Dietary factors are often suggested to contribute to excess mucus production. Dairy, wheat and corn have been proposed to promote a more globular mucus, disable sinus drainage and promote antigen exposure.¹⁰ While certain individuals may be predisposed to inflammatory responses with certain foods, the concept that some foods are universally mucus-promoting is an oversimplification of the process.¹¹ In people who believe this, however, the consumption of such products does dispose them to greater subjective respiratory symptoms,¹¹ demonstrating a potential psychosomatic component. (For risk factors for lower respiratory tract (LRT) congestion, see Chapter 6 on respiratory infections and immune insufficiency and Chapter 7 on asthma.)

CONVENTIONAL TREATMENT

The predominant conventional treatment of sinusitis centres on antibiotics to control infection and corticosteroids to reduce acute inflammation.^10,¹² Adjunctive treatments include topical and oral decongestants and antihistamines to reduce mucosal blood flow, decrease tissue oedema and perhaps enhance drainage of secretions from the sinus ostia.^10,¹² In chronic or unresponsive cases, nasal endoscopic surgery may assist in clearance of the sinuses, and restoration of mucociliary activity.¹³

While antibiotics are frequently prescribed, a Cochrane review of 49 studies concluded that they produced insignificant cure rates, with only a small treatment effect on patients in a primary care setting.¹⁴ (For conventional treatment of LRT congestion, see Chapter 6 on respiratory infections and immune insufficiency and Chapter 7 on asthma.)

KEY TREATMENT PROTOCOLS

As congestive respiratory disorders differ significantly from one another (for example, COAD and allergic rhinitis), general treatment protocols will require adaptation to suit the individual presentation. However, for all of these conditions, an overwhelming priority will be the reduction of congestion and easing of airway blockage with the use of mucolytic and anticatarrhal herbs and nutrients. Obstruction may also be eased by reducing inflammation and, in LRT disorders, enhancing bronchodilation. If there is a cough, this may be relieved and/or used to assist airway clearance.

NATUROPATHIC TREATMENT AIMS

• Reduce congestion (clear the paranasal sinuses or bronchioles).

• Reduce bacterial colonisation.

• Support immune response.

• Support the integrity of the mucous membranes.

• If chronic, support elimination via the lymphatic system.

• Use tonifying protocols after acute infection is cleared.

Acute immune support and reduction of pathogens will also be necessary in the acute infection. If congestion is chronic or repeated, then longer-term immune tonics and adaptogens should be used in order to strengthen the resistance of the individual. In forms of congestion linked to atopy, antiallergic substances and those which modulate hypersensitivity can be useful.

Often in chronic conditions, there are underlying factors to be addressed. Digestive disturbance or general lymphatic stagnation may play a role in exacerbating and/or perpetuating the complaint.

Whenever there is an overproduction of catarrh, the respiratory mucous membranes will be stressed and compromised. Trophorestoratives and nutritive support are essential to nourish these back to health. Their strength is vital as they are one of the few body surfaces exposed continually to the external environment, and play a large role in first-line innate immune defence.

Reduce congestion in the sinuses and airways

Blocked sinuses: steam inhalations, heat therapy and nasal irrigation

With chronic sinusitis it is important to liquefy the congested secretions in an effort to clear the sinus passages. Herbal mucolytics act to thin out mucosal secretions and make them easier to expel.¹⁵ Trigonella foenum-graecum¹⁶ is particularly useful, especially as a hot infusion, with the heat and steam being an integral part of the process. It is important to warn your patient that they should expect a nasal discharge to result, so they can plan the best time for the intervention. If they know, they are also less likely to take antihistamines, which would suppress the desired effect. Other mucolytic herbs to consider are Foeniculum vulgare, Allium cepa, Armoracia rusticana and Allium sativum.^17,¹⁸

An additional category of herbs applied in the case of sinus congestion are upper respiratory tract anticatarrhals, such as Euphrasia spp., Plantago lanceolata, Sambucus nigra and Hydrastis canadensis.¹⁸ Anticatarrhals differ from mucolytics in that their action involves the reduction of mucus production, rather than simply breaking it down to expel.¹⁹ Few well-designed clinical trials were found to substantiate the effectiveness of these interventions, but they have a history of traditional use.^18,²⁰ H. canadensis is traditionally contraindicated in acute inflammatory conditions of the mucous membranes but may be used in subacute or chronic conditions.¹⁸ A combination of Gentiana lutea, Primula veris, Rumex spp., Sambucus nigra and Verbena officinalis is approved by Commission E to treat sinusitis and seems to exert mucolytic or anticatarrhal, antiviral and anti-inflammatory effects in a number of trials.^21,²²

Nutritional mucolytics may also be very useful when included in a supplement regimen. N-acetylcysteine (NAC) is perhaps the most researched and broadly used mucolytic.^23,²⁴ The sulfhydryl group works to cleave disulphide bonds in mucous glycoproteins, making nasal secretions easier to expel.²⁵ NAC has demonstrated the ability to increase the mucociliary clearance rate by 35%, in comparison to no effect by placebo.²⁶

Proteolytic enzymes, including bromelain, may also be useful. Proteolytic enzymes show an ability to break down the naked peptide region of mucous glycoproteins when applied topically.²⁵ There have been questions surrounding the bioavailability of these agents upon oral ingestion, but studies show that ingestion of the compounds leads to appreciable increases in their serum concentration.^28,^29,³⁰ In a number of trials

POSSIBLE FENUGREEK ALLERGY

One study has found that fenugreek seed powder may contain a number of potential allergenic proteins. In most cases, this reactivity seems to be due to cross-reactivity with peanut sensitisation.^19,² While true fenugreek allergy is unlikely to be a concern, practitioners should be aware of the potential for cross-reactivity when using this mucolytic agent in patients with peanut allergies.

conducted on patients with chronic sinusitis or allergic rhinitis, the administration of bromelain (in addition to individualised conventional treatment) produced significant improvements in parameters including nasal mucosal inflammation, overall symptoms, breathing difficulties and nasal discomfort.³⁰^–³²

One of the longer-standing traditional remedies for blocked sinuses and nasal congestion has been the inhalation of steam. Often this is with an additive (see below). Studies are mixed on the use of hot, moist air alone, with some positive trials ^33,³⁴ and others showing no effect greater than room-temperature air.^35,³⁶

The ‘old wives’ tale’ cure of chicken soup may not be such a myth. The inhalation of hot air (from hot water) is known to help clear nasal congestion,^35,³⁶ but research has shown that hot chicken soup is more effective than hot water.³⁷ The addition of aromatic spices and culinary herbs will also help to open up the nasal passages and clear secretions.³⁸ As an additional benefit, the liquid component inhibits neutrophil migration, possibly helping reduce symptoms in infection.³⁸

The use of botanicals may improve therapeutic effectiveness of steam inhalation. For example Commission E supports the use of inhalation of Matricaria recutita for inflammation and irritation of the respiratory tract.²¹ The essential oils of Cinnamomum zeylanicum, Thymus vulgaris, Mentha piperita, Perilla frutescens, Cymbopogon spp. and Eucalyptus spp. have demonstrated antibacterial activity against common respiratory pathogens through vapour contact, and thus may also be of use.³⁹^–⁴¹ One of the most common inhalants is eucalyptus oil; when administered via inhalation or as a chest rub, it has demonstrated ability to reduce nasal congestion and improve breathing function in those with respiratory infection.^40,⁴² A German product combining cineol, limonene and alpha-pinene also has great efficacy in treating purulent mucosinusitis.⁴³ These are constituents of many essential oils including Mentha piperita, citrus oils, Anethum graveolens, Pinus spp., Piper nigrum, Eucalyptus spp. and Melaleuca cajuputi.⁴⁴ Other common inhalations include Mentha piperita, Lavandula spp., Pinus sylvestris, Melaleuca alternifolia and Rosmarinus officinalis.⁴⁵ As an extension of this principle, local application of heat more generally has also been shown to alleviate the symptoms of allergic rhinitis.^46,⁴⁷

Nasal irrigation is another natural method of clearing sinus congestion. The origins of this technique lie in yogic and homoeopathic traditions.^48,⁴⁹ Jala neti is a Hatha yoga technique of pouring water in through one nostril using a neti pot so that it pours out the other. The method is believed to be an essential part of health maintenance, and is recommended three or four times a week.^50,⁵¹ There are a number of positive trials of nasal irrigation among people with allergic rhinitis or chronic sinusitis.⁵² A Cochrane review in 2007 reported that nasal irrigation could improve the symptoms of chronic rhinosinusitis in the majority of patients, with few adverse effects.⁴⁹ Benefits are derived not solely from the initial mechanical clearance of the airways, but also due to the physiological benefits of topical saline (sodium chloride), which has been proposed to improve mucus clearance, enhance ciliary beat activity, remove antigens, biofilm or inflammatory mediators, and to be protective of the mucous membranes.⁴⁹ Sodium bicarbonate is also mucolytic in nature and may therefore be useful in nasal irrigation.⁵³

One method of nasal irrigation is suggested in Figure 8.1, but there are many slight variations, and it is recommended that the practitioner become comfortable with their chosen technique themselves first before recommending it to others. It should also be noted that bulb syringe irrigators have been found to be a potential source of contamination in rhinosinusitis,⁵⁴ so attempts should be made to ensure the cleanliness of the equipment and procedure.

Figure 8.1 Nasal irrigation

Phlegm and cough

With regards to mucus congestion and cough, a number of different treatment strategies may be used. Dry (non-productive) or particularly severe coughs can benefit from suppression with an antitussive agent. Otherwise, although it may be annoying, it is best not to suppress the productive cough reflex, as it helps to clear infectious organisms from the airways.⁵⁵

Expectorants may enhance a productive cough, allowing greater clearance of abnormal and thick phlegm and mucus. This will assist the removal of pathogens, speeding recovery and decreasing the fatiguing effort required to cough. The majority of expectorants fall into one of two categories:

1. stimulating expectorants, which provoke cough by reflex irritation of the upper digestive tract membranes ⁵⁶

2. warming expectorants, which increase blood flow to the respiratory mucosa, provide reflex stimulation of the upper digestive lining and alter the mucopolysaccharides constituents of mucus, making it runnier and easier to expel.⁵⁷

Mucolytics and anticatarrhals may also be of use where there is a great deal of phlegm, mucus and/or congestion present. These agents will help to reduce catarrhal congestion of the upper or lower respiratory system. As with mucolytic pharmaceuticals, their mechanism of action is not fully understood, but they may act by altering the mucopolysaccharide structure of mucus, decreasing its elasticity or viscosity.²⁴

Herbal medicines with demulcent action may help to reduce a cough if it is a reflex response to hyperactive or irritated receptors in the oropharynx.⁵⁵ Treatments used in Western herbal traditions for productive cough include Thymus vulgaris, Glycyrrhiza glabra, Lobelia inflata and Polygala senega.²¹ Additionally, Verbascum thapsus, Tussilago farfara and Althaea officinalis are marked demulcents and antitussives indicated for dry or unproductive coughs.²¹ Some herbs, such as Prunus serotina, are primary antitussives; however, caution needs to be applied when prescribing these as they can suppress a cough despite there being mucus to expectorate. This may potentially exacerbate an acute respiratory infection.

Glycyrrhiza glabra is approved by Commission E to treat upper respiratory catarrh and cough.²¹ In addition to its expectorant and antitussive actions, G. glabra has anti-inflammatory, immune-enhancing and mucoprotective effects, the traditional reason behind its use in respiratory tract infections. The herb has demonstrated antitussive effects in animal studies, most likely due to the component liquiritin and its metabolite, liquiritigenin.⁵⁸ Thymus vulgaris has been used successfully in a large trial for the treatment of bronchial cough.⁵⁹ It demonstrates an ability to improve mucociliary clearance in vivo, although the mechanism remains to be elucidated.⁶⁰ In conjunction with the herbs Sambucus nigra, Primula veris, Rumex acetosa, Verbena officinalis and T.vulgaris Gentiana lutea, the extract demonstrated ability to reduce the frequency of symptomatic coughing fits.^61,⁶² It is also traditionally recommended for use in respiratory tract infections as an extract or gargle due to its antimicrobial and antitussive qualities.^21,^57,⁶³

In the case of productive cough, Inula helenium is another key herb to use, due to its combined effects as a stimulating expectorant and antibacterial agent.⁶⁴ Given that it contains a high level of mucilage, it also contributes to soothing the mucous membranes, thus covering a wide range of the required therapeutic actions. It is also a respiratory spasmolytic that is well tolerated in long-term therapy.⁵⁹ Traditional eclectic texts purport Althaea officinalis to be useful in the case of catarrh or irritated mucous membranes.^17,⁶⁵ The polysaccharide constituent has demonstrated inhibition of coughs caused by laryngopharangeal and tracheobronchial irritation.⁶⁶ New research indicates a relatively pronounced antibacterial effect (stronger than that of Thymus vulgaris) on various strains of E. coli, exerted via inhibition of microbial metabolism.⁶⁷ Althaea officinalis is more indicated for an irritating than a congestive cough.²¹

Adhatoda vasica is mentioned in the Vedas for treatment of a number of respiratory illnesses, and is also listed in the Pharmacopoeia of India.⁶⁸ Extracts of the aerial parts administered orally exhibit the ability to inhibit both mechanical and chemically induced coughs.⁶⁸ When this treatment was combined with Echinacea spp. and Eleutherococcus senticosus extracts in clinical trials, it produced additive benefits in treating URTI.⁶⁹ Patients showed greater improvement in many of the parameters tested, including severity of coughing, frequency of coughing, efficacy of mucus discharge in the respiratory tract, nasal congestion and general feeling of sickness.⁶⁹

Inhaled preparations containing menthol, such as eucalyptus oil, have shown the ability to significantly increase tracheobronchial clearance of mucus from the lungs ⁷⁰ and help to reduce cough.⁷¹

As discussed above, nutritional mucolytic agents such as N-acetylcysteine and proteolytic enzymes may be useful in LRT congestion. Dietary treatment should also be employed. Allium spp. is an antimicrobial, expectorant, mucolytic and anti-inflammatory agent.⁵⁷ The respiratory system is one of the main systems to benefit from the antimicrobial action of its volatile oil, as it is excreted from the lungs. Culinary herbs such as Pimpinella

CHRONIC OBSTRUCTIVE AIRWAYS DISEASE

Overview

Chronic obstructive airways disease (COAD) or chronic obstructive pulmonary disease (COPD) includes emphysema and chronic bronchitis. Unlike asthma, the airflow obstruction is only partially reversible, and the disease process is progressive and irreversible.⁷² Airflow obstruction is usually associated with abnormal inflammation of the airways, parenchyma and pulmonary vasculature in response to chronic inhalation of noxious particles or gases.^5,^72,⁷³

COAD is diagnosed when a patient has spirometry readings of:

• FEV₁/FVC ^∗ of less than or equal to 70%

• FEV₁ of less than or equal to 80% after administration of a bronchodilator ⁷² and symptoms that may include cough, dyspnoea, wheezing and sputum or mucus production.⁴

The major risk factors include:^72,⁷⁴

• smoking (this is the major environmental factor)

• heavy exposure to occupational dusts and chemicals (vapours, irritants and fumes)

• indoor/outdoor air pollution

• genetic factors

• repeated/severe respiratory infections.

CAM interventions

Mucolytics and anticatarrhals: Trigonella foenum-graecum, Plantago lanceolata, Hydrastis canadensis, Foeniculum vulgare, Allium cepa, Armoracia rusticana, Allium sativum, N-acetylcysteine, ^80,^23,⁸¹ bromelain, trypsin, papain and aromatic inhalants.⁸²

Anti-inflammatory: Boswellia serrata, Curcuma longa, Zingiber officinale, omega-3 fatty acids, quercetin, fish, antioxidant foods (fruit and vegetables) ⁸³^–⁸⁵ ²⁷ and possibly antioxidant nutrients,^7,^86,⁸⁷ Camellia sinensis.⁸⁵

Bronchodilating: Adhatoda vasica, Euphorbia spp., Coleus forskohlii, Grindelia camporum, Glycyrrhiza glabra, magnesium⁸⁸ (dietary and supplemental).

Acute immune enhancement (in the case of infection): vitamin C, vitamin A, zinc, quercetin, Echinacea spp., Andrographis paniculata, Picorrhiza kurroa, Uncaria tomentosa

Immune tonics (during chronic stages where there is no acute infection): Astragalus membranaceus, Eleutherococcus senticosus, Withania somnifera and Echinacea spp. may be used throughout both periods of remission and exacerbation.

Mucous membrane trophorestoratives: Hydrastis canadensis, vitamins A and C, zinc, selenium, adequate protein intake.⁸⁹

^∗ ^∗FEV₁ = forced expiratory volume, FVC = forced expiratory vital capacity

anisum, Foeniculum vulgare, Trigonella foenum-graecum and Zingiber officinale are warming expectorants and can be incorporated into treatment, either in food or as hot beverages.⁵⁷

Reduce microbial colonisation

Herbal antimicrobials (encompassing antivirals, antibacterials and antifungals) differ from some pharmaceutical products in that they usually exert a biocidal or bacteriostatic effect on the pathogen rather than being directly cytotoxic. Biocidal agents act via a number of mechanisms, at a number of different target sites in the cell. The combined overall activity seems to result in the bactericidal death of the microbe.⁹⁰ According to Maillard, when used at lower doses, biocides exert a bacteriostatic effect, inhibiting the growth and colonisation of a pathogen.⁹⁰ Although more research is needed in the area, it seems that herbal agents (given at the right doses) exert a bacteriostatic, rather than a cytotoxic or even biocidal, effect.

While there are many individual constituents which have been identified as antimicrobial, whole plant extracts remedies seem to be more efficacious at clearing pathogens due to synergism between components.⁹¹ For further information on plant compounds and their antimicrobial efficacy, see Table 8.1.

Table 8.1 Plant constituents and their antimicrobial effects

In the case of respiratory infections, antimicrobials are useful to address the primary infection, inhibiting further replication of the causative organism and additionally to prevent secondary infection. However, they are unlikely to ‘cure’ an infection when used alone. Rather, they are most effective when combined with other botanicals, such as those with immune-modulating activity.

Antimicrobial herbs traditionally recommended for the respiratory system are Allium sativum, Inula helenium, Hydrastis canadensis and Thymus vulgaris. The essential oil of Thymus vulgaris exhibits some of the most pronounced antimicrobial effects of herbs that have been scientifically evaluated. It contains a multitude of compounds with activity against microorganisms, including thymol, carvacrol, luteolin and linalool.^91,⁹² The combined effect of these is more potent than the individual constituents alone, illustrating the importance of using whole plant extracts for the most rapid antimicrobial effects.⁹¹ When tested against a number of the most common bacterial respiratory pathogens, T. vulgaris oil exhibited marked inhibitory effects on bacterial cell growth.⁹³ The two other oils with marked significant action against these pathogens were Cinnamomum zeylanicum and Syzygium aromaticum.⁹³ It is interesting to note that these effects were just as strong in antibiotic multi-resistant strains of bacteria, suggesting a role for increasing use of botanical agents in clearing respiratory infection.⁹³ When combined with either primrose herb or ivy leaf extract, T. vulgaris shows marked efficacy in treating the symptoms and shortening the duration of acute bronchitis, an effect which is likely to be due in part to its antimicrobial action.^62,^63,⁹⁴

Inula helenium also exhibits antimicrobial activity in vitro, but clinical trials of the herb are sorely lacking.⁶⁵ Among its constituents, I. helenium contains thymol derivatives, and thus, at least in theory, some of the results of research with thyme oil may be extrapolated.⁹⁵ Among the most potent antivirals in the herbal repertory are Hypericum perforatum and Thuja occidentalis. The hypericin component of H. perforatum is especially active against enveloped viruses, such as HIV and herpes simplex while T. occidentalis has a broader spectrum of viricidal targets.⁹⁶ When T. occidentalis is given in combination with Baptisiae tinctoriae radix, E. purpureae radix and E. pallidae radix, the mixture exhibits ability to inhibit Influenza A virus pathology in animals.⁹⁷ One widely available antimicrobial is Allium sativum.⁹⁸ It has demonstrated activity against a number of bacteria, fungi and viruses implicated in respiratory infection, with some of its most potent constituents being allicin and allitridin.⁹⁹^–¹⁰² In a recent trial, intranasal garlic powder was shown to decrease the likelihood of contracting an airborne infection while travelling.¹⁰³

Increasing food intake of shallots (Allium ascalonicum), garlic and onions (Allium cepa) will also provide the active organosulfur compounds and exert an antimicrobial effect, and be beneficial in treating respiratory infection.^98,^104,¹⁰⁵ These foods will be at their most potent fresh or as close to fresh as possible.¹⁰⁵ Other nutrients and foods that exhibit bacteriostatic qualities are zinc and unripe papaya.^106,¹⁰⁷

If considering a topical throat spray or gargle, suspended nanoparticles of zinc and silver colloidal may be useful, as they demonstrate antimicrobial (bacteriostatic and bactericidal) efficacy against a range of organisms including Enterococcus faecalis, Staphylococcus spp., Streptococcus pyogenes, Pseudomonas aeruginosa and Escherichia coli.^107,¹⁰⁸

Support immune response

In congestive respiratory disorders, it is important to identify the cause, as this will affect what type of immune modulation is necessary. In cases of infection or an altered immune response the practitioner should boost general immunity and, if allergies are present or contributing, then give antiallergic agents. In asthma, immune modulation of T-cell ratios may be necessary. Chronic diseases will very likely benefit from immune tonics.

Pelargonium sidoides has been found to be significantly superior to placebo in the treatment of acute rhinosinusitis ¹³¹ with decreased debilitating symptoms and faster recovery. The activity of this herb is likely to be due to moderate antimicrobial activity and marked immune modulating activity, including an ability to alter the release of tumour-necrosis factor (TNF-α) and nitric oxide.¹³²

Vitamin C has proven efficacious in the treatment of chronic sinusitis and allergic rhinitis. As a nutrient, it enhances both innate and adaptive components of the immune system, including natural killer cells, T-cells and B-cells.¹³³ It is also antiallergic, in that it stabilises mast cells and inhibits histamine release.¹³⁴ Levels of ascorbic acid, vitamin E, copper and zinc were found to be lower in children with chronic rhinosinusitis than in controls without the condition.¹³⁵ Treatment of allergic rhinitis with an ascorbic acid solution intranasally three times daily has been shown to reduce symptoms in up to 74% of treated subjects. They experienced a decrease in nasal secretions, blockage and oedema.¹³⁶

Allergic concerns may also be treated with Urtica dioica, which may inhibit inflammation, ironically, through its histamine content, which inhibits leukotriene formation.¹³⁷ The herb has demonstrated success in treating allergic rhinitis, with all treated patients in a randomised controlled trial (RCT) reporting improved global assessments.¹³⁸ Other antiallergic agents include quercetin and the herbs Albizzia lebbeck and Scutellaria baicalensis. (Refer to Chapter 6 on respiratory infections and immune insufficiency and Chapter 7 on asthma for review of the evidence.)

Support the integrity of the mucous membranes

Continual goblet cell activation and mucus production may compromise the mucosal linings of the airways. This necessitates support of the mucous membranes themselves through herbal mucous membrane trophorestoratives and nutritionally with collagen supportive nutrients. Hydrastis canadensis and Euphrasia spp. are traditionally indicated for the support of mucosal surfaces in the body, especially in the upper respiratory tract.^18,⁶⁴ At present, no pharmacological research or clinical trials have been found to substantiate these effects.

Nutrients that are important in the healing of wounds and help to support the integrity of collagen, epithelium and mucous membranes are vitamins A and C, lysine, proline and zinc. In addition to its antioxidant role, vitamin C is required for the conversion of proline and lysine to hydroxyproline and hydroxylysine so that they may be incorporated into collagen structures.¹¹³ Zinc is a cofactor for RNA and DNA polymerase, meaning that it is essential for DNA replication, repair and cell proliferation.¹³⁹ It also stimulates reepithelialisation, fibroblast proliferation and is involved with collagen synthesis,^139,¹⁴⁰ and thus is essential for the correct structure of the airways. Copper is also essential for collagen and elastin cross-linking.¹³⁹

Vitamin A is essential for the strength and health of the mucous membranes and epithelial integrity.^141,¹⁴² It assists ‘normal endodermal differentiation as well as maintaining balanced cell proliferation, differentiation and apoptosis’.¹⁴³ Studies have repeatedly demonstrated the beneficial effects of vitamin A supplementation on gastrointestinal mucosa,¹⁴⁴ and the benefits may be extrapolated to also apply to the respiratory mucosa.

Support elimination via the lymphatic system

The idea of lymphatic cleansing is a traditional naturopathic approach to many chronic congestive conditions, including respiratory, musculoskeletal and skin disorders. The beneficial herbal actions are lymphatic and alterative, and herbs such as Phytolacca decandra, Echinacea spp., Urtica spp., Galium aparine and Calendula officinalis are viable options.²⁰

INTEGRATIVE MEDICAL CONSIDERATIONS

Yoga

Participation in yoga programs may be of benefit in congestive disorders. After participating in a specially adapted program, elderly COAD sufferers were able to tolerate more activity without dyspnoea-related distress and improved functional performance.¹⁴⁵ One session of yogic breathing techniques alone may produce favourable respiratory changes in sufferers.¹⁴⁶

Acupuncture

A review ¹⁴⁷ examined seven high-quality RCTs and concluded that there was sufficient evidence to recommend acupuncture for improving symptoms of perennial rhinitis. Vasomotor rhinitis has also been shown to respond favourably to acupuncture–patients in a recent trial showed significant improvement in nasal sickness score both over baseline and in comparison to controls given sham acupuncture.¹⁴⁸

In COAD, acupuncture may be useful due to its ability to reduce disease-related dyspnoea.^149,¹⁵⁰ Acu-TENS also produces increased FEV and decreased dyspnoea in patients compared to controls, even after a single 45-minute session.¹⁵¹

Reflexology and massage

An early trial into reflexology treatment of COAD shows some moderate improvements, perhaps relating to the increased relaxation felt by patients.¹⁵² In a small trial of five patients treated with twenty 4-weekly treatments of neuromuscular release massage therapy, four of these experienced increases in thoracic gas volume, peak flow and FVC.¹⁵³

Aromatherapy

Aromatherapy is most useful in these conditions when used as an inhaled preparation. Most of the beneficial essential oils have been covered above.

Figure 8.2 Naturopathic treatment decision tree – congestive respiratory disorders

Case Study

A 32-year- old male presents with constant nasal congestion and sinus pressure, which ‘comes and goes’ in severity but has been ongoing for at least 2 years. The pressure and associated facial pain are aggravated by bending over or lying down, with an underlying dull headache. He presents with an acute flare-up with a nasal discharge that is thick and yellow-coloured. The patient has a history of regular prescriptions of antibiotics and use of antihistamines.

SUGGESTIVE SYMPTOMS

• Thick and discoloured mucus (suggesting bacterial colonisation)

• Frontal and maxillary pressure and pain

• Recurrent flare-ups

Example treatment

Naturopathically, the primary aim is to aid the removal of mucous congestion, which acts as a reservoir for infection. The patient will need to agree to, and be fully informed about, this process as there is likely to be a period of increased discomfort while the mucus is liquefied and expelled. A key priority is to help the patient avoid the use of antihistamines, as these may prevent the long-term resolution of the condition by drying up the secretions and maintain or even encourage the pathogenic reservoir.

Immune enhancement and antimicrobial actions are also required. Once the acute infection has eased, long-term management will need to address the underlying causes of immune dysregulation, most likely related to altered colonic microflora and increased GIT permeability.

Herbal and nutritional prescription

Warm Trigonella foenum-graecum infusion taken t.d.s. may be beneficial as a mucolytic and anticatarrhal. Raw honey can be added to assist with taste if needed. This may be made by steeping 10 g of fenugreek seeds in boiling water for 5 minutes, or adding 5 mL of the herbal extract to boiling water. This remedy will liquefy mucosal secretions and clear the nasal passages, removing the reservoir for chronic infection.

Echinacea root blend (60/40) was chosen for its immune modulating properties, which assist in modulating a potentially over-responsive immune system.

Being astringent, anticatarrhal, anti-inflammatory, and a mucous membrane tonic, Euphrasia officinalis is particularly useful to control the excess production of mucus.

Foeniculum vulgare synergistically enhances the mucolytic action of Trigonella foenum-graecum, clearing congestion and

Herbal formula

Echinacea root blend^∗ 1:2	20 mL
Euphrasia officinalis 1:2	20 mL
Foeniculum vulgare 1:2	15 mL
Pelargonium sidoides 1:5	20 mL
Albizzia lebbeck 1:2	25 mL
	100 mL

5 mL t.d.s. in a little water or juice.

Herbal infusion

Trigonella foenum-graecum as a hot infusion t.d.s.

Nutritional prescription

Tablet formulation containing betacarotene, vitamin D3, papain, pancreatin and Allium sativum

2 tablets t.d.s. during the initial stage of treatment

^∗ E. purpurea 60%; E. angustifolia 40%

removing the microbial reservoir. Additionally, it addresses infection directly, via its antibacterial action.

Pelargonium sidoides has confirmed action in rhinosinusitis, reducing the symptoms and enhancing resolution of the condition. It is antimicrobial and a marked immune modulator.

Albizzia lebbeck is an antiallergic herb to reduce the need for antihistamine medication.

Betacarotene, a vitamin A precursor and antioxidant, helps repair damaged cells of the mucous membranes. It also reduces membrane sensitivity to various irritants.

Papain and pancreatin digest mucus accumulations, break up immune complexes and provide anti-inflammatory activity. Combined with the mucolytic garlic, this combination is effective at breaking down sinus congestion.

Lifestyle and dietary advice

The patient should be advised to maintain or increase fluid intake to assist with hydration of the mucous membranes. In the case of any acute infection, it is important to rest and avoid excess stress in order to enhance the body’s healing capacity. Onions and garlic and shallots can be emphasised in the diet, as they have strong antimicrobial activity. Garlic in particular needs to be used raw, and, if used in cooking, heated for less than 5 minutes where possible. Shallots, however, appear to retain their antimicrobial activity after significant heating for long periods. Chicken soup has also demonstrated mucolytic and antimicrobial properties, and is an easy way to encourage increased fluid intake.

Any allergenic foods should be avoided. Some practitioners may wish to advise the avoidance of foods that are commonly considered ‘mucus causing’ or inflammatory (for example, wheat, dairy products and sugar). The regular use of nasal irrigation techniques with clean equipment may assist in clearing chronic infection, and preventing further acute exacerbations of sinusitis. It is important to educate the patient on the effects of the medication they may use for the condition. Antibiotic overuse may lead to gastrointestinal dysbiosis and contribute to antibiotic-resistant pathogens, while antihistamines may suppress symptoms and contribute to chronicity of a condition. Regardless, there is a time and place for these medications, and the patient should be advised to weigh up the facts in each situation and make their own decision.

Expected outcomes and follow-up protocols

In the above case, the acute infection is expected to be addressed within the week of treatment. If the patient’s infection worsens, then referral for antibiotic treatment may be advised (although it is desirable to avoid this). In this case, the process of treatment and prevention can start after the infection has been removed. After the acute infection is addressed, the treatment process may take months for him to be ‘sinusitis-free’. It will take time for the inflammatory process to desist, and for the nasomaxillary mucosa and architectural structures to repair. Due to this the patient must be advised to endure the process, as flare-ups may occur even after months of treatment.

The use of mucous membrane trophorestoratives (for example, Hydrastis canadensis) and tonics (for example, Astragalus membranaceus and Eleuthrococcus senticosus) may be of assistance in preventing a flare-up after the acute infection has abated.⁵⁸ Signposts of recovery include reduction of the severity and the frequency of the sinusitis. Over time sinus pain and tenderness should decline and the infectious flare-ups should abate.

Table 8.2 Review of the major evidence

INTERVENTION	KEY LITERATURE	SUMMARY OF RESULTS
N-acetylcysteine (NAC)	In vitro Sheffner et al. 1964 ¹⁵⁴ Rhee et al. 1999 ⁵³	In vitro, decreases the viscosity and elasticity of mucopurulent nasal mucus and tracheobronchial secretions.^154,⁵³
	Meta-analyses and reviews Grandjean et al. 2000 ²³ Stey et al. 2000 ⁸² Sadowska et al. 2007 ¹⁵⁵	• Prolonged NAC administration results in fewer acute exacerbations of bronchopulmonary disease.²³ • Reduces the risk of exacerbations and improves symptoms in patients with chronic bronchitis when given orally for 12–24 weeks.⁸² • At dosages used in COAD treatment, it reduces exacerbation rate and limits the number of hospitalisation days, but has little or no influence on lung function parameters.¹⁵⁵
	Clinical trials Todisco et al. 1985 ²⁶	NAC increases mucociliary clearance in people with slow mucociliary clearance. These people are in a higher risk category for congestive bronchopulmonary disease.²⁶
Thymus vulgaris	In vitro Fabio et al. 2007 ⁹³ Iten et al. 2009 ⁹¹	• Demonstrated antimicrobial activity against a number of common respiratory pathogens.⁹³ • The effects of Thymus vulgaris extract are more potent than isolated constitutents.⁹¹
	Animal studies Wienkötter et al. 2007 ⁶⁰	In animal studies, improves mucociliary clearance by an unknown mechanism.⁶⁰
	Clinical trials Büechi et al. 2005 ¹⁵⁶ Kemmerich 2007 ⁶¹ Kemmerich et al. 2007 ⁶² Marzian 2007 ⁹⁴	Clinical trials have all used the herb as part of a combination formula, whereby it reduces the frequency of symptomatic cough.^61,^62,^94,¹⁵⁶
Proteolytic enzymes	Review Majima 2002 ²⁵	Split the peptide bond of naked mucous glycoprotein when applied topically.²⁵
	Clinical trials Seltzer 1967 ³⁰ Ryan 1967 ³¹ Taub 1967 ³²	Clinical trials are quite old, but demonstrate that bromelain may decrease: • nasal inflammation • breathing difficulties • overall symptoms • nasal discomfort in allergic rhinitis and sinusitis.³⁰^–³²
Nasal irrigation	Review Harvey et al. 2007 ⁴⁹	Nasal lavage with saline, or additional sodium hypochlorite, is well tolerated, with only minor side effects.⁴⁹
	Clinical trials Rabago et al. 2002 ⁵² Rabago et al. 2005 ¹⁵⁷ Rabago et al. 2006 ¹⁵⁸ Raza et al. 2008 ¹⁵⁹	It improves symptoms of: • nasal obstruction • posterior nasal discharge • headache • nasal endoscopic grading of oedema • erythema • purulent discharge • nasal crusts • nasal airway resistance • concomitant allergic rhinitis, asthma or polyposis.^52,¹⁵⁷^–¹⁵⁹
Inhalation of essential oils	Much of the literature in this area is in German or Russian.
	In vitro Cowan 1999 ¹⁰⁹ Inouye et al. 2001 ³⁹ Fabio et al. 2007 ⁹³	Many plant constituents, especially essential oils, show marked antimicrobial activity.^93,^109,³⁹
	Reviews Lim et al. 2008 ¹⁶⁰	Systemic review shows that topical antimicrobial agents appear effective in the treatment of chronic rhinosinusitis.¹⁶⁰
	Clinical trials Federspil et al. 1997 ⁴³ Meister 1999 ⁸² Matthys et al. 2000 ¹⁶¹ Hasani et al. 2003 ⁷⁰	Trials demonstrate: • Improvement of mucociliary clearance from the lungs of patients with chronic bronchitis after inhalation of aromatics.⁷⁰ • Decreased symptoms of mucopurulent sinusitis.⁴³ • More rapid regression of acute bronchitis.¹⁶¹ • Protection against acute exacerbation of chronic bronchitis.⁸²