• Cough with or without the production of mucus (sputum)
• Usually proceeded by upper respiratory tract infection or irritation of the airways
• Pneumonia shows classic signs of lung involvement (shallow breathing, cough, abnormal breath sounds, etc.)
• In pneumonia: X-ray shows infiltration of fluid and lymph in lungs
Bronchitis is inflammation of the mucous membranes of the bronchi, the passages that carry air from the trachea into the lungs. Pneumonia is inflammation of the lungs. Both acute bronchitis and pneumonia are characterized by the development of a cough with or without the production of mucus. Acute bronchitis often occurs during the course of an acute viral illness such as the common cold or influenza. Viruses cause about 90% of cases of acute bronchitis.
Although pneumonia may occur in healthy individuals, it is usually seen in those who are immune-compromised, particularly drug and alcohol abusers, individuals with chronic lung diseases, and those on chemotherapy and other drugs that suppress the immune system. Hospital-acquired pneumonia is also a serious problem and carries with it a high mortality rate. Acute pneumonia is still the seventh-leading cause of death in the United States.1 It is particularly dangerous in the elderly.
In individuals who are not taking drugs to suppress their immune system or who are suffering from diseases associated with impaired immunity, pneumonia most often follows a viral infection (especially influenza) or an insult to the host defense mechanisms: cigarette smoke and other noxious fumes, impairment of consciousness (which depresses the gag reflex, allowing aspiration), cancer, or hospitalization (being hospitalized for any purpose increases the risk of developing pneumonia). Cigarette smoking is the strongest independent risk factor for severe pneumonia.2
Differentiating Between Bronchitis and Pneumonia
Since both acute bronchitis and pneumonia are characterized by a cough, it is sometimes difficult to know which is which. A chest X-ray clears up the diagnosis, but an X-ray should not be done every time someone has a cough. In patients with an acute cough, the following findings suggest the need for a chest X-ray: (1) heart rate greater than 100 beats per minute, (2) respiratory rate greater than 24 breaths per minute, (3) body temperature above 100.4°F (measured orally), and (4) characteristic chest sounds in a chest examination by a physician. Typically when a person has pneumonia there are characteristic chest sounds:
• Rales (a bubbling or crackling sound) heard on one side of the chest or while the patient is lying down
• Rhonchi (abnormal rumblings indicating the presence of thick fluid).
• On percussion, instead of a healthy hollow-drum-like sound, a dull thud that suggests consolidation (a condition in which the lung becomes firm and inelastic) and pleural effusion (fluid buildup in the space between the lungs and the lining around it)
Special Considerations with Pneumonia
The three most common forms of pneumonia are the viral, mycoplasmal, and pneumococcal types.
Viral pneumonia is most often caused by adenovirus, influenza virus, parainfluenza virus, or respiratory syncytial virus. Viral pneumonia is responsible for about 30% of cases of pneumonia and will often develop as a complication of an upper respiratory infection caused by one of the viruses. People who are at risk for more serious viral pneumonia include those with impaired immune function (e.g., cancer patients undergoing chemotherapy, and elderly patients with multiple nutrient deficiencies). Antibiotics are of no value in viral pneumonia.
Clinical Summary for Viral Pneumonia
• People who are at risk for more serious viral pneumonia are often immunocompromised.
• Antibiotics are of no value in viral pneumonia.
• Symptoms of viral pneumonia often begin slowly and may not be severe at first.
• The most common symptoms of viral pneumonia are
Cough (with some pneumonias patients may cough up mucus or even bloody mucus)
Fever, which may be mild or high
Shortness of breath (may occur only upon mild exertion, such as climbing stairs)
Mycoplasmal pneumonia is caused by Mycoplasma pneumoniae. Mycoplasma is a genus of bacteria that lack cell walls. Various studies suggest that M. pneumoniae is responsible for 15 to 50% of all cases of pneumonia in adults and even more than that in school-age children. It is often referred to as “walking pneumonia.” Antibiotics are usually not necessary but may speed recovery. Effective classes of antibiotics that may be effective against M. pneumoniae include macrolides, quinolones, and tetracyclines.
Clinical Summary for Mycoplasmal Pneumonia
• Most commonly occurs in children or young adults.
• Onset is insidious, over several days.
• Nonproductive cough, minimal physical findings, temperature generally less than 102°F.
• Headache and malaise are common early symptoms.
• White blood cell count is normal or slightly elevated.
• X-ray pattern is patchy.
Pneumococcal pneumonia (due to Streptococcus pneumoniae) is the most common bacterial pneumonia and the most common cause of pneumonia requiring hospitalization. Antibiotics are almost always indicated in pneumococcal pneumonia. Unfortunately, antibiotics are becoming less effective, as there has been an increase in resistant strains of bacteria.3–5 In two multinational studies, the worldwide prevalence of penicillin- and macrolide-resistant S. pneumoniae ranged from 18 to 22% and from 24 to 31%, respectively.6,7 This is why it is important to consider natural treatments in cases resistant to antibiotics or as an adjunct to antibiotics.
Clinical Summary for Pneumococcal Pneumonia
• Pneumonia is usually preceded by upper respiratory tract infection.
• There is a sudden onset of shaking, chills, fever, and chest pain.
• Sputum is pinkish or blood-specked at first, then becomes rusty at the height of the infection, and finally becomes yellow and green during resolution.
• A rapid urine test (BinaxNOW) for S. pneumoniae antigens is positive.
• Initially breath sounds are suppressed and fine inspiratory rales are heard.
• Later, classic signs of consolidation appear (deeper rales, dullness).
• X-ray shows lung consolidation.
The natural approach to bronchitis and pneumonia involves three primary goals: (1) stimulation of normal processes that promote the expectoration (removal) of mucus; (2) thinning the mucus to aid expectoration; and (3) enhancement of immune function.
Bacterial pneumonia can be quite serious, and any individual with symptoms suggestive of pneumonia should consult a physician immediately, as antibiotics may be required. However, antibiotics offer no benefit in viral pneumonia. Nor are they useful in bronchitis, as demonstrated in more than a dozen double-blind studies over the past 30 years. According to the guidelines of the American College of Chest Physicians, “The widespread use of antibiotics for the treatment of acute bronchitis is not justified, and vigorous efforts to curtail their use should be encouraged.”8 Nonetheless, roughly 70% of doctors regularly prescribe an antibiotic for acute bronchitis even though it provides no benefit and significant risk. The risks include overgrowth of Candida albicans, disruption of normal gut microflora, and the possibility of developing antibiotic-resistant strains of bacteria.
Many doctors persist in prescribing antibiotics for acute bronchitis, despite the scientific facts, because of their own misconceptions—such as that a fever is a sign antibiotics are required, or that antibiotics are required to prevent progression to pneumonia. They may also prescribe antibiotics because of pressure from patients who mistakenly believe antibiotics are necessary.9
Botanical expectorants act to increase the quantity of mucus produced by the respiratory tract, decrease its viscosity, and promote its expulsion. Botanical expectorants have a long history of use in bronchitis and pneumonia. Because impaired cough reflexes have been thought to play a role in recurrent bronchitis and pneumonia, it seems reasonable that these botanicals would be useful in helping to relieve this condition and prevent recurrences.10 Many also have antibacterial and antiviral activity. Some expectorants are also cough suppressants; however, Lobelia inflata, a commonly used expectorant, actually helps promote the cough reflex.11 Therefore Lobelia may be more effective at clearing the lungs than other expectorants when the cough is productive. Other commonly used expectorants include Glycyrrhiza glabra(licorice), Pelargonium sidoides (South African geranium), Hedera helix (ivy), and wild cherry bark.
South African Geranium (Pelargonium sidoides)
Pelargonium sidoides is a medicinal plant in the geranium family that is native to South Africa. Its common name, umckaloaba, is a close approximation of a Zulu word that means “severe cough” and is a testimony to its effect in bronchitis. Extracts from the underground parts of the plant (rhizomes and tubers) have been shown to have a number of effects beneficial in upper respiratory tract infections, particularly bronchitis. Almost all of the research has been conducted using an extract known as EPs 7630 (also marketed as Umcka), and it is an approved drug for the treatment of acute bronchitis in Germany. The primary active ingredients include highly oxygenated coumarins (e.g., umckalin) and polyphenolic compounds.12
Research with EPs 7630 shows that it provides a three-pronged approach in acute bronchitis: (1) it enhances immune function; (2) it has some antimicrobial effects, including antimycobacterial13 and antiviral activity,14 and it appears to inhibit the attachment of bacteria, viruses, and perhaps other organisms to mucous membranes of the respiratory tract;12 and (3) it acts as an expectorant.12 In regard to its antiviral effects, EPs 7630 has been shown to interfere with the replication of seasonal influenza A virus strains (H1N1, H3N2), respiratory syncytial virus, human coronavirus, parainfluenza virus, and coxsackievirus, but did not affect replication of avian influenza A virus (H5N1), adenovirus, or rhinovirus.14
A 2008 meta-analysis of four randomized clinical trials of EPs 7630 comprising 1,647 patients with acute bronchitis support its safety and efficacy.15 On average, participants who received EPs 7630 were able to return to work two days earlier than those given a placebo. In another study, 742 children with acute bronchitis showed a drop of at least 80% in the severity of symptoms within two weeks of therapy, and over 88% of the treating physicians rated the treatment as “successful.”
Since the 2008 meta-analysis there have been additional studies that offer additional evidence of the safety and efficacy of EPs 7630 in acute bronchitis as well as further insight on dosage. In the most recent of these, 406 patients with acute bronchitis were randomly assigned to one of four parallel treatment groups—10-mg EPs 7630 tablets three times a day (30 mg group), 20-mg EPs 7630 tablets three times a day (60 mg group), 30-mg EPs 7630 tablets three times a day (90 mg group), or a placebo three times a day (control group)—for seven days.16 Effects were measured by change in the total bronchial symptom score (BSS). Between day 0 and day 7, the mean BSS score decreased by 2.7 (control group), 4.3 (30-mg group), 6.1 (60-mg group), and 6.3 (90-mg group). These results indicated that the 20-mg tablets of EPs 7630 taken three times per day constitute the optimal dose. Similar results were seen in a study of 400 children with acute bronchitis using the same dosage assessment.17
Ivy (Hedera helix)
In Europe, herbal preparations containing extracts from the leaves of ivy (Hedera helix) enjoy great popularity for the relief of cough as well as asthma. In 2007, more than 80% of herbal expectorants prescribed in Germany, totaling nearly 2 million prescriptions, included ivy extract. Ivy leaf contains saponins that show expectorant, mucolytic, spasmolytic, bronchodilatory, and antibacterial effects. The mucolytic and expectorant action of ivy is due to the saponins alpha-hederin and hederacoside C, the latter of which is metabolized to alpha-hederin when ingested.18
Ivy is often used as a sole therapy in both acute and chronic bronchitis and has very good safety, compliance, and efficacy ratings.19,20 One double-blind study used a combination of ivy and thyme (Thymus vulgaris) in 361 patients with acute bronchitis suffering from 10 or more coughing fits during the day, bronchial mucus production with impaired ability to cough up the mucus, and a BSS score of 5 or more. Patients were randomly assigned to an 11-day treatment with either thyme-ivy combination syrup (5.4 ml three times per day) or placebo syrup. The average reduction in coughing fits on days seven to nine was 68.7% with the thymeivy combination compared with 47.6% with the placebo. In the thymeivy combination group, a 50% reduction in coughing fits was reached two days earlier compared with the placebo group. Symptoms as assessed by BSS score improved rapidly in both groups, but regression of symptoms was faster and responder rates were higher at the second visit (83.0% vs. 53.9%) and third visit (96.2% vs. 74.7%) with the thyme-ivy combination. Treatment was well tolerated, with no difference in the frequency or severity of side effects between the thyme-ivy combination and placebo groups.21
A mucolytic agent should be used to thin the mucous secretions so as to promote expectoration. Guaifenesin (also known as glycerol guiacolate) is a derivative of a compound originally isolated from beech wood. Guaifenesin is an approved over-the-counter expectorant and mucolytic. It is available in many over-the-counter preparations. Alternatives include N-acetylcysteine and bromelain.
N-acetylcysteine (NAC) has an extensive history of use as a mucolytic in the treatment of acute and chronic lung conditions. It directly splits the sulfur linkages of mucoproteins, thereby reducing the viscosity of bronchial and lung secretions. As a result, it improves bronchial and lung function, reduces cough, and improves oxygen saturation in the blood.
NAC is helpful in all lung and respiratory tract disorders, especially chronic bronchitis and chronic obstructive pulmonary disease. Detailed analyses of 39 trials suggest that oral NAC reduces the risk of exacerbation (severe worsening) and improves symptoms in patients with chronic bronchitis, compared with a placebo.22
In addition to its effects as a mucolytic, NAC can increase the manufacture of glutathione, a major antioxidant for the entire respiratory tract. The typical dosage for NAC is 200 mg three times per day.
Bromelain is a useful adjunctive therapy for bronchitis and pneumonia owing to its fibrinolytic, anti-inflammatory, and mucolytic actions and enhancement of antibiotic absorption.23 Bromelain’s mucolytic activity is responsible for its particular effectiveness in respiratory tract diseases, including pneumonia, bronchitis, and sinusitis.24
In the early part of the 20th century, before the advent of effective antibiotics, many controlled and uncontrolled studies demonstrated the efficacy of large doses of vitamin C in bronchitis and pneumonia, but only when they were started on the first or second day of infection.25 If administered later, vitamin C tended only to lessen the severity of the disease. Researchers also demonstrated that in pneumonia, white blood cells take up large amounts of vitamin C.
The value of vitamin C supplementation in elderly patients with pneumonia was demonstrated clearly in a double-blind study of 57 elderly patients hospitalized for severe acute bronchitis and pneumonia.26The patients were given either 200 mg per day of vitamin C or a placebo. Patients were assessed by clinical and laboratory methods (vitamin C levels in the plasma, white blood cells, and platelets; sedimentation rates; and white blood cell counts and differential). Patients receiving this modest dosage of vitamin C demonstrated substantially increased vitamin C levels in all tissues even in the presence of an acute respiratory infection. Using a clinical scoring system based on major symptoms of respiratory infections, patients receiving the vitamin C fared significantly better than those on the placebo. The benefit of vitamin C was most obvious in patients with the most severe illness, many of whom had low plasma and white blood cell levels of vitamin C on admission.
Vitamin A supplementation appears to be of value, especially in children with measles, which has pneumonia as one of its complications. This may be because of the increased rate of excretion of vitamin A found during severe infections such as pneumonia. One study evaluated 29 patients with pneumonia and sepsis and found that their mean excretion rate of vitamin A was significantly greater than normal. A remarkable 34% of the patients excreted more than 1.75 mmol a day of vitamin A (retinol), which is equivalent to 50% of the U.S. recommended dietary intake.27 This may be particularly important for children. A randomized, double-blind trial of 189 children with measles (average age 10 months) in South Africa evaluated the efficacy of vitamin A in reducing complications. Providing 400,000 international units (120 mg retinyl palmitate), half on admission and half on the day after admission, reduced the death rate by more than 50% and the duration of pneumonia, diarrhea, and hospital stay by 33%.28 However, another study did not show any benefit from vitamin A supplementation. The difference may be due to the lower dose (100,000 IU) used in the second study or to the fact that it was not limited to children with pneumonia as a complication of measles.29
Evidence also indicates there are positive results from the use of vitamin A and concomitant zinc supplementation. One study of 2,482 children from six months to three years old revealed that those children given initial high doses of vitamin A followed by four months of elemental zinc (10 mg per day for infants and 20 mg per day for children older than one year) brought about a reduced incidence of pneumonia, which was not seen in the group given only vitamin A.30
In the United States, we do not think it is necessary to give such extreme dosages of vitamin A, but we do feel that in children especially, reasonable dosages of vitamin A (e.g., 10,000 IU per day for one week) may provide benefit and that it should be accompanied by zinc at the levels given above. (Note that women of childbearing age should not take more than 3,000 IU of vitamin A per day.)
Bottle Blowing and Salt Pipes
A Swedish study carried out with 145 adults hospitalized for pneumonia showed that the patients who were instructed to sit up and blow bubbles in a bottle containing 10 ml water through a plastic tube 20 times on 10 occasions per day had shorter hospital stays.31 Another study found this also helped decrease impairment of pulmonary function and an increase in total lung capacity in patients who had undergone coronary artery bypass surgery.32 Bottle blowing or another similar activity, such as a playing a wind instrument, may well prove useful as a means of decreasing the frequency and duration of respiratory events in patients who are vulnerable to respiratory infections such as pneumonia.
An alternative to bubble blowing is the use of a salt pipe. These pipes are inhaler-type devices containing tiny salt particles said to ease breathing. The practice originated in central Europe, where individuals with respiratory complaints would spend time in salt caves or mines to help relieve their breathing problems.
Postural Drainage Position
One of the main treatment goals in bronchitis, sinusitis, and pneumonia is to help the lungs and air passages get rid of the excessive mucus. We recommend applying a heating pad, hot water bottle, or mustard poultice to the chest for up to 20 minutes twice per day. A mustard poultice is made by mixing 1 part dry mustard with three parts flour and adding enough water to make a paste (the strength of mustard powder varies greatly, so test a small amount on the skin first to be sure it is not too strong, as indicated by excessive redness). The paste is spread on thin cotton (an old pillowcase works very well) or cheesecloth, and the folded cloth is placed on the chest. Check often, as mustard can cause blisters if left on too long. After the hot pack or mustard poultice, perform postural drainage by lying with the top half of the body off the bed, using the forearms as support, for a 5- to 15-minute period while trying to cough and expectorate into a basin or newspaper on the floor.
• Most cases of bronchitis and/or pneumonia do not require antibiotics.
• The natural approach to bronchitis and pneumonia involves three primary goals: (1) stimulate normal processes that promote the expectoration (removal) of mucus; (2) thin the mucus to aid expectoration; and (3) enhance immune function.
• Despite sufficient data showing no clinical benefit for antibiotics in acute bronchitis, many doctors prescribe these drugs for patients with acute bronchitis.
• Botanical expectorants act to increase the quantity, decrease the viscosity, and promote expulsion of the secretions of the respiratory mucous membranes.
• A 2008 meta-analysis of randomized clinical trials of EPs 7630 (Umcka) supports its safety and efficacy
• N-acetylcysteine has shown good results in the treatment of bronchitis.
• Vitamin C supplementation is warranted in all elderly patients with acute respiratory infection, especially those who are severely ill.
• The application of local heat followed by postural drainage can help get rid of excessive mucus.
As stated above, the basic approach is to use expectorants, mucolytics, and immune-supportive nutrients to help resolve the condition. Some general physical measures may also be helpful, including the use of a mustard poultice or hot pack along with postural drainage and the use of a salt pipe or bottle blowing. In addition, it is important to:
• Get plenty of rest.
• Drink enough liquids.
• Use a humidifier.
• One or more of the following:
– Dried herb: 0.2 to 0.6 g three times per day
– Tincture: 15 to 30 drops three times per day
– Fluid extract: 8 to 10 drops three times per day
Licorice root (Glycyrrhiza glabra):
– Powdered root: 1 to 2 g
– Fluid extract (1:1): 2 to 4 ml
- Solid (dry powdered) extract (4:1): 250 to 500 mg
Pelargonium sidoides (EPs 7630 or equivalent):
– Adults: 1.5 ml three times per day or 20 mg tablets three times per day for up to 14 days
– Children: ages 7 to 12, 20 drops (1 ml) three times per day; 6 years or less, 10 drops (0.5 ml) three times per day
Ivy (Hedera helix), available as tincture, fluid extract, and dry powdered extract in capsules and tablets; typical dosage for adults and children over 12 years of age for a 4:1 dry powdered extract is 100 mg per day (the equivalent of 420 mg dried herbal substance); for children 1–5 years old, dosage is the equivalent of 150 mg dried herbal substance; for children 6–12 years old, the equivalent of 210 mg dried herbal substance
• One or more of the following:
– Adults and children 12 years of age and older: 200 to 400 mg every four hours (do not take more than 2,400 mg in a 24-hour period)
– Children 6 to 11 years old: 100 to 200 mg every 4 hours (do not take more than 1,200 mg in a 24-hour period)
– Children 2 to 5 years old: 50 to 100 mg every four hours (do not take more than 600 mg in 24 hours)
– Children under 2 years of age: not recommended
N-acetylcysteine: 200 mg three times per day
Bromelain (1,200 to 1,800 MCU or GDU): 500 to 750 mg three times per day between meals
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin A: 10,000 international units per day for 1 week (women who are pregnant or who may become pregnant should not take more than 3,000 IU per day)
Vitamin C: 500–1,000 mg every two hours
Zinc: 20–30 mg per day
• One of the following:
Bioflavonoids (mixed citrus): 1,000 mg per day
Grape seed extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day.