Available online on 15.10.2025 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright  © 2025 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access Full Text Article                                                                                 Review Article

Etiopathogenesis of Chronic Bronchitis: A Symptom-Based Correlation with Sūʿāl and Its Management in Unani Medicine

Ansari Sabahat Mansoor ¹, Abid Ali Ansari *², Shaikh Mohd Razik ³, Nasreen Jahan ⁴

¹ PG Scholar, Department of Mahiyatul Amraz, National Institute of Unani Medicine, Bengaluru, Karnataka, India 

² Professor & HoD, Department of Mahiyatul Amraz, National Institute of Unani Medicine, Bengaluru, Karnataka, India 

³ PG Scholar, Department of Mahiyatul Amraz, National Institute of Unani Medicine, Bengaluru, Karnataka, India 

⁴ Professor, Department of Ilmul Advia, National Institute of Unani Medicine, Bengaluru, Karnataka, India 

 

 

Introduction:

Obstructive lung diseases comprise a diverse group of conditions characterized by airflow limitation, which is usually progressive and not completely reversible. This limitation occurs due to increased resistance to airflow, particularly during expiration, resulting from partial or complete obstruction of the airways. ^1,2 Within this spectrum, chronic obstructive pulmonary disease (COPD) is the most widely recognized entity, incorporating chronic bronchitis, emphysema, and small airways disease (bronchiolitis). Other important disorders, such as bronchial asthma and bronchiectasis also fall under this category. ^1,3

Among these, chronic bronchitis (CB) remains a key phenotype of COPD and is an important cause of global respiratory morbidity and mortality. ⁴ The term was first introduced by Charles Badham in 1808 to describe an inflammatory condition of the bronchial mucous membranes, manifesting with chronic cough and excessive mucus secretion. These clinical features continue to define the disease today.⁵ Chronic bronchitis is clinically diagnosed when a persistent productive cough lasts for at least three months in two successive years, provided no other underlying cause is present.^1,6 Globally, COPD ranks as the third leading cause of death, with chronic bronchitis making a major contribution to this burden.⁷ Its prevalence varies across populations, ranging from 2.6% to 16% in general populations and from 7.4% to over 50% among individuals with COPD. In the United States alone, nearly 10 million adults, primarily between the ages of 44 and 65, are affected. Notably, chronic bronchitis may also be seen in individuals with relatively preserved lung function, underscoring its independent clinical and public health relevance.^4,7

In Unani medicine, the clinical entity resembling chronic bronchitis is described under the term Waram-i- shoab Muzmin, denoting chronic inflammation of the mucous lining of the bronchioles, which manifests as persistent cough and excessive expectoration. Although this exact terminology is a modern adaptation provided by contemporary Unani scholars, the symptomatology is already well reflected in classical Unani texts under conditions such as Su‘āl (cough), also known as Surfa.^8,9 Unani physicians defined Surfa as an abnormal movement of the lungs and associated respiratory organs, serving as a natural mechanism by which Ṭabī‘at’ (the innate faculty) expels irritating or morbid matter from the chest. They compared the function of coughing in the lungs, to sneezing in the brain or hiccups in the stomach, each representing a protective reflex designed to restore balance.^8-11

According to Ibn Sīnā, cough and its related disorders are more common during winter and spring and are observed with greater frequency in men.¹⁰ Eminent unani scholar described the condition as particularly affecting elderly individuals with a predominance of Balghamī Mizāj (cold and moist temperament), which renders them more susceptible to chronic respiratory afflictions.^8,10 Thus, while modern medicine recognizes chronic bronchitis as a well-defined clinicopathological condition within COPD, Unani scholars interpreted it as a disorder of altered temperament and humoral imbalance, manifested clinically as Su‘āl and Waram-i- shoab Muzmin 

Methodology:

This paper is a narrative review based on both classical Unani and modern biomedical sources. Primary Unani references were extracted from standard texts such as Al-Qānūn fi’l Ṭibb by Ibn Sīnā, Kāmil al-Ṣanā‘a al-Ṭibbiyya by Majūsī, Ṭibb-i-Akbar by Arzānī, and Dhakhīra Khwarizm Shāhī by Jurjānī. Contemporary commentaries and translations published by CCRUM and other institutes were also consulted. For the modern perspective, a literature search was conducted using PubMed, Google Scholar, and StatPearls databases, along with standard textbooks such as Textbook of Pathology and Pulmonary Pathology. Search terms included “chronic bronchitis”, “COPD”, “etiopathogenesis”, “cough”, and “Unani medicine”. Relevant articles published between 2000 and 2025 were considered, with emphasis on clinical features, pathogenesis, and management. Sources that did not directly relate to chronic bronchitis or its correlation with cough were excluded.

Etiopathogenesis:

The development of chronic bronchitis is multifactorial, resulting from a complex interaction of environmental exposures and host susceptibility. Cigarette smoking is the most important and well-documented cause, with the risk increasing in proportion to cumulative exposure.¹² Tobacco smoke, composed mainly of gaseous compounds with a smaller fraction of particulate matter, injures the airways through persistent inflammation, structural remodeling, and oxidative stress. It induces hypertrophy and hyperplasia of submucosal glands and an increase in goblet cells, leading to excessive secretion of mucins such as MUC5AC and MUC5B, impaired mucociliary clearance, and progressive airway obstruction.¹³ In addition, cigarette smoke generates reactive oxygen species, including superoxide anions, hydrogen peroxide, and hypochlorous acid, that damage epithelial cells, disrupt repair mechanisms, and sustain inflammation. This oxidative stress recruits neutrophils and macrophages, which further release proteolytic enzymes and reactive species, amplifying epithelial injury and mucus hypersecretion.^14,15 Other forms of tobacco use, such as bidi, hookah, pipes, and cigars, confer comparable risks, while passive exposure to environmental tobacco smoke also increases susceptibility to chronic respiratory disease.¹⁶ Beyond smoking, occupational exposure to dust, vapours, and fumes, along with indoor air pollution from biomass fuels like firewood and cow dung, remains a significant contributor, particularly in low and middle-income countries.¹⁷ 

In Unani medicine, Sūʿāl (cough) is described as a physiological defence mechanism governed by the Quwwat Dāfi‘a (expulsive faculty), which helps eliminate irritants and excessive secretions from the lungs.^8-11  Sūʿāl Aṣlī originates directly from the bronchi and lungs due to underlying pathological conditions affecting these structures. Its causes are attributed to both Asbāb Bādiya (external factors) and Asbāb Wāṣila (internal factors). Common internal factors include Waram (inflammation), Yubūsat (dryness), Buthūr (eruptions), and the accumulation of Mawād-i-Fāsida (morbid matter) within the pulmonary passages. Additionally, Sū’-i-Mizāj (derangement of temperament) whether Sāda (simple) or Māddi (associated with morbid matter), as well as the descent of pathological fluids from the Dimāgh (brain) or Ḥalq (throat) into the lungs, are considered important contributors. External triggers such as cold air, cold diet, dust, smoke, and other environmental allergens or irritants often precipitate symptoms, particularly in individuals predisposed to Bārid (cold) or Raṭb (moist) temperaments.^8,9,10,11,18 The spongy and delicate structure of the lungs makes them prone to absorb excess Ruṭūbat (moisture) from the head or neighbouring organs, or to produce hypersecretions locally. When such accumulations exceed physiological limits, the Quwwat Dāfi‘a attempts to evacuate them through coughing.¹⁹ From a pathophysiological perspective, the act of coughing is mediated by coordinated expansion and contraction of the chest with diaphragmatic movements.¹⁰

Unani scholars further classified as clinical or symptomatic types of coughs, namely productive cough and dry cough. Productive cough is more common in individuals with moist temperament and the elderly, characterized by Balgham Ghalīẓ (thick phlegmatic expectoration) and nocturnal crepitations. Dry cough, on the other hand, is marked by little or no expectoration, aggravation with exertion or movement, and relative relief with rest, food intake, or sleep. The clinical picture varies with Mizāj (temperament). Individuals with Mizāj Balghamī (phlegmatic) typically present with a productive cough, whereas those with Mizāj Ṣafrawī (bilious) experience a dry, irritative cough associated with ʿAlāmāt Ḥārr (heat signs) such as thirst, restlessness, and yellow sputum.^{8,9,10,11,18,20}

Management:

1. Complete smoking cessation ^21,22,23
2. Prompt respiratory infection with antibiotics ^21,22
3. Bronchodilator for reducing dyspnoea ^22,23
4. Mucolytic agents ²⁴
5. Glucocorticoid ^21,23

Unani Principle of Treatment:

In Unani medicine, the management of Sūʿāl (cough) involves a holistic approach combining Ilāj bi’l-Tadbīr (regimenal therapy), Ilāj bi’l-Ghizā (dietotherapy) and Ilāj bi’l Dawa (pharmacotherapy). Regimenal measures such as Inkibāb (steam inhalation), Takmīd (fomentation) over the chest, and Tadhīn (oil massage) are employed to relieve airway obstruction, soften morbid matter, and facilitate expectoration.¹⁸ Dietotherapy plays a vital role in restoring balance and supporting recovery. Moist and easily digestible foods, goat’s milk, Māʾal-Shaʿīr, chicken soup, nuts, figs, and linctus preparations are commonly recommended for their soothing, nutritive, and expectorant properties, thereby strengthening the respiratory system and promoting overall health.^18,19

Ilāj bi’l Dawa: 

In the management of Suʿāl (cough), Unani physicians advocate the use of single as well as compound formulations, some of which are outlined below.

 

 

Table 1:   Single Drugs

S.NO	Drug	Botanical Name	Temperament	Part used	Action
1	Arusa	Adhatoda vasica	Hot1Dry1	Leaf	Expectorant, Antispasmodic, Sedative, Analgesic 25
2	Asl-Us-Soos	Glycyrrhiza glabra	Hot2Dry1	Root	Expectorant, sedative Demulcent, Concoctive of phlegm 26
3	Atees	Aconitum heterophyllum	Hot1Dry1	Root	Antipyretic, Nervine tonic, Astringent 25
4	Anjir	Ficus carica	Hot1Moist2	Fruit	Concoctive, Laxative, Expectorant, Resolving 25,27
5	Behidana	Cydonia oblonga	Cold2Moist2	Seed	Exhirant, Demulcent, Antitussive, Anticold 25,27
6	Gul-e-Banafsha	Viola ordata	Cold1moist1	Flower	Expectorant, Laxative 25,27,28
7	Kateera	Cochlospermum religiosum	Hot1Dry1	Gum	Glutinous, Demulcent, Sedative 25,27,28
8	Katan	Linum usitatissimum	Hot1Dry1	Seed	Resolving, concoctive, Demulcent, Expectorant 25,27,28
9	Khobazi	Malva sylvstris	Cold1Moist1	Fruit	Concoctive, Glutinous, Demulcent, Expectorant 25,27,28
10	Kheyar shambar	Cassia fistula	Hot1Moist1	Pulp	Resolving, Purgative, Expectorant 25
11	Sapistan	Cordia latifolia	Balanced	Fruit	Demulcent, Glutinous, Expectorant 25,27
12	Unnab	Ziziphus jujuba	Cold1Moist1	Fruit	Concoctive, Expectorant, Antipyretic 25,28
13	Zanjabeel	Zingiber officinale	Hot2Dry3	Rhizome	Concoctive, Antitussive 25
14	Zufa Yabis	Hyssopus officinalis	Hot3Dry3	Flower	Resolving, Expectorant 25,28
15	Zafaran	Crocus sativus	Hot2Dry1	Stigma	Exhilarant, Antitussive 25,28,29

 

 

Table 2:  Compound Drugs ^30,31

Sr.No.	Drug Name	Dosage Form	Dose
1	Ḥabb-e-Su'al	Solid	125-25mg
2	Ḥabb-e-Surfa	Solid	125-250mg
3	Ḥabb-e-Sadar	Solid	3-5g
4	Joshānda-e-Munḍij	Liquid	7g
5	La‘ūq-e-Sapistan	Semisolid	4g
6	La‘ūq-e-Khashkhash	Semisolid	5-10g
7	Qurṣ-e-Tabasheer Kafoori	Solid	4.5g
8	Sharbat-e-Ejaz	Liquid	20ml
9	Sharbat-e-Zufa	Liquid	20ml
10	Sharbat-e-Unnab	Liquid	20ml

 

 

For the management of cough, several compound formulations are described in classical Unani medicine. One such preparation involves finely powdered roasted Buzr-e-Katan (flax seeds) mixed with a decoction of Anjir (figs) and subsequently blended with honey to form a La‘ūq (linctus), which is administered orally. Another recommended formulation consists of Rubb-us-Soos (extract of licorice) 9g, with 2.25g each of Afyoon (opium) and Zafaran (saffron), prepared according to traditional methods in Shīra-e-unnab (sweet grape syrup), and converted into Ḥubūb (pills). These formulations are reported to serve as Musakkin (soothing) remedies for cough. Take 18g of Rubb-us-Soos (licorice extract), 7g each of Filfil Quroomana (long pepper), Murmakki (myrrh) and bitter almond oil, along with 3.5g of Hing (asafoetida). Prepare pills of these ingredients by mixing them with honey. Keeping these pills in the mouth is highly beneficial for cleansing the chest from thick morbid matter.^18,19

 Prevention: 

1. Foods that cause Nāfikh (flatulence) and Qabz (constipation) should be avoided.

2. Diets with a cold and moist temperament promote sputum production; therefore, fat, curd, cold water, and citrus fruits are discouraged.

3. Avoid exposure to cold water and cold environments.

 4. Phlegm producing foods must be avoided in cases of cough associated with a cold.

Discussion:

The present review establishes that although the literal term Waram-i- shoab Muzmin is not found in early Unani texts, the symptom-based entity Suʿāl, particularly Suʿāl Aṣlī, closely parallels the modern concept of chronic bronchitis. Both systems recognize environmental irritants such as smoke, dust, and cold air as primary triggers. Modern medicine explains the condition through airway inflammation, goblet cell hyperplasia, oxidative stress, and mucociliary dysfunction. In contrast, Unani scholars attributed the pathology to Sū’-i-Mizāj, Waram, Yubūsat, and deposition of Mawād-i-Fāsida, with Quwwat Dāfi‘a attempting to expel these through cough. The differentiation of cough types in Unani medicine, productive in Balghamī Mizāj and dry in Ṣafrawī Mizāj, illustrates a nuanced clinical understanding that resonates with the recognition of disease heterogeneity in modern medicine.

Management approaches in both systems emphasize prevention. Smoking cessation, pollution control, and vaccination remain the pillars in modern medicine, while Unani physicians stressed avoiding phlegm-producing diets, cold environments, and irritants. Pharmacologically, modern therapies rely on bronchodilators, mucolytics, and corticosteroids, which though effective, carry long-term risks. Unani management integrates regimenal therapies like Inkibāb (steam inhalation), dietary regulation, and safe, time-tested herbal drugs with expectorant, demulcent, and anti-inflammatory actions. Notable among these are Asl-us-Soos, Zufa, Behidana, and compound drugs like Laʿūq-e-Khashkhash and Sharbat-e-Unnab. 

Several clinical trials have explored the role of herbal and traditional interventions in cough management with encouraging results. Ghaemi et al. (2020) conducted a randomized controlled trial in which a traditional Persian medicine preparation was evaluated for chronic cough, showing significant improvement compared with placebo. Similarly, Jabbari et al. (2020) investigated the role of Persian medicine approaches in the management of acute cough and reported favorable therapeutic effects.^26,28 

In addition, Aslani et al. (2023) studied crocin, a bioactive constituent of Crocus sativus L., in patients with COPD, focusing on its impact on inflammatory mediators such as IL-6 and TNF-α. Their results demonstrated a significant reduction in these markers, suggesting that crocin may exert an anti-inflammatory effect that contributes to symptom relief in chronic respiratory disorders.²⁹Collectively, these studies provide supportive evidence that herbal medicines, including Persian medicine formulations and plant-derived compounds, hold promise as adjunctive therapies in both acute and chronic cough. They also emphasize the need to integrate traditional approaches with modern clinical research to establish safe, effective, and standardized treatments for respiratory diseases.

Conclusion:

Chronic bronchitis, although not explicitly described in Unani classics, can be closely correlated with Suʿāl, particularly Suʿāl Aṣlī. Both Unani and modern frameworks recognize similar causative factors, such as smoke, dust, and exposure to cold, while differing in their explanatory models. Modern medicine, however, emphasizes airway inflammation and oxidative stress. In contrast, Unani medicine attributes the condition to humoral imbalance and altered Mizāj. Preventive and therapeutic strategies show notable convergence, though Unani care extends further by emphasizing holistic approaches, including regimenal therapies, dietary regulation, and pharmacotherapy with single and compound herbal formulations. Evidence from clinical studies suggests that herbal and traditional interventions, including Persian medicine formulations and crocin from Crocus sativus L., can have beneficial effects in managing both acute and chronic cough, highlighting their potential as complementary therapies in respiratory care. Integrating these interventions with modern evidence-based care may offer safer and more sustainable options for managing chronic bronchitis.

Conflict of interest: The authors have no conflict of interest relevant to this article.

Author Contributions: All authors have equal contributions in the preparation of the manuscript and compilation.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting this paper are available in the cited references. 

Ethical approval: Not applicable.

References:

1. Mohan H. Textbook of pathology. 9th ed. Revised reprint. New Delhi: Jaypee Brothers Medical Publishers; 2024.

2. Green LK. Emphysema and diseases of large airways. In: Zander DS, Farver CF, editors. Pulmonary pathology. Foundations in Diagnostic Pathology Series. Churchill Livingstone; 2008. p. 416-33. https://doi.org/10.1016/B978-0-443-06741-9.50026-4 PMid:18692465 PMCid:PMC2602844

3. Gingo MR, Morris A, Crothers K. Human immunodeficiency virus-associated obstructive lung diseases. Clin Chest Med. 2013;34(2):273-82. https://doi.org/10.1016/j.ccm.2013.02.002 PMid:23702176 PMCid:PMC3690924

4. Kim V, Criner GJ. The chronic bronchitis phenotype in chronic obstructive pulmonary disease: features and implications. Curr Opin Pulm Med. 2015;21(2):133-41. https://doi.org/10.1097/MCP.0000000000000145 PMid:25575367 PMCid:PMC4373868

5. Petty TL. The history of COPD. Int J Chron Obstruct Pulmon Dis. 2006;1(1):3-14. doi:10.2147/copd.2006.1.1.3. https://doi.org/10.2147/copd.2006.1.1.3 PMid:18046898 PMCid:PMC2706597

6. Widysanto A, Goldin J, Mathew G. Chronic bronchitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.

7. Rycroft CE, Heyes A, Lanza L, Becker K. Epidemiology of chronic obstructive pulmonary disease: a literature review. Int J Chron Obstruct Pulmon Dis. 2012;7:457-94. https://doi.org/10.2147/COPD.S32330 PMid:22927753 PMCid:PMC3422122

8. Jurjani I. Zakhira Khwarazm Shahi. Khan HH, translator. Vol. 6. New Delhi: Idara Kitab-ul-Shifa; 2010.

9. Akbar Arzani H. Tibb-e-Akbar. Deoband: Faisal Publications; [Y.N.M.].

10. Sina I. Al-Qanoon fi'l Tibb. Kantoori GH, translator. New Delhi: Idara Kitab-ul-Shifa; 2010.

11. Baghdadi IH. Kitabul Mukhtarat-fil-Tibb. Central Council for Research in Unani Medicine, translator. Vol. 1. New Delhi: CCRUM; 2005.

12. Meteran H, Thomsen SF, Hjelmborg J, Miller MR, Christensen K, Sigsgaard T, et al. Genetic factors explain half of the individual susceptibility to chronic bronchitis, airflow obstruction and COPD regardless of the spirometric definition: a nationwide twin study. Lung. 2025;203(1):70. https://doi.org/10.1007/s00408-025-00825-3 PMid:40579575 PMCid:PMC12204911

13. Raby KL, Michaeloudes C, Tonkin J, Chung KF, Bhavsar PK. Mechanisms of airway epithelial injury and abnormal repair in asthma and COPD. Front Immunol. 2023;14:1201658. https://doi.org/10.3389/fimmu.2023.1201658 PMid:37520564 PMCid:PMC10374037

14. Rahman I, Adcock IM. Oxidative stress and redox regulation of lung inflammation in COPD. Eur Respir J. 2006;28(1):219-42. https://doi.org/10.1183/09031936.06.00053805 PMid:16816350

15. Janciauskiene S. The beneficial effects of antioxidants in health and diseases. Chron Obstr Pulm Dis (Miami). 2020;7(3):182-202. https://doi.org/10.15326/jcopdf.7.3.2019.0152 PMid:32558487 PMCid:PMC7857719

16. Patel M, Khangoora V. A review of the pulmonary and health impact of hookah use. Ann Am Thorac Soc. 2019;16(11):1219-28. https://doi.org/10.1513/AnnalsATS.201902-129CME PMid:31091965

17. Pérez-Padilla R, Ramirez-Venegas A, Sansores-Martinez R. Clinical characteristics of patients with biomass smoke-associated COPD and chronic bronchitis, 2004-2014. Chron Obstr Pulm Dis (Miami). 2014;1(1):23-32. https://doi.org/10.15326/jcopdf.1.1.2013.0004 PMid:28848808 PMCid:PMC5559138

18. Khan MA. Akseer-e-Azam (Al-Akseer). New Delhi: Idara Kitab-us-Shifa; 2011.

19. Al-Qumri AMH. Ghina Muna (Tarjuma Minhaj al-'Ilaj). New Delhi: CCRUM; 2008.

20. Majoosi AHBA. Kamil-us-Sana. (Urdu transl. Hkm G.H. Kantoori). New Delhi: Idara Kitab-us-Shifa; 2010.

21. Calverley PM. Modern treatment of chronic obstructive pulmonary disease. Eur Respir J Suppl. 2001;34:60s-66s. https://doi.org/10.1183/09031936.01.00229801 PMid:12392036

22. Braman SS. Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):104S-115S. https://doi.org/10.1378/chest.129.1_suppl.104S PMid:16428699 PMCid:PMC7094692

23. Shaddock E, Richards G. Pharmacological management of chronic obstructive pulmonary disease. S Afr Med J. 2015;105(9):790. https://doi.org/10.7196/SAMJnew.8426 PMid:26636171

24. Poole P, Black PN. Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2010;(2):CD001287. https://doi.org/10.1002/14651858.CD001287.pub3

25. Najmul Ghani R. Khazain-ul-Advia. Vols. 1-4. New Delhi: Idara Kitab-us-Shifa; 2011.

26. Ghaemi H, Masoompour SM, Afsharypuor S, Mosaffa-Jahromi M, Pasalar M, Ahmadi F, et al. The effectiveness of a traditional Persian medicine preparation in the treatment of chronic cough: a randomized, double-blinded, placebo-controlled clinical trial. Complement Ther Med. 2020;49:102324. https://doi.org/10.1016/j.ctim.2020.102324 PMid:32147070

27. National Formulary of Unani Medicine. New Delhi: CCRUM; 2006.

28. Jabbari Sabbagh A, Mohammadian Rasanan F, Bahrami A, Minaie Zangii B, Aliasl J, Rambod M, et al. Acute cough management in Persian medicine. Galen Med J. 2020;9:e1854. https://doi.org/10.31661/gmj.v9i0.1854N PMid:34466601 PMCid:PMC8343586

29. Aslani MR, Abdollahi N, Matin S, Zakeri A, Ghobadi H. Effect of crocin of Crocus sativus L. on serum inflammatory markers (IL-6 and TNF-α) in chronic obstructive pulmonary disease patients: a randomised, double-blind, placebo-controlled trial. Br J Nutr. 2023;130(3):446-453. https://doi.org/10.1017/S0007114522003397 PMid:36628554

30. The Unani Pharmacopoeia of India. Vols. 1-6. New Delhi: Government of India; 2007.

31. Kabiruddin H. Al-Qarabadeen (Al-Qarabadin). 2nd ed. New Delhi: Central Council for Research in Unani Medicine (CCRUM); 2006.