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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 86-90

Integrated management of interstitial lung disease associated with rheumatoid arthritis - A case report


Department of Panchakarma, KAHER's Shri. BMK Ayurveda College, Belagavi, Karnataka, India

Date of Submission21-May-2021
Date of Decision29-Sep-2021
Date of Acceptance08-Oct-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Deepti Basavraj Bagewadi
Department of Panchakarma, KAHER's Shri. BMK Ayurveda College, Shahapur, Belagavi - 590 003, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijaim.ijaim_19_21

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  Abstract 


Interstitial lung disease (ILD) is a broad term for a large group of disorders that leads to fibrosis of the lungs. A female of 58 years with ILD associated with rheumatoid arthritis was well managed by integrated treatment of Ayurveda and physiotherapy. This is shown in our case report where in the symptoms of the patient were relieved by more than 80% by the combined approach of treatment. The patient consulted for complaints of intermittent cough and exertional dyspnea for 1 month and pain and stiffness of joints for the last 3 years. This report emphasizes the importance of integrated management of ILD associated with RA by Ayurvedic therapies such as sadhyo-virechana (instant purgative therapy) vaitarana basti (special enema with revival property) and ayurvedic oral medications with physiotherapy procedures such as postural breathing exercise, postural drainage, and deep breathing exercise. Although the disease is not completely curable, integrated approach could provide convenient and a better way of treatment which relieved the symptoms and also improved the quality of life.

Keywords: Interstitial lung disease, Panchakarma, physiotherapy, rheumatoid arthritis


How to cite this article:
Prasad BS, Korgaokar DG, Bagewadi DB. Integrated management of interstitial lung disease associated with rheumatoid arthritis - A case report. Indian J Ayurveda lntegr Med 2021;2:86-90

How to cite this URL:
Prasad BS, Korgaokar DG, Bagewadi DB. Integrated management of interstitial lung disease associated with rheumatoid arthritis - A case report. Indian J Ayurveda lntegr Med [serial online] 2021 [cited 2022 Jan 19];2:86-90. Available from: http://www.ijaim.com/text.asp?2021/2/2/86/331490




  Introduction Top


Interstitial lung disease (ILD) is a cluster of disorders that leads to fibrosis of the lungs. The fibrosis leads to stiffness in the lungs which leads to difficulty in breathing. Most of the patients come to medication mainly because of the onset of progressive exertional dyspnea or persistent nonproductive cough.[1] Morphologically, the lungs are firm, heavier with reduced volume and develops honeycombing, particularly in the subpleural region of the lungs.[2] In rheumatoid arthritis, pulmonary involvement is accounting around 10%–20% of the morbidity. Most cases occur within 5 years of rheumatological diagnosis, but pulmonary manifestations might precede joint involvement in 10%–20%.[3]

Ayurvedic treatment and physiotherapy were adopted based on the clinical conditions and to improve the quality of life. Ayurvedic treatment such as sadhyo-virechana (instant purgative therapy) was done before starting some medicines as it would clear the intestines helping in better assimilation of the medicines. Basti, owing to the diversity of combination of drugs used, it can perform diverse functions such as Shodhana (bio-cleansing therapy), Shaman (pacifying), and Sangrahana (checking). In rheumatoid arthritis, as disease progresses, Margavarodha (obstruction) increases. Hence, it requires cleansing therapy which can cleanse the closed channels and restore its normal function. Vaitarana Basti (special enema with revival property) has very potent cleansing action.[4] Postural drainage was done to drain out the congestion from different lobes and deep breathing exercises were given to increase lung volume and capacity.

Patients information

A female patient of 58 years, residing at Karnataka, visited KLE Ayurveda Hospital, outpatient department, with MR Number KLE20002158. The patient complained of intermittent cough for 4 years and morning stiffness of joints for 3 years. The patient also complained of exertional dyspnea on climbing stairs for 1 month for which she was admitted in IPD for 9 days for Ayurveda and physiotherapy treatment.

Clinical findings

The patient was apparently healthy 4 years back, gradually she developed cough on and off. Initially, it was dry cough associated with exertional dyspnea mostly during climbing stairs. Slowly, after a year, she developed pain and stiffness of joints. The patient took alternative therapies for 3 years but could not find any relief. Since last 1 month, the patient complains of increased dyspnea. She gets intermittent cough due to which her daily routine activities are disturbed. There are no symptoms of rhinitis. Twenty days back, she had fever, and since then, symptoms have aggravated. Hence, she visited KLE Ayurveda Hospital for the above said complaints.

The patient was suffering from rheumatoid arthritis for 3 years. There is no history of hypertension, diabetes mellitus, or any significant family history. She is homemaker and takes vegetarian diet. The patient does not give a history of addiction to any substance. Appetite and digestive power were good; micturition and defecation were normal. Moreover, sleep was disturbed due to cough.

The patient's Twacha (Skin complexion) was Ruksha (Rough), Raktasara (Blood complexion), nakha (Nails), Pani-padatala (Palm and Sole) were little pale. Mamsasara (Muscle complexion) was Laghu (Wasting), Shithila (Loose). Medasara (Fatty complexion) was Asneha (lacking fat), Ashtisara (Bony complexion) – kleshaasaha (Toleratable), kriyahani (Loss of function). Patient's prakrati is Pitta and kapha predominant. Her Samhanana, Pramana and Vaya were madhyam, Patient's Abhyavarana Shakti (Food taking power) and Jaranashakti (Digestive power) were normal, and patient was presenting sarvarasa satmya.

After examining asthasthana-pareksha, her Nadi was vatakaphaja, Jihva was alipta. Mootra (Urine), Mala (Stool), Drika (Eye power), and Aakrati (Shape) were Prakata and Sparsh (Touch) was Anushna-sheet (mild heat and cold).

After general examination, the patient's BP was 120/80 mm Hg, PR-96/min, nail-mild pale, sclera, conjunctiva, and lymph nodes were normal.

After systemic examination, CNS conscious, she was well oriented to place, time, and person. CVS-S1 and S2 were heard clearly. RS – Air entry was not clear, and on auscultation, there was the presence of B/L Rhonchi with crepitus.

Timeline:

  • Sputum for A. F. B. (January 18, 2020) – Negative
  • Dengue NS1 AG, IGG and IGM test (January 18, 2020) – Negative
  • Widal test {tube method} (January 18, 2020) – Negative
  • Urine routine: (January 18, 2020).


Physical examination:

  • Specimen: Random


  • Appearance: Clear
  • Color: Pale yellow
  • pH: Acidic.


Chemical examination:

  • Albumin: Trace
  • Sugar: Absent.


Microscopic examination:

  • Epithelial cell: 0 – 2/hpf
  • Pus cells: 100 – 150/hpf
  • Red Blood cells: 0 – 2/hpf
  • Casts: Nil
  • Crystals: Nil
  • Bacteria: Absent
  • High-resolution computed tomography (CT) chest (December 10, 2018).


Possible ILD – Usual interstitial pneumonia progressing to idiopathic pulmonary fibrosis with possible superadded infection [Figure 1].
Figure 1: (a and b) High-resolution computed tomography scan: Possible interstitial lung disease – usual interstitial pneumonia progressing to idiopathic pulmonary fibrosis with possible superadded infection. Marked part in (Figure 1a) shows pulmonary fibrosis

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CT thorax plain (September 18, 2019):

  • Multi-focal peribronchovascular interstitial thickening in both lungs, predominantly in bilateral lower lobes with mild traction bronchiectasis. Mild early honeycombing in posterior basal segment of the left lobe. Features represent ILD (fibrotic nonspecific interstitial pneumonia) [Figure 2]
  • Prominent prevascular, right paratracheal, and subcarinal lymph nodes – reactive.
Figure 2: Computed tomography scan: Multi- focal peribronchovascular interstitial thickening in both lungs, predominantly in bilateral lower lobes with mild traction bronchiectasis. Mild early honeycombing in the posterior basal segment of the left lobe. Features represent interstitial lung disease (fibrotic nonspecific interstitial pneumonia). Marked *part in (Figure 2a) shows the honeycombing and **shows fibrosis. Marked *part in (Figure 2b) shows pulmonary fibrosis

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Diagnostic assessment and diagnosis

Based on signs and symptoms along with investigations [Table 1], [Figure 1] and [Figure 2], she was diagnosed with ILD associated with rheumatoid arthritis (Swasa with Amavata).
Table 1: Blood investigations

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Therapeutic intervention

Treatment was planned focusing on ILD and rheumatoid arthritis for 9 days.

1st day Sadhyo-virechana (instant purgative therapy) and then after Vaitarana basti (special enema with revival property) with matra basti with Indukanta ghrita (in pattern 1MB+3VB+1MB+2VB+1MB) along with Sthanika abhyanga to ura, prushta followed by nadi sweda followed by postural expectoration for 9 days.


  Discussion Top


ILDs are the salient causes of respiratory morbidity and mortality worldwide, yet treatment choice for patient with ILD is very limited. In Ayurveda, ILD can be described under “Shwas roga” (diseases of the respiratory system). It is a disease caused by the tridoshas with predominance of vata dosha.

Panchakarma treatment advised in [Table 2] like Sadhyo-virechana (instant purgation therapy), followed by Basti plan was mainly focused on RA, as Vaitarana basti (special enema with revival property) is considered as the best basti for amavata.[4] Based on the signs and symptoms, RA can be correlated to Amavata as per Ayurveda. Sadhyo-virechana with Gandharvahastadi eranda taila 50 ml and 50 ml milk was given on the 1st day of admission in the morning as Sadhyo-virechana is the therapy in which the medicine is given orally to induce purgation, to remove out morbid doshas from the body and improve the metabolism. Sadhyo-virechana before Basti karma was planned to achieve maximum benefits of Basti karma. Matra basti (ghee enema) administered 60 ml with Indukanta ghrita to promote strength and curative of vata dosha vitiation. Indukantha ghrita is Shothahara (anti-inflammatory), vedanahara (analgesic), balya (improves strength), brimhana (Nourishing), and rasayana (rejuvenation).[5] Sthanika abhyanga (Local massage) with Bruhat-saindhavadi taila followed by Nadi sweda (tubular fomentation) in the thorax region was advised, as it is type of snehana swedana (Oleation and fomentation) it helps in liquification and breakdown of sticking phlegm (shleshma) to the walls of channels and flow out of channels. As result channels were cleansed, and the blockages were removed which helped in normal movement of air. Bruhatsaindhavadi taila is bhedana (break down), sroto-vishodhana (purification of channels), digestive and hepatoprotective.[6] As in this patient after local massage and fomentation postural expectoration was done as to remove the liquified phlegm out which was liquified after Oleation and fomentation.
Table 2: Panchakarma treatment

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Physiotherapy treatment as shown in [Table 3] such as postural drainage (mobilizing secretions in one or more lung segments to the central airways by placing the patient in various positions so that gravity assists in the drainage process) was advised to improve pulmonary function.[7] It helps to prevent the accumulation of secretions and to remove accumulated secretions from the lungs.[8] The postural drainage positions are based on the anatomy of the lungs and the tracheobronchial tree.[9] ILD effects increase in lung stiffness leading to increase in breathing work and decreased surface area of the alveolar-capillary membrane hampering exchange of gas.[10] Breathing exercise in cycles around 2−3 were performed to increase lung volume, so maximum effort is put on each breath to avoid dizziness because of over-breathing and discourage shoulder tension.[11] Deep breathing exercise also helps in increasing lung volume, increase ventilation and decrease airways resistance, increases surfactant secretion, thereby improving lung compliance and increases oxygen saturation.[12]
Table 3: Physiotherapy treatment for 9 days

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Shamana (Oral medicaion) as shown in [Table 4] like Kaphaketu rasa was used as it is significant in reducing the Kasa (cough) and Swasakruchrata (difficulty in breathing). Vasakasava has its main drug Adhatoda vasica, which is reported to have cellular hypoxic response and modulates the inflammation-thrombosis axis to reduce lung injury, thrombosis, fibrosis, and also has hepatoprotective activity.[13],[14] Sitophaladi churna helps in restoration of respiratory, digestive, immune, and several other systems of the body. Tankan bhasma acts on cough, chest congestion, bronchitis, and wheezing.[15] For better action and palatability, honey is added with this powder as anupana (vehicle). Bharangyadi Kashaya acts as antipyretic, anti-emetic, hypatoprotective.[16] With the combined treatment, the patient started showing improvement within 4 days, and by 7 days, there was a remarkable reduction in the symptoms.
Table 4: Shamana (Oral) medications for 9 days

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  Conclusion Top


Panchakarma along with physiotherapy treatment has provided symptomatic and functional improvement in the management of ILD associated with RA. At the end of the 9th day of treatment, the patient showed 70%−80% improvement as compared to before treatment as shown in [Table 5]. Thus, it can be concluded that the integrated management protocol with Ayurveda (Panchakarma and oral medication) and physiotherapy is effective in patients of ILD with RA in relieving symptoms and improving the quality of life. However, well-designed clinical trials including larger sample size are needed.
Table 5: Outcome

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18th ed., Vol. 2. New York: The McGraw-Hill Companies, Inc.; 2012. p. 2160.  Back to cited text no. 1
    
2.
Mohan H. Textbook of Pathology. 7th ed., Ch. 15. Nepal: Jaypee Brothers Medical Publisher (P) Ltd.; 2015. p. 475.  Back to cited text no. 2
    
3.
Walker BR, College NR, Raiston SH, Penman ID. Davidson's Principles and Practice of Medicine. Part 2. 22nd ed., Ch. 19. Edinburgh, London: Churchill Livingstone Elsevier; 2014. p. 712.  Back to cited text no. 3
    
4.
Charapanidatta, Chakradatta, Vaidyapradha Hindi Commentary by Acharya Ramnath Dwivedi, Edition. Niruhaadhikara 72/32. Varanasi: Chaukhambha Publication; 2002. p. 455.  Back to cited text no. 4
    
5.
Prabhakar Rao G, Prakarana G. Sahasrayogam, Sanskrit text with English translation and Prabhakara Vyakhyanam. 1st ed. Ansari Road, Darya Ganj: Chaukhambha Publication; 2016. p. 571.  Back to cited text no. 5
    
6.
Gupta RK, Jain JK, Dwivedi OP, Singhai SS. Pharmacological review of Brihat Saindhavadi Taila. IJIRR 2018;05:5314. Available from: https://www.ijirr.com/sites/default/files/issues-pdf/2755.pdf. [Last accessed on 2021 Oct 26].  Back to cited text no. 6
    
7.
Hill K, Patman S, Brooks D. Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: A systematic review. Chron Respir Dis 2010;7:9-17.  Back to cited text no. 7
    
8.
Balachandran A, Shivbalan S, Thangavelu S. Chest physiotherapy in pediatric practice. Indian Pediatr 2005;42:559-68.  Back to cited text no. 8
    
9.
Takahashi N, Murakami G, Ishikawa A, Sato TJ, Ito T. Anatomic evaluation of postural bronchial drainage of the lung with special reference to patients with tracheal intubation: which combination of postures provides the best simplification? Chest. 2004 Mar;125(3):935-44. doi: 10.1378/chest.125.3.935.  Back to cited text no. 9
    
10.
Hough A. Physiotherapy in Respiratory Care. 3rd ed., Ch. 4. United Kingdom: Nelson Thornes Ltd.; 2001. p. 96.  Back to cited text no. 10
    
11.
Hough A. Physiotherapy in Respiratory Care. 3rd ed., Ch. 6. United Kingdom: Nelson Thornes Ltd.; 2001. p. 152.  Back to cited text no. 11
    
12.
Hough A. Physiotherapy in Respiratory Care. 3rd ed., Ch. 6. United Kingdom: Nelson Thornes Ltd.; 2001. p. 153.  Back to cited text no. 12
    
13.
Bhattacharyya D, Pandit S, Jana U, Sen S, Sur TK. Hepatoprotective activity of Adhatoda vasica aqueous leaf extract on D-galactosamine-induced liver damage in rats. Fitoterapia 2005;76:223-5.  Back to cited text no. 13
    
14.
Gheware A, Dholakia D, Kannan S, Panda L, Rani R, Pattnaik BR, et al. Adhatoda vasica attenuates inflammatory and hypoxic responses in preclinical mouse models: Potential for repurposing in COVID-19-like conditions. Respir Res 2021;22:99.  Back to cited text no. 14
    
15.
Sankpal J, Takalikar J. Comperehencive review of Tankana, Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4. pg.no.111,112. [Last accessed on 2021 Nov 06].  Back to cited text no. 15
    
16.
Khichariya S, Jain JK, Singhai S. Role of bharangyadi kwath in the cases of vishamjwara (malaria). IJDR 2017;07:13653. Available from: https://www.journalijdr.com/sites/default/files/issue-pdf/9241.pdf. [Last accessed on 2021 Oct 26].  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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