Patients with chronic apnea, either due to cervical spine trauma or diseases, such as ALS, may benefit from Diaphragmatic Pacing.

Improvement in the quality of life has been demonstrated in these patients by delaying the need for mechanical ventilation and decreasing the incidence of pulmonary infections.

Phrenic nerve stimulation or direct diaphragmatic stimulation are preformed via implanted electrodes connected to a radiofrequency receiver which receives radio signals from an external transmitter.

Candidates for phrenic nerve stimulation must have intact phrenic nerve cell bodies, therefore patients with lower motor neuron diseases, such as ALS or damage to the cervical spine bellow C2, may be treated with direct diaphragmatic pacing only.

The electrodes are placed using minimally invasive surgical techniques. Phrenic nerve pacers are placed using cervical or thoracic approaches. Diaphragmatic pacers are placed laparascopically at diaphragmatic motor points, attachment points of the phrenic nerve on the diaphragm. These points are mapped using specialized computer software.

This procedure was developed at University Hospitals Case Western Medical Center. Patients include Christopher Reeves, who suffered a cervical spine injury following a riding accident leaving him quadriplegic and respirator dependent.

Reeves: "“The constant and high cost of care for ventilator-dependent patients not only exhausts most insurance policies but contributes to strain on families and caregivers. Once this procedure receives FDA approval, these patients and their caregivers should be able to achieve significant improvements in their quality of life.”

This procedure has been FDA approved since 2008 and is now gaining worldwide accreditation for its role in ICU patient rehabilitation.

Case report "Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis" By dr Khan, dr Parab & dr Ghaisas is published in international Journal The Laryngoscope. The link is :
http://onlinelibrary.wiley.com/doi/10.1002/lary.21029/abstract


http://onlinelibrary.wiley.com/doi/10.1002/lary.21029/abstract

Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis - Parab - 2010 - The Lar
onlinelibrary.wiley.com
Parab, S. R., Khan, M. M. and Ghaisas, V. S. , Simultaneous involvement of larynx and middle ear in pulmonary tuberculosis. The Laryngoscope, n/a. doi: 10.1002/lary.21029

Many clinical research groups have studied the possibility that cancer therapy can be selected on the basis of specific mutations suspected of driving cancer growth, but the new initiative, called BATTLE (Biomarker-integrated Approaches of Targeted Therapy for Lung cancer Elimination), is testing the hypothesis with a high degree of rigor. In BATTLE, molecular features of the tumor entirely drive the treatment selection.The basis is to stop looking at drugs and start looking at the individual tumors.The traditional way has been a retrospective analysis of tissue samples to stratify response rates by tumor characteristics.The new way is to base therapy on the tissue characteristic of the biopsy taken at diagnosis.It is a very important study which shows that it is possible to collect tissue and evaluate it for biomarkers in a time frame, that is acceptable for directing therapy.

Respiratory system performs functions of ventilation (V), perfusion (Q), and diffusion (DL). All respiratory function tests are based on the measurement of these functions. Spirometry measures the echanical function of the lung, chest wall, and respiratory muscles by assessing the total
volume of air exhaled from a full lung (total lung capacity [TLC]) to an empty lung (residual volume). This volume, the forced vital capacity (FVC) and the forced expiratory volume in the first second of the forceful exhalation (FEV1), should be reproducible to within 0.15 L upon
repeat efforts unless the largest value for either parameter is less than 1 L. Flow-volume loop recording is one of the dynamic ventilatory function tests. This is a safe, simple and reproducible. It is performed routinely in general practice. The shape of the flow-volume loop can differentiate between normal or abnormal lung function. Abnormalities like obstructive or restrictive lung conditions can be differentiated. Although these tests cannot give a pathological
diagnosis and assesses the mechanical functional impairment of various respiratory conditions, but they support other respiratory function tests. Moreover, they are important prognostic indicators of disease process and are commonly used to monitor drug therapy. This review explains the interpretation of flow volume curves in health and disease which will provide an
easy guide for both clinicians and physiologists.
Keywords: Spirometry, FEV1, FVC, Obstructive lung disease, Restrictive lung disease

Introduction

Respiratory Disease will afflict every human being at some time in their life. Whether it’s a cough associated with the common cold or respiratory distress associated with allergies and asthma, respiratory challenges are a constant source of irritation and misery for the afflicted.

Classical Ayurvedic Medicine categorizes respiratory challenges into two main categories. These are Kasa (cough) and Swasa ( dyspnea or difficulty breathing). From an understanding of ayurvedic knowledge, common conditions such as the common cold, asthma and bronchitis can be understood and managed. This article address the condition of kasa (cough).

Kasa (Cough)

In the Allopathic medicine, Cough are understood to be the result of either infection or irritation of the bronchial tissue and are known as bronchitis. Infectious bronchitis commonly accompanies the common cold but may occur separately and may or may not be associated with fever. Cough may be dry or productive. Irritative bronchitis is usually the result of pollutants, smoke, or chemicals and may have an allergic component.

Samprapti (Pathology)

Kasa occurs when apana vayu is obstructed resulting in an increase in upward motion. Vitiation of udana vayu propels the air upward and out of the body. Vata may however lodge in the chest, back, or head resulting in pain and repeated coughing.

All disease has its physicial origins in the digestive system. This is the site of accumulation and aggrevation of the doshas. Kasa begins with vitiation of apana vayu in the purishavaha srota (large intestine). Vata eventually overflows into circulation (raktavaha srota) and relocates to the pranavaha srota (respiratory system.) Additional doshas may mix with vata or become dominant in the pathology.

Purvarupa (Prodomal symptoms)

Cough are often preceeded by symptoms of the common cold such as a sore throat, and a decrease in appetite. Proper early management of the prodromal symptoms can prevent the onset of bronchitis.


Types of Kasa

Kasa (cough) is of five types; vata, pitta, kapha, ksataja and ksaya. Those of a vata, pitta and kapha nature represent different doshic manifestations of a cough. Ksataja type are due to chest injuries while ksaya type is due to disease that results in wasting of the bodily tissues such as tuberculosis.


Rupa (symptoms)

Cough due to vitiation of vata are called “vataja kasa”. They present as a dry cough with little mucous production. While small amounts of hard mucous may occasionally accompany a cough, the condition is for the most part dry. Examination of the mucous reveals it to be gray in color and ununctuous (not very sticky). The cough may be accompanied by a loss of voice and severe chest pain. The frequency of the cough is episodic and may occur in fits.

Cough due to pitta vitiation are called “pittaja kasa”. They present with a greater amount of mucous. Examination of the mucous reveals a yellow color and possible blood within the mucous giving it a “rusty” appearance. This latter appearance indicates that the infection has penetrated deeper in the respiratory system as is seen in pneumonia. Pittaja kasa is accompanied by fever. The cough is more continuous than that of vata type.

Cough due to kapha vitiation are called “kaphaja kasa.” They present with the greatest amount of mucous. Examination of the mucous reveals a cloudy, white color and the mucous is thick and sticky. The condition is often accompanied by a runny nose, nausea, and vomiting. Actual pain in the chest and head is mild. Kaphaja kasa is not associated with fever. Coughing is continuous.



Comparative Rupa (symptomatology) of Vataja, Pittaja and Kaphaja Kasa
Vataja Pittaja Kaphaja
Minimal mucous, hard mucous, grey in color Moderate mucous, sticky, yellow in color Large amounts of mucous, sticky, cloudy and white in color


Cough due to trauma, called “ksataja kasa” reveal a combination of symptoms related to vata and pitta types. Sputum may be red, yellow or black indicating infection and bleeding. While the mucous is abundant, it is ununctuous. Fever is probable and there may be joint pains as well. Due to trauma, blood may simulatanously appear in the urine. Cough due to trauma are described as resembling the cooing of a pigeon.

Cough due to ksaya occur with wasting disease such as tuberculosis. Tuberculosis is called “rajayaksmadi” literally the “kind of diseases” in the Ayurvedic literature. The condition results in a drying up and loss of tissue (ksaya). While vata dosha plays the most important role in this condition, the condition is sannipattika in nature (due to the vitiation of all three doshas).


Chikitsa: Treatment and Management

The management of kasa (cough) requires an understanding of the state of the patients agni, ama, and ojas as well as an appreciation of the doshic pathology present. In addition to treatment at the site of relocation in the pranavaha srota (respiratory system), treatment should also be directed toward the mahavaha srota (digestive system) as this is the physical root of the condition and the raktavaha srota (circulatory system) as the pathway of overflow.


Management of Vataja Kasa

The management of vataja kasa, at the site of relocation focuses on the application of oils and heat to the pranavaha srota (respiratory system). Sesame oil massaged into the chest followed by fomentation is recommended. Fomentation may be performed simply using hot water bottles, a heating pad or locally applied steam as in nadi svedana. Popular cough relieving herbs from India include kantakari (solanum xanthocarpum; VK-P+) and vamsa rochana (bamboo manna; VP-K+) . These are commonly used and may be prepared as ghrita (medicated ghee). Popular herbs used in the West include licorice (glycyrrhiza glabra; VP-K+) and wild cherry bark (prunis virginiana, prunia serotina; VP-K+).
Care of the digestive system requires dietary modification and the use of anuvasana basti (oil enema) or niruha basti (decoction enema). The diet, though nourishing should be taken in small quantities at first until the agni becomes strong. Nourishing soups are most beneficial. Patients should receive plenty of rest.

For both vataja and pittaja kasa, the classical formulation, Sitopaladi churna is commonly used. It may also be prepared in warm water or with honey. Sitopaladi churna is a combination of many herbs and spices with vamsa rochana as the chief herb in the formulation.


Management of Pittaja Kasa

The management of pittaja kasa, at the site of relocation focuses on herbal therapies. Oil and heat are not recommended. Medicated ghrita (ghee) may be prepared with cough relieving, expectorant herbs such as vamsa rochana (bamboo manna; VP-K+) and vasa (adhatoda vasica; PK- V+). Western herbal alternatives include licorice (VP-K+), mullein (verbascum thapus; PK-V+) and wild cherry bark (prunis virginiana, prunia serotina; VP-

K+). The classical Indian formulation, sitopaladi churna may also be used.
Virechana performed early in the condition is most beneficial to allieviate pitta at its root. The diet should emphasize a greater amount of the bitter taste as the bitter taste is cooling and purifies the rasa and rakta dhatu helping to destroy the infection. The diet should be light and and consist of easy to digest foods until improvement is noted. Stronger antimicrobial bitter herbs may be given to accompany the cooling, cough reducing herbs. These include kutki (Gentiana kuroo; PK- V+) and neem (Azadirachta indica; PK-V+) as well as well as Western alternatives such as goldenseal (Hydrastis Canadensis; PK-V+) and echinecea (Echinecea augustifolia, echinecea purpura; PK-V+). Patients should receive plenty of rest.



Management of Kaphaja Kasa

In the management of kaphaja kasa, treatment focuses on strong purification and may include vamana, virechana and niruha basti. Nasya is also recommended to purify the nasal passages and sinuses. An important herb from India is kantakari (solanum xanthocarpum; VK-P+). Kantakari alleviates cough and is a bronchodilator. Kantakari is one of the herbs in the famous ten roots formulation, dashmoola. Along with kantakari, additional herbs may be added to formulations such as vidanaga (embelia ribes; KV-P+) and chitrak (plumbago zeylancia; K-VP+). Dry, expectorant herbs may also be added to formulation or prepared for inhalation. Clove (caryophyllus aromatica) and bayberry (myrica nagi, myrica sapida, myrica cerifera) are commonly prepared in cigarette form or simply burned and inhaled. Western herbs that are beneficial include elecampane (inula helinum), eucalyptus (eucalyptus globulis) and black pepper (piper nigrum).

The diet of patients with kaphaja kasa should be very light and patients may fast for several days according to their strength. The diet emphasizes the pungent taste to support drying the lung tissues. Patients who are not experiencing great fatigue should remain active but should not overly exert themselves.



Managing Cough due to trauma requires referral to a medical specialist as the lung may be punctured. Until medical care can be administered, patients should take hemostatic herbs such as the Indian herbs manjishta and praval pisthi . Patients should also stay well hydrated.

Cough associated with wasting disease are difficult to treat and careful management is required. Weak patients usually require tonification to combat weight loss and increase strength. Medicated ghees with demulcent herbs such as bala rejuvenate the body and support repair of respiratory tissues. The dosage of the herbs is dependent upon the state of the patient’s agni. Anuvasana basti should also be administered to improve strength and can be prepared with nourishing herbs such as bala and ashwaganda in a sesame oil base. The diet should be nourishing. Meat and bone soups may be required to prevent continued weight loss.

Vegetarian patients may object, however they are strongly recommended if the patients life is in danger. The quantity of food taken should be proportional to the bodies abililty to digest it. Hence, dipanas to strengthen agni are required.


Sadhyasadhyata (Prognosis)

Doshic disturbances resulting in kasa are relatively easy to treat with vataja considered the easiest and kaphaja the most difficult. Those of mixed dosha pathology such as ksataja type are more difficult. Ksaya kasa is the most difficult of all. Ayurvedic texts state that kasa of any kind, if not treated properly can progress to ksaya type.