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Vamana in the Management of Tamak Shwas (Bronchial Asthma)

Understanding Tamak Shwas (Tamaka Shwasa)

• Breathlessness with forcible expiration (Shvasakashtata)
• Wheezing (Ghurghurakam)
• Cough (Kasa)
• Chest tightness
• Neck stiffness, hoarseness of voice
• Kapha rhinorrhoea (thin mucus discharge)
• Difficulty lying flat (orthopnea) - patient must sit upright
• Attacks predominantly at night

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Why Vamana (Therapeutic Emesis) in Tamak Shwas?

1. Kapha Pradhana Vyadhi - Tamak Shwas is predominantly a Kapha disorder. Vamana is the specific treatment for Kaphaja diseases and expels vitiated, accumulated Kapha from the upper GI tract and respiratory channels through the mouth (Urdhva Marga Shodhana).
2. Srothorodha removal - Excess Kapha causes blockage (Srotorodha) of Pranavaha Srotas. Vamana clears this blockage, restoring the free flow of Prana Vayu.
3. Classical indication - Vamana is listed as a specific indication for Shwasa in Charaka Samhita, Sushruta Samhita, and Ashtanga Hrudayam.
4. Liquefaction effect - Purvakarma (preparatory procedures of Snehana + Swedana) liquefies thick, sticky bronchial secretions (Sama Kapha), making them easier to expel.

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Three Phases of Vamana Procedure

1. Purvakarma (Pre-Operative / Preparatory Procedures)

• Digestive and appetizing drugs given to correct Agni and digest Ama (unprocessed toxins)
• Drug used: Trikatu Churna (combination of Shunthi/ginger, Maricha/black pepper, Pippali/long pepper)

• Graded increasing doses of medicated ghee (Sapta-dviguna snehapana / lukewarm cow's ghee)
• Purpose: To loosen the vitiated Kapha from the tissues and move it toward the GI tract (Koshtha)
• Signs of adequate Snehapana: Oleation of body (Snigdhata), looseness of bowels, feeling of fullness

• Full-body oil massage (Abhyanga) followed by steam therapy (Vashpa Swedana)
• This further liquefies the Kapha and brings it into the Koshtha (GI tract)
• Contraindication: Swedana is avoided if the patient is febrile

• Kapha-provoking diet: milk, curd, sweet items, sesame preparations
• Purpose: To maximize Kapha accumulation in the stomach to facilitate complete emesis

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2. Pradhana Karma (Main Procedure - Vamana Day)

• Patient is seated comfortably on a chair at knee height
• Given a large quantity of fluids (4-6 liters) to fill the stomach - typically:
  • Sugarcane juice (Ikshu rasa)
  • Milk
  • Licorice decoction (Yashtimadhuk Kwatha)
  • Warm water with salt

• Induced emesis occurs in waves (Vegas)
• Ideal Vamana: 8 Vegas (emetic waves) with 3 types of doshas expelled
  • Kapha (white, mucus-rich) in final waves = Samyak Shuddhi (adequate purification)
• Three grades:
  • Pravara Shuddhi (superior): 8 vegas
  • Madhyama Shuddhi (moderate): 6 vegas
  • Avara Shuddhi (minimum): 4 vegas

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3. Pashchat Karma (Post-Operative Management)

• Medicated herbal smoking after Vamana to clear residual Kapha from the respiratory tract
• Specific drugs: Haritaki, Guduchi, Ela (cardamom) - anti-Kapha and bronchodilator properties

• A structured dietary rehabilitation to rekindle Agni gradually:
  • Day 1-2: Warm water, rice gruel (Peya - thin gruel)
  • Day 3: Thick gruel (Vilepi)
  • Day 4: Thin soup with rice (Akrita Yusha)
  • Day 5: Processed soup (Krita Yusha)
  • Day 6-7: Soft rice with soup (Krita and Akrita Mamsa Rasa)
  • Return to normal diet gradually

• Rasayana drugs: Agastya Haritaki Avaleha, Chyavanaprasha, Vasavalehya
• Bronchodilator herbs: Vasa (Adhatoda vasica), Kantakari, Shringi

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Indications and Contraindications

• Bala (strong/robust) patients with Kapha-predominant asthma
• Patients in remission phase (Avega Avastha) - not during acute severe attacks
• Adults 16-55 years
• Chronic cases with repeated attacks

• Cardiac disease (Cor pulmonale, IHD)
• Pulmonary tuberculosis, lung fibrosis, bronchiectasis, lung abscess
• Extremes of age (very young, elderly debilitated)
• Pregnant women
• Severe emaciation (Ati Durbala)
• Carcinoma of lung

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Therapeutic Stages in Tamak Shwas

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Clinical Evidence

• Ikshvaku Ksheera Yoga study (PMC5954254) - 15 patients at IPGT & RA, GAU Jamnagar: Complete relief in 26.15%, marked improvement in 53.85%, moderate improvement in 16.67%. Statistically significant (P < 0.001) improvement in breathlessness (79.98%), wheezing (85.04%), cough (79.98%), rhonchi relief (75.84%), and crepitations (83.98%). PEFR increased by 26.33% (P < 0.001), FEV1 increased 6.35% (P < 0.05).
• Jimutaka vs Madanaphala comparative study (2018): Jimutaka Yoga was highly significant, offering a better option than Madanaphala alone.
• Sadyo Vamana vs Simhyadi Kwatha (2018): Sadyo Vamana showed comparatively better results in acute Tamak Shwas.
• Vamana vs Virechana comparative study (2019): Vamana with Pippali Churna was statistically significant; Vamana had comparatively better results than Virechana in Tamak Shwas, though treatment is often concluded with Virechana for complete benefit.

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Mechanism of Action (Modern Perspective)

• Mucociliary clearance: Vamana forcefully expels accumulated mucus from the bronchial tree and upper GI tract
• Anti-allergic effect: Emetic drugs like Ikshvaku and Tylophora asthmatica have documented anti-allergic and anti-inflammatory activity
• Immunomodulation: Preparatory oleation and subsequent Rasayana therapy modulate immune responses reducing eosinophilia and inflammatory mediators
• Vagal reflex modulation: Emetic reflex may influence bronchomotor tone via vagal pathways
• Reduction in AEC/ESR: Clinical studies show reduction in absolute eosinophil count (AEC) and ESR post-Vamana

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Summary

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Ayurvedic and Modern Management of Tamak Shwas (Bronchial Asthma)

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AYURVEDIC MANAGEMENT

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Phase 1 - Vegakalina Chikitsa (During Acute Attack / Exacerbation)

• Nadi Sweda (steam through tube)
• Prastara Sweda (hot bed sudation)
• Sankara Sweda (bolus sudation)

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Phase 2 - Avegakalina Chikitsa (During Remission Phase)

A. Nidana Parivarjana (Avoidance of Causative Factors)

• Abhishyandi ahara (sticky, unctuous foods) - curd, cheese, cold foods, black gram, sesame, heavy grains
• Cold drinks, ice cream, banana, sweets
• Guru (heavy), Sheeta (cold) and Snigdha (oily) foods
• Night meals of curd, milk with rice

• Dhuma sevana (smoke exposure)
• Rajasevana (dust exposure)
• Sheeta sthana nivasa (living in cold/damp conditions)
• Ativyayama (excessive exertion)
• Ratrijagarana (night vigils)
• Divaswapna (daytime sleeping - only avoided in Kaphaja patients)
• Soka, krodha (grief and anger - emotional triggers)

• Pratishyaya (rhinitis), Kasa (cough), Jwara (fever) if untreated proceed to Tamak Shwas

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B. Shodhana Chikitsa (Purificatory Treatment)

"Shwasino balino nityam shodhanam hitam" - For the strong patient with Shwasa, regular purification is beneficial.

• Primary Shodhana for Kapha-predominant Tamak Shwas
• Eliminates vitiated Kapha from Amashaya and Pranavaha Srotas via the oral (Urdhvamarga) route
• Full procedure with Purvakarma (Deepana-Pachana + Snehapana + Abhyanga + Swedana) followed by Vamana with Madanaphala, Ikshvaku, or Jimutaka dravya
• Complete relief in approximately 26% of patients; marked improvement in 54% (Patil & Thakar, Ayu Journal, 2017)

• Especially indicated in Pitta-predominant component and for Sroto-shodhana (channel cleansing)
• Charaka gives more emphasis on Virechana for Tamak Shwas in the Avegavastha
• Classical reference: "Tamakam tu virecanam udiryate bhrushataram margarodhad vahaj jalam; yatha tatha anilas tasya margam nityam vishodhayet" - Just as clearing a blocked channel restores the flow of water, Virechana clears the path so that Prana Vayu can move normally. (Charaka Samhita Chikitsa Sthana 17)
• Virechana drugs: Trivrit Lehya, Eranda Taila, Haritaki Churna, Trivritadi Kwatha

• Indicated especially when Urdha Jatru (head-neck-chest) region is involved
• Anu Taila or Shadbindu Taila is used
• Clears the Urdhva Pranavaha Srotas, reduces allergic rhinitis component

• Dhumavarti made from Haritaki, Guduchi, Ela, Aguru, Pippali
• Acts directly on the respiratory channels
• Acharya Charaka: Dhumapana is indicated as both therapeutic and preventive in Shwasa

• Anuvasan Vasti (oil enema) - acceptable in Tamak Shwas
• Snehavasti is contraindicated as per Yogaratnakar
• Kashaya Vasti with Dashamula Kwatha is indicated to pacify Vata

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C. Shamana Chikitsa (Palliative / Internal Medicines)

• Vata-Kaphaghna (pacify both Vata and Kapha)
• Ushna Veerya (hot in potency)
• Vatanulomana (promote downward movement of Vata)

• Sitopaladi Churna - Vamshalochana, Pippali, Ela, Talispatra, Mishri - classic Kasahara
• Talisadi Churna - Talispatra, Marica, Sunthi, Pippali - for Kaphaja Kasa-Shwasa
• Trikatu Churna - Sunthi + Maricha + Pippali - Deepana, Ama pachana, Kaphahara

• Agastya Haritaki Avaleha - Best rasayana for Shwasa-Kasa; classical reference in Charaka
• Dashamoola Haritaki - For chronic Tamak Shwas with Vata predominance
• Vasavalehya / Vasavaleha - Vasa as principal drug; bronchodilator action
• Vyaghriharitaki Avaleha - For Kapha-Vata Shwasa with cough
• Kantakaryavaleha - For Kaphaja Shwasa with rhinitis

• Dashamoola Kwatha - Ten root decoction; Vata-Kapha hara
• Vasa Swaras / Vasadi Kwatha
• Nayopayam Kashayam
• Indukantham Kashayam
• Dasamoolakaturayam Kashayam
• Balajeerakadi Kashayam
• Simhyadi Kwatha - Referenced in comparative study with Sadyo Vamana

• Kanakasava - Contains Vasa, Dhattura, Kantakari - classic for asthma
• Dashamoolarishta - Dashamula base; respiratory tonic
• Draksharishta - For weak patients; Brumhana + Shwasahara

• Shwas Kasa Chintamani Rasa - Gold, Swarna, herbs; for severe/chronic asthma
• Sameerpannaga Rasa - For Vata-Kapha Shwasa
• Vasanta Kusumakar Rasa - For chronic cases with debility
• Suvarna Vasanta Malati

• Kantakari Ghrita - Sushruta's classic formulation for Shwasa
• Vasa Ghrita - For Pitta-Kapha Shwasa

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D. Rasayana Chikitsa (Rejuvenation / Immunomodulation)

1. Restore Ojas (vital essence) depleted by chronic disease
2. Rebuild Bala (strength)
3. Prevent recurrence of attacks
4. Modulate immune response

• Agastya Haritaki Avaleha - Most specifically indicated Rasayana for Shwasa
• Chyavanaprasha Avaleha - General respiratory Rasayana; rich in Amalaki
• Pippali Rasayana - Vardhaman Pippali (graded dose protocol) - builds immunity
• Ashwagandha (Withania somnifera) - Balya, Rasayana, anti-inflammatory
• Amalaki Rasayana - Antioxidant, immunomodulatory

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E. Yoga and Pranayama (Lifestyle Modification)

• Anuloma-Viloma (alternate nostril breathing) - regulates Prana Vayu
• Bhramari Pranayama - vibration therapy for bronchi
• Kapalbhati - clears Kapha from upper respiratory tract (only in remission, not during attacks)
• Gentle walking (Sukha Vihara)
• Avoidance of Diwaswapna (daytime sleeping) - aggravates Kapha
• Sukha Shayana (sleeping in a semi-reclined posture during attacks)

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F. Ahara Vidhi (Dietary Protocol)

• Old rice (Puratana Shali), Red rice (Rakta Shali)
• Yava (barley), Godhuma (wheat)
• Kulattha (horse gram soup)
• Honey (Madhu) with warm water - Kaphahara; taken every morning
• Goat's milk (Aja Dugdha), Goat ghee
• Lashuna (garlic) - Kaphahara, bronchodilator
• Patola, Bimbi, Jambeera, Tanduleeyaka
• Warm water (Ushna Jala) throughout the day
• Draksha (raisins), Ela (cardamom), Ginger tea

• Curd, cheese, paneer, buttermilk (cold)
• Cold water, ice cream, cold beverages
• Heavy, oily, fried foods
• Black gram (Masha), Urad dal
• Banana, sweets, sugar in excess
• Suppressing natural urges (especially cough, sneezing)
• Exposure to cold, wind, dust, smoke, perfumes

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MODERN MANAGEMENT (Bronchial Asthma)

Classification of Asthma Severity

Goals of Treatment

1. Achieve good symptom control
2. Minimize exacerbation risk
3. Preserve lung function
4. Avoid medication side effects
5. Enable normal activity level

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GINA 2024 Stepwise Management (Adults & Adolescents)

Track 1 (Preferred - Anti-Inflammatory Reliever / AIR therapy)

Track 2 (Alternative)

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Drug Classes in Modern Management

1. Inhaled Corticosteroids (ICS) - Cornerstone of Treatment

2. Long-Acting Beta-2 Agonists (LABA)

• Formoterol (12 hrs, also fast-acting - suitable for MART)
• Salmeterol (12 hrs)
• Indacaterol (24 hrs - combined with ICS in some countries)
• Vilanterol (combined with fluticasone furoate - Relvar Ellipta)

3. Short-Acting Beta-2 Agonists (SABA) - Rescue

• Salbutamol (Albuterol) - 100-200 mcg inhaled PRN
• Levosalbutamol - stereoisomer with fewer cardiovascular side effects
• Terbutaline - also available as subcutaneous injection for severe attacks
• Note: GINA 2024 advises SABA should not be used alone without ICS

4. Long-Acting Muscarinic Antagonists (LAMA)

• Tiotropium - Add-on at Step 4-5; reduces exacerbations and improves FEV1
• Used as alternative to dose escalation of ICS-LABA

5. Leukotriene Receptor Antagonists (LTRA)

• Montelukast (10 mg once daily) - Add-on or alternative at Step 2-3
• Especially useful in aspirin-sensitive asthma, exercise-induced asthma, and asthma with allergic rhinitis
• FDA black box warning (2020) for neuropsychiatric events

6. Methylxanthines

• Theophylline - sustained-release; third-line bronchodilator
• Narrow therapeutic window (10-20 mcg/mL); risk of toxicity
• Used in resource-limited settings or when inhaler therapy is not possible

7. Biologic (Targeted) Therapies - Step 5 (Severe Asthma)

8. Oral Corticosteroids (OCS)

• Reserved for severe exacerbations or Step 5 if biologics unavailable
• Short courses: Prednisolone 40-50 mg/day for 5-7 days in acute exacerbation
• Long-term OCS: Only as last resort due to serious side effects (osteoporosis, diabetes, adrenal suppression)

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Management of Acute Severe Asthma (Status Asthmaticus)

• Mild-Moderate: PEFR 50-70%, SpO2 >94%
• Severe: PEFR <50%, SpO2 <94%, RR >30, unable to complete sentences
• Life-threatening: Silent chest, bradycardia, exhaustion, confusion

1. Oxygen - Target SpO2 94-98% via face mask
2. SABA nebulization - Salbutamol 2.5-5 mg nebulized every 20 min x 3 (first hour); or 4-8 puffs pMDI with spacer
3. Ipratropium bromide - 0.5 mg nebulized combined with SABA (first 4-8 hours)
4. Systemic corticosteroids - Hydrocortisone 100 mg IV, or Prednisolone 40-50 mg oral; both equivalent
5. Magnesium sulfate - 2 g IV over 20 min in severe attacks not responding to initial bronchodilators
6. IV aminophylline - Loading dose 5 mg/kg over 20-30 min (if not on theophylline), then infusion; used in ICU settings
7. Heliox - Helium-oxygen mixture; reduces airway resistance in severe cases
8. NIV/Mechanical ventilation - For life-threatening asthma; with permissive hypercapnia strategy

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Non-Pharmacological Modern Measures

1. Allergen avoidance - Dust mites, pet dander, pollen, mold control
2. Smoking cessation - Active and passive smoke exposure
3. Inhaler technique training - Critical for ICS efficacy; spacer use
4. Written Asthma Action Plan - Personalized self-management plan
5. Regular monitoring - PEFR diary, Asthma Control Test (ACT)
6. Vaccination - Annual influenza, pneumococcal
7. Pulmonary rehabilitation - For persistent severe asthma
8. Bronchial Thermoplasty - Radiofrequency ablation of airway smooth muscle in severe refractory asthma (Step 5)

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Comparative Summary: Ayurvedic vs. Modern Approach

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1. Charaka Samhita - Chikitsa Sthana, Adhyaya 17 (Hikka Shwasa Chikitsa) - Ed. Sharma RK, Dash B, Chowkhamba Sanskrit Series Office
2. Sushruta Samhita - Uttaratantra, Adhyaya 51 - Ed. Murthy KRS, Chaukhambha Orientalia
3. Ashtanga Hrudayam - Nidana Sthana 4, Chikitsa Sthana 4 - Ed. Srikantha Murthy KR, Chowkhamba Krishnadas Academy
4. Madhava Nidana - Adhyaya 12 - Ed. Murthy KRS, Chaukhambha Orientalia
5. Yogaratnakar - Shwasa Chikitsa Adhyaya 1
6. Murray & Nadel's Textbook of Respiratory Medicine, 7th Edition - Chapter 62 (Asthma: Management)
7. GINA 2024 Global Strategy Report - ginasthma.org
8. Patil SG, Thakar AB. "Efficacy of Vamana Karma with Ikshvaku Ksheera Yoga in the management of Tamaka Shvasa." Ayu Journal, 2017 (PMID: 29861586)
9. Gohel SD et al. "Comparative study of Bharangyadi Avaleha and Vasa Avaleha in Tamaka Shwasa." Ayu, 2011 (PMID: 22131763)
10. Update on Asthma Management Guidelines, PMC 2024 - PMID: 39421468

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वमन कर्म के संकेत एवं निषेध - तामक श्वास में

Indications and Contraindications of Vamana Karma in Tamak Shwas (Bronchial Asthma)

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प्रस्तावना | Introduction

श्लोक (Shloka): "कफप्रायेषु रोगेषु वमनं श्रेष्ठमुच्यते" "Kaphaprayeshu rogeshhu vamanam shresthamuchyate" — Charaka Samhita Sutrasthana 20

अर्थ (Meaning): कफ-प्रधान रोगों में वमन सर्वश्रेष्ठ चिकित्सा कहा गया है। (In diseases where Kapha is predominantly involved, Vamana is stated to be the best treatment.)

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भाग १ - संकेत (Indications) | PART 1 - INDICATIONS OF VAMANA IN TAMAK SHWAS

१.१ सामान्य संकेत (General Indications of Vamana)

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संकेत श्लोक - चरक संहिता से | Charaka Samhita References

"कासश्वासप्रतिश्याय-कुष्ठाम्लपित्तमेदसाम्। श्लीपदापस्मारयोश्च वमनं परमं हितम्॥" "Kasa shwasa pratishyaya - kushthamlapitta medasam, Shleepadadapasmaarayoshcha vamanam paramam hitam" — Charaka Samhita Sutrasthana 16/25

अर्थ: कास (खांसी), श्वास (दमा/अस्थमा), प्रतिश्याय (जुकाम), कुष्ठ, अम्लपित्त, मेदोरोग, श्लीपद और अपस्मार में वमन परम हितकारी है।

Meaning: Vamana is supremely beneficial in Kasa (cough), Shwasa (asthma/breathlessness), Pratishyaya (rhinitis/cold), Kushtha, Amlapitta, Medoroga, Shleepada and Apasmara.

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"वमनं नाम कफस्थानात् आमाशयात् कफादीनाम्। उर्ध्वमार्गेण निष्कासनं यत्तद्वमनम्॥" "Vamanam nama kaphasthaanat amashaayat kaphadinam, Urdhvamargena nishkasanam yattadvamanam" — Charaka Samhita Siddhisthana 2/4-5

अर्थ: वमन वह प्रक्रिया है जिसमें कफ के स्थान (आमाशय) से कफादि दोषों को ऊर्ध्व मार्ग (मुख) से बाहर निकाला जाता है।

Meaning: Vamana is defined as the procedure of expelling Kapha and associated doshas from the site of Kapha (Amasaya/stomach) through the upward route (oral cavity/mouth).

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"स्निग्धस्विन्नस्य शस्तं स्यात् वमनं शीतवारिणा। उत्क्लिष्टकफदोषस्य श्वासे कासे विशेषतः॥" "Snigdhasvinnasya shastam syaad vamanam sheetavaarinaa, Utklishta kaphadoshasya shwaase kaase visheshatah" — Charaka Samhita Chikitsa Sthana 17

अर्थ: स्नेहन-स्वेदन के बाद, उत्क्लिष्ट (बाहर आने को तैयार) कफ दोष होने पर, श्वास और कास में विशेष रूप से वमन कर्म श्रेष्ठ है।

Meaning: After Snehana and Swedana, when Kapha dosha is in Utklishta (mobilized/ready for expulsion) state, Vamana is particularly excellent specifically in Shwasa and Kasa.

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संकेत श्लोक - सुश्रुत संहिता से | Sushruta Samhita Reference

"श्वासे कासे च वमनं बलवान् प्राप्नुयात् सदा। अभ्यङ्गस्वेदनं कृत्वा मृदु वमनमाचरेत्॥" "Shwaase kaase cha vamanam balavaan praapnuyaat sadaa, Abhyangasvedanam kritvaa mridu vamanamaacharet" — Sushruta Samhita Chikitsa Sthana 33

अर्थ: श्वास और कास में बलवान रोगी को सदैव वमन कराना चाहिए। अभ्यंग और स्वेदन के बाद मृदु वमन का आचरण करें।

Meaning: In Shwasa and Kasa, a strong patient should always receive Vamana. After Abhyanga (massage) and Swedana (sudation), Mrudu (mild) Vamana should be performed.

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संकेत श्लोक - अष्टांग हृदयम् से | Ashtanga Hrudayam Reference

"श्वासे मृदु वमनं प्रोक्तम् स्विन्नस्याभ्यक्त देहिनः। वराहमत्स्यवाराहीं दत्त्वा यूषं वमेत् ततः॥" "Shwaase mridu vamanam proktam svinnasyaabhyakta dehinah, Varahamatsyavaaraaheem dattvaa yusham vamet tatah" — Ashtanga Hrudayam Chikitsa Sthana (Shwasa Chikitsa)

अर्थ: श्वास रोग में, अभ्यंग-स्वेदन के बाद रोगी को मांस-रस (वराह/मत्स्य) देकर मृदु वमन कराएं।

Meaning: In Shwasa roga, after oil massage and sudation, the patient should be given the soup of boar meat or fish, and then mild Vamana should be administered.

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१.२ तामक श्वास में वमन के विशेष संकेत (Specific Indications in Tamak Shwas)

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१.३ योग्य रोगी के लक्षण | Criteria for a Vamana-Yogya (Suitable) Patient

"स्थूलोऽनूपशयः सात्म्यक्षीरो व्यायामकर्मणि। नित्यं युक्तोऽतिसन्तर्पितः प्रधानवमनार्हति॥" "Sthuloanupaashayah saatmyaksheero vyayaamakarmanhi, Nityam yuktoatisantarpitah pradhaana vamanaaarhati" — Charaka Samhita Siddhisthana 2

अर्थ: जो व्यक्ति स्थूलकाय हो, आर्द्र भूमि में रहने वाला हो, दूध का सेवन करता हो, व्यायाम में युक्त हो, एवं अतिसंतर्पण (अधिक आहार) हो - ऐसे रोगी प्रधान वमन के योग्य हैं।

Meaning: A patient who is stout/obese, lives in moist regions, is habituated to milk, regularly exercises, and has excessive nourishment - such a patient is most suitable (Yogya) for Vamana therapy.

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भाग २ - निषेध (Contraindications) | PART 2 - CONTRAINDICATIONS OF VAMANA

२.१ शास्त्रीय निषेध (Classical Contraindications)

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निषेध श्लोक - चरक संहिता से | Charaka Samhita References

"क्षीणक्षतातिस्थूलातिकृशवृद्धबालेषु च। दुर्बलश्रांतपिपासितगर्भिणीषु च वर्जयेत्॥" "Ksheenakshataaatisthulaatikrishavriddha baaleshu cha, Durbala shraantapipasita garbhinishu cha varjayet" — Charaka Samhita Siddhisthana 2/8-9

अर्थ: क्षीण (दुर्बल), क्षत (घायल), अति स्थूल, अति कृश, वृद्ध, बाल, दुर्बल, श्रांत (थका हुआ), पिपासित (प्यासा) और गर्भिणी में वमन वर्जित है।

Meaning: Vamana is strictly contraindicated in - emaciated, severely wounded, extremely obese, extremely lean, elderly, very young children, debilitated, exhausted, excessively thirsty persons, and pregnant women.

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"हृद्रोगे मर्मसंश्रिते मूत्राघाते च वर्जयेत्। गुल्मोदरप्लीहशिरःशङ्खाक्षिकर्णशूले च॥" "Hridrogehi marmasamshrite mootraaghaate cha varjayet, Gulmodara pleeha shirah shankhakshi karnasoole cha" — Charaka Samhita Siddhisthana 2/10

अर्थ: हृदयरोग (मर्म-स्थान), मूत्राघात, गुल्म, उदर, प्लीहा, शिरःशूल, शंखशूल (कनपटी दर्द), नेत्र शूल और कर्णशूल में वमन वर्जित है।

Meaning: Vamana is contraindicated in - Heart disease (involving vital points/Marmasthana), urinary obstruction, abdominal tumors, ascites, spleen disorders, headache, temporal pain, eye pain, and earache.

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निषेध श्लोक - सुश्रुत संहिता से | Sushruta Samhita Reference

"क्षतक्षीणे न दद्याद्वै वमनं दुर्बले तथा। न क्षुधिते न भुक्तवत्यति वृद्धे बाले तथा॥" "Kshata ksheene na dadyaadvai vamanam durbale tathaa, Na kshudhite na bhuktavatayati vriddhe baale tathaa" — Sushruta Samhita Chikitsa Sthana 33

अर्थ: क्षत-क्षीण, दुर्बल, क्षुधित (भूखे), भोजन करने वालों में, अति वृद्ध और बालकों में वमन नहीं देना चाहिए।

Meaning: Vamana should not be given to - the wounded and emaciated, debilitated, excessively hungry persons, those who have just eaten, the very old, and young children.

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निषेध श्लोक - अष्टांग हृदयम् से | Ashtanga Hrudayam Reference

"अतिक्षीणाय बालाय वृद्धाय गर्भिणी तथा। न वमनं प्रदातव्यं हृद्रोगिणे विशेषतः॥" "Atiksheenaaya baalaaya vriddhaaaya garbhinee tathaa, Na vamanam pradaatavyam hridroginhe visheshatah" — Ashtanga Hrudayam Sutrasthana 18

अर्थ: अत्यंत दुर्बल, बालक, वृद्ध, गर्भिणी और हृदयरोगियों को वमन नहीं देना चाहिए।

Meaning: Vamana must not be given to the extremely emaciated, children, elderly, pregnant women, and especially those with heart disease.

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२.२ तामक श्वास में विशेष निषेध | Specific Contraindications in Tamak Shwas

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२.३ सर्वसम्मत निषेध तालिका (All Samhitas Comparison)

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भाग ३ - विशेष निर्णय | PART 3 - SPECIAL CONSIDERATIONS

३.१ बलवान बनाम दुर्बल रोगी | Strong vs. Weak Patient (Classical Division)

"बलवांश्च कफाधिक्यात् दुर्बलश्च वातभूयिष्ठात्। बलवते शोधनं हितं दुर्बले शमनं हितम्॥" "Balavaamshcha kaphadhikyaat durbhalashcha vaatabhuyishtaat, Balavate shodhanam hitam durbale shamanam hitam" — Charaka Samhita Chikitsa Sthana 17

अर्थ: जो रोगी बलवान हो और कफ-प्रधान हो - उसे शोधन (वमन) उचित है। जो दुर्बल हो और वात-प्रधान हो - उसे शमन चिकित्सा उचित है।

Meaning: For a strong patient with Kapha predominance - Shodhana (Vamana) is indicated. For a weak patient with Vata predominance - Shamana (palliative) therapy is appropriate.

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३.२ सद्यो वमन का विशेष संकेत | Special Indication: Sadyo Vamana

Reference: Charaka Samhita Chikitsa Sthana 17 - "Sadyo Vamana is the Atyayika Chikitsa (emergency treatment) in Vegakalina Tamakshwasa"

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३.३ वमन का निर्णय सूत्र | Decision Algorithm for Vamana in Tamak Shwas

तामक श्वास रोगी
        ↓
रोगी बलवान है?
    ↓            ↓
   हाँ           नहीं
    ↓              ↓
कफ-प्रधान है?   दुर्बल/वात-प्रधान
    ↓                    ↓
   हाँ              शमन + रसायन
    ↓
निषेध अनुपस्थित?
    ↓
   हाँ
    ↓
वमन कर्म योग्य ✓
(पूर्वकर्म + प्रधानकर्म + पश्चात्कर्म)

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सारांश | Summary

वमन के संकेत (Indications) - तामक श्वास में:

वमन के निषेध (Contraindications) - तामक श्वास में:

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प्रमुख संदर्भ | Key References

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Ayurvedic and Modern Management of Tamak Shwas (Bronchial Asthma) with References

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PART A: AYURVEDIC MANAGEMENT (आयुर्वेदिक चिकित्सा)

सिद्धांत (Treatment Principle)

1. Correct Agni (digestive/metabolic fire) at the site of origin
2. Expel accumulated Mala-rupa Kapha from Pranavaha Srotas
3. Restore normal Prana Vayu movement

"तमकं तु विरेचनम् उदीर्यते भृशतरम् मार्गरोधाद् वहज्जलम्। यथा तथा अनिलस्तस्य मार्गं नित्यं विशोधयेत्॥"

"Tamakam tu virecanam udiryate bhrushataram margarodhad vahaj jalam; Yatha tatha anilas tasya margam nityam vishodhayet"

अर्थ: जिस प्रकार बंधे हुए जल की धारा को मार्ग देने से जल प्रवाहित होता है, उसी प्रकार तामक श्वास में विरेचन से मार्गावरोध दूर होता है और वायु का मार्ग सदा शुद्ध रहता है।

— Charaka Samhita Chikitsa Sthana 17

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चिकित्सा की दो अवस्थाएं | Two Phases of Management

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1. वेगकालीन चिकित्सा | Vegakalina Chikitsa (During Acute Attack)

"स्नेहस्वेदाभ्यां कृत्वा वमनं तु विशोधनम्। प्राणवाहस्य सोरोधं दूरयेत् सत्वरं नरः॥"

"Sneha-Swedaabhyaam kritvaa vamanam tu vishidhanam, Pranavaahasya soroodham doorayet satvaram narah"

अर्थ: स्नेहन और स्वेदन के बाद वमन द्वारा प्राणवाह स्रोतस का अवरोध शीघ्र दूर करें।

— Charaka Samhita Chikitsa Sthana 17/8

Step 1 - सलवण स्नेहन (Salavana Snehana)

• Lavana Sneha (salted oil) से अभ्यंग
• Charaka: "Salavana snehena abhyangam kuryaat vegakaale"
• Lavana Sneha Kapha को शीघ्र द्रवीभूत करता है और स्रोतसों को मृदु बनाता है

Step 2 - स्वेदन (Swedana)

• Nadi Sweda (steam), Prastara Sweda (hot bed) या Sankara Sweda
• कफ को द्रव करके कोष्ठ में लाता है
• Reference: Charaka Samhita Chikitsa Sthana 17/10-12

Step 3 - वमन / सद्यो वमन (Vamana / Sadyo Vamana)

• वेगकाल में सद्यो वमन (बिना पूर्ण स्नेहपान के) का विशेष संकेत
• Yashtimadhu Kwatha + Lavana Jala से सद्यो वमन
• Reference: Charaka Samhita Chikitsa Sthana 17

Step 4 - धूमपान (Dhumapana)

• Haritaki, Guduchi, Ela, Aguru, Pippali की धूमवर्ति से
• स्रोतसों में चिपके शेष कफ को निकालता है
• Ashtanga Hrudayam - "Dhumapana after Vamana for residual Kapha"

वेगकाल में औषधि | Medicines during Acute Attack:

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2. अवेगकालीन चिकित्सा | Avegakalina Chikitsa (During Remission)

"बलवांश्च कफाधिक्यात् दुर्बलश्च वातभूयिष्ठात्। शोधनं बलवतां पथ्यं दुर्बलानां च तर्पणम्॥"

"Balavaamshcha kaphadhikyaat durbhalashcha vaatabhuyishtaat, Shodhanam balavataampathyam durbalaanam cha tarpanaam"

अर्थ: बलवान (कफ-प्रधान) रोगी के लिए शोधन चिकित्सा पथ्य है और दुर्बल (वात-प्रधान) रोगी के लिए तर्पण।

— Charaka Samhita Chikitsa Sthana 17

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A. शोधन चिकित्सा | Shodhana Chikitsa (Purificatory Treatment)

"स्नेहावस्थावर्जं सर्वं शोधनं तामके हितम्।"

"Snehavastivarjam sarvam shodhanam tamake hitam"

अर्थ: तामक श्वास में स्नेहवस्ति को छोड़कर सभी प्रकार का शोधन हितकारी है।

— Yoga Ratnakar, Shwasa Chikitsa 1

(i) वमन कर्म (Vamana Karma)

"कफप्रायेषु रोगेषु वमनं श्रेष्ठमुच्यते" "Kaphaprayeshu rogeshhu vamanam shresthamuchyate" — Charaka Samhita Sutrasthana 20

(ii) विरेचन कर्म (Virechana Karma)

"तमकं तु विरेचनमुदीर्यते भृशतरम्।" "Tamakam tu virecanam udiryate bhrushataram" — Charaka Samhita Chikitsa Sthana 17

• Charaka gives particular emphasis to Virechana in Avegavastha
• Best for Sroto-shodhana and Pitta-shamana in Tamak Shwas
• Virechana Dravyas: Trivrit Lehya, Eranda Taila, Haritaki Churna, Aragvadha (Cassia fistula) - Charaka considers Aragvadha the best Mrudu Virechana Dravya
• Ref: Charaka Samhita Chikitsa Sthana 17/55-62

(iii) नस्य कर्म (Nasya Karma)

• Anu Taila / Shadbindu Taila Nasya
• Urdhva Jatru Pranavaha Srotas shodhana
• Ref: Ashtanga Hrudayam Chikitsa Sthana

(iv) धूमपान (Dhumapana)

• Medicated smoking with Kapha-Vata-hara herbs
• "Dhumapano hitah shwase kase" — Charaka Samhita

(v) वस्ति (Vasti)

• Kashaya Vasti (Dashamula Kwatha) - Vatanulomana
• Snehavasti CONTRAINDICATED in Tamak Shwas (Yoga Ratnakar)
• Anuvasana Vasti acceptable in Vata-predominant cases

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B. शमन चिकित्सा | Shamana Chikitsa (Palliative Treatment)

"वातकफघ्नमुष्णं च वातानुलोमनं तथा। द्रव्यं पानान्नभेषज्यं श्वासिनां परिकल्पयेत्॥"

"Vaatakaphaghnam ushnam cha vaatanulomanam tathaa, Dravyam paanaannabhaishajyam shwaasinaam parikalpayet"

अर्थ: श्वास रोगियों के लिए औषध, पान और अन्न - सभी वात-कफघ्न, उष्ण वीर्य और वातानुलोमन गुण वाले होने चाहिए।

— Charaka Samhita Chikitsa Sthana 17/17

श्वासहर महाकाशय (Charaka's 10 Shwasahara Drugs):

कासहर महाकाशय (Charaka's 10 Kasahara Drugs):

प्रमुख शास्त्रीय औषधियां | Key Classical Formulations:

• दशमूल क्वाथ — Vata-Kapha hara; Ref: Ashtanga Hrudayam
• नयोपायम् कषायम् — South Indian classical for Shwasa
• इन्दुकान्तम् कषायम् — Kaphahara, Shwasahara
• बलजीरकादि कषायम् — For Vata-Kapha
• सिंह्यादि क्वाथ — Clinical trial (Sadyo Vamana vs Simhyadi Kwatha, 2018)

• कण्टकारी घृत — Sushruta's classic formulation for Shwasa: Sushruta Samhita
• वासा घृत — Pitta-Kapha Shwasa

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C. रसायन चिकित्सा | Rasayana Chikitsa (Rejuvenation)

"रसायनं च शस्तं स्याद् रोगघ्नं बलवर्धनम्। श्वासिनां कासिनां चैव आयुर्वर्धनकारणम्॥"

अर्थ: रसायन चिकित्सा रोगनाशक, बलवर्धक और श्वास-कास रोगियों में आयुवर्धक है।

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D. निदान परिवर्जन | Nidana Parivarjana (Avoidance of Causes)

"हेतोर्वर्जनं प्रथमम् उपचारः।"

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E. योग-प्राणायाम | Yoga and Pranayama

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PART B: MODERN MANAGEMENT (आधुनिक चिकित्सा)

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उद्देश्य | Goals of Treatment (GINA 2024)

1. Good symptom control and maintain normal activity
2. Minimize risk of exacerbations, fixed airflow limitation, and medication side-effects
3. Achieve remission (possible in a subset of patients)

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औषधि वर्गीकरण | Drug Classification

• Inhaled Corticosteroids (ICS) - cornerstone
• ICS + Long-Acting Beta-2 Agonists (ICS-LABA)
• Leukotriene Receptor Antagonists (LTRA)
• Long-Acting Muscarinic Antagonists (LAMA)
• Biologic agents (Step 5)

• Short-Acting Beta-2 Agonists (SABA)
• ICS-formoterol (both maintenance AND rescue in MART)

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GINA 2024 - सोपान उपचार | Stepwise Management

Track 1 (Preferred - AIR Therapy: Anti-Inflammatory Reliever)

Track 2 (Alternative)

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औषधियां | Drug Details

1. Inhaled Corticosteroids (ICS) - आधारभूत चिकित्सा

2. Short-Acting Beta-2 Agonists (SABA) - बचाव चिकित्सा

• Salbutamol (Albuterol) 100-200 mcg inhaled PRN
• Levosalbutamol - fewer cardiovascular effects
• Terbutaline - also SC injection in acute attacks
• GINA 2024: SABA alone is NO LONGER acceptable - must have ICS

3. Long-Acting Beta-2 Agonists (LABA) - नियंत्रण

• Formoterol (fast-onset, 12h) - used in MART
• Salmeterol (slow-onset, 12h)
• Vilanterol (24h, with fluticasone furoate - Relvar)
• Indacaterol (24h)

4. ICS-LABA Combinations (प्रमुख संयोजन)

5. Leukotriene Receptor Antagonists (LTRA)

• Montelukast 10 mg once daily (adults)
• Add-on at Steps 2-3; especially useful in aspirin-sensitive asthma, exercise-induced asthma, asthma + allergic rhinitis
• FDA Black Box Warning (2020): neuropsychiatric events

6. Long-Acting Muscarinic Antagonists (LAMA)

• Tiotropium (Spiriva) - add-on at Steps 4-5
• Reduces exacerbations, improves FEV1 in adults ≥6 years
• Used as alternative when ICS-LABA inadequate
• Ref: GINA 2024 Step 4-5 add-on options

7. Biologic Agents (Step 5 - Severe Asthma)

8. Oral Corticosteroids (OCS)

• Short courses: Prednisolone 40-50 mg/day x 5-7 days for acute exacerbation
• Long-term: Last resort due to serious systemic effects
• Ref: GINA 2024 - "Minimize OCS use; prefer biologic therapy for persistent severe asthma"

9. Theophylline / Aminophylline

• Sustained-release theophylline: third-line bronchodilator
• Therapeutic window: 10-20 mcg/mL (narrow margin)
• IV aminophylline loading: 5 mg/kg over 20-30 min in ICU
• Much less used now due to side effects and drug interactions

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तीव्र गंभीर दमा का प्रबंधन | Management of Acute Severe Asthma (Status Asthmaticus)

1. Oxygen - Target SpO2 94-98%, high-flow via mask
2. SABA nebulization - Salbutamol 2.5-5 mg every 20 min × 3 (first hour), or 4-8 puffs pMDI + spacer
3. Ipratropium bromide - 0.5 mg nebulized with each SABA (first 4-8 hours); reduces need for hospitalization
4. Systemic corticosteroids - Hydrocortisone 100 mg IV 6-hourly, OR Prednisolone 40-50 mg oral (both equivalent per GINA)
5. Magnesium sulphate - 2 g IV over 20 min in severe attack not responding to initial bronchodilators (Evidence A)
6. IV Aminophylline - Reserved for ICU; 5 mg/kg loading, then infusion
7. Heliox (Helium-Oxygen) - Reduces airway resistance in severe/near-fatal asthma
8. NIV (Non-Invasive Ventilation) - For impending respiratory failure
9. Mechanical ventilation - Permissive hypercapnia strategy; last resort

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गैर-औषधीय आधुनिक उपाय | Non-Pharmacological Modern Measures

1. Allergen/Trigger Avoidance - House dust mites, pet dander, pollen, mold
2. Smoking cessation - Active and passive exposure
3. Inhaler technique training + Spacer - Critical for ICS efficacy
4. Written Asthma Action Plan (WAAP) - GINA 2024: All patients should have a personalized WAAP
5. Regular monitoring - PEFR diary, Asthma Control Test (ACT)
6. Vaccination - Annual influenza; pneumococcal
7. Allergen immunotherapy (AIT) - House dust mite SLIT for allergic asthma with FEV1 >70%
8. Bronchial thermoplasty - Radiofrequency ablation of airway smooth muscle; Step 5 refractory asthma
9. Pulmonary rehabilitation - For persistent severe asthma

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आयुर्वेदिक बनाम आधुनिक - तुलना | Comparative Summary

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संदर्भ सूची | References

आयुर्वेदिक संदर्भ (Ayurvedic References)

1. Agnivesa. Charaka Samhita with Vidyotini Hindi commentary by Pt. Sastri Kasinath and Dr. Chaturvedi Gorakha Natha. Chikitsa Sthana 17/8, 17/17, 17/55-62, 17/123-24. Chaukhambha Bharti Academy, Varanasi, Part II, 2011.
2. Vagbhata. Ashtanga Hrudayam with Vidyotini Hindi commentary by Kaviraja Gupta Atrideva. Chikitsa Sthana 4/57. Chaukhambha Bharti Academy, Varanasi, 2012.
3. Sushruta. Sushruta Samhita, Uttaratantra 51/4; Chikitsa Sthana 33. Ed. Murthy KRS. Chaukhambha Orientalia, Varanasi, 2015.
4. Madhavakara. Madhava Nidana, Chapter 12/17-34. Ed. Murthy KRS. Chaukhambha Orientalia, Varanasi, 1993.
5. Yoga Ratnakar. Shwasa Chikitsa Adhyaya 1 - "Snehavastivarjam sarvam shodhanam tamake hitam"
6. Das Govinda. Bhaishajyaratnavali with Vidyotini Hindi commentary. Hikka-Shwasa Chikitsa Prakarana 28. Chaukhambha Sanskrit Sansthan, Varanasi, 2016.
7. Sharangdhara. Sharangdhara Samhita, Madhyakhanda - Sitopaladi Churna, Talisadi Churna.

शोध संदर्भ (Research References)

1. Patil SG, Thakar AB. "Efficacy of Vamana Karma with Ikshvaku Ksheera Yoga in the management of Tamaka Shvasa (bronchial asthma)." Ayu Journal 2017 Jan-Jun. [PMID: 29861586] (PMC5954254) - Ikshvaku showed 79.98% relief in breathlessness, 85.04% in wheezing; PEFR increased 26.33% (P<0.001)
2. Badwaik PP, Ade VN. "A Critical Review of Shamana, Shodhana, and Rasayana Therapies in Tamaka Shwasa with Pranayama." Journal of Clinical and Diagnostic Research, 2025.
3. Comparative Clinical Study of Shamana vs Shodhana Purvaka Shamana in Tamaka Shwasa. JAIMS, Vol. 6. [jaims.in/jaims/article/view/361]
4. "Management of Tamakashwasa with special reference to Bronchial Asthma." World Journal of Advanced Research and Reviews, 2023; 17(01): 555-559.

आधुनिक संदर्भ (Modern References)

1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024 Report. ginasthma.org - GINA 2024 PDF - "All adults with asthma should receive ICS-containing therapy; Track 1 preferred with as-needed ICS-formoterol"
2. Mason RJ, Murray JF et al. Murray & Nadel's Textbook of Respiratory Medicine, 7th Edition. Elsevier. Chapter 62 - Asthma: Management. (Stepwise management table - Fig 62.3)
3. Update on Asthma Management Guidelines. PMC 2024 - PMC11482852 - GINA 2024 review article (PMID: 39421468)
4. Lockey RF, Ledford DK. Allergens and Allergen Immunotherapy, 5th Edition. CRC Press, 2014. (Allergen immunotherapy in asthma)
5. Harrison's Principles of Internal Medicine, 21st Edition. Chapter 285 - Asthma. McGraw-Hill. (Biologic therapy, classification, acute management)
6. Katzung's Basic and Clinical Pharmacology, 16th Edition. Chapter on Bronchodilators. (Mechanism of ICS, LABA, LAMA, biologics)

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Modern Management of Tamak Shwas (Bronchial Asthma) — Summary

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1. Goals of Treatment (GINA 2024)

• Control symptoms and maintain normal daily activity
• Minimize risk of exacerbations and lung function decline
• Avoid medication side effects
• Achieve remission where possible

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2. Two Types of Medicines

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3. Stepwise Treatment (Adults - GINA 2024 Track 1 Preferred)

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4. Main Drug Classes

A. Inhaled Corticosteroids (ICS) — Cornerstone

• Reduce airway inflammation
• Examples: Budesonide, Fluticasone, Beclomethasone
• Must be used daily for long-term control

B. Short-Acting Beta-2 Agonists (SABA) — Rescue

• Immediate bronchodilation (within 5 min)
• Example: Salbutamol (Albuterol) 100-200 mcg inhaled
• Only for rescue; never as sole therapy

C. Long-Acting Beta-2 Agonists (LABA) — Add-on Controller

• Duration 12-24 hours; always combined with ICS
• Examples: Formoterol, Salmeterol, Vilanterol

D. Leukotriene Receptor Antagonist (LTRA)

• Alternative or add-on at Steps 2-3
• Example: Montelukast 10 mg once daily
• Especially useful in aspirin-sensitive and exercise-induced asthma

E. Long-Acting Muscarinic Antagonist (LAMA) — Step 4-5 Add-on

• Example: Tiotropium (Spiriva)
• Reduces exacerbations; used when ICS-LABA insufficient

F. Biologic Agents — Step 5 (Severe Asthma)

G. Oral Corticosteroids (OCS)

• Short course: Prednisolone 40-50 mg × 5-7 days for acute attacks
• Long-term use: last resort only (serious side effects)

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5. Management of Acute Severe Attack (Emergency)

1. Oxygen — Target SpO₂ 94-98%
2. Salbutamol nebulization — 2.5-5 mg every 20 min × 3 doses
3. Ipratropium bromide — 0.5 mg nebulized (first 4-8 hours)
4. Systemic corticosteroids — Hydrocortisone 100 mg IV or Prednisolone 40 mg oral
5. Magnesium sulphate — 2 g IV over 20 min (severe cases not responding)
6. IV Aminophylline — ICU setting only
7. Ventilation — NIV or mechanical ventilation if life-threatening

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6. Non-Drug Measures

• Avoid known triggers (dust, pollen, smoke, cold air, pet dander)
• Quit smoking (active and passive)
• Annual flu + pneumococcal vaccination
• Correct inhaler technique + use spacer
• Written Asthma Action Plan — personalized guide for self-management
• Regular PEFR monitoring
• Moderate exercise (swimming preferred)
• Bronchial thermoplasty — for refractory severe asthma (Step 5)

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7. Summary Flowchart

Diagnosis confirmed (spirometry / PEFR variability)
              ↓
Assess severity + control
              ↓
Start Step 1 or 2 → ICS-formoterol as-needed
              ↓
Not controlled after 2-3 months → Step UP
              ↓
Well controlled for 3 months → Step DOWN
              ↓
Step 5 (severe) → Phenotype → Biologic therapy

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8. Key Points to Remember

• ICS is the most important drug — must be started early
• SABA alone is no longer acceptable (GINA 2024)
• MART therapy (budesonide-formoterol) is the preferred approach at Steps 3-4
• Biologics are targeted, highly effective for severe eosinophilic or allergic asthma
• Treatment is stepwise — always reassess every 2-3 months
• Asthma is manageable but not curable in most patients - the goal is full control

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