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Hikka Shwasa Chikitsa (view source)

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The patient suffering from ''hikka'' and ''shwasa'' should be treated with oleation, unctuous sudation to liquefy the accumulated ''kapha'', soften the channels and to facilitate ''vatanulomana'' (movement of ''vata'' in its normal direction). This should be followed by the administration elimination therapy in the form of ''vamana'' (emesis therapy), ''virechana'' (purgation), ''nasya'' and following of wholesome diet and regimen. The palliative medications should be administered keeping in view the condition of patient and stage of disease. Avoiding the causative factors and following wholesome regimen is important to prevent progress of disease and to reverse the pathogenesis. In brief ''shodhana'' followed by ''brimhana'' therapy (nourishing therapy) and ''shamana'' treatment (palliative therapy) are the ideal management methods in ''hikka'' and ''shwasa''.

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=== Sanskrit Text, Transliteration and English Translation ===

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== Sanskrit Text, Transliteration and English Translation ==

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</div></div>

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Now we shall expound the chapter ~~on the management~~ of ''Hikka''(~~hiccups~~) and ''Shwasa''(~~dyspnoea~~). Thus said Lord Atreya. [1-2]

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Now we shall expound the chapter "Hikka-Shwasa chikitsa"(Management of Hikka (Hiccups) and Shwasa (Dyspnea)). Thus said Lord Atreya. [1-2]

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==== Agnivesha’s query ====

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=== Agnivesha’s query ===

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Agnivesha , an intelligent disciple, asked his doubt with modest salute of folded hands to Lord Atreya, who has the knowledge about the subject and principles of the Vedas “The diseases are categorized under two categories (''samanyaja'' and ''nanatmaja'') of three ''dosha'' (''vata, pitta'' and ''kapha'') aggravated due to three factors (like unwholesome utilization of sense organs (''asatmendriyartha samyoga''), intellectual errors (''pajnaparadha'') and advent of maturity of time (''parinama'')). Which among these diseases is most difficult to cure?” [3-4]

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==== Atreya’s reply and nature of disease of ''shwasa'' and ''hikka'' ====

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=== Atreya’s reply and nature of disease of ''shwasa'' and ''hikka'' ===

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After listening to Agnivesha, Lord Punarvasu, the most prudent among the sages was very delighted and made ultimate and conclusive statement. “In fact there are many diseases which can kill a patient. But none of the diseases is as lethal as ''shwasa'' and ''hikka'' as they can cause immediate death. The person suffering from any other disease can also get eventually afflicted with enormously painful ''hikka'' and ''shwasa'' at the time of death.”[3-7]

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==== Predominance of ''dosha'' and affliction of ''dhatu'' ====

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=== Predominance of ''dosha'' and affliction of ''dhatu'' ===

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''Hikka'' and ''shwasa'' are mainly ''kapha'' and ''vata'' dominant in nature. They originate at the site of ''pitta'' (upper part of stomach). This results in further depletion of ''dhatus'' like ''rasa'' situated in heart. Hence generally they are extremely difficult to treat. After getting afflicted with this disease, if one indulges in unwholesome regimens, then disease gets aggravated and results in death just as from fatal snake venom. [8-9]

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==== Etiological factors ====

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=== Etiological factors ===

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*Others: Various types of ''vibandha'' (obstructions) [10-16]

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==== General ''Samprapti'' (pathogenesis) ====

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=== General ''Samprapti'' (pathogenesis) ===

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By the above mentioned etiological factors the ''vata'' gets aggravated in the ''pranavahasrotas'' ( channels carrying ''prana'') and deranges the ''kapha'' situated in the chest region producing lethal blockage of ''pranavayu'' and five types of dreadful ''hikka'' and ''shwasa''. [17-18]

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==== Premonitory symptoms ====

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=== Premonitory symptoms ===

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''Anaha'' (constipation with flatulence), pain in the flanks, pain in the cardiac region, abnormal movement of ''pranavayu'' are the premonitory symptoms of ''shwasa''.[18-20]

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==== Specific pathogenesis of ''hikka'' ====

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=== Specific pathogenesis of ''hikka'' ===

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*''Vayu'' along with aggravated ''kapha'' obstructs the ''pranavaha srotas'' and ''marma jatharagni'' resulting in loss of consciousness, stiffness in the body and also obstructs the channels of food and drinks. There is impairment of memory, tears in the eyes and stiffness in the temples and displacement of eyebrows. He suffers from delirium along with obstruction of speech, which does not get relief by any means. ''Maha hikka'' is ''mahamula'' (deep rooted), ''mahavega'' (massive attack), ''mahashabda'' (very loud sound), ''maha bala'' (very strong). This can lead to death immediately, hence named as ''mahahikka''. [21-26]

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==== ''Gambhira hikka'' ====

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=== ''Gambhira hikka'' ===

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Excessive aggravation of ''kapha'' and ''vayu'' in an aged, emaciated and mentally depressed individual leads to ''hikka''. This ''hikka'' is characterised by deep and resonant sound, and affliction of the chest. He yawns, contracts and expands his body, and while respiring he contracts both the flanks making murmuring sounds, and suffers from stiffness and pain. In such a patient the ''hikka'' arises from the umbilicus or ''pakvashaya'' (intestines) with pain all over the body. During this time his body bends and he suffers from black outs, obstruction in the respiratory tract and loss of strength and unconsciousness. Such ''hikka'' is known as ''gambhira hikka'' which ultimately results in death. [27-30]

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==== ''Vyapeta hikka'' ====

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=== ''Vyapeta hikka'' ===

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The ''vyapeta hikka'' produced after the intake of four types of food (i.e. eatable, chewable, drinkable, lickable) and gets aggravated after food gets digested. He suffers from delirium, vomiting, diarrhea, thirst and unconsciousness. There is yawning, watering of eyes, dryness of mouth and bending of the body, and ''adhmana'' (distension of the abdomen). This ''hikka'' originates from the root of the clavicle and attack is not continuous. ''Hikka'' is injurious to life. [31-33]

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==== ''Kshudra hikka'' ====

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=== ''Kshudra hikka'' ===

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The ''vayu'' gets slightly aggravated in the ''koshtha'' (alimentary tract), due to the physical exercises and reaches the throat and produces ''kshudra hikka''. This does not produce much pain and does not afflict the head and vital parts (''hridaya marma''). In this type of ''hikka'', the ''doshas'' do not reside or get lodged in the channels of respiration, food and drinks. This gets aggravated on exertion and subsides on taking food. ''Hikka'' gets subsided by itself also. The ''doshas'' are situated in cardiac region, ''kloma'', throat and palate. This mild form of ''hikka'' is curable and known as ''kshudra hikka''. [35-37]

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==== ''Annaja Hikka'' ====

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=== ''Annaja Hikka'' ===

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The ''vayu'' gets aggravated and moves in the upward direction due to the intake of excess food or drinks in hurry or excess of alcohol, anger, talking, laughing, weightlifting etc. factors aggravate ''vayu'' in ''koshtha'' (alimentary tract) gets afflicted by food and drinks and move in the upward direction and get lodged in channels of chest and produce ''annaja hikka''. This ''hikka'' occurs slowly and intermittently along with sneezing. The ''hikka'' that does not afflict vital points (''marma'') and organs and it subsides after drinking water or taking food is known as ''annaja hikka''.[38-41]

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==== Prognosis of ''hikka'' ====

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=== Prognosis of ''hikka'' ===

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The ''yamika hikka'' is curable in an individual who is not emaciated, not weak mentally, the ''dhatus'' and ''indriyas'' are unaffected and performing their normal function. Otherwise in case if body is weak, it is incurable. [42-44]

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==== Specific pathogenesis of ''Shwasa'' ====

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=== Specific pathogenesis of ''Shwasa'' ===

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The aggravated ''vayu'' along with vitiated ''kapha'' obstructs the channels (of ''prana, udaka'' and ''annavaha'') and spreads throughout the body and produces ''shwasa''. [45]

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==== ''Mahashwasa'' ====

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=== ''Mahashwasa'' ===

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The patient breathes with a loud noise during the night due to the upward movement of aggravated ''vayu'' like intoxicated bull. The ''vayu'' gets obstructed and the person becomes unconscious. The eyes get distorted and he cannot visualize properly. The eyes and face become abnormal and the elimination of urine and feces is obstructed and the voice becomes feeble and the person looks tired and respiration could be heard from distance, such person suffering from ''mahashwasa'' succumbs to death very fast. [46-48]

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==== ''Urdhva Shwasa'' ====

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=== ''Urdhva Shwasa'' ===

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The vitiated ''kapha'' obstructs channels of respiration leading to aggravation of ''vata'' resulting in prolonged expiration and shallow inspiration (breath doesn’t get deeply inspired). The patient looks up with moving eye balls as if he is scared of something. When he gets afflicted with this type of ''shwasa'' he suffers from unconsciousness, dryness of mouth, restlessness. The upward movement of ''vayu'' is aggravated resulting in obstruction of downward movement and unconsciousness, black outs and he succumbs to death quickly. [49-51]

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==== ''Chhinna Shwasa'' ====

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=== ''Chhinna Shwasa'' ===

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The patient suffering from ''chhinna shwasa'' has interrupted breath as the prana(vital centers referred in [[Sutra Sthana]] Chapter 29) is afflicted. There is complete stoppage of breath, such individual suffers from intense pain as if cutting of the ''marma'' (vital parts), constipation with abdominal distension, sweating, unconsciousness, burning sensation in ''basti'' (bladder and urinary system), excessive tears in the eyes, emaciation of the body, the eyes become red when patient struggles to breath, mental disorientation, dryness of mouth, discoloration of skin, delirium, looseness of joints. An individual suffering from above said features of ''chhinna shwasa'' succumbs to death very quickly. [52-54]

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==== ''Tamaka Shwasa'' ====

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=== ''Tamaka Shwasa'' ===

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The ''vayu'' moves in the opposite direction due to the obstruction in the respiratory tract, stiffness in the neck, head aggravates the ''kapha'' and produces rhinorrhoea, and ''gurghuraka'' sound (rhonchi). Exceedingly severe attack afflicts the ''prana'' and enhances severity. During severe attack, the patient faints repeatedly, has severe cough and becomes unconscious. The patient finds it difficult to expectorate the phlegm and feels relieved for period of 1 ''muhurta'' (3 hours) after expectoration of phlegm. There is hoarseness of voice and patient speaks with difficulty, even he does not get proper sleep, and on lying down he suffers from dyspnea as his flanks are afflicted by ''vayu''. He feels comfortable in the sitting position. He likes hot things. His eye balls are always prominent, there is sweat on the forehead, dryness of the mouth, gets repeated attacks of dyspnea, and it increases and subsides repeatedly. In gets aggravated when appearance of clouds in the sky, rains, cold weather, easterly winds and ''kapha'' enhancing food and behavior. The ''tamaka shwasa'' having above mentioned features is ''yapya'' (palliable) and in the initial stages it is curable disease. [55-62]

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==== Types of ''Tamaka Shwasa'' ====

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=== Types of ''Tamaka Shwasa'' ===

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In a patient of ''tamaka shwasa'' if ''jwara'' (fever) and unconsciousness are occurring as complication, then it is called as ''pratamaka shwasa''. The ''shwasa'' produced due to ''udavarta'' (upward movement of ''vayu'' in ''koshtha''), dust, indigestion, excessive liquid accumulation in the body (''klinna kaya''), and suppression of natural urges results in increase of ''tama''. This gets relieved by following of cooling regimen. The person suffering from this ''shwasa'' feels as if he is submerged in darkness, thus it is known as ''santamaka''.[63-64]

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==== ''Kshudra shwasa'' ====

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=== ''Kshudra shwasa'' ===

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Due to intake of dry food and exertion, ''vata'' is mildly vitiated in ''koshtha'' and moves in the upward direction i.e respiratory tract resulting in ''kshudra shwasa''. The patient suffering from this type of ''shwasa'' does not have any affliction of various body parts and the functions are not affected. It is not very painful as it does not affect the channels of food and drinks nor does it cause pain to the sense organs. This is curable if the symptom is not completely manifested and the patient is strong. Thus all the types of ''hikka'' and ''shwasa'' are elaborated along with their signs and symptoms.[65-67]

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==== Necessity of quick management of ''hikka'' and ''shwasa'' ====

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=== Necessity of quick management of ''hikka'' and ''shwasa'' ===

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Among them the fatal varieties (like ''maha hikka, gambhira hikka, vyapeta hikka, maha shwasa, urdhva shwasa, chhinna shwasa'' are incurable types) should not be treated. While the curable and controllable variety of ''hikka'' and ''shwasa'' should be treated with medicine quickly. If neglected then it destroys the ''prana'' of the patient as the fire burns away the dry grass very fast.[68-69]

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==== Guidelines for treatment of ''hikka'' and ''shwasa'' ====

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=== Guidelines for treatment of ''hikka'' and ''shwasa'' ===

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After the administration ''snehana'' (oleation) and ''swedana'' (sudation), one has to give rice along with unctuous substances. The meat soup prepared from fish or pig or curds in large quantity should be taken in meals. When the ''kapha'' gets aggravated due to above mentioned means ''vamana'' (emesis therapy) should be administrated with powder of ''pippali'' (piper longum Linn), ''saindhava'' (rock salt) and honey. While selection of the drugs care should be taken not to administer the ''vata'' aggravating drugs. After the expulsion of vitiated ''kapha'' the patient feels relieved as the ''vata'' gets alleviated and moves in the normal direction as obstructed ''srotas'' are cleared. [70-76]

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==== Treatment of remaining ''dosha'' ====

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=== Treatment of remaining ''dosha'' ===

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Cow’s horn, hair, ligaments are mixed and used for smoking by putting it in ''dhuma netra''. ''Shyonaka,'' roots of ''eranda'' (Ricinis communis Linn) and ''kusha'' (Desmostachya bipinnata Stapf.) should be filled with above mentioned drugs and used as a pipe for smoking. ''Padmaka'' (Prunus puddum), ''guggulu'' (Commiphora mukul (Hook ex Stocks), ''agaru'' (Aquallaria agollacha Roxb) and ''shallaki'' (Boswellia serrata Roxb.) are powdered and mixed with ghee and used for smoking. [77-80]

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==== Management of complications ====

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=== Management of complications ===

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The ''hikka'' and ''shwasa'' patient accompanied with complications like feeble voice, diarrhea, ''raktapitta'' (bleeding disorder) should be treated with medicines having properties of sweet, unctuous, and cold. [81]

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==== Precautions and guidelines for ''swedana'' (sudation) ====

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=== Precautions and guidelines for ''swedana'' (sudation) ===

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</div></div>

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===== Contra-indication for ''swedana'' in ''shwasa'' =====

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==== Contra-indication for ''swedana'' in ''shwasa'' ====

The patient of ''shwasa'' and ''hikka'' suffering from burning sensation, bleeding, and excessive sweating, depleted ''dhatus'', loss of strength, dryness, and associated with condition of pregnancy or having ''pitta prakriti'' should not be administered ''swedana'' (sudation).

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===== ''Mridu swedana'' (mild sudation) =====

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==== ''Mridu swedana'' (mild sudation) ====

In such condition, if it is very essential then mild sudation should be given over chest and throat region for short duration, in the form of ''parisheka'' with warm oil or application of warm ''utkarika'' (a kind of poultice) mixed with sugar or ''upanaha''(poultice).

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===== ''Utkarika''(poultice) =====

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==== ''Utkarika''(poultice) ====

''Utkarika'' is prepared with powders of sesame, black gram and wheat are mixed with ''vatahara sneha'' and gruel and ''swedana'' is done or warm gruel and milk are used for ''swedana'' in the form of ''parisheka''.

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===== ''Vamana'' =====

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==== ''Vamana'' ====

The patient suffering from fever of recent origin and ''ama dosha'' should be treated with ''ruksha sweda'' and ''langhana''. Or ''vamana'' (emesis) should be induced by administering ''saindhavalavana'' (rock salt) and water.

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Meal should be taken along with ''vata''alleviating meat soups etc. in condition of aggravation of ''vata'' due to excessive ''vamana''. Alleviation of ''vata'' should also be done by massage with ''vatahara'' drugs which are not cold, nor hot in property. [82-87]

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==== Two types of patients as per ''dosha'' dominance ====

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=== Two types of patients as per ''dosha'' dominance ===

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Management of weak patient:The patient having aggravation of ''vata'' and weakness, children and elderly ''hikka, shwasa'' patients should be managed with ''vata'' alleviating medicines and nourishing ''sneha'', soups, and meat soup. [88-90]

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==== Contra-indication for Purification therapy in ''hikka'' and ''shwasa'' patients ====

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=== Contra-indication for Purification therapy in ''hikka'' and ''shwasa'' patients ===

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''Brimhana'' therapy in ''hikka shwasa'': Strong and sturdy patient with aggravated ''kapha'' should be administered with meat soup prepared from aquatic and marshy animals followed by ''swedana'' and ''vamana''. Weak patient without aggravation of ''kapha'' should be administered ''brimhana'' (nourishment therapy). [91-93]

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==== Various formulations ====

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=== Various formulations ===

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Above said ''kshara lehya'' (Alkaline linctus) clear the ''kapha'' in the obstructed respiratory tract and subsides the aggravated ''pranavayu''. Hence the alkaline linctus should be given to purify the channels obstructed by ''kapha'' if there is no obstruction by ''kapha'' it should not be administered. [105-120]

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==== Guidelines for management of ''tamaka shwasa'' ====

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=== Guidelines for management of ''tamaka shwasa'' ===

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If the path of flowing water is blocked the enhancing pressure of water breaks the dam similarly the path obstructed by ''kapha'' aggravates ''vata'' and causes harm, hence always the path of ''vayu'' should be cleaned by means of purification. [121-122]

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==== ''Shatyadi churna'' ====

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=== ''Shatyadi churna'' ===

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An equal quantity of the fine powders of ''shati'' (Hedychium spicatum Buch Ham.), ''choraka'' (Angelica glauca Edgew), ''jivanti'' (Leptadenia reticulate W & A.), ''tvak'' (Cinnamomum zeylanica Breyn), ''musta'' (Cyperus rotundus Linn.), ''pushkara mula'' (Inula recimosa Hook f.), ''surasa'' (Ocimum sanctum Linn.), ''tamalaka'' (Phyllanthus urinaria Linn.), ''pippali'' (Piper longum Linn.), ''agaru'' (Aquilaria agollacha Roxb.), ''nagara'' (Zingiber officinale Roxb.), ''balaka'' (Vetiveria zizinioidis (Linn.) Nash.) is mixed with eight parts of sugar should be kept and us in ''tamaka shwasa'' and ''hikka''. [123-124]

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==== ''Muktadi churna'' ====

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=== ''Muktadi churna'' ===

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Equal quantities of the ''bhasmas'' of ''mukta'' (pearls), ''pravala'' (coral), ''vaidurya'' (cat’s aye gem), ''shankha'' (conch), ''sphatika'' (crystal quartz), ''anjana'' (lead), ''sasara'' (potent crystals of above mentioned drugs), ''gandhaka'' (sulfur), ''arka'' (Calotropis procera (Ait) R Br.), ''sukshmaila'' (Elettaria cardomum Maton), ''lavana dvayam'' (sauvarchala and saindhava), ''tamra'' (copper), ''ayas'' (iron), ''rajata'' (silver), ''saugandhika'' (variety of ''manikya'', ruby), ''jatiphala'' (Myristica fragrans Houtt), seeds of ''shana, apamarga'' (Achyranthes aspera Linn. ) are given in the dose of one ''panitala'' (karsha-12gms) along with ghee and honey. The administration of this powder cures ''hikka, shwasa'' and ''kasa''. On application in the form of ''anjana'' (collyrium) to eyes destroys ''timira'' (blindness), ''kacha''(glaucoma), ''nilika, pushpaka,'' vision defects, itching of eyes, ''abhishyanda'' (conjunctivitis) and ''arma'' (pterigium).[125-128]

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===== ''Shatyadi churna'' =====

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==== ''Shatyadi churna'' ====

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Equal quantity of fine powders of ''shati'' (Hedychium spicatum Buch Ham.), ''pushkaramula'' (Inula racemosa Hook f.) or ''amalaki'' (Emblica officinalis Gaertn.) or ''loha bhasma'' ( iron ore) should be licked along with honey.

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===== ''Nasya formulations'' =====

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==== ''Nasya formulations'' ====

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The supernatant part of ghee mixed with ''saindhava lavana'' or juice of ''alaktaka'' along with bees’ feces or human milk should be given in the form of ''nasya''. Medicated ghee prepared from ''madhura varga'' should be given orally or in the form of ''nasya'' pacifies ''hikka'' and ''shwasa'' very quickly. Alternate oral consumption of hot and cold milk or usage in the form of ''nasya'' alleviates ''hikka'' quickly. [130-134]

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===== Ghee formulations and other therapies =====

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==== Ghee formulations and other therapies ====

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''Dashamuladi ghrita'': Medicated ghee prepared from boiling ''dashamula kashaya, dadhimanda'' (supernatant part of curd), ''krishna'' (Piper nigrum Linn.), and ''sauvarchala'' (Variety of salt), ''yava kshara'' (alkali made of barley), ''vayastha'' (Bacopa monnieri), ''hingu'' (Ferula narthex Boiss), ''choraka'' (Angelica glauca Edgew), ''kayastha'' (Ocimum sanctum) are used internally in ''hikka'' and ''shwasa''.[135-140]

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==== ''Tejovatyadi'' ghee ====

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=== ''Tejovatyadi'' ghee ===

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''Tejovatyadi ghrita'': ''Tejovati'' (Zanthoxylun armatum DC.), ''abhaya'' (Terminalia chebula Retz.), ''kushtha'' (Saussurea lappa C.B. Clarke.), ''pippali'' (Piper longum Linn.), ''katukarohini'' (Picrorhiza kurroa Royle ex Benth), ''bhutika'' (Cymbopogon Citratus), ''paushkara mula'' (Inula recemosa Hook f.), ''palasha'' (Butea monosperma (Linn.) Kuntze.), ''chitraka'' (Plumbago zeylanica Linn.), ''shati'' (Hedychium spicatium Buch Ham.), ''sauvarchala'' (variety of salt), ''tamalaki'' (Phyllanthus urinaria Linn.), ''saindhava'' (rock salt), ''bilva'' (Aegle marmelos Corr.), ''talisa patra'' (Abies webbiana Lindle.), ''jivanti'' (Leptadenia reticulate W & A.), each are taken in one ''karsha'' quantity and ''hingu'' (Ferula narthex Boiss.) in 1/4th quantity and ghee in one ''prastha'' quantity (4 parts) and ghee is prepared as per classics. This ghee should be taken as per ones strength to conquer ''hikka'' and ''shwasa''. It is also effective in edema ''vataja arsha'' (hemorrhoids), ''grahani'' (digestive disorders), ''hritparshva rija'' (pain in the cardiac region and flanks).[141-144]

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==== ''Manahshiladi'' ghee ====

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=== ''Manahshiladi'' ghee ===

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Ghee prepared in ''jivaniya gana'' drugs is licked with honey or ''trishna'' (''maricha, pippali, shunthi'') or ''dadhika ghrita'' or ''vasa ghrita'' should be consumed in ''hikka'' and ''shwasa''.

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==== General guidelines for prevention and management ====

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=== General guidelines for prevention and management ===

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Hence ''shamana'' (palliative) and ''brimhana'' (nourishment) therapy should be done in ''hikka'' and ''shwasa'' with or without purification of the body. [147-150]

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==== Summary ====

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=== Summary ===

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== Vidhi Vimarsha (Applied Inferences ) ==

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==== ''Hikka'' ====

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=== ''Hikka'' ===

Continuous stimulation of diaphragm causes bouts of hiccups. Due to which the air is expelled out with loud sound (''mahasabdha'') and due to continuous diaphragmatic movement the patient is unable to eat (''margam chaivannapananam runaddhi''). Severe and prolonged hiccups may lead to exhaustion, fatigue, malnutrition, weight loss, dehydration and even death in the extreme situations.

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''Pranvahasrotas'' involves the respiratory center in the brain (''prano atra murdhaga'') along with respiratory tract from nasal cavity till the alveoli. Role of ''hridaya'' is also significant. The cardio-pulmonary relationship can be easily understood in diseases like left ventricular failure with marked decrease in ejection fraction and pulmonary congestion leading to respiratory distress. ''Hridaya'' is ''mulasthana'' for ''rasavahasrotas''. ''Rasa'' and ''rakta dhatu'' are part and parcel of ''udakvahasrotas''. The content of ''udakvahasrotas'' is decided by the gastrointestinal tract. Thus one can understand why ''mahasrotas'' has been mentioned as ''mulasthana'' of ''pranvahasrotas''.

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===== ''Matta rishabha eva nisha'' (like a bull)=====

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==== ''Matta rishabha eva nisha'' (like a bull)====

''Matta rishabha eva nisha'' explains the nasal flares. Nasal flaring is when the nostrils widen while a person is breathing. It is a sign that the person is having difficulty breathing. It is most commonly seen in children and infants; in those cases nasal flaring can indicate respiratory distress. Respiratory distress occurs in connection with various physical ailments, such as acute respiratory distress syndrome, a serious reaction to various forms of injuries to the lung, and infant respiratory distress syndrome, a syndrome in premature infants caused by developmental insufficiency of surfactant production and structural immaturity in the lungs.

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==== Management ====

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=== Management ===

The management protocol for ''hikka'' and ''shwasa'' includes following:

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