Spring is the season when kapha liquefies throughout the body and especially in the bronchial tree. Although cleansing kapha is helpful for everyone at this time of year, it is of particular importance for asthmatics. In the classical Ayurvedic texts, asthma is known as tamaka svasa, one of the kaphaja diseases in the category of svasa or dyspnoea (shortness of breath). (1)
Initially in the samprapti (pathogenesis) of asthma, vata is provoked with urdva gati (upward vector). Entering prana vaha srota, the respiratory tree, it aggravates kapha in the bronchial mucus membranes.
The purva rupa or premonitory signs outlined in the texts include headache, cough, chest pain, mood swings, running nose and thirst. "Vata, getting aggravated, begin to move in the respiratory channels, aggravating kapha and producing breathlessness with catching pain in the head, neck, chest and flanks, cough accompanied with cracking sound, delusion, loss of appetite, running in the nose and thirst." (1) It is worth noting that all these premonitory signs are now listed in the standard checklists of early warning signs of asthjma attacks which are given to patients at National Jewish Hospital for Respiratory Diseases in Denver. (2)
The disease process, moving through astayi rasa dhatu, can swiftly proceed to rupa, cardinal signs and symptoms of a full blown asthma attack: cough, wheezing, breathlessness, chest tightness, rapid breathing and orthopnoea (difficulty breathing when lying down).
"The bouts of respiration are very forceful, producing great distress to life, the patient goes into darkness by its force, finds momentary comfort after expectoration, is unable to breathe while lying down and finds comfort sitting." (1)
In terms of nidan or causation, both remote (viprakrushta) and proximate (sannikrushta) causes are of importance. Remote causes relate to khavaigunya in prana vaha srota. Complex hereditary causes of airway hyper-responsiveness are very significant in atopic or allergic asthma, and play a major role in the wheezing response. (3) Vagbhat relates many of the proximate causes of asthma attacks to the shita (cold) quality of vata and kapha, the involved doshas, as well as to the avila/pichila (cloudy/sticky) quality of kapha. "The condition gets increased by accumulation of clouds in the sky, drinking cold water, cold breeze, direct breeze, and ingestion of substance which cause accumulation of kapha." (1). Dust, irritant gases, pollens and smoke are also mentioned as sannikrushta causes of asthma in Ayurvedic classic texts (4-5). These sannikrushta causes are now regarded as asthma triggers. Triggers include allergens such as animal dander, pollens, moulds, dust mites, cockroaches and food allergens, non-allergen irritants such a cigarette smoke, perfumes, paints and particulate pollution and environmental factors such as cold air. "Symptoms of asthma are exacerbated by exercise, strong emotions, viral infection, airborne allergen exposure, airborne pollutants, and change in the weather."(6). Asthma is on the rise, (7) increasing worldwide by 5-6 percent per year (8) because of both indoor and outdoor environmental pollution and is a much more important condition today than it was when the Ayurvedic texts were written.
Vagbhat regards asthma as a yapya condition, one that cannot be completely cured but can be effectively managed. (1)
Ayurvedic management of asthma involves removal of triggers and application of a kapha cleansing program including kapha pacifying diet, pranayama, asana, oleation, sweating, emesis, virechan, nasal therapies and herbal therapies. (9) However, the ways in which these basic therapeutic measures are introduced will differ depending whether the patient is a child, adolescent or adult.
Managing asthma in children
Asthma is a disease that is considerably more common in children and adolescents than in adults, affecting over 5.3 million children in America (6). We will examine some management options for paediatric asthma through the lens of a case history. A six year old girl of kapha constitution developed asthma following an infection with respiratory syncytial virus (RSV) as an infant. RSV is a common childhood respiratory infection which can increase the risk of developing asthma by tenfold (10). Asthma development after RSV is particularly important if there is a genetic predisposition (10) or khavaigunya or if food allergies go undiagnosed. This kapha girl of Eastern European extraction was suffering from undiagnosed gluten sensitivity and was living mainly on processed foods such as cereal with cold milk, macaroni and cheese and peanut butter sandwiches, all of which served both to trigger her gluten sensitivity and to exacerbate the pichila/avila, sandra and shita qualities associated with kapha and asthma. She also had mild eczema, a typical manifestation of atopy (allergic tendencies). Eczema is frequently associated with asthma and food allergies. She was currently using one steroidal and one albuterol (bronchodilator) type of inhaler.
She was placed on a gluten free, Kapha soothing diet, since gluten was her main asthma trigger. Outdoor exercise in cold air was limited since it is an asthma trigger, and indoor exercise in the school gym was encouraged. Her mother was advised to spend some time with her each day doing deep breathing and mother and child were trained to apply deep breathing whenever there was an emotional upset, since strong emotions can trigger asthma. Her mother was trained in nasya application and with her mother's help the child used nasya oil daily to reduce post-nasal drip, another asthma trigger.
Local oleation and sudation were applied when she had an upper respiratory tract infection with increased cough. The form of oleation most suitable for young children is local application of either warm mustard oil or warm kapha massage oil, which can be applied to the chest to ease tight breathing. Internal oleation takes the form of sipping a cup of Licorice tea with ten drops of Mahanarayan oil at the onset of an attack. Sudation in paediatric asthma is best done by steam inhalation. Natural mineral salt can be used in the steam inhalation to ease asthma by providing essential trace minerals needed for lung function. Aromatic herbs such as Cardamom and Cinnamon can be used in the inhalation as well as Dashamoola, which contains castor root and helps dilate the bronchi and reduce allergic airway reactivity. Older children can also do mild sudation in a tub with natural mineral salt, dry ginger powder and baking soda. Note that is important not to apply sudation to children five and under when they have a fever, as they can overheat and have a febrile convulsion.
Daily Chyavanprash was well accepted because of its sweet taste, and led to a considerable increase in energy, to the point where she could keep pace with other children her age. Although Pippali is an excellent lung herb, compounds containing Pippali, such as Sitopaladi and Talisadi were not accepted due to her sensitivity to the pungent taste. Many children do accept Sitopaladi because of its sweet, cinnamon-y taste, so it is always worth trying in paediatric asthma. Our patient accepted other herbal formulas well with honey as anupan. Herbs used in her regime included Punarnava as a lung strengthener and dosha vyadhi for kapha, Vasaka as a bronchodilator, Cinnamon, a useful lung herb, and Chitrak for kindling agni and clearing ama.
Asthma has a strong emotional component related to breathing space.
When a child is being engulfed or controlled by a parent or does not have breathing space within the family ego mass, asthma symptoms can be greatly exacerbated. As in all paediatric situations, a child with severe asthma may well be the presentation of a distressed family system. For truly holistic Ayurvedic care, it is important to see the whole family and to assess and gently address the deep tensions within the family system.
Managing asthma in adolescents
Management of any yapya condition in adolescents is largely a matter of securing compliance. Parents cannot exercise the control they could during childhood and adolescents tend to be impulsive and susceptible to peer-pressure. The best advice to practitioners is to keep things as simple as possible and to enlist the teenager's 'trophy-ism' by making Ayurvedic asthma care a way to be special and different. A redheaded vata-pitta adolescent girl had a family history of allergic asthma and was experiencing significant asthma. She lived in a damp, cold, kaphagenic climate in a damp cottage. Her mother was diligent in addressing triggers, maintaining an immaculate home. To address kaphagenic foods in the simplest way possible, she avoided cow dairy products, substituting goat milk in its place. She typically used an Albuterol inhaler was also able to get off the inhaler for a time by using a smoking mix which included Calamus root, which helps asthma due to its anti-inflammatory and antispasmodic properties (11). The best way for teens to smoke herbs is in a water pipe, which essentially provides local sudation to the lungs in the form of herbalized steam. Older adolescents can also learn to use the neti pot to manage post-nasal drip, an important asthma trigger. Adolescents can also begin using Lung Formula to strengthen the lungs. This formula contains Pushkaramoola (Elecampane), which relieves bronchospasm, as well as Pippali, Licorice, cane sugar and cinnamon, which are expectorant, and Triphala which will reduce the inflammation involved in atopic asthma.
This patient also suffered from gastroesophageal reflux disease (GERD), which is closely associated with asthma in children and adolescents due to the urdva gati of vata involved in both GERD and asthma. By later adolescence, as her impulse control strengthened, she managed her GERD with a strict pitta pacifying diet and pitta soothing herbs such as Shatavari and Guduchi.
Managing asthma in adults
Although paediatric asthma is more common in boys than girls, by mid-life women are affected more frequently than men (7, 8). A fifty-five-year old pitta woman complained of mild asthma which she managed Ayurvedically to obtain optimal functioning. Like the previous patient, her niece, she had red hair and freckles and grew up in a damp climate in a damp Victorian house. Much of her childhood was spent in an industrial region with high particulate pollution. She was extremely allergic to yeast and moulds. She was advised to manage asthma triggers by strictly avoiding yeasted breads and limiting exposure to dust, mould and animal dander. Harsh chemicals were banned from her home and she used only unscented natural cleaning products. When she received an accidental allergen exposure, she took Mahasudarshan to support the liver in clearing the allergen from her system.
Annual pancha karma including vaman with licorice tea or natural mineral salt and virechan with Amlaki helped keep her asthma under control. She used Mahanarayan oil for oleation to help ease asthma-related chest pain and tight shoulders, did frequent sudation with natural mineral salt tubs to great effect and used nasya oil for post-nasal drip. Chest opening asanas such as camel pose and cobra helped keep her lungs open. She massaged krukatika marma at the base of the neck posteriorly, amsa phalak in the centre of the scapula and nasa marma at the lateral side of the nostrils with Almond Oil.
Chyavanprash was an important part of her daily routine, strengthening prana vaha srotas, helping fight upper respiratory infections and combating free radical damage caused by living in a polluted city and undergoing various life-stresses (13). She daily drank "Trinity Tea"--ginger, turmeric and tulsi, which helped combat respiratory viruses, allergic reactions and the inflammatory response that underlies asthma. At night she took warm milk with Turmeric, nutmeg and cinnamon to reduce night time coughing, limit allergic reactions and help ensure sound sleep. If her prakruti were kapha instead of pitta, we might have recommended warm goats milk with Pippali.
Herbs that we recommended when her asthma was exacerbated--usually by influenza--included Punarnava, Vasaka, Boswellia, Dashamoola, Pippali and Sitopaladi. The anti-inflammatory effect of Boswellia has been found to be of significant benefit in reducing atopic reactive airways disease (14). A pitta pacifying diet and use of Aloe Vera as anupan helped her tolerate herbs that might otherwise be unsuitable for pitta prakruti. She could also take Lung Formula to good effect.
The same basic treatment protocol of removing asthma triggers, kapha pacifying diet, pranayama, asana, oleation, sweating, emesis, virechan, nasal therapies and herbal therapies are applicable to all ages and stages of asthma although, as we have seen compliance levels and methods of application vary with the patients age. As a yapya condition, asthma requires a long term commitment to Ayurvedic care in order to sustain optimal wellbeing.
KS Srikantha Murthy, Vagbhata's Astanga Hrdayam, Chowkhamba Krishnadas Academy, Varanasi, 2003, Nidanasthan p 39
Kate G. Ackerman et al, Interacting genetic loci cause airway hyperresponsiveness. Physiol. Genomics 21: 105-111, 2005. First published January 18, 2005; doi:10.1152/physiolgenomics.00267.2004 1094-8341/05
KS Srikantha Murthy, Vagbhata's Astanga Sangraha, Chaukhamba Orientalis Varanasi, 1986 p326
PV Sharma, Chakradutta, a treatise on the principles and practice of Ayurveda, Chaukhamba Orientalis Varanasi 1994 p 145
Christine Cole Johnson, Dennis R. Ownby et al, Environmental Epidemiology of Pediatric Asthma and Allergy Epidemiologic Reviews 24:154-175 (2002)
Beasley R, Crane J, Lai CK, et al. Prevalence and etiology of asthma. J Allergy Clin Immunol 2000;105:S466-72.
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Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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