Botanical Treatment of Community-Acquired Pneumonia
Eric Yarnell, ND and Lauren Russel, ND
Pneumonia and other lower respiratory tract infections (LRTI) are major health issues affecting millions of people each year. Pneumonia is a leading cause of death worldwide, usually acquired through community or nosocomial exposure. Most cases in adults older than age 30 are caused by bacteria, with Streptococcus pneumoniae the most commonly isolated pathogen. We will discuss only community-acquired pneumonia here; nosocomial pneumonia is beyond the scope of this discussion.
Deciding on Treatment Approach
The decision to treat a patient naturopathically with high-force home treatments or to refer them for hospitalization is a fine art. Because it can be challenging to determine how ill a patient is at presentation with community-acquired pneumonia (CAP), a prediction rule for patient risk and mortality was established, known as the Pneumonia Severity Index (Fine et al., 1997). Based on 14,199 cases of CAP patients, the prediction rule uses clinical variables to stratify patients into five mortality risk classes. These categories are used along with clinical judgment to determine whether to hospitalize a patient. Other trials have supported the mortality-predictive power of this rule (España et al., 2003). It is our contention that patients in risk class I can be treated solely naturopathically, patients in classes II and III with joint naturopathic and pharmacologic treatment, and those in classes IV and V should be referred for hospitalization.
Serum procalcitonin (PCT) can help make decisions about treatment of people with pneumonia, particularly by differentiating patients who have bacterial pneumonia from those with viral or inflammatory syndromes. Serum PCT is elevated in systemic bacterial infections, particularly pneumonia (Mueller et al., 2005). In a randomized trial, 302 patients with CAP were randomly treated with antibiotics or treated based on PCT measurements (Christ-Crain et al., 2006). Patients treated using PCT measurements required fewer days of antibiotics, reducing their exposure. Other studies have shown similar results and no adverse effects from limiting antimicrobial therapy (Christ-Crain et al., 2004). It is also useful in children (Gendrel et al., 1999). PCT levels were more reliable than white blood cell count or C-reactive protein in identifying bacterial infection vs. other inflammatory processes (Delevaux, 2003). Some studies have not shown a significant advantage to using PCT alone and recommend a combination of C-reactive protein, PCT and other clinical markers during initial workup (Holm et al., 2007; Stolz et al., 2007; Schetz et al., 20007). The usual cutoff for normal PCT is 1ng/ml (1mg/L) – levels above that suggest more serious infections. Clearly, more research is needed in this area.
Treatment of CAP requires multiple, aggressive strategies. Frequent, high doses of antimicrobials are the backbone of any program, though immunoactive herbs are also critical. If IV therapies are available, these should be implemented immediately along with oral herbal treatments, topical herbal treatments, diathermy, fasting with vegetable broths and water, and other natural treatments.
- Ligusticum porteri (oshá) and L. grayi (oshala) root are antimicrobial immune stimulants commonly used for respiratory infections (Yarnell, 2006). Indications for use include debility with copious amounts of mucus and congestion. Typical tincture doses are 2-3ml every two to three waking hours.
- Baptisia tinctoria (wild indigo) root is commonly used for serious respiratory tract infections and sepsis (Hauke et al., 2002). Its glycoprotein derivatives show immune modulating activity in vivo and in vitro. A typical tincture dose for CAP patients would be 1-2ml every two to three waking hours.
- Thymus vulgaris (thyme) is a potent antibacterial, antimicrobial, expectorant and spasmolytic used effectively in the treatment of respiratory conditions. Traditionally it has been used to relieve spasmodic cough, sore throat and catarrh. The Eclectics used it as a tonic and tea for convalescence after debilitating illness. Clinical trials have shown that as a syrup combined with the stimulating expectorant and immunomodulator Hedera helix (English ivy) leaf or the stimulating expectorant Primula veris (cowslip) root, it is effective for patients with acute bronchitis (Kemmerich, 2007; Kemmerich et al., 2006). Clearly, trials are needed in CAP patients, but clinically thyme is effective. Doses of oral volatile oil are 3-5 drops every three to four waking hours, or tincture 2-3ml every two to three waking hours, in adults.
- Propolis is a resin made by bees that is an effective expectorant, antioxidant and antiseptic. It is often used for respiratory and urinary tract infections and as a topical antiseptic. Typical tincture dose is 2-3ml every two to three waking hours.
Echinacea is one of those plants that historically has been found to have a stimulating effect on the immune system as well as being antimicrobial. As with so many other herbs presented here, robust, frequent doses are key to efficacy. Additionally, E. angustifolia fresh root is preferred, and was historically viewed as the most potent species. Tincture doses, extracted using high concentrations of ethanol, are 3-5ml every two waking hours.
Spilanthes acmella (toothache plant, paracress) root in the Asteraceae family is known for its immunostimulant effects. It is also antiviral, antifungal and antiseptic, which makes it useful for treating most types of infections. Tincture doses are the same as for Echinacea, and it is a potentially more sustainable alternative to that herb.
Thuja plicata (red cedar) is perhaps the most important Pacific Northwest antiviral and antimicrobial that contains volatile oils. The volatile oils encourage expectoration and stimulate the immune system. Typical tincture doses are 1-2ml every two waking hours. T. occidentalis (arbor vitae) can be substituted for those living in the eastern U.S./Canada.
Immunomodulating herbs or adaptogens also appear to have a role in patients with CAP, despite some theories that they will “tonify the pathogen” and prolong the illness. One clinical trial looked at a formula containing three immunomodulators, Rhodiola rosea (rose root) root, Schisandra chinensis (wu wei zi) fruit and Eleutherococcus senticosus (eleuthero) root in patients with CAP (Narimanian et al., 2005). The formula was combined with conventional treatment or placebo; duration and severity of illness was significantly reduced in the combination group.
Miscellaneous Herbal Treatments
Plant essential oils are very effectively used as decongestants, antipyretics and antitussives. Bill Mitchell, ND was fond of using chest rubs for respiratory conditions, and one of his favorites was a popular vapo-rub ointment, something many of us may have experienced as children. This ointment contains camphor, Eucalyptus oil and menthol, all effective cough suppressants, along with thymol, an effective antibacterial. The rub is applied to the chest at bedtime and in the morning and left on.
Lobelia inflata, also known as Indian tobacco, is a spasmolytic and nervine that, in moderate doses, relaxes the respiratory tract and promotes sleep. Lobelia oil is also an effective topical used as a chest rub (Yarnell, 2005).
Other herbs to include in the treatment of pneumonia and respiratory conditions are the mucolytics, effective for productive, wet cough marked by spasms. These herbs include Grindelia camporum (gumweed) and Eriodictyon californica (yerba santa). Grindelia is a bronchospasmolytic that was used therapeutically by Native Americans for coughs, colic in children and the common cold. Eriodictyon contains a resin, eriodictyol, and is a stimulating expectorant good for reducing respiratory mucus secretions. Typical doses of both these plants as tinctures for acute pneumonia patients are 3-5ml every two to three waking hours.
Asclepias tuberosa (pleurisy root) is a pulmonary lymphagogue and peripheral vasodilator indicated for use with bronchitis, pneumonia, influenza and other catarrhal complaints. The Eclectics wrote that it was “best adapted to the acute stage, where the lesion seems to be extensive, taking in a large area of lung parenchyma and mucous tissues. In the convalescing stage … small doses at frequent intervals will correct the trouble” (Felter and Lloyd, 1898). The dosage for the tincture is 10-20gtt every two to three waking hours. A southwestern native plant, A. asperula (inmortál) root, is used for similar purposes, though it has more of an affinity for the heart as well. Thus, patients with any chronic heart disease and CAP should probably receive inmortál.
Antibiotic Resistance Modulators
Antibiotic resistance is a major problem in the treatment of pneumonia, hence the search for inflammatory markers that can reduce or eliminate the need for antibiotics. Important antibiotic resistance modulators in the naturopathic armamentarium include Camellia sinensis (green tea), Theobroma cacao (chocolate) and Rosmarinus officinalis (rosemary). While studies are limited, there is evidence to support their effectiveness when administered concurrently with antibiotics (Abascal and Yarnell, 2002). Extracts of green tea, for example, have reversed methicillin resistance with MRSA and penicillin resistance with Staphylococcus aureus, and Rosmarinus has been effective in reducing erythromycin resistance (Sibanda, 2007; Yamada et al., 2006). Though chocolate has not been specifically studied, its constituents are very similar to tea and patients are generally overjoyed to have chocolate prescribed. Only dark chocolate free of milk should be used for optimal benefits.
Eric Yarnell, ND is a graduate of Bastyr University. He completed a two-year residency with Silena Heron, ND, and served as chair of botanical medicine at SCNM. He is past senior editor of the Journal of Naturopathic Medicine. Dr. Yarnell is a founding member and current president of the Botanical Medicine Academy and author of numerous textbooks and articles, including Naturopathic Urology and Men’s Health, Naturopathic Gastroenterology and Clinical Botanical Medicine. His area of clinical focus is urology and men’s health. He is assistant professor in botanical medicine at Bastyr University.
Lauren Russel, ND is a graduate of Bastyr University, currently focusing on therapies for cancer and endocrine disorders. She has been a medical writer and editor for many years, with numerous publications to her name.
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