Chronic bronchitis and emphysema
Chronic bronchitis is a condition where there is excessive mucus production in the airways for at least three months in a year. This can be with or without pus in the sputum. Associated with this is wheezing. Emphysema is defined as distension of the air spaces distal to the terminal bronchiole, with destruction of the alveolar septae.
In chronic bronchitis, there is increase in the size and number of mucus-secreting glands. In emphysema, the cells of the lungs are permanently destroyed.
Again, for both the diseases, the causative factors are smoking, air pollution, occupational hazards, infection, etc. In emphysema, there can be a deficiency of an enzyme inhibitor that normally prevents the cells of the lungs from being eaten away by certain other enzymes. Lack of this inhibitor can be a genetic problem.
On the functional level, there is airways obstruction in both the diseases. In emphysema, there is loss of elastic recoil of the airways and the cells of the lungs. As the alveoli are inelastic and overstretched, drawn in air is not easily pushed out, resulting in air being trapped in the lungs. This makes the patient gasp as the lungs are over-distended. Poor oxygen exchange and expulsion of carbon dioxide, poor circulation of blood, and stagnation of secretions leading to easy infection, occur. The heart is constantly strained as breathing is laboured.
In the bronchitic patient, there is carbon dioxide trapping, with the patient becoming markedly blue in some cases; respiratory failure can result. The heart is overloaded, leading to cardiac failure. In contrast, patients with emphysema manage to maintain the carbon dioxide and oxygen levels in balance fairly well.
There is a history of recurrent mucopurulent cough with expectoration. This is often of long duration. The strain on the heart is greater in this disorder. The back pressure creates cardiac or, more often, cardio-respiratory failure. Because of mucus plugging, it is more exacting for the blood to flow into the lungs; and the right ventricle finds it increasingly difficult over the years to pump blood. Carbon dioxide levels are high. Hypertension develops in the pulmonary vessels.
Breathlessness (dyspnoea) is the cardinal factor. This is associated with varying degrees of wheezing and cough. Chronic hyperventilation and exertion of breathing keep the chest constantly elevated, giving the appearance of a puffed-up chest. The increased effort in breathing is due to deficient elastic recoil of the lungs which retain air and become over-distended. The diaphragm is always kept in the lowest possible position. The constant struggle often tires the patient. The accessory muscles of respiration in the neck are prominent.
The principles of management in both the disorders are somewhat similar. Oxygen is of prime value in both. In emphysema, it is beneficial for the patient to use oxygen for at least ten hours daily, especially in advanced cases. This helps to maintain the saturation of oxygen at near normal levels. In bronchitis, the infection should be treated with antibiotics, and oxygen if necessary. The emphasis here should be on preventing episodes of infections. In both disorders bronchodilators are useful to open the airways and push out the secretions. Sputum liquefiers are valuable to help expectorate. The goal in treating both the diseases is to maintain near normal respiratory function to help the patient carry on with daily activities. The pollution in the atmosphere today makes life miserable for both types of patients.
Antibiotics remove infection, bronchodilators dilate, but to maintain the health of the respiratory system after recovery or before unhealthiness sets in, exercise is the only viable tool. Exercise is the only way to help improve the mechanical efficiency of the lungs. The usual repertoire of exercises is too strenuous for the lungs, especially in emphysema. Exercises that do not raise the respiratory rate and yet help excretion of the sputum, increase oxygen levels in the blood, increase the elastic recoil of the lungs, prevent recurrent infections, and aerate the whole lungs, invigorating the patient at the end of the session, are necessary. Yoga stands out as the only system eminently meeting all these requirements.
Asanas are very valuable in treating both disorders. Props are needed to prevent the patient from becoming breathless as the lungs are already unhealthy, particularly for the patient with emphysema. Asanas, especially inversions, are useful in promoting better drainage from the basal parts of the lungs. The steady pressure of the abdominal organs on the diaphragm develops endurance. But for the patient, head stand is done on the ropes. This does not create pressure on the lungs. As these disorders are due to clogging, poor clearance, fatigue of the lungs and spasms, yoga works very well in all these parameters and also at the micro level, improving oxygenation to the cells. The principal point to remember is that while other exercises exhaust the lungs, yoga gives rest and rejuvenation. Asanas and pranayama work by gentle and steady methods, wafting the air into the lungs; other exercises are harsh and strenuous.
Back bends help clear the bronchial tree of mucus by massaging the lungs. These poses give rest to the lungs and improve stamina. Effort tolerance improves. The heart is made strong in the bronchitic. The opening of the thoracic cage in back bends creates negative pressure in the lungs, allowing blood from the right ventricle to enter without strain. As back bends improve vital capacity, the emphysematic benefits. For the bronchitic, excellent oxygenation occurs. These poses are very valuable as they invigorate the lungs.
In forward bends, the posterior lobes of the lungs are massaged and blood flow is improved. For the emphy-sematic, this position relieves constant strain on the heart. Twisting asanas squeeze the lateral parts of the lungs, improving their function. The asanas help better expulsion of trapped air in the emphysema patient. Resting poses such as supta virasanaand viparita karani are very useful to remove strain on the heart and reduce the respiratory rate in the emphysematic.
All standing poses improve the endurance of the patient in a manner similar to that of other exercises, but without the added strain. The vascularity of the lung, its mechanical components, its exchange capacity for gases, and the softness of the lung are all preserved by the practice of asanas and pranayama. The drainage of mucus helps prevent recurrent infections. This benefit is of a significant nature for both conditions.
Role of Pranayama
Pranayama improves mucociliary clearance and stamina. The practice of kumbhaka (breath retention) facilitates better percolation of oxygen into the lungs. In the process of retention, the partial pressure of gases (in this case, oxygen) increases, which facilitates better and deeper entry as there is enough time for percolation. The improved uptake creates better adsorption onto haemoglobin, thus enriching the quality of cellular food. This gives greater energy. To begin with, ujjayi pranayama is introduced as it does not strain the lungs. Later, other varieties are more beneficial. A minimum time of 15 minutes of daily practice is essential.
All the asanas are done on props. This gives rest to the lungs, especially in the emphysematous patient. As the lungs recover faster from breathlessness, fatigue is relieved. The benefit of easier breathing is appreciated more in bronchitis as the mucociliary clearance mechanism is activated. In emphysema, the need is to reduce the strain on the lungs by using a prop while practising pranayama which allows more complete evacuation of the trapped air in the alveoli. With regular practice, the lungs empty and fill in a coordinated manner. The normal medical instruction for patients with emphysema, to press the abdominal area to squeeze more air out of the lungs and through the mouth, is a strain on the system. The dorsal spine must be supported by a prop. Only then must breathing begin. The accessory muscles of respiration in the neck are already strained in emphysema. Forcibly using them by pressing the diaphragm which, in turn, tenses the neck muscles, must be avoided. Moreover, with the abdominal area compressed, the heart is also strained. There is also no time to prevent recurrent infections (by enhancing clearance mechanisms) if breathing is done fast. The moment the patient lies down on the prop, the strain on the accessory muscles of respiration reduces and he or she can make a `relaxed effort' to empty the lungs. The benefits depend, of course, on how much of healthy lung tissue remains.
All passive poses are good for emphysema. As the patient improves, active asanas can be practised. In chronic bronchitis, both active and passive asanas can be done, depending on the condition of the patient. As the strain on the heart is relieved (by the lungs functioning better), premature failure of the heart can be avoided. The asanas are modified according to the condition and age of the patient. Continuous follow-up is essential.
The relevant asanas for the three conditions mentioned above include supta virasana, setu bandha sarvangasana on pillows, dog pose with the rope, purvottanasana on pillows, head stand on the ropes, viparita dandasana on the rack, urdhva dhanurasana on the stool,
sarvangasana on the chair and viparita karani against the wall. All other asanas can be done as the condition improves. Pranayama is instituted when the frequency of attacks decreases, the spasms lessen, and the intercostal muscles function well.