Evaluating Dhumapana Therapy for Anurjatajanya Tamakashvasa: A Comparative Study in the Purview of ‘Vātaśleṣmavibandhe vā bhiṣag dhūmaṃ prayojayet.’

Introduction

In Ayurveda, “Shvasa Roga” refers to respiratory disorders, encompassing a range of conditions characterized by difficulty in breathing. It includes various respiratory disorders that impair respiratory function, such as asthma, bronchitis, chronic obstructive pulmonary disease (COPD), and other ailments. The term “Shvasa” is derived from the Sanskrit word for “Shvasa” + “ghay,” meaning dyspnea, and “Roga” means disease. Tamakashvasa is a type of Shvasa Roga (respiratory disease) affecting the Pranavaha Srotas (respiratory channels) and is characterized by Pratiloma Vayu (prolonged expiration), Ghurghuraka (wheezing), and Ativa Tivra Vagam Cha Shvasa Pranaprapidakam (extremely severe dyspnea that is highly detrimental to life), among other symptoms[2]. Acarya Sushruta has also mentioned the Vamathu symptom in Tamakashvasa[3]. Two types of Tamakashvasa are described in the Carakasamhita[4]:

• PraTamakashvasa
• SanTamakashvasa

Acarya Sushruta has called the condition where fever and unconsciousness occur along with breathing “PraTamakashvasa.” While explaining hereditary disorders, Acarya Sushruta has mentioned that the properties of Dosha are fixed at the time of fertilization. During pregnancy, Mithya Ahara-Vihara (improper lifestyle) can also cause hereditary disorders[5]. This may indicate placental transfer of antibodies.

In Ayurveda, Shodhana, Shamana, and Rasayana therapies are described for different types of diseases. Dhumapana is a type of antahparimarjana aushadh (internal purification medicine). There are different routes of drug administration as antahparimarjana. The oral route is the most common route in Ayurveda, which includes the intake of drugs in Pancavidha Kasaya Kalpana and their modifications. The inhalation route has also been used in Ayurveda for centuries, particularly in diseases of Pranavaha Srotas. Inhalation allows the direct administration of a drug to the affected site, i.e., Pranavaha Srotas, in the form of smoke, representing the minutest form of gaseous substances. It can have immediate effects, such as reducing mucous membrane irritability, exhibiting antihistaminic properties, blocking secretions, and providing anti-inflammatory and bronchodilatory effects without adverse outcomes. This is termed as dhumapana and is well prescribed in all the Ayurveda Samhitas. It is used in both preventive and curative medicine. Dhumapana literally means “smoking medicinal drugs.[6]” This Ayurveda medicinal therapy involves inhaling smoke generated by burning a portion of a medicinal plant called dhumavarti. This powerful mixture of hot, medicated smoke is absorbed into the lungs through the bronchi and provides relief in episodes and intensity of Shvasa. When medicinal herbs are combusted, they form very fine aerosol droplets suspended in the smoke. When inhaled, these droplets reach the deranged site and act therapeutically.

In modern medicine, inhalers are frequently used, but the basic difference lies in that inhalers use medicine in suspension form, which is mostly steroids, and may result in serious systemic effects. Recent research shows that frequent use of inhalers by children results in stunted growth. In contrast, dhumapana, defined and prescribed centuries ago in Ayurveda, is a safe therapy. Overall, it is equally beneficial for both healthy and diseased Pranavaha Srotas. However, its popularity in clinical practice has declined in recent decades. The modern stressful lifestyle has deteriorated Bala (vital strength), giving rise to immune system-related illnesses like Anurjata. Although allergies are not specifically mentioned in Ayurveda, several causative factors, including raja (dust), dhuma (smoke), and vata, indicate that allergens also play a role in causing Shvasa. These allergens penetrate directly into the pranavahasrotas and lead to an achaya-koptaya attack of Shvasa roga. Like Anurjata, Shvasa is a tridoshaja vyadhi (involving all three dosha). Dhumapana therapy appears to have a direct influence on pranavahasrotas and may alleviate symptoms in allergic asthmatic patients. For this study, Manahshiladi Dhuma was selected, and Vasadikvatha was used for comparative analysis. This therapy may offer advantages over nebulizers and inhalers and could potentially establish itself as a standard therapeutic option for managing Shvasa Roga.

Aims and Objectives

The present research was initiated with the following objectives:

• To re-establish dhumapana therapy as a standard therapeutic measure in Anurjatajanyatamakashvasa.
• To assess the efficacy of dhumapana in patients with Anurjatajanyatamakashvasa.
• To compare the efficacy of manahshiladi dhuma and vasadi kvatha for managing Anurjatajanyatamakashvasa.

Materials and Methods

• Literary Perspective: References were collected from classical Ayurveda texts as well as previous research works, theses, research articles, and modern science texts to understand the fundamental theories of allergy.
• Clinical Perspective: A randomized double-blind clinical study was conducted on patients with allergic asthma at the NIA OPD, IPD, and Bombaywala Hospital, Jaipur, after obtaining informed consent.

Methods

Patients were diagnosed using a variety of subjective and objective parameters from both Ayurveda and modern medicine.

Inclusion Criteria

Diagnosed and confirmed cases of Anurjatajanyatamakashvasa (allergic asthma), based on clinical signs and symptoms mentioned in Ayurveda texts and laboratory investigations.

• Patients aged 16–60 years.
• Patients with mild to moderate Anurjatajanyatamakashvasa.

Exclusion Criteria

• Patients below 16 and above 60 years.
• Patients with cardiac complaints such as cardiac asthma.
• Patients with other chronic and complicated respiratory diseases like COPD.
• Patients with allergic asthma complicated by other serious systemic diseases.

Criteria for Diagnosis

For this research, patients presenting with signs and symptoms of Anurjatajanyatamakashvasa as described in contemporary medicine, along with relevant classical references, were selected.

Laboratory Investigations

• IgE estimation.
• Other laboratory investigations: C.B.C., T.E.C., E.S.R.
•  
• Peak Expiratory Flow.

Clinical Study

A simple randomized study was conducted on patients with allergic asthma in two groups.

Administration of Drug

Thirty clinically diagnosed patients were randomly divided into two groups:

• Group A: Patients were administered “manahshiladi dhuma” twice daily.
• Group B: Patients were administered “vasadi kvatha” in a 20 ml dose twice daily.

Observations and Results

Comparative results of clinical recovery in 30 patients across the two groups of Anurjatajanyatamakashvasa are described below:

Showing comparative symptomatic improvement in the patients of two different groups after therapy:

Overall effect of therapy:

Overall Effect of Therapy

It is shown in the table that in Group A 33.33% patients got marked relief from the therapy followed by mild relief in 33.33 patients. Moderate relief was foundin 26.67% patients whereas 06.67% patients got no relief. In Group B 46.66% patients showed the mild relief followed by 40.00% patients with moderate relief. Marked relief was found in 06.67% patients whereas 06.67% patients showed no relief.

Discussion

Demographic Data Analysis:

• Age-wise Distribution: The highest incidence of patients (46.67%) falls within the age group of 16-30 years. This peak incidence could be due to the lifestyle stressors associated with career-building and exposure to environmental pollutants (e.g., dust, smoke), with limited time for health care, which collectively contribute to disease prevalence in this age group.

• Sex-wise Distribution: A male predominance (60%) was observed for Anurjatajanyatamakashvasa, followed by females (40%). This aligns with data from the National Family Health Survey-2 (NFHS-2) conducted in India in 1998-99, indicating a slightly higher prevalence of asthma in males. This difference may be attributed to an increased risk factor profile for males with respect to Anurjatajanyatamakashvasa.
• Hereditary Influence: A majority of patients (43.34%) exhibited a hereditary predisposition to allergic asthma, followed closely by those with no hereditary background (40.00%). This strongly supports the genetic basis of Anurjata.
• Habitat-wise Distribution: Urban patients (76.67%) predominated compared to rural patients (23.33%), likely due to the study’s location in Jaipur, an urban setting. The urban environment, with increased air pollution from industrial emissions and vehicle exhaust, exacerbates respiratory conditions. Additionally, smoking and passive smoking in urban workplaces further aggravate symptoms. In contrast, rural areas, while generally less polluted, have unique exposures, such as cold weather and outdoor activities, particularly during winter and rainy seasons, which can precipitate asthma attacks due to ‘prana vayu’ and ‘kapha-vata vitiates nidana.’
• Kostha-wise Distribution: Patients with Anurjatajanyatamakashvasa had varying digestive capacities, with 40.00% presenting krura-kostha and 36.67% showing madhyam-kostha. Krura-kostha indicates a disturbance in apana-vayu, particularly in pranavahasrotasAnurjata
• Sattva and Satmya Distribution: Most patients showed a moderate level of sattva (mental strength) and satmya (tolerance) at 56.67% and 60.00%, respectively. This highlights the role of mental strength and the psycho-somatic connection in disease development, with increased sensitivity in those with madhyamsatmya to anurjaskara factors, leading to disease recurrence.
• Abhyaharana Shakti (Digestive Power): A significant proportion (53.33%) exhibited low digestive power, or alpa abhyaharana Shakti, indicating decreased jatharagni (digestive fire).
• Jarana Shakti (Metabolic Power): A majority (76.67%) of patients showed reduced metabolic power, or alpajaraṇa Shakti, indicating a weakened jatharagni in Anurjatajanyatamakashvasa
• Vyayama Shakti (Exercise Capacity): The majority (56.67%) had low exercise capacity (avara vyayama shakti), while 43.33% showed moderate capacity. This underscores the impact of a sedentary lifestyle on the increased incidence of lifestyle disorders, including Anurjata.
• Addictions: Most patients were addicted to tea or coffee (40%), with others using tobacco (26.67%), smoking (26.67%), and alcohol (6.67%). These substances, though not allergens, act as irritants that can exacerbate disease through sympathomimetic action. Tobacco smoke, in particular, damages airway structures, allowing dust and mucus to accumulate and act as both a causative and exacerbating factor for Shvasa by affecting pranavahasrotas.
• Seasonal Triggers: Anurjatajanyatamakashvasa predominantly manifested in winter (46.67%), followed by perennial occurrence (23.33%) and spring (16.67%). The least manifestation occurred during the rainy season (13.33%). This aligns with documented allergy cases and the seasonality of house dust mites, which thrive in moderate temperatures and high humidity, peaking in August and September, and declining during dry, extreme conditions.
• Symptom-wise Distribution: Common symptoms included ghurghurukam (100%), sannirudhyate (100%), kasa (93.33%), and ativativravegashvasa (93.33%). Symptoms indicative of vatadosa dominance were prevalent.
• Chronicity: Most patients (46.66%) had disease duration of 0-1 years, followed by 2-5 years (23.33%). A smaller percentage had chronic conditions lasting over 10 years. This suggests that Anurjata is a chronic condition, with limited public trust in Ayurveda for acute cases.
• Trigger Factors: House dust (93.33%) was the primary trigger, followed by weather changes (83.33%), cold days (80.00%), and tobacco smoke (80.00%). Other triggers included parks and fields during pollen season (43.33%) and certain fabrics (33.33%). Seasonal mite populations influence disease onset, with peaks in humid months and troughs during dry and extreme temperatures.
• Ama Lakshana Presence: Symptoms such as srotorodha (100%) and anila mudhata (100%) were predominant, followed by malasanga (60.00%). These symptoms reflect pranavahasrotodusti, highlighting the poor energy and immunity status due to agnimandya.
• Ama Lakshana Grading: Most patients (66.67%) had moderate ama lakshana, with a smaller percentage exhibiting severe (20.00%) or mild (13.33%) symptoms, indicating ama as a significant predisposing factor for Anurjata.

Total Effect of Therapy:

Symptomatic Improvement (Subjective Parameters):

• Group A (Manahshiladidhuma): This group showed significant improvement across several symptoms, with the overall symptomatic improvement at 62.50%, which is statistically highly significant (P < 0.001).
• Group B (Vasadi Kvatha): Improvement was noted across various symptoms, with an overall symptomatic improvement of 48.83%, also statistically significant (P < 0.001).
• Statistical analysis revealed significant improvement in both groups (P < 0.001); however, Group A demonstrated faster and greater symptom relief.

Conclusion

• Prevalence: Anurjatajanyatamakashvasa (allergic asthma) is a prevalent lifestyle disorder in the current era of urbanization.
• Ayurveda Perspective: Although the condition is not directly mentioned in Ayurveda, descriptions of similar disorders suggest that it was uncommon historically, possibly due to fewer exogenous pollutants.
• Etiology: Unlike modern allergy concepts, Anurjatajanya Shvasa is not purely allergen-based. Malpractice in diet promotes amadosa through impaired agni in both jathara and dhatu, predisposing individuals to Anurjata.
• Pathogenesis: Previously afflicted individuals may retain toxins in a latent state, which can be activated by incompatible foods or environmental stressors, leading to Anurjatajanya Shvasa.
• Classification: Anurjatajanyatamakashvasa is categorized as vatolvaṇasannipataja and may be hereditary or acquired later in life.
• Symptomatology: Symptoms of allergic asthma closely align with those of Tamakashvasa as per Ayurveda texts.
• Treatment Efficacy: The study demonstrates that Ayurveda effectively manages asthma through its multi-dimensional approach.
• Treatment Durability: Patients require prolonged treatment as symptoms tend to recur post-treatment cessation.
• Comparative Efficacy: Manahshiladidhuma (Group A) showed greater efficacy in symptom relief than Vasadi Kvatha (Group B).
• Clinical Safety: Manahshiladidhuma, with kapha-vatahara effects, is established as an anti-allergic, safe alternative, showing no adverse effects.
• Statistical Analysis: Group A displayed statistically significant improvements in ghurghurukam and kasa, among other symptoms, with overall greater efficacy than Group B. Both groups showed statistically equal efficacy, though Group A provided a higher percentage of relief.

Acknowledgements: The authors are thankful to National Institute of Ayurveda for giving the platform to carry out the clinical research.

Financial Support & Sponsership: National Institute of Ayurveda, Jaipur Conflicts of Interest: Nil

References:

1. Carakasaṁhita, Cikitsasthana, HikkaShvasacikitsa, 17/11-13. Available from: http://niimh.nic.in/ebooks/ecaraka/ (Accessed on 21/07/2024).
2. Caraka Saṁhitā, Cikitsasthana, HikkaShvasacikitsa, 17/55-62. Available from: http://niimh.nic.in/ebooks/ecaraka/ (Accessed on 21/07/2024).
3. Suśruta Saṁhitā, Uttaratantra, Shvasapritishedhadhyaya, 51/10. Available from: http://niimh.nic.in/ebooks/esushruta/ (Accessed on 21/07/2024).
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