Bronchial Asthma and Homoeopathy

Dr  Mansoora  K

Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise.

Normally, with every breath you take, air goes through your nose and down into your throat, into your airways, eventually making it to your lungs. There are lots of small air passages in your lungs that help deliver oxygen from the air into your bloodstream.

Asthma symptoms occur when the lining of your airways swell and the muscles around them tighten. Mucus then fills the airways, further reducing the amount of air that can pass through. These conditions then bring on an asthma “attack,” the coughing and tightness in your chest that is typical of asthma.

EPIDEMOLOGY:
In 2015, 358 million people globally had asthma, up from 183 million in 1990. It caused about 397,100 deaths in 2015,  most of which occurred in the developing world. Rates vary between countries with prevalences between 1 and 18%. It is more common in developed than developing countries. One thus sees lower rates in Asia, Eastern Europe and Africa. While asthma is twice as common in boys as girls, severe asthma occurs at equal rates. In contrast adult women have a higher rate of asthma than men and it is more common in the young than the old.

HISTORY:
Asthma was recognized as early as Ancient Egypt. The word “asthma” is from the Greek ἅσθμα, ásthma, which means “panting” and was treated by drinking an incense mixture known as kyphi. It was officially named as a specific respiratory problem by Hippocrates circa 450 BC, with the Greek word for “panting” forming the basis of our modern name. In 200 BC it was believed to be at least partly related to the emotions. In the 12th century the Jewish physician-philosopher Maimonides wrote a treatise on asthma in Arabic, based partly on Arabic sources, in which he discussed the symptoms, proposed various dietary and other means of treatment, and emphasized the importance of climate and clean air.

In 1873, one of the first papers in modern medicine on the subject tried to explain the pathophysiology of the disease while one in 1872, concluded that asthma can be cured by rubbing the chest with chloroform liniment. Medical treatment in 1880 included the use of intravenous doses of a drug called pilocarpine. In 1886, F. H. Bosworth theorized a connection between asthma and hay fever. Epinephrine was first referred to in the treatment of asthma in 1905.Oral corticosteroids began to be used for this condition in the 1950s while inhaled corticosteroids and selective short acting beta agonist came into wide use in the 1960s.

During the 1930s to 1950s, asthma was known as one of the “holy seven” psychosomatic illnesses. Its cause was considered to be psychological, with treatment often based on psychoanalysis and other talking cures.

CAUSES:
Asthma is caused by a combination of complex and incompletely understood environmental and genetic interactions. These influence both its severity and its responsiveness to treatment.  It is believed that the recent increased rates of asthma are due to changing epigenetics  (heritable factors other than those related to the DNA sequence) and a changing living environment. Asthma that starts before the age of 12 years old is more likely due to genetic influence, while onset after age 12 is more likely due to environmental influence.

ENDOGENOUS FACTORS-

• Genetic predisposition
• Atopy
• Airway hyper responsiveness     

  ENVIRONMENTAL FACTORS-

• Indoor allergens
• Outdoor allergens
• Occupational sensitizers
• Passive smoking
• Respiratory infections
• Obesity
• Early viral infections

TRIGGERS 

• Allergens
• Upper respiratory tract viral infections  
• Exercise & hyperventilation
•  Cold air
•  Sulphur dioxide   Drugs (aspirin)  
• Stress
•  Irritants (household sprays, paint fumes)

ATOPY:

• Atopy is due to the genetically determined production of specific IgE antibody, with many patients showing a family history of allergic diseases.
• Atopy is the major risk factor for asthma, and nonatopic individuals have a very low risk of developing asthma.
• Patients with asthma commonly suffer from other atopic diseases, particularly allergic rhinitis, which may be found in over 80% of asthmatic patients, and atopic dermatitis (eczema).
• Environmental or genetic factor(s) predispose to the development of asthma in atopic individuals.

INFECTIONS:

• Viral infections are common as triggers of asthma.
• There is some association between respiratory syncytial virus infection in infancy and the development of asthma, but the specific pathogenesis is difficult to elucidate, as this infection is very common in children.
• More recently, atypical bacteria such as Mycoplasma and Chlamydia have been implicated in the mechanism of severe asthma, but thus far evidence of a true association is not very convincing.

HYGIENE HYPOTHESIS:

• This “hygiene hypothesis” proposes that lack of infections in early childhood preserves the T_H2 cell bias at birth, whereas exposure to infections and endotoxin results in a shift toward a predominant protective T_H2response.
• Intestinal parasite infection may also be associated with a reduced risk of asthma.

GENETIC CONSIDERATIONS:

• The familial association of asthma and a high degree of concordance for asthma in identical twins indicate a genetic predisposition to the disease
• It now seems likely that different genes may also contribute to asthma specifically, and there is increasing evidence that the severity of asthma is also genetically determined.
• The most consistent findings have been associations with polymorphisms of genes on chromosome 5q, including the T helper 2 (T_H2) cells interleukin (IL) 4, IL-5, IL-9, and IL-13, which are associated with atopy.

DIET:

• Diets low in antioxidants, such as vitamin C and vitamin A, magnesium, selenium, and omega-3 polyunsaturated fats (fish oil), or high in sodium and omega-6 polyunsaturated are associated with an increased risk of asthma.
• However, interventional studies have not supported an important role for these dietary factors.
• Obesity is also an independent risk factor for asthma, particularly in women, but the mechanisms are thus far unknown.

AIR POLLUTION:

• Air pollutants, such as sulphur dioxide, ozone, and diesel particulates, may trigger asthma symptoms.
• Indoor air pollution may be more important with exposure to nitrogen oxides from cooking stoves and exposure to passive cigarette smoke.
• There is some evidence that maternal smoking is a risk factor for asthma.

ALLERGENS:

• Inhaled allergens are common triggers of asthma. Domestic pets, particularly cats, have also been associated with allergic sensitization, but early exposure to cats in the home may be protective through the induction of tolerance.
• In thunderstorms the pollen grains are disrupted, and the particles that may be released can trigger severe asthma exacerbations (thunderstorm asthma).

OCCUPATIONAL ASTHMA

OTHER FACTORS :Lower maternal age, prematurity and low birth weight

COLD AIR AND EXERCISE

HORMONAL FACTORS

• Premenstrual worsening of asthma,
• Thyrotoxicosis and hypothyroidism can both worsen asthma, although the mechanisms are uncertain.

STRESS :Many asthmatics report worsening of symptoms with       stress.

PATHOPHYSIOLOGY:

• Airway hyper-reactivity (AHR) is integral to the diagnosis of asthma.
• Exaggerated bronchoconstriction to a wide range of non-specific stimuli, e.g. exercise, cold air .
• Eosinophils, lymphocytes, mast cells, neutrophils.
• Associated oedema, smooth muscle hypertrophy and hyperplasia, thickening of basement membrane, mucous plugging and epithelial damage.
• Limitation of airflow is due mainly to bronchoconstriction, but airway oedema, vascular congestion, and luminal occlusion with exudate may also contribute.
• This results in a REDUCTION in forced expiratory volume in 1 s (FEV₁), FEV₁/forced vital capacity (FVC) ratio, and peak expiratory flow (PEF), as well as an increase in airway resistance.

SIGNS AND SYMPTOMS:

• The onset is abrupt in most cases.
• The attack may occur seasonally or during all times of year(perennially) .
• In moderately severe cases the pt is orthopneic and cyanosed and accessory muscles are active.
• There may be only ineffective cough with scanty mucoid sputum
• In severe cases pulses paradoxus  may occur.

Characteristic symptoms :

• Cough, dyspnoea, wheeze.
• Worse at night, and patients typically awake in the early morning hours .
• Increased mucus production in some patients, with typically tenacious mucus that is difficult to expectorate.
• Asthma characteristically displays a diurnal pattern, with symptoms and PEF being worse in the early morning.
• Particularly when asthma is poorly controlled, symptoms such as cough and wheeze disturb sleep and have led to the use of the term ‘nocturnal asthma’.
• Typical physical signs are inspiratory, and to a great extent expiratory, rhonchi throughout the chest, and there may be hyperinflation

Associated conditions:
A number of other health conditions occur more frequently in people with asthma, including gastro-esophageal reflux disease (GERD), rhinosinusitis, and obstructive sleep apnea. Psychological disorders are also more common, with anxiety disorders occurring in between 16–52% and mood disorders in 14–41%.  It is not known whether asthma causes psychological problems or psychological problems lead to asthma. Those with asthma, especially if it is poorly controlled, are at increased risk for radiocontrast reactions.

CLASSIFICATION:

• Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in one second (FEV₁), and peak expiratory flow rate. 
• Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic), based on whether symptoms are precipitated by allergens (atopic) or not (non-atopic).

Extrinsic/early onset asthma

• With external precipitating factor
• Have other atopic manifestation like urticaria,eczema,allergic rhinitis
• Family history of asthma
• Better prognosis

Intrinsic Asthma / late onset

• Without definable relation to environmental antigen
• After 30 yrs
• Negative skin test to common inhalant allergens and normal serum concentrations of IgE
• But show high frequency of esnophilia,aspirin sensitivity, nasal polyposis
• They usually have more severe, persistent asthma. Little is understood about mechanism, but the immunopathology in bronchial biopsies and sputum appears to be identical to that found in atopic asthma.
• There is recent evidence for increased local production of IgE in the airways, suggesting that there may be common IgE mediated mechanisms.

Although asthma is a chronic obstructive condition, it is not considered as a part of chronic obstructive pulmonary disease, as this term refers specifically to combinations of disease that are irreversible such as bronchiectasis and emphysema. Unlike these diseases, the airway obstruction in asthma is usually reversible; however, if left untreated, the chronic inflammation from asthma can lead the lungs to become irreversibly obstructed due to airway remodeling. In contrast to emphysema, asthma affects the bronchi, not the alveoli.

DIAGNOSIS:

SIGNS:

• General -Evidence of respiratory distress manifests as increased respiratory and cardiac rates, and use of accessory muscles of respiration
• Pulsus paradoxus: This is an exaggerated fall in systolic blood pressure during inspiration and may occur during an acute asthma exacerbation.
• Depressed sensorium: This finding suggests a more severe asthma exacerbation with impending respiratory failure.

CHEST EXAMINATION:

• End-expiratory wheezing or a prolonged expiratory phase is found most commonly, although inspiratory wheezing can be heard.
• Diminished breath sounds and chest hyperinflation may be observed during acute exacerbations.
• The presence of inspiratory wheezing or stridor may prompt an evaluation for an upper airway obstruction such as vocal cord dysfunction, vocal cord paralysis, thyroid enlargement, or a soft tissue mass (eg, malignant tumor).

INVESTIGATION:

• Sputum – sputum may reveal numerous esnophils,mucus plugs and curschmann’s spiral(cast of small airways)
• Hematologic Tests-Moderate eosinophilia
• Blood tests are not usually helpful. Total serum IgE and specific IgE to inhaled allergens may be measured in some patients.

PULMONARY FUNCTION TESTS:

• Peak flow meters- peak flow readings after rising in the morning and before retiring in the evening. A diurnal variation in PEF (the lowest values typically being recorded in the morning) of more than 20% is considered diagnostic and the magnitude of variability provides some indication of disease severity. PEF values less than 200 L/min indicate severe airflow obstruction.
• Bronchial provocation tests with the suspected agent may be required. Skin prick tests or the measurement of specific IgE may confirm sensitivity to the suspected agent.
• Spirometry –A reduced ratio of FEV1 to forced vital capacity, when compared with predicted values, demonstrates the presence of airway obstruction.
• Further lung function tests are rarely necessary, but whole body plethysmography shows increased airway resistance and may show increased total lung capacity and residual volume.
• Gas diffusion is usually normal but there may be a small increase in gas transfer in some patients.
• Radiological examination is generally unhelpful in establishing the diagnosis but may point to alternative diagnoses. Acute asthma is accompanied by hyperinflation, and lobar collapse may be seen if mucus has occluded a large bronchus.
• Measurement of allergic status An elevated sputum or peripheral blood eosinophil count may be observed and the serum total IgE is typically elevated in atopic asthma. Skin prick tests are simple and provide a rapid assessment of atopy. Similar information may be provided by the measurement of allergen-specific IgE.

There is currently no precise test for the diagnosis, which is typically based on the pattern of symptoms and response to therapy over time. A diagnosis of asthma should be suspected if there is a history of recurrent wheezing, coughing or difficulty breathing and these symptoms occur or worsen due to exercise, viral infections, allergens or air pollution. Spirometry is then used to confirm the diagnosis. In children under the age of six the diagnosis is more difficult as they are too young for spirometry.

DIFFERENTIAL DIAGNOSIS:

• In children, other upper airway diseases such as allergic rhinitis and sinusitis should be considered as well as other causes of airway obstruction including foreign body aspiration, tracheal stenosis, laryngotracheomalacia, vascular rings, enlarged lymph nodes or neck masses.Bronchiolitis and other viral infections may also produce wheezing.
• In adults, COPD, congestive heart failure, airway masses, as well as drug-induced coughing due to ACE inhibitors should be considered. In both populations vocal cord dysfunction may present similarly.

Chronic obstructive pulmonary disease can coexist with asthma and can occur as a complication of chronic asthma. After the age of 65, most people with obstructive airway disease will have asthma and COPD. In this setting, COPD can be differentiated by increased airway neutrophils, abnormally increased wall thickness, and increased smooth muscle in the bronchi. However, this level of investigation is not performed due to COPD and asthma sharing similar principles of management: corticosteroids, long-acting beta-agonists, and smoking cessation. It closely resembles asthma in symptoms, is correlated with more exposure to cigarette smoke, an older age, less symptom reversibility after bronchodilator administration, and decreased likelihood of family history of atopy.

PREVENTION:

• The evidence for the effectiveness of measures to prevent the development of asthma is weak.
• The World Health Organization recommends decreasing risk factors such as tobacco smoke, air pollution, chemical irritants including perfume, and the number of lower respiratory infections.
• Other efforts that show promise include: limiting smoke exposure in utero, breastfeeding, and increased exposure to daycare or large families, but none are well supported enough to be recommended for this indication. 
• Pets be removed from the home if a person has allergic symptoms.
• Dietary restrictions during pregnancy or when breast feeding have not been found to be effective at preventing asthma in children and are not recommended.
• Reducing or eliminating compounds known to sensitive people from the work place may be effective.
• It is not clear if annual influenza vaccinations affects the risk of exacerbations. Immunization, however, is recommended by the World Health Organization. Smoking bans are effective in decreasing exacerbations of asthma.^[134]

MANAGEMENT:

• Avoid precipitating factores-Cessation of smoking
• Control of pollution
• Yoga and controlled breathing exercises
• Aim of treatment – Achieve and maintain control of symptoms.

• • Prevent asthma exacerbations.
  • Maintain pulmonary function as close to normal levels as possible.
  • Maintain normal activity levels, including exercise

• The main drugs for asthma can be divided into bronchodilators, which give rapid relief of symptoms mainly through relaxation of airway smooth muscle, and controllers, which inhibit the underlying inflammatory process.
• Bronchodilators act primarily on airway smooth muscle to reverse the bronchoconstriction of asthma. There are three classes of bronchodilator in current use:b₂-adrenergic agonists, anticholinergics, and theophylline; of these, b₂-agonists are by far the most effective.
• _b2-Agonists- The primary action is to relax airway smooth-muscle cells of all airways
• Short-acting b₂-agonists (SABAs), such as salbutamol,albuterol and terbutaline. Long-acting b₂-agonists (LABAs) include salmeterol and formoterol
• Anti-Cholinergics-Muscarinic receptor antagonists, such as ipratropium bromide, prevent cholinergic nerve–induced bronchoconstriction and mucus secretion.
• Controller Therapies
• Inhaled Corticosteroids
• ICSs are by far the most effective controllers for asthma

Lifestyle modification

• Avoidance of triggers is a key component of improving control and preventing attacks. The most common triggers include allergens, smoke (from tobacco or other sources), air pollution, non selective beta-blockers, and sulfite-containing foods.
• Cigarette smoking and second-hand smoke (passive smoke) may reduce the effectiveness of medications such as corticosteroids.
• Dust mite control measures, including air filtration, chemicals to kill mites, vacuuming, mattress covers and others methods had no effect on asthma symptoms. There is insufficient evidence to suggest that dehumidifiers are helpful for controlling asthma.
• Overall, exercise is beneficial in people with stable asthma.
• Yoga could provide small improvements in quality of life and symptoms in people with asthma.

Adverse effects

Long-term use of inhaled corticosteroids at conventional doses carries a minor risk of adverse effects. Risks include thrush, the development of cataracts, and a slightly slowed rate of growth. Higher doses of inhaled steroids may result in lower bone mineral density.

PROGNOSIS:

The prognosis for asthma is generally good, especially for children with mild disease. Mortality has decreased over the last few decades due to better recognition and improvement in care. In 2010 the death rate was 170 per million for males and 90 per million for females. Rates vary between countries by 100 fold.

RUBRICS IN REPERTORY:

SYNTHESIS REPERTORY-

• Respiration asthmatic:3-ambr,arg n,ars,ars i,cupr,ip,kali c,kali n,kali ar,lob,puls,samb,sil,spong,stram,sulph
• Respiration – asthmatic – eruptions, after suppressed: ant-c. Apis Ars. calc. Carb-v. cupr. Dulc. Ferr. graph. hep. Ip. mez. Psor. PULS. rhus-t. sec. Sulph.
• Respiration difficult

MURPHY’S REPERTORY-

• Clinical-Asthma: ambra,arg n,ars,ars i,blatta,carc,cupr,ip,kali ar,kali c.kali n,lob,nat s,puls,samb,sil,spong,stram,sulph,visc
• Allergic hay fever with- all c,ars,carc,iod,thuj
• Clinical- Asthma – childrenant-t. ars.  carc. cham. ip.  kali-n. kali-s. . med.nat-s. phos. puls. samb.. tub.
• Lung- Asthma general

BOERICK

• Respiration asthma
• Respiration wheezing-2 ant t,ars,grind,hep,ip,kali c,samb,spong

THERAPEUTICS:

BLATTA ORIENTALIS

• A remedy for asthma.
• Especially when associated with bronchitis.
• Indicated after arsenic when this is insufficient.
• Cough with dyspnoea in bronchitis and phthisis.
• Acts best in stout and corpulent patients.
• Much pus-like mucus.
• Lowest potencies during an attack.
• After the spasm, for the remaining cough, use the higher.
• Stop with improvement to prevent return of aggravation.

GRINDELIA

• An efficacious remedy for wheezing and oppression in bronchitic patients.
• The sibilant rales are disseminated with foamy mucus, very difficult to detach.
• Asthma, with profuse tenacious expectoration, which relieves.
• Stops breathing when falling asleep; wakes with a star, and gasps for breath.
• Must sit up to breathe. .
• Cannot breathe lying down

ICTODES FOETIDA

• Sudden anxiety, with dyspnoea and sweat, followed by stool and relief of that and other complaints.
• Inclined to take a deep breath; with hollowness of chest; with constriction in chest.
• Spasmodic asthma.
• Asthma, worse or caused by dust, as for example, the inhalation of dust in a hay-loft. 
• Is cross, impetuous and inclined to contradict, has a redness like a saddle across the nose, the nose swollen, sneezes, has a spasmodic couch, is better after stool and in open air.

SENEGA

• Cough often ends in a sneeze. Rattling in chest. [Tart. emet.] Chest oppressed on ascending.
• Bronchial catarrh, with sore chest walls; much mucus; sensation of oppression and weight of chest.
• Difficult raising of tough, profuse mucus, in the aged.
• Asthenic bronchitis of old people with chronic interstitial nephritis or chronic emphysema.
• Old asthmatics with congestive attacks.

SEPIA

• Dry, fatiguing cough, apparently coming from stomach. Rotten-egg taste with coughing.
• Dyspnoea; worse, after sleep; better, rapid motion. Cough in morning, with profuse expectoration, tasting salty. [Phos.; Ambr.].
• Cough excited by tickling in larynx or chest.

ANTIMONIUM ARSENICOSUM

• Found useful in emphysema with excessive dyspnoea and cough,much mucous secretion. Worse on eating and lying down.
• Sense of weakness .Inflammation of eyes and oedema of face.

ARALIA RACEMOSA

• Asthma with cough<lying down
• Dry cough coming on after first sleep(around middle of night)
• Sensation of foreign body in throat
• Extremely  sensitive to draught
• Least current of air causes sneezing, copious excoriating watery discharge from nostrils with salty acrid taste

LOBELIA

• Dyspnoea from constriction of chest; worse, any exertion.
• Sensation of pressure or weight in chest; better by rapid walking.
• Asthma; attacks, with weakness, felt in pit of stomach and preceded by prickling all over.
• Cramp, ringing cough, short breath, catching at throat.
• Senile emphysema.

ANT TART

• when the patient coughs there appears to be a large collection of mucus in the bronchi; it seems as if much would be expectorated, but nothing comes up.
• Relieves the “death-rattle” (Taran.).
• Children not easily impressed when Ant. tart. seems indicated in coughs, require Hepar.
• When lungs seem to fail, patient becomes sleepy, cough declines or ceases, it supplants Ipec.
• Dyspnoea >eructation,lying on Rt side, sitting upright
• <n damp, cold weather; lying down at night; warmth of room, change of weather in spring (Kali s., Nat. s.).

NAT SULPH

• Grief from+++
• Dyspnoea, during damp weather.
• Must hold chest when coughing.
• Humid asthma; rattling in chest, at 4 and 5 a.m.   
• Cough, with thick ropy, greenish expectoration; chest feels all gone.
• Constant desire to take deep, long breath.
• Asthma in children, as a constitutional remedy.
• Pain through  lower left chest.
• Every fresh cold brings on attack of asthma.

IPECAC

• Dyspnoea; constant constriction in chest.
• Asthma.
• Yearly attacks of difficult shortness of breathing.
• Continued sneezing; coryza; wheezing cough.
• Cough incessant and violent, with every breath.
• Chest seems full of phlegm, but does not yield to coughing.
• Suffocative cough; child becomes stiff, and blue in the face.
• Dr. Nash in his Leaders states that Ipecac is the best remedy in the first stage of Asthma before much mucus is present. 

KALI  CARB

• Dry, hard cough about 3 a.m.  , with stitching pains and dryness of pharynx.
• Expectoration scanty and tenacious, but increasing in morning and after eating; aggravated right lower chest and lying on painful side.
• Leaning forward relieves chest symptoms.
• Expectoration must be swallowed; cheesy taste; copious, offensive, lump.
• Wheezing.

HEPAR SULPH

• Loses voice and coughs when exposed to dry, cold wind. 
• Cough troublesome when walking.
• Dry, hoarse cough.
• Cough excited whenever any part of the body gets cold or uncovered, or from eating anything cold.
• Croup with loose, rattling cough; worse in morning. 
• Rattling, croaking cough; suffocative attacks; has to rise up and bend head backwards.
• Anxious, wheezing, moist breathing, asthma worse in dry cold air; better in damp.

ARS ALB

• Debility, exhaustion, and restlessness, with nightly aggravation,
• Unable to lie down; fears suffocation. 
• Asthma worse midnight.
• Burning in chest. 
• Cough worse after midnight; worse lying on back. Must sit or bend forward
• Expectoration scanty, frothy. Darting pain through upper third of right lung.
• Wheezing respiration.
• Follows  Ipecac.  well either in catarrhal or nervous Asthma. 

SPONGIA

• Great dryness of all air-passages.
• Cough, dry, barking, croupy,no mucus rales
• Croup; worse, during inspiration and before midnight.
• Every mental excitement< or increase cough.
• Respiration short, panting, difficult; feeling of a plug in larynx. Cough abates after eating or drinking, especially warm drinks.
• Worse after sleep or sleep into<
• Bronchial catarrh, with wheezing, asthmatic cough, worse cold air, with profuse expectoration and suffocation; worse, lying with head low and in hot room,sweets,reading,talking,swallowing
• Amenorrhoea with asthma

AMBRA GRISEA

• Violent cough in spasmodic paroxysms, with eructations and hoarseness; worse talking or reading aloud (Dros., Phos.); evening without, morning with expectoration (Hyos.); whooping-cough, but without crowing inspiration.
• <presence of people
• Hollow spasmodic barking cough coming deep from chest

PSORINUM

• Asthma, with dyspnoea; worse, sitting up,open air; better, lying down and keeping arms spread wide apart.
• Cough c/c of years duration<morning on waking and evening on lying down.
• Sputa green,yellow or salty mucus.cough a long time before expectorating
• Dry, hard cough, with great weakness in chest. 
• Pain in chest; better, lying down.
• Cough returns every winter, from suppressed eruption.
• Hay-fever returning irregularly every year.

TUBERCULINUM

• Follow psorinum as a constitutional remedy in hay fever,asthma
• Take cold easily
• Hard racking cough,profuse sweating,rales all over chest

MEDORRHINUM

• Incessant, dry, night cough. Better at seaside
• Asthma,choking caused by weakness or spasm of epiglottis,larynx is stopped so that no air could enter >lying on face and protruding tongue
• Cough dry incessant painful as if mm was torn from larynx<night,sweets lying down
• Dyspnoea; cannot exhale. [Samb,meph,chlor.]
• Cough; better lying on stomach.

BROMIUM

• Sailors suffer from asthma “on shore”
• Dyspnoea can,t inspire deep enough as if brething through a sponge or air passage full of smoke or vapour of sulphur;rattling sawing danger of suffocation from mucus in larynx
• Cold sensation in larynx on inspiration>after shaving

CARB VEG

• Asthma in aged with blue skin.
• Cough, with burning in chest; worse in evening, in open air, after eating and talking.
• Spasmodic cough, bluish face, offensive expectoration, neglected pneumonia.
• Breath cold; must be fanned.

CUPR MET

• Cough as a gurgling sound, better by drinking cold water.
• Suffocative attacks, worse 3 a.m.   [Am.c. ]
• Spasm and constriction of chest; spasmodic asthma, alternating with spasmodic vomiting
• Dyspnoea with epigastric uneasiness.
• Spasmodic dyspnoea before menstruation.
• Angina with asthmatic symptoms and cramps (Clarke).

KALI NITRICUM

• Dry, morning cough, with pain in chest and bloody expectoration.
• Asthma, with excessive dyspnoea, nausea, dull stitches, and burning in chest.
• Dyspnoea so great that breath cannot be held long enough to drink, though thirsty.
• Oppression worse in morning.
• Sour-smelling expectoration.

LACHESIS

• Sensation of suffocation and strangulation on lying down, particularly when anything is around throat; compels patient to spring from bed and rush for open window.
• Little secretion and much sensitiveness; worse, pressure on larynx, after sleep, open air.
• Breathing almost stops on falling asleep. [Grind.]

PULSATILLA

• Dry cough in evening and at night; must sit up in bed to get relief; and loose cough in the morning, with copious mucous expectoration.
• Urine emitted with cough. [Caust.]
• Expectoration bland, thick, bitter, greenish.
• Short breath, anxiety, and palpitation when lying on left side. [Phos.]

PHOSPHORUS

• Cough from tickling in throat; worse, cold air, reading, laughing, talking, from going from warm room into cold air.
• Hard, dry, tight, racking cough.
• Burning pains, heat and oppression of chest.
• Do not give it too low or too frequently here, it may but hasten the destructive degeneration of tubercular masses.
• Nervous coughs provoked by strong odors, entrance of a stranger; worse in the presence of strangers; worse lying upon left side; in cold room.

SAMBUCUS

• Chest oppressed with pressure in stomach, and nausea Hoarseness with tenacious mucus in larynx.
• Paroxysmal, suffocative cough, coming on about midnight, with crying and dyspnoea.
• Loose choking cough.
• Child awakes suddenly, nearly suffocating, sits up, turns blue. Cannot expire. [Meph.] Millar’s asthma.

SULPHUR

• Oppression and burning sensation in chest.
• Difficult respiration; wants windows open. 
• Loose cough; worse talking, morning, greenish, purulent, sweetish expectoration.
• Much rattling of mucus.
• Dyspnoea in middle of night, relieved by sitting up.

STANN MET

• Hoarse; mucus expelled by forcible cough.
• Violent, dry cough in evening until midnight.
• Cough excited by laughing, singing, talking; worse lying on right side,drink anything warm
• >coughing and expectorating
• During day, with copious green, sweetish, expectoration.
• Chest feels weak; can hardly talk.
• Respiration short, oppressive; stitches in left side when breathing and lying on same side.

NUX VOM

• Asthma, with fullness in stomach, morning or after eating.
• Asthmatic attacks are brought on by gastric disturbances; simple spasmodic asthmas; there is some relief by belching, the patient must loosen the clothing. It must also be thought of in those who drink much coffee or liquor. Irritable bilious temperaments also correspond to the drug.
• Cough, with sensation as if something were torn loose in chest.
• Shallow respiration. Oppressed breathing.
• Tight, dry hacking cough; at times with bloody expectoration.
• Cough brings on bursting headache and bruised pain in epigastric region.

ZINGIBER

• Farrington describes thus: “Zingiber is analogous to Nux Vom. It may be used in asthma of gastric origin. The attack comes on in the night towards morning. The patient has to sit up to breathe, but despite the severity of the paroxysm, there seems to be no anxiety.”

PASSIFLORA

• Anti spasmodic
• Asthma
• Insomnia

MEPHITIS

• Suffocative feeling,asthmatic paroxysm,spasmodic cough,cough  so violent  as if  each spell  would terminate life
• Child must raised up,getblue and can’t exhale.mucous rales through  upper part of chest.
• Pt want to bath in ice cold water
• Few paroxysm during day many at night
• Asthma as if inhaling sulpher.<talking,at night
• Indicated when drosera fails

COCA

• Asthma spasmodic variety
• Want of breath short breath especially in aged athlets and alchoholics
• >wine,riding,fast motion in open air
• <ascending,high altitude

HYDROCYANIC ACID

• Noisy and agitated breathing.dry spasmodic suffocative cough
• Asthma with contraction of throat
• Paralysis of lung,marked cyanosis,venously congested lung

ARS IOD

• Cough dry, with little difficult expectoration.

NAPHTHALINUM

• Respiration: labored and irregular; asthmatic
• Cough is incessant paroxysms almost arresting breath.
• Night cough preventing sleep.
• Hay asthma.
• Spasmodic asthma; better in open air.
• Emphysema in the aged with asthma.

APIS MELLIFICA

• Difficult breathing,  esp.  the unique symptom, “he does not see how he can get another breath“.

FERRUM METALLICUM

• Asthma associated with orgasm of blood to the chest, agg. after 12 P.M. , when the patient must sit up and uncover his chest, which he does to get cool and sits up in order to breathe and moves slowly about for relief.
• It acts best in young persons, male or female, who are subjects to irregular distribution of blood.

ERIODICTYON CALIFORNICUM

• Catarrhal Asthma, with thickening of the bronchial tubes and oppression of breathing, >> by expectoration.
• Wheezing; asthma, with coryza and mucous secretions. Dull pain in right lung. Burning in fauces.

JUSTICIA ADHATODA

• Highly efficacious medicine for acute catarrhal conditions of the respiratory tract
• Dry cough from sternal region all over chest.
• Hoarseness, larynx painful. Paroxysmal cough, with suffocative obstruction of respiration. Cough with sneezing. Severe dyspnoea with cough. Tightness across chest
• Asthmatic attacks, cannot endure a close, warm room.
• Severe aggravation have been noticed from lower potencies.

EUCALYPTUS

• Asthma, with great dyspnoea and palpitation.
• Moist asthma. Expectoration white, thick mucus. Bronchitis in the aged. Bronchorrhoea. [Bals.Peru.]
• Profuse expectoration of offensive muco-pus. Irritative cough. Whooping-cough in rachitic children. Fetid form of bronchitis, bronchial dilatation and emphysema.

Respiration –difficult-bending forward>

• Arg nit,Ars alb,Cenchris,Kali bich,Kali carb,Lachesis,Spongia(2 mark)
• Coccus cacti &colchicum(1mark)

Respiration-difficult-bending forward

• Spigelia(2mark)
• Apis,Senega(1mark)

Respiration-difficult-bending head backward

• Bell,Chamomilla,Hepar(1mark)

Respiration-difficult-bending head backward>

• Spongia(1mark)

Respiration-difficult-bending-rise up &bend head backward must

• Hepar(1mark)

REFERENCES:

• Davidsons principles and practice of  medicine- 23^rd edition
• Harrisons  text book of internal medicine
• Clinical medicine by kumar and clark
• Text book of medicine by K V Krishna das
• Homoeopathic medical repertory- Robin Murphy
• Repertorium homoeopathicum syntheticum
• www.healthline.com
• www.medicalnewstoday.com
• Boericke’s new manual of homoeopathic materia medica with repertory
• A study on materia medica – N M Choudhuri
• Homoeopathic therapeutics(The classical therapeutic hints) – Samuel lilienthal