Daily regimen (Dincharya): Jala neti

Jala neti is a simple and essential process that cleanses the nasopharyngeal passage and reduces nasal congestion. It should be incorporated into the daily morning routine (Dincharya).

A. Mode of action: Regular irrigation of nasal passage with warm saline water: 

1. Cleans the nasal passage.
2. It reduces nasal congestion and pacifies Vata dosha [More M et al, 2021].
3. Increases muco-ciliary clearance [Talbot AR, 1997], [Homer JJ et al 2000], [Ural A, 2008], [Robinson M et al, 1997].

B. Frequency: Daily in the morning.

C. Benefits:

1. Rhino sinusitis [Robago D et al, 2002].
2. Nasal polyps.
   
3. Allergic conditions [Meera S et al, 2018].
4. Improvement in vision [Meera S et al, 2018].
5. Improvement in presence of mind and intelligence [Meera S et al, 2018].
6. Mitigation of post irradiation rhinosinusitis in nasopharyngeal carcinoma [Meera S et al, 2018].

D. Requirements:

1. Warm saline water (Osmotic pressure of salt water is higher than regular water. This will ensure that water does not get absorbed by the nasal mucous membrane. If plain warm water is used, it's absorption would result in slight sensation of pain).
2. Neti pot (irrigation pot, 150-200 ml capacity).

E. Steps:

Preceding steps:

1. Netra prakshalan (Eye cleansing) using water soaked (overnight) with Tripahala herbs.
2. Danta dhavan (Using herbal powder to cleanse the mouth and massage the gums).

Process:

1. Sit in Kaga asana. Maintain comfortable distance between feet.
2. Bend the lower back forward.
3. Verify the active nostril (determined by the ability to breath freely). 
4. Tilt the head to the side opposite to the active nostril. 
5. Insert the neti pot (filled with warm saline water) nozzle into the active nostril. 
• Ensure that there is no gap between the nostril and the nozzle of neti pot. 
• Do not press/push the nozzle against the active nostril.
6. Let the body relax.
7. Breath through slightly open mouth. 
8. Let the water enter through the active nostril and exit through the other nostril.
9. Clear the nose (Bhastrika pranayama) (moderately to avoid harm to the ears) This will remove the excess water from both the nostrils. 
10. Repeat steps 5-8 by shifting the neti pot nozzle into opposite nostril.

Next steps:

1. Gandusha (Oil pulling)

2. Kaval (Oral gargle) 

F. Note:

a. HC Shashikiran et al [2018] suggested the use of disposable Normal saline (NS) (isotonic) bottle for Jala neti (warmed in water bath, pierced using sterile needle). A small survey among 10 participants  compared conventional and this alternative method of Jala neti. Following benefits of using NS bottles were noted:

1. Convenient to use, easily available, portable, disposable.

2. Pre-sterilized hence minimal chances of contamination or cross-infection.

3. Fixed proportion of salt (isotonic).

4. Measured amount of water.

b. In the initial stages, water might return from same nostril or some salt water might be felt in the throat. Neti might also trigger nasal or throat irritation. Usually correcting the posture and breathing resolves the issue. 

G. Disclaimer:

Please consult your physician before implementing these suggestions to confirm their appropriateness for your case.

H. Appendix:

1. Samudra lavana (Sea salt)

• Rasa: Lavana, Madhura
• Lavana guna: Vishyandi (liquefy Kapha), Sukshma (permeate minute channels), Mridu (soft), Tikshna (sharp)
• Virya: Ushna (hot potency)
• Dosha: Vata shamaka (pacifies vata)
• Karma: Rochana (improves taste), Pachana (digestive)

2. Research findings related to Jala neti and:

1. Rhino-sinusitis [Robago D et al, 2002]:
1. Design: Randomized control trial (n=76 subjects with frequent sinusitis, 69 subjects completed the study)
1. Group1: Experimental (n=52)
2. Group2: Control (n=24)
3. Data collection: baseline, 1.5, 3, and 6 months.
4. Intervention: "Subjects in the experimental group were asked to irrigate the nose (150 mL through each nostril) daily for 6 months with the SinuCleanse nasal cup containing 2.0% saline buffered with baking soda (1 heaping teaspoon of canning salt, one half teaspoon of baking soda, and 1 pint of tap water. Solution was mixed fresh every 1 to 2 days."
2. Outcomes: 
1. Baseline: No significant differences between two groups
2. Compliance: 87%
3. Medical Outcomes Survey Short Form (SF-12), 
4. Rhinosinusitis Disability Index (RSDI)
5. Single-Item SinusSymptom Severity Assessment (SIA)
3. Results: "In our study, RSDI scores among treated subjects averaged 6.0 and 15.5 points better than controls at 3 and 6 months, respectively. On the SIA, treated subjects averaged 0.6, 0.9, and 1.6 points better. Extrapolating from these findings, these differences appear to be clinically significant."
4. Conclusion: Improvement in sinus-related quality of life, decrease in symptoms, and decreased medication.  

3. Muco-ciliary clearance

1. "Buffered hypertonic saline nasal irrigation improved mucociliary transit times of saccharin, while buffered normal saline had no such effect" [Talbot AR, 1997].
2. A randomised double-blind crossover trial in 38 normal subjects concluded that "Hypertonic saline solutions improve mucociliary clearance, although this was only observed with solutions of 5% tonicity" [Homer JJ et al 2000].
3. A clinical study among 132 adults (Control: 45; Allergic rhinitis: 21, Acute sinusitis: 24, Chronic sinusitis: 42) measured mucociliary clearance time using the saccharine clearance test on, before and after 10 days' application of intranasal isotonic or hypertonic saline. "Irrigation with hypertonic saline restored impaired mucociliary clearance in chronic sinusitis patients, while isotonic saline improved mucociliary clearance times significantly in allergic rhinitis and acute sinusitis patients" [Ural A, 2008] 
4. Inhalation of hypertonic saline enhanced mucociliary clearance in patients [Ten patients (seven men) of mean (SE) age 22] with cystic fibrosis. This improvement was found to be dose dependent and with all the concentrations of hypertonic saline (HS) examined in the study [Robinson M et al, 1997].

4. Sinusitis, rhino-sinusitis, allergic conditions, improving vision, presence of mind and intelligence, mitigating post irradiation rhinosinusitis in nasopharyngeal carcinoma. 

1. A recent review attempted to collate and review articles that highlighted the therapeutic effects of neti kriya (with special reference to Jala Neti). Since few articles related to jala neti, neti kriya, were identified, they expanded their search to include articles related to saline nasal irrigation. "Most studies included in the review supported the role of Neti in treating sinusitis, rhino-sinusitis, allergic conditions and in improving vision. It also has a significant role in improving the presence of mind and intelligence. Neti can be applied in mitigating post irradiation rhinosinusitis in nasopharyngeal carcinoma" [Meera S et al, 2018].

J. References:

1. More Manjusha, Bhere Harshala, Rasal Prachi. Comparative Clinical Study of Nasya and Jala Neti in Allergic Rhinitis. Ayushdhara [Internet]. 2021Aug.1 [cited 2024Nov.24];8(3):3301-8. Available from: https://ayushdhara.in/index.php/ayushdhara/article/view/745
2. Talbot AR, Herr TM, Parsons DS. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997; 107:500–3.
3. Homer JJ, Dowley AC, Condon L, El-Jassar P, Sood S. The effect of hypertonicity on nasal mucociliary clearance. Clin Otolaryngol Allied Sci. 2000 Dec;25(6):558-60. doi: 10.1046/j.1365-2273.2000.00420.x. PMID: 11122299.
4. Ural A, Oktemer TK, Kizil Y, Ileri F, Uslu S. Impact of isotonic and hypertonic saline solutions on mucociliary activity in various nasal pathologies: clinical study. J Laryngol Otol. 2009 May;123(5):517-21. doi: 10.1017/S0022215108003964. Epub 2008 Oct 28. PMID: 18957157.
5. Ural A, Oktemer TK, Kizil Y, Ileri F, Uslu S. Impact of isotonic and hypertonic saline solutions on mucociliary activity in various nasal pathologies: clinical study. J Laryngol Otol. 2009 May;123(5):517-21. doi: 10.1017/S0022215108003964. Epub 2008 Oct 28. PMID: 18957157.
6. Robinson M, Hemming AL, Regnis JA, Wong AG, Bailey DL, Bautovich GJ, King M, Bye PT. Effect of increasing doses of hypertonic saline on mucociliary clearance in patients with cystic fibrosis. Thorax. 1997 Oct;52(10):900-3. doi: 10.1136/thx.52.10.900. PMID: 9404379; PMCID: PMC1758438.
7. Meera S, Vandana Rani M, Sreedhar C, Robin DT. A review on the therapeutic effects of NetiKriya with special reference to JalaNeti. J Ayurveda Integr Med. 2020 Apr-Jun;11(2):185-189. doi: 10.1016/j.jaim.2018.06.006. Epub 2019 Jan 5. PMID: 30616871; PMCID: PMC7329727.
8. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract. 2002 Dec;51(12):1049-55. PMID: 12540331.
9. HC Shashikiran, P Shetty, S Shetty, Effect of saline nasal irrigation (Jala Neti) versus Pranayama (Suryabhedana and Anuloma-viloma) in chronic rhino sinusitis–a comparative study, Int J Innov Res Adv Stud, 2018.