1

DETAILS

According to Ayurveda, pneumonia may be equated to 'Vishabhi sangaja' jvara caused by the infection of 'Pneumococcus'(gram positive bacteria)/ and Karkataka Sannipata Jvara, In this apart from fever, the patient constantiy coughs lac-juice-colour sputum. He feels difficulty in breathing because of the congestion of lungs. If the congestion of lungs is not taken care of, consolidation of the lungs develops.

In such stage some times there is blood stain in the sputum of i the patient and temperature rises. There is tubular breathing. It is called as 'Shvasanaka Jvara' because of the involvement of Svasana yantra i.e. Respiratory apparatus. There are two main varieties of pneumonia viz.

(1) Lobar pneumonia(khandiya shvasanaka jwara) -shotha in vayu kosha

(2) Bronchial pneumonia(pranalik shvasanaka jwara) –shotha in vayu shakha

These are further divided and sub-divided according to the involvement of the

parts of respiratory organs.

Comparisonly hina-pitta Madhya vata and kapholavana sannipata jwara. 

2

Purva rupa- 

1. Parshvsula(pain in ribs)

2. Swasa(dyspnoea)

3. Avasada(depression)

4. Kasa(cough)

5. Kampa(tremors) 

3

SYMPTOMS

1. Shita tivra jwara(fever with chills)

2. Atitrisha(excessive thirst)

3. Aruchi(anorexia)

4. Parshvsula

5. Kasa

6. Raktasthivana(haemoptysis)

7. Tivra swasagati(increased rate of respiration)

8. Redness over cheeks

9. Sweating on fore head

10.Weakness

11.Kanthakunjan(wheezing)

12.Small boils over body 

4

SAMPRAPTI GHATAK

DOSHA-tridosha

DUSYA-rasa,rakta

SROTAS-Pranvaha srotas

ADHISTHAN-lungs 

5

UPADRAVA

1. Nidranasa(loss of sleep)

2. Pralapa(delirium)

3. Kampa(tremors)

4. Sangyanasa(loss of sensation)

5. Heart attack 

6

TREATMENT

The treatment depends on the 'Condition' of the patient. Perfect bed-rest is most important in an Hygienic and Airy place. Patient's strength and vitality must be maintained by nutritive and easily digestible food.

Brihat Kasturi Bhairava Rasa, Niradiya Laksmi Vilas Rasa, Tribhuvana Kirti Rasa, Trilokya Chintamani Rasa are recommended with suitable Anupiina.

Pathya-Sukosna Jala pana. Goat's milk is best/cow's milk is next best in this condition. Food-items-Manda, peya, vilepi should be served in lukewormly. Patola, Jira, Saindhava, Mudga yashz‘t, Karela etc. Dry grapes, apples are good. Other nutritive things should also be given. 

7

PNEUMONIA 

Pneumonia is an acute infection of lung parenchyma including alveolar spaces and interstitial tissue.

• Involvement may be confined to an entire lobe -Lobar pneumonia

• A segment of a lobe-Segmental or lobular pneumonia

• Alveoli contiguous to bronchi - Bronchopneumonia

• Interstitial tissue - Interstitial pneumonia

These distinctions are generally based on x-ray observations.

INCUBATION PERIOD- 1-3 DAYS

Predisposing factors for pneumonia include:-

• Preceding respiratory viral infections

• Alcoholism

• Cigarette smoking

• Underlying diseases such as Heart failure, COPD

• Age extremes

• Immunosuppressive therapy and disorders

• Decreased consciousness, comma , seizure etc

• Surgery and aspiration of secretions

The usual mechanisms to develop pneumonia are either to inhale droplets small enough to reach the alveoli, or to aspirate secretions from the upper airways. Other means include hematogenous dissemination, via the lymphatics, or directly from contiguous infections.

drkamleshbiswas@gmail.com

Microbial Pathogen that cause Pneumonia: depend on the setting in which pneumonia is acquired

1. Community-acquired pneumonia

o Streptococcus pneumoniae ( pneumococcal pneumonia ) commonest cause

o Mycoplasma pneumoniae

o Chlamydia pneumoniae

o Haemophilus influenza

o Oral anaerobic bacteria

o Staphylococcus aureus

o Legionella pneumophila

o Mycobacterium tuberculosis

2. Aspiration pneumonia: This occurs when large amount of oropharyngeal or gastric

contents are aspirated into the lower respiratory tract. Aspiration occurs more frequently in patients with:

• Decreased level of consciousness (alcoholism, seizure, strokes or general anesthesia)

• Neurologic dysfunction of oropharynx and swallowing disorders.

• People with periodontal disease are affected more.

Common Etiologic agents of Aspiration pneumonia: It is often polymicrobial

o Anerobic organisms in the oral cavity

o Enterobateriacae

o S. pneumoniae

o S.aureus

Patients present with cough and foul smelling sputum. The cough may be chronic

forming lung abscess and may resemble TB. There will be signs of cavity on physical

exam and CXR. It is treated with crystalline penicillin and metronidazole IV for several

weeks if lung abscess develops.

3. Community acquired Pneumonia in Immunocompromised hosts:

Immunocompromised hosts such as transplant recipients, HIV infected patients, and

patients on Chemotherapy etc. are prone to develop pneumonia.The etiologic agents

are

o Common bacterial causes of CAP : St. Pnumoniae , H.influenzae,Mycoplasma

o Gram negative organisms : enterobacteriaceae

o Funguses such as Pneumocystis carinii ( jerovecii ), C. neoformans,Histoplasmosis , Aspergillus

o Mycobaterium tuberculosis

o Viruses : HSV , CMV

4. Hospital-acquired pneumonia: a patient is said to have hospital acquired pneumonia if the symptoms begin 48 hours after hospital admission and not incubating at the time of admission. Common organisms that cause hospital-acquired pneumonia are:-

o Gram-negative bacilli including Pseudomonas aeroginosa, K.pneumoniae

o Staphylococcus aureus ( may ne drug resistant )

o Oral anaerobes.

drkamleshbiswas@gmail.com

Clinical Presentation of community acquired pneumonia

• Community acquired pneumonia can have typical or atypical presentations. This

classification is less distinct but it may have diagnostic value. More commonly patients

have “typical” presentation and it is mainly caused by S.Pneumonae. But other

organisms like H. influenza and oral flora can be causes.

• Pneumonia is often preceded by a URTI.

The “typical” Community acquired pneumonia: is characterized by:-

• Sudden onset with a single shaking chill. This is followed by high grade fever (upto

40.50c )

• Cough productive of purulent, blood streaked or rusty sputum

• Pleurtic chest pain on the involved side worsened during inspiration and coughing

• Daphnia ( shortness of Breath )

• Headache , myalgia , arthralgia and fatigue

Physical findings

• The Patient will have tachycardia (pulse 100 to 140/min)and tachypnea (RR > 20/min).

• There will be pulmonary signs of consolidation (lobar pneumonia), which are

Increased tactile fremitus and vocal fremitus , dullness on percussion Bronchial breath sound, egophony, wispering pectoriloquy, crackles and pleural friction rub.

The “atypical” pneumonia present with:

• Atypical” pneumonia is usually caused by M. pneumoniae, C.pneumoniae, oral

anaerobes and P. carinii (usually in HIV patients), as well as S. Pneumoniae. Some

viruses like influenza virus, Varicella zoster virus and cytomegalovirus may cause

“atypical” pneumonia. Tuberculosis could also present in this form.

• More gradual onset of symptoms, dry cough, shortness of breath.

• Prominence of systemic symptoms like headache, malign, fatigue, nausea, vomiting and diarrhea.

• Chest findings on physical examination are minimal even though X-ray changes are

marked.

Complications:

• Local: Parapneumonic effusion or pus in the pleural space (empyema).

• Distant complications: include septic arthritis and meningitis. Pneumonia can progress

to sepsis, sometimes with septic shock.

Laboratory findings:

1) CBC: leucocytosis with increased neutrophils is seen in most cases.

2) Gram stains from sputum may show a predominant pathogen like Gram-positive

diplococci.

3) Chest x-ray shows pulmonary infiltrates or homogeneous opacity indicating lobar

pneumonia. Very early in the course, it may be normal.

drkamleshbiswas@gmail.com

Diagnosis:

• Pneumonia should be suspected in patients with acute febrile illness, associated with

chest pain, dyspnea and cough.

• Presumptive diagnosis can be made from history, changes on chest x-ray, blood and

sputum culture and sputum Gram stains. An absolute diagnosis requires demonstration

of S. pneumoniae or other etiologic agents in pleural fluid, blood, lung or transtracheal

aspirate.

Prognosis: The overall mortality rate is low, if treated early. Factors that herald a poor

prognosis include the following:-

• Extremes of age, especially < 1 yr or >60yrs,

• Positive blood culture

• Involvement of more than one lobe

• Peripheral WBC < 5000/ml

• Presence of associated diseases (e.g. cirrhosis, CHF, immunosuppression)

• Development of extrapulmonary complications like meningitis and endocarditis.

Management:

drkamleshbiswas@gmail.com

Mild form of CAP

Patients with uncomplicated “typical” pneumonia can be treated at OPD

• Amoxicillin 500 mg PO TID or Ampicillin 500 mg PO QID for 7 to 10 days OR.

• Procaine penicillin 600,000 IU IM every 12 hrs.

If “atypical” pneumonia is suspected,

• Erythromycin 500 mg PO QID for 7-10 days or Doxycycline100 mg PO BID

Supportive Therapy: Patients should also get bed rest, adequate fluids and analgesics for pleuritic chest pain and fever.

Response – In mildly ill patients who are treated early, fever subsides in 24 to 48 hrs. Others may require 4 days to respond.

• If Patients are allergic to penicillins, cephalosporins, erythromycin, and clindamycin can be given. TTC are less predictable and should not be used in seriously ill patients.

• If a patient does not improve, the following factors should be considered:

Wrong etiologic diagnosis

Adverse drug reaction

Far advanced case or superinfection

Inadequate host defenses due to associated condition

Non-compliance to the drug regimen in outpatients

Antibiotic resistance of the strain and

Complications like empyema requiring drainage, or metastatic foci of infection

requiring higher doses (e.g. meningitis, endocarditis or septic arthritis).

• Persistent cough and infiltration on chest x-ray for more than 6 weeks after therapy

suggests possibility of an underlying bronchogenic neoplasm or tuberculosis.

Severe forms of CAP

If patients are seriously ill they should be admitted and treated as inpatient.

Criteria for Hospitalization of patients with Pneumonia are:

1) Respiratory rate of >28/min ( Tachypnea ) tachycardia >140/min

2) Systolic blood pressure <90mm Hg (hypotension

3) Hypoxemia arterial PO2 < 60mm Hg) while breathing room air or O2 saturation < 90%

4) New onset of confusion or impaired level of consciousness .

5) Unstable /Significant co-morbidity (e.g. Heart faiure , uncontrolled diabetes, Chronic

Renal insufficiency ,alcoholism , immunosuppresion )

6) Multilobar pneumonia is Hypoxemia is present

7) Pleural effusion and with analysis showing characteristics of complication

Other conditions in which inpatient management may be advisable

• Elderly patient >65 yrs of age

• Leukopenia <5000 WBC/ml

• Pneumonia caused by St. aureus or Gram negative bacilli

• Suppurative complications e.g. empyema, arthritis, meningitis, endocarditis

• Failure of Outpatient treatment

• Inability to take oral medication or persistent vomiting

Management of CAP

Supportive management

• Ensure adequate oxygenation to patients with cyanosis, significant hypoxemia, sever

dyspnea, circulatory disturbance or delirium.

• Patients should be well hydrated

• Fever and pain should be managed

Antibiotic Therapy

• Admitted patients should be started on antibiotics empirically

• High dose of crystalline penicillin 3-4 million IU IV every 4-6 hours

• Alternatives are Ceftriaxone 1gm IV daily or 2X /day or Ampicillin 500 mg IV QID Or

Cefotaxime

• In severely ill patients erythromycin or a flouroquinolone can be added.

• Choice of Antibiotics may be modified based on culture and sensitivity results, if

available.

• If the patient improves, IV treatment can be changed to oral after 3-4 days to complete a 7-10 days course.

Prevention

• Cessation of smoking and alcoholism

• Vaccines : Influenza an Pneumococcal vaccines ( available in developed countries )

drkamleshbiswas@gmail.com

Pneumonia in the Compromised Host

• Immunocompromised hosts include patients with AIDS, acute leukemia, cancer

chemotherapy, diabetes, sickle cell disease, Hodgkin's disease, and corticosteroid

treatment.

• The potential pathogens in compromised hosts are many, as it has been stated above.

• Pathogens like Streptococcus pneumonia, which cause pneumonia in immunocompetent people, are still responsible for the majority of pneumonia in compromised patients.

Diagnosis:

• Sputum examination and culture are used but they are not specific.

• Transtracheal aspirate, bronchoscopy and biopsy have high accuracy; however these

are done only in specialized hospitals.

• High index of suspicion from clinical presentation is important to diagnose pneumonia in immunocompromised hosts.

drkamleshbiswas@gmail.com

Treatment:

• Acutely ill patients who have suspected bacterial infections are often treated with

antibiotics selected on the basis of probabilities and the findings with sputum gram stain

and culture. Later treatment is adjusted on the basis of more definitive diagnostic

evaluation.

• In patients with HIV infection and “atypical” pneumonia, PCP should be considered and treated with high dose of co-trimoxazole ( 3 tablets every 6 hours for 3 weeks) if clinically considered.

Hospital acquired Pneumonia (HAP)

The definition of HAP includes the presence of a new or progressive infiltrates of Chest X-ray ,plus at least two of the following

• Fever >37.8 oC

• Leukocytosis > 10,000/mm3

• Production of purulent sputum

Other findings: dyspnea, hypoxemia and chest pain

Treatment

Antibiotics: Should be initiated empirically which latter on may be modified based on culture and sensitivity result.

The selection of drugs should be guided by an understanding of local patterns of antibiotics resistance

Antibiotics should cover at least gram negatives and S. aureus

• Ceftriaxone 1gm IV daily or BID plus Cloxacillin or meticillin Or

• Levofloxacin 500 mg IV /day

When resistant organisms are suspected

• Cefotaxime 750 mg IV TID plus Vancomycin 1gm IV BID

Prevention

• Strict hand washing protocols by health care providers

• Extubate an entubated patient as soon as the patient is stable

• Remove NG tubes when the patient is stable

• Proper aseptic handling of IV lines

PATHYA-

- Purana Sali, Mudga, Masoor, Parval, Karela, Sahijan, Choulai, Gaduchi, Jeevanti, Makoya, Manukka, Anar, Laghu Ahar, Yavagu, Peya, Vilepi, Yava, Lajamanda, Daliya

APATHYA-

- Guru, vidahi, vistambhi, dushita jala sevana, ankurita anna, tilkuta, sweet, chole, lassi, chana dal

- Vegadharana, vyayama, divasvapna, sanana, adhyasana

NISHEDHJA-

- Nava jvar me divasvapna, snana, abhyanga, maithuna, krodha, dhimi hava   

RASODHI/BHASMA/PISTI-(120-250MG WITH MADHU/USHNODAKA)

- Tribhuvan kirti rasa-(hingula,vatsanabh,trikatu,tankan)

- Godanti bhasma-(godanti)

- Shringa bhasma-(mrigshringa)

- Laxmivilas rasa-(swarn,rajat,abhrak,tamra,nagabhasma)

- Praval pisti

- Svasakuthar rasa

- Achintay sakti rasa

- Shringrabh rasa

VATI-(250-500MG WITH USHNA JALA)

- Lavangadi vati

- Vayoshadi vati

- Maricyadi vati

- Vibhitaki curna

- Yastimadhu curna

- Sitophaladi curna-(dalchini,ela,pippali,vanshlochan,mishri)

- Talisadi curna-(talisa,marich,sunthi,pippali,vanshlochan,mishri)

- Lavangadi curna-(lavanga,sheetal chini,khas,sveta chandana,tagar,bhringraja,motha)

- Drakshadi curna-(draksha,harad,mustak,kutki,amaltas,parpat)

KAVATH/ASAV/ARISHTA-(20-40ML WITH SAMABHAG WATER)

- Gojivhadi kvatha

- Bhadangyadi kvatha

- Asthadasanga kvatha

- Dasamula kvatha

- Vasavaleha

- Kantakaryavaleha

- Chyavanprasaha