Abnormal Breathing Sounds as explained in Ayurveda Treatises: Clinical significance

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S

Description of respiratory disorders in Ayurveda are found explained in the contexts of Shwasa – different conditions presenting with difficulty in breathing, Kasa – cough and its types and Rajayakshama – a condition which has been often correlated with pulmonary tuberculosis but is actually a syndrome which covers many diseases in its spectrum.

The explanation of Pranavaha Sroto Dushti – contamination or afflictions of the channels of the body concerned with conveyance of prana energy – the vital breath being a part of it, and the symptoms mentioned therein, also explain the respiratory disorders.

Respiratory diseases manifest with different signs and symptoms, cough and shortness of breath / difficulty in breathing being the main symptoms which become troublesome in the long run.

Respiratory diseases also present with many kinds of abnormal breathing sounds and patterns which by themselves help in diagnosis and differential diagnosis of many of these conditions. Modern medicine has explained different abnormal / pathological sounds of respiratory diseases including wheezing, rales, rhonchi and stridor.

In this article we shall explore the abnormal respiratory sounds as explained in Ayurveda treatises.

Abnormal Breathing Sounds as explained in Ayurveda Treatises

We cannot find straight references indicating the explanation of abnormal breath sounds in Ayurveda treatises. But we can infer certain things from the minimum available references.

A. From the context of Shwasa

Shwasa comprises a group of conditions presenting chiefly ‘difficulty in breathing’ along with other distressing symptoms. Though they explain different breathing disorders and disturbed patterns, abnormal breath or lung sounds have been mentioned in a couple of conditions.

1. Maha Shwasa

This is a type of shwasa whose prognosis is said to be difficult, this condition is incurable according to Ayurveda. In this condition the term ‘Matta Rshabha iva’ describes the pattern in which the person while breathing – producing sounds similar to ‘huffs and puffs of an intoxicated bull’. This condition is caused due to vata constantly trying to move upwards.

Maha Shwasa is marked by strenuous and painful inspiration (breathing in of air). During inspiration, loud noises or sounds which are abnormal are audible. Since the aggravated vata moves haphazardly in the upward direction and blocks the channels in the body, the person breathes the air in with difficulty throughout the day and night. This person breathes deeply with difficulty producing the sounds similar to those produced by an intoxicated bull throughout the day and night.

This condition reflects ‘abnormal sounds produced during inspiration’.

The disease manifests as a respiratory complication or emergency since other symptoms reflect severe deficiency in oxygenation leading to complicated systemic symptoms including loss of consciousness and fainting.

These abnormal lung sounds produced in Maha Shwasa can be correlated to ‘Rales / Crackles’ explained in modern medicine – which is also an abnormal sound produced during inspiration.

A brief note on ‘Rales’

Crackles / Rales are discontinuous, interrupted, explosive sounds, sound like rattling, bubbling, clicking sounds. Fine crackles or crepitation are short, high pitched sounds. Coarse crackles are low pitched and last long. These sounds are produced during inspiration when the air tries to move into closed passages as in alveoli. As the air tries to fill up into the small airways i.e. alveoli which is damaged or weighed down with fluid or mucus a crackling sound is produced, with the air trying to open the closed spaces. Mucus may also be clogged in the small airways. Crackles may be moist or dry, fine or coarse in nature. Typically, rales do not get relieved with coughing. Rales are caused due to restrictive lung diseases like interstitial lung disease (scarring or fibrosis of lungs), pulmonary oedema, pneumonia, atelectasis or asbestosis. Rales may also be present in asthma and heart failure. Fine crackles indicate that alveoli are afflicted. Coarse crackles indicate that large airways are affected. In severe cases, both fine and coarse crackles can be heard together.

We can see that the nature of rales / crackles resembles the abnormal lung sounds produced in Maha Shwasa.

2. Tamaka Shwasa

Tamaka Shwasa is also a type of Shwasa. It is a condition which is said to be yapya – manageable but cannot be cured completely. This condition is also caused when the upward moving vayu disturbs kapha in the upward channels. These two doshas first cause pinasa – cold and congestion. Later severe breathing trouble which could in due course of time become life threatening (if not managed) is caused while producing ‘ghurghuraka’ sound from the chest.

The pathogenesis of shwasa tells ‘when the aggravated kapha obstructs vayu, the vayu moves in abnormal directions and causes blocks in the srotas, shwasa disease is caused’. Similar pathogenesis happens in tamaka shwasa also. The aggravated vata moving upwards disturbs kapha and this kapha causes obstruction of free movement of vata causing shwasa.

The ‘ghurghuraka’ sound produced in tamaka shwasa can be correlated to –

a.    Wheezing
b.   Rhonchi

Both wheezing and rhonchi are caused due to difficulty in expiration.

In tamaka shwasa – it is said that the person finds himself in a zone of severe discomfort and distress as long as there is blockage caused by kapha. Once this kapha is expelled from the srotas through expectoration, the person feels at comfort and breathes easily. Tamaka Shwasa is correlated with asthma and COPD, both present with abnormal sounds during expiration i.e. wheeze. Even in these conditions excess mucus or secretions are found in the respiratory passages.

Rhonchi gets relieved after coughing or expectorating kapha and so also in case of wheezing, as in tamaka shwasa.

A brief note on ‘rhonchi and wheezing’

Rhonchi are continuous low-pitched sounds. Sometimes they may come and go. They are produced during expiration. These sounds can be heard at different parts of the chest when one coughs moving the mucus around. It is also described as snoring or gurgling.

The cause is mucus, fluid or secretions gathering in large airways (bronchi or bronchioles) / fluid blocking the airway. The sounds are produced due to the air making sound as it moves around the blockage. Rhonchi is temporarily relieved by coughing. Obstructive lung disease – damage of airways causes air to leave the lungs slower than it should as you exhale. Examples – COPD, Bronchiectasis, asthma, cystic fibrosis and pneumonia. Rhonchi is also a low-pitched wheeze.

Wheeze is a continuous high pitched hissing sound, usually expiratory (common). It may be both while breathing in and out. Wheeze is mainly found in asthma and COPD.

3. Urdhwa Shwasa

It is yet another subtype of shwasa wherein we do not get any mention of this condition producing any kind of ‘abnormal chest or lung sounds’. The main presenting features of urdhwa shwasa are –

–        ‘Urdhwam Shwasati Yo deergham na cha pratyaharati adhah’ – which means ‘the person can breathe out for long duration but cannot take the air in for longer time’
–        ‘Urdhwa Shwase prakupite hi adhah shwaso nirudhyate’ – which means ‘while the output of air i.e. exhalation is exacerbated, the input of air i.e. inhalation gets obstructed’

The reasons for these mechanisms is the channels of the body being occupied and clogged by shleshma – mucus and secretions. This eventually hampers the easy flow and movements of vata, leading to its aggravation. All these events lead to manifestation of urdhwa shwasa, which is said to be incurable because of its complicated nature. The other symptoms of urdhwa shwasa like upward gaze, fluctuation in eyeball movements, loss of consciousness due to severe pain and distress, whiteness of the face (looking pale) and restlessness indicate severe deficiency in oxygenation and nutrition to body parts and also appears like a clinical emergency.

Very important feature to note here is, there is an imbalance between the lengths of inspiration and expiration, the expiration being long and inspiration being short (due to the blockage in the channels by kapha) – indicating severe respiratory distress. So, the breathing pattern is definitely abnormal and abnormal breathing patterns will show abnormal breath sounds. This is an indirect method of understanding abnormal sounds in urdhwa shwasa.

In Urdhwa Shwasa, we can see that the person is feeling respiratory distress both during inspiration and expiration. One is longer and one is shorter, causing ultimate distress. This is a case of both rales and rhonchi being present together.

Both Rhonchi and Rales are present in pneumonia, bronchitis, COPD etc. These conditions are marked with shortness of breath, cough, weakness, pain with breathing and difficulty in breathing.

4. Chinna Shwasa

Chinna Shwasa is another type of shwasa which has a bad prognosis i.e. it cannot be cured. In this condition there are bouts of breathlessness. In other terms the person suffers from interrupted breathing, like breathing in breaks, in spite of him or her putting all efforts to breathe properly. Herein the heart and other vital organs (marma) are under distress and pain and therefore the person breathes with difficulty. This is said to be a life-threatening condition, a clinical emergency.

Here also, we do not get a description of abnormal breath / chest or lung sounds mentioned but we can infer that with the abnormal pattern of breathing which has been explained.

Looking at the pattern of breathing, chinna shwasa has a non-continuous type, i.e. a series of short and broken, intermittent and interrupted patterns. So, the breathing sounds cannot be normal. The sounds too are noncontinuous, broken up and non-musical in nature.

Crackles or rales are of similar type. The sounds are discontinuous, explosive – like rattling, bubbling, clicking. They may be short and high pitched when fine and low pitched, long lasting when coarse. This depicts blocks in small airways and most of the times it is during intake of air i.e. inspirational, as in pulmonary oedema, interstitial lung disease, heart failure or asthma. These conditions fit into the description of chinna shwasa and chinna shwasa presents ‘rales’ like lung sounds. Rhonchi, though a continuous type of noise, may sometimes be discontinuous too. So, chinna shwasa may present as rales as a rule, and sometimes as rhonchi, may be mixed sometimes.

The other symptoms of chinna shwasa like distension of abdomen, excessive sweating, fainting, tear filled eyes, burning sensation in the region of urinary bladder, emaciation, blood red eye, loss of consciousness, dry mouth, discolouration and delirium indicates the grave nature of the disease.

B. From the perspective of Pranavaha Sroto Dushti

Master Charaka, amongst the symptoms of affliction of pranavaha srotas has mentioned ‘sa Shabda shwasam’, which means ‘breathing which produces abnormal sounds which are otherwise not audible’. This explains the clinical precision of Ayurveda Acharyas of olden times and their subtle observations in relation to abnormal breath sounds and patterns.

The other symptoms explained by Master Charaka in the same context depict various abnormal breathing patterns.

When we observe that one or more of these patterns of abnormal breathing have association with ‘sa Shabda shwasa’ being the common factor for those patterns, we can derive some abnormal breath sounds as explained in modern medicine.

Let us see through some of them.

The abnormal breath patterns in afflictions of pranavaha srotas (Charaka) are –

–        Atis srushta shwasam – too long (prolonged) breathing
–        Ati baddham shwasam – too short breathing (short of breath)
–        Kupitam shwasam – difficult breathing
–        Alpam alpam shwasam – frequent and interrupted / intermittent breathing
–        Abheekshnam shwasam – highly disturbed breathing patterns looking scary
–        Sa shabda shwasam – abnormal sounds during breathing
–        Sa shula shwasam – painful breathing

Inference of abnormal sounds from the above said description –

a.    Ati srusta shwasam with sa Shabda shwasam – can be a case of prolonged breathing / expiration, as in Urdhwa Shwasa – a mixture of rhonchi and rales – manifesting together. In case of Maha Shwasa – it may be a case of long inspiratory – rales and in case of Urdhwa Shwasa – it may be a case of prolonged expiratory – rhonchi.

b.   Ati baddham shwasam with sa Shabda shwasam – can be a case of too short breath or shortness of breath – as in maha, urdhwa or tamaka shwasa – presenting with rales, rhonchi or wheezing. In case of Maha Shwasa – it may be a case of short expiration – rales and in case of Urdhwa Shwasa, it may be a case of short inspiratory – rhonchi.

c.    Kupitam Shwasam with sa Shabda shwasam – can be a case of difficulty in breathing which is a feature of Maha, Urdhwa, Chinna or Tamaka Shwasa. So, the presentation may be rales, rhonchi or both or wheezing – as the case may be.

d.   Alpam Alpam Shwasam – with sa Shabda shwasa – can be a case of frequent and interrupted / intermittent breathing, a feature of Chinna Shwasa and the abnormal sounds are rales in this case.

e.    Abheekshnam Shwasam with sa Shabda shwasam – can be a case of highly disturbed breathing patterns which look scary. Again, Maha, Urdhwa or Chinna Shwasa or a complicated picture of Tamaka Shwasa. So, the presentation may be rales, rhonchi, both or wheezing – as the case may be.

f.     Sa Shula Shwasam with sa Shabda shwasam – can be understood on the lines of Abheekshnam Shwasam and other patterns above and may include all patterns of shwasa and all kinds of abnormal sounds as the case may be.

g.    Sa Shabda Shwasam – can be a case of ‘just abnormal sounds’. This again includes all kinds of shwasa and all kinds of abnormal sounds produced therein.

‘As the case may be’ – that I have mentioned in a few of the above-mentioned patterns means ‘when associated with the classical symptoms of that particular variant of shwasa’.

C. Other Sounds

1. Vataja Kasa

Among the symptoms of cough caused due to aggravated vata, both nirghosha – absence of sound and stanana – manifestation of sounds is mentioned. This sound may be the sound of cough or sounds heard on the chest. Since it belongs to the pattern of discontinuous type of sounds, vataja kasa can be inferred to produce ‘crackles or rales’. They may be fine or coarse. Rales generally do not get relieved by coughing, and so does vataja kasa. Here there is less mucus or phlegm. So, the cough and sounds produced are of dry variety. Coughing can increase the symptoms.

2. Kaphaja Kasa

Cough produced by predominant vitiation of kapha can also cause abnormal sounds. The sounds may mimic those found in patients of ‘tamaka shwasa’. Like tamaka shwasa, kaphaja kasa is also caused by obstruction of pathways of vata by aggravated kapha and filling of chest cavity (respiratory passages) by kapha – mucus or phlegm or stubborn secretions. The person expectorates thick sputum. Kaphaja Kasa, thus may exhibit mild to moderate forms of wheezing.

3. Kshataja Kasa

‘Paravata iva akujan’ is one of the symptoms of a cough developed due to ‘chest injury’. It means ‘the person produces sounds from the throat and chest resembling the sounds made by a pigeon. This probably explains sounds similar to stridor.

A brief note on stridor

Stridor is a continuous, harsh, high-pitched whistle / squeaking sound / bark / sounds like a cough. This sound is produced during inspiration, mainly in children with croup, or airway blocked by swelling, foreign object or tumour. It is a wheeze-like sound caused due to a block of airflow in the windpipe (trachea) or in the back of the throat. This condition can also be present in kanthagata rogas – throat disorders.