. Shvasa with jwara chardi, trishna, atisara and shopha.93 Page 35Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  52. 52. Literary ReviewSADHYA-ASADHYATA Sadyasadhayata gives the clear picture of curability of the disease i.e. whetherthe disease is curable, incurable or difficult to cure. It depends upon so many factorslike nature of disease, severity of disease, Vaya, Prakruti, Bala of patient etc. o According to Charaka it is Yapya ie difficult to cure. If it is in Navavastha (early stage) then it is Sadhya.94 o Also Charaka says Tamaka Shvasa is curable in strong persons when the symptoms are not manifested fully.95 o According to Sushruta it is Kastasadhya, but Asadhya in Durbala Rogi (weak patient).96 o Dalhana commenting on the above version says that it is Asdhya when it is associated with Jwvara, Moorcha and others.97 o According to Vagbhata it is Yapya. But says if it is treated in the begining and patient is strong (Balina) then Tamaka Shvasa is Sadhya.98 o When Maha, Chinna, Urdhva Shvasa Lakshanas appear in Tamaka Shvasa then it is considered to be Asdhya.99YAPYATA OF TAMAKA SHVASA IN CHIDREN Generally Tamaka Shvasa is said to be Yapya disorder74 i.e. difficult to cure.It is Sadhya in early stages and in strong patients and if it is not associated with othercomplications. The disease becomes Asadya in Durbala patients. It is explained that in Balyavastha Kapha is predominant Dosha and childhooddiseases caused by Kapha naturally take a serious turn.100 So children are mostsucceptible for Kaphaja diseases like Pratishyaya, Kasa and Shvasa. Dalhana hasexplained that Tamaka Shvasa is Kaphabhuyista Vyadhi i.e. Kapha predominantdisease. Therefore the diseases like Tamaka Shvasa occurring in Kapha predominantage (childhood) may be difficult to cure. Page 36Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  53. 53. Literary ReviewPROGNOSIS The prognosis for young asthmatic children is generally good. In majority ofchildren there will be occasional attacks of mild to moderate severity. But a minorityof children experience severe intractable asthma usually perennial rather thanseasonal. The prognosis is also poor in those with a diagnosis of asthma, of which about50% are still wheezing at age of 10yrs. (Park et. al. 1986)101CHIKITSA VIVECHANA After reviewing the literature about Tamaka Shvasa Nidana, Samprapti,Roopa, Sadhyasadhyata etc, it became clear that there is vitiation of Kapha & Vataand Tamaka Shvasa is Pittasthana (Amashaya) Samudbhava Vyadhi102. Therefore ourtreatment should be aimed to pacify the vitiated Vata and Kapha Dosha along withNidana Parivarjana. Acharya Charaka has given the guidance for better management of TamakaShvasa i.e Shodhana followed by Shamana Chikitsa, should be done in Balavana andKaphadika patients, whereas Shamana and Tarpana should be done in Durbala andVatadhika patients.103 Here the question arises, whether the same treatment can be adopted inchildren? For that it is better to review the literatures about the line of treatment incase of children.PRINCIPLES OF TREATMENT IN CHILDREN Acharya Kashyapa explains that for children neither Shoshana (desiccation)nor AtisamShodhana (excerssive cleaning) and Raktamokshana (blood letting) are Page 37Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  54. 54. Literary Reviewbenefical. They should be treated with oral medications, ointments etc. 104 In childrenVata, Pitta and Kapha are similar as like adults but they are in less quantity. 105 The similar explanation is given by the Acharya Charaka in Chikitsa Sthanai.e. Dosha, Dushya, Mala, and diseases present in children are same as like adults butthe dosage will be less compared to adults. 106 Vagbhata accepting the above opinion, says that the Dosha, Dushya, diseasessuch as fever etc. and methods of treatment are the same in both children and adultswhereas the dosages (of medicines or therapies) are minimum for children since theyare of tender aged and having small body. 107Madhavakara also explains the same regarding treatment of children. 108SHODHANA IN CHILDREN Acharya Charaka explains that after observing the Mrudutva (tenderness) andParatantrata (dependency) and in those children, who are unable to speak and act, oneshould not advice for Vamana etc. treatment. But according to disease, Bheshaja(medicines or therapies) should be used in reduced doses. 109 Chakrapani explains that Balas (children) are of two types i.e. Svatantra andparatantra. In paratantra (dependant) children Vamana etc should not be administeredwhere as in independent children who can act and speak, Vamana etc therapies shouldbe administered in Mrudu form. 110Vegakaleena Chikistsa of Shvasa (Acute Management)Snehana and Svedana (Oleation & Sudation)To the person having Shvasa (i.e. at acute condition) Bahya Snehana (externalapplication of oil) should be done with Lavana Taila and Nadi or Prastara or SankaraSveda with Snigdha Dravya. 111 Page 38Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  55. 55. Literary Review By this Grathita Kapha (tenacious sputum) present in Pranavaha Srotas(respiratory tract) undergoes Vilayana (liquification) thus Srotomardavata takes placeresulting in Vatanulomana. 112 Thus respiratory tract becomes clear for easy passageof air. Above process is compared as the ice on the mountain dissolves afterexposure to sun, in the same way Grathita Kapha dissolves after Svedana procedure.113 In Vatadlika Snigdha Sveda, in Kaphadika Rooska Sveda and in combinationof Kapha and Vata, Sadharana (general) Svedana can be adopted. 114 Svedana is contraindicated in Pitta Prakruti persons, and in persons sufferingfrom Pittaja disorders, Madhumeha, Kshuda, Trishna, Shosha (emaciation) Rosha(anger), Kamala, Udara Roga, Karshya, Bhrushagni (voracious appetite) etc. 115 Charaka includes Rooksha and Ksheena Dhatubala (diminished Dhatubala)persons in the list of contraindicated for Svedana. 116 In such Patients‟ Mrudu Sveda for Uras and Kantha Pradesha can be done bydoing Snehaseka with Sharkara or by Utkarika mixed with sugar or by Upanaha. 117 Soon after Svedana, Snigdha Anna along with Dadhi, Matsya, Mansarasa orShookara Rasa should be given which does the Shleshma Vruddhii. 118VAMANA Once there is Shleshma Vruddhii, Vamana should be performed by giving acombination of Pippali, Madhu and Saindhava, but it should be Vata Avirodhi. 119 For the term Vata Avirodhi, Chakrapani opines that „it rules out the use ofRuksha and Teekshna Vamaka drvyas,‟ indicating the need of Mrudu Vamana.Gangadhar opines that Vatahara Vamana dravya have to be used along the above said Page 39Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  56. 56. Literary Reviewdrugs. Astanga Hridaya states that there should not be aggrevation of Vata byVamana. 120 By this liquefied Kapha which is present in Pranavaha Srotas comes out byUrdhva Marga. After Kapha Nirharana, Srotavishuddhi takes place leading to freemovement of Vata in the Srotas. 121DOOMAPANA After Vamana for expulsion of the avashista Kapha (to remove remainedsputum), Dhoomapana with Haridra Manashiladi Yoga etc should be given. 122 Here it is interesting to note that Acharya Charaka has not mentioned theroutine classical Vamana procedure for the management of acute attack. Instead ofAbhyantara Snehapana, he has advised Bahya Snehana. After proper Svedana,Shleshmavriddhikara Ahara and Vamana should be done. Here we can conclude that the above said therapy is for Vegakallena Chikitsaof Tamaka Shvasa. Because classical method of Vamana is not followed, here insteadof it, acute management of Shvasa is explained, as there will be less time to do allthose procedures.GENERAL LINE OF TREATMENT IN TAMAKA SHVASA: As it is an episodic disease and Yapya it is difficult to cure. So before startingthe treatment, special attention has to be given, for detail examination of the children,to know Rogibala and Rogabala. The general line of treatment is Nidana Parivarjana, SanShodhana andShamshamana. Page 40Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  57. 57. Literary ReviewNIDANA PARIVARJANA Nidana, Dosha and Dushya are the essential factors in the of disease process.Anubandha and Ananubandhya of these three factors influence in the ocurence of 123signs and symptoms of disease. That is why acharya Charaka has given muchimportance for the Nidana Parivarjana in Hikka and Shvasa Roga. It is said that if theperson suffering from the Shvasa wants the healthy condition (Arogya) he must avoidthe Nidana factors. 124 Acharya Sushruta stressing for the Nidana parivarjana explained as 125“sankshepatah kriyayogo Nidana parivarjanam”. However but avoiding thecausitive factors may be difficult in children because they are more susceptible forallergens, upper respiratory tract infections, dust and exercise during play works andmany are allergic to variety of foods etc. Avoiding these causative factors may reducefrequency of attacks in children. As the Tamaka Shvasa is Yapya in nature, properadvises should be given to both children and parents regarding the NidanaParivarjana.AVOIDANCE OF TRIGGERS / AGGREVATORS126PHYSICAL FACTORS: The physical factors, which can cause symptoms in asthmatic children, areexercise, strong smell, cold air, changes in weather etc. In majority of cases thepatient or parents easily identify these factors. For the better management ofasthmatic children, it is necessary to avoid the exposure to these factors.ALLERGENS: Aero-allerges are important triggers of attack in most allergic asthmatics. Thechild may get severe disease if the child had been exposed to allergen within first yearof life. Most of the allergens include dust, mites, moulds, pollens and animal proteins. Page 41Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children
  58. 58. Literary ReviewNow house dust mite (dead or alive) claimed to be the important cause for nocturnalsymptoms. Particular care should be taken for the children who are having familyhistory of allergy, because these children are susceptible for allergic disorders.Therefore avoidance of allergens plays an important role.RECOMMENDATIONS FOR REDUCING ALLERGEN o The humidity in houses should be minimised by good ventilation. o All the bedding (mattresses, pillow etc) which is washable should be washed regularly with hot water. o Pillow and bed is to be covered with mite proof covers. o Woollen clothing‟s and bedding are better to avoid because they may harbour dust and house dust mite. Carpets in the bedroom are better to remove. o Whenever practical, bedding should be exposed to the sun which kills mites. 127RHINITIS / SINUSITIS: When the child is having repeated attacks of rhinitis or sinusitis or otitis then aprompt treatment should be advocated. Always enquiry is must to know the history ofnasal obstruction, sneezing, snoring, night cough, interrupted sleep and gastric reflux(heartburn). If present, then best solution would be avoidance of causative factors andadequate treatment of these conditions.Tamaka Shvasa patients can be grossly divided into two categories. 1. Kaphadhika and Balavana 2. Durbala and Vatadhika. 128 Page 42Role of Virechana and Kantakaryavaleha in the Management ofTamakaShvasa in Children