Respiratory System Scope: - Management of
Respiratory System Scope: - Management of
Respiratory System Scope: - Management of
Scope
Apart from their use to provide non-specific support for recuperation and repair, specific
phytotherapeutic strategies
include the following :
Treatment of:
inflammatory catarrhal conditions of the upper respiratory mucosa (e.g. common cold,
rhinitis, sinusitis, otitis media)
acute bronchial and tracheal infections
allergic rhinitis
nervous coughing patterns.
Management of :
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Because of its use of secondary plant products, particular caution is necessary in applying
phytotherapy in cases of known allergic reactions to specific medicinal plant products.
This is, however, the one area where the divide between traditional and modern approaches is
not very wide.
Elsewhere, there are very few modern endorsements of early treatment strategies.2 Modern
medical science, which at first
embraced such agents in the earlier part of this century, now sees no role for their use. For
example, modern editions of Martindales Extra Pharmacopoeia claim that: There is little
evidence to show that expectorants are effective. Some modern drugs may have expectorant
activity, such as bromhexine, but they are usually referred to as mucolytic. The impact of
traditional remedies on the respiratory system is relatively poorly researched. Reliable external
measures of change in mucosal function are elusive; many respiratory diseases are either selflimiting or are among some of the most persistent conditions in the clinic. Even in asthma, where
peak flow rates provide a simple measure of benefit, the complexity of the condition and the
usual presence of confounding and violent influences make easy characterisation of the
condition, and the measurement of all but the most powerful across-theboard remedies,
unreliable.
A sense that traditional approaches should be relegated to history is possibly reinforced in the
medical psyche by the
knowledge that one of the most dramatic advances of modern drugs was in controlling at last the
old scourge of tuberculosis. However, this dismissal is not as conclusive as once thought.
Tuberculosis is making a serious come-back on the world stage, attacking first the very
impoverished and malnourished as it always did. As modern drugs struggle with this new
manifestation, there may once again be value in looking at the lessons from the past, that
treatment should be
based on supportive remedies in a regime of convalescence. With the luxury of choice, with the
option of taking modern
drugs where these are necessary, but also being able to select more supportive strategies at
other times, there is real value
in reviewing the treatments forged out of desperate but not always unsuccessful battles with
disease in earlier times. These lessons are fortunately quite well learnt.
The dominant feature of respiratory conditions is how readily changes in their behaviour are
appreciated subjectively. The
often immediate effects of eating and drinking different foods and drinks, of temperature and
humidity changes and of the various treatments used through history have been the main guide
in determining therapeutic strategy. From such experience has come the view of the respiratory
mucosa and musculature as being particularly sensitive to reflex responses, notably from the
upper digestive tract, from the pharynx to the stomach. There is a persistent tradition in many
cultures that respiratory problems are extensions of digestive dysfunctions. Embryology supports
such links, with the bronchial tree originating as a diverticulum of the pharyngeal zone of the
alimentary duct and sharing common vagal innervation, and the association, for example,
between asthma and histamine H2 receptors in the stomach3 add further support to such
connections.
Phytotherapeutics
Part of the problem with expectorants probably arises from confusion over their definition.
Another stems from the difficulties involved with measuring their efficacy.
Overview of expectorants
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secretory glands, there may also be vagal stimulation of smooth muscle tissue in the
lungs. Hence they should be used with caution in asthma, and combined with bronchiolar
spasmolytics (but not anticholinergics that can dry respiratory secretions).
Many lower respiratory tract disorders will benefit from the action of expectorants, but
particularly those where mucus is tenacious and difficult to cough up. However, it
depends on the cause of a cough whether an expectorant action is also antitussive.
The four definitions of expectorants given below highlight the difficulties. The dictionary meaning
is only concerned
with the actual oral production of phlegm or sputum. Since the majority of mucus produced from
the lungs is swallowed,
this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are
more useful, but probably the best definition comes from Brunton, a 19th century
pharmacologist. Bruntons functional definition best
explains the various ways in which medicinal plants can act as expectorants.
Definitions of expectorants
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Why expectorants?
Many respiratory conditions are characterised by abnormal mucus (catarrh) that can narrow
airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from
the airways. If expectorants can render this catarrh more fluid and/ or assist in its expulsion, then
a clinical benefit should be achieved.
Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways
(such as tenacious
abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and
larger airways. The sensitivity progressively decreases in the finer airways and in the very fine
airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex,
whereas for tracheitis the stimulus is strong.) By clearing abnormal mucus or by changing its
character and making it more demulcent, expectorants can allay cough and are therefore
antitussive.
In spite of the incomplete scientific case and lack of a consensus orthodox view, traditional
approaches to expectoration
are strong and consistent across cultures and history. They include mechanisms that are rational
and usually immediately apparent.
Cephaelis (ipecacuanha), Lobelia inflata (Lobelia), Urginea (squills), Primula veris (cowslip), Bellis
(daisy), Saponaria
(soapwort), Polygala senega (snakeroot)
Cough linked to bronchial congestion, especially where mucus is thick and tenacious or
where there is unproductive cough
Bronchitis, emphysema
Although there is no firm evidence of unsuitability, as gastric irritants they can transiently upset
some individuals (immediately relieved by withdrawing or changing the remedy). In addition, the
use of stimulating expectorants should be kept under review in cases of
dry and irritable conditions of the lungs
asthma
young children
dyspeptic conditions
Application
Stimulating expectorants are best taken in hot infusions or as tinctures or fluid extracts, before
food.
Long-term therapy with stimulating expectorants is appropriate in the management of chronic
bronchial conditions as
long as digestive functions are not affected.
Advanced phytotherapeutics
Stimulating expectorants may also be usefully applied in some cases (depending on other
factors) of rheumatic and connective tissue diseases
fresh ginger and cinnamon remains one of the most effective home treatments for the common
cold.
Essential oils from various herbs (either administered as essential oils or contained in herbal
extracts or tinctures) are
the most important agents that directly influence goblet cells to secrete more respiratory tract
fluid and mucus. Boyd studied the effects of several essential oils in various experimental models
(see Chapter 2). The most pronounced increase
of respiratory tract fluid was seen after ingestion of oil of anise. Interestingly ingestion of oil of
eucalyptus had a moderate
effect that was not eliminated by cutting afferent gastric nerves. This finding supports the
premise that essential oils do not generally act as reflex expectorants.
As aromatic digestives
l Congestive chronic infections and inflammatory conditions.
Applications
Warming expectorants are best taken immediately before meals. They are particularly effective
taken in hot aqueous infusions. Long-term therapy with warming expectorants is usually
acceptable.
Respiratory demulcents
These herbs contain mucilage and have a soothing and anti-inflammatory action on the lower
respiratory tract. Although
the mechanism is not clear, an opposite effect to that of the stimulating expectorants has been
postulated; that is the
effect is a reflex one from the demulcent effect on the pharynx and upper digestive tract, again
involving common embryonic origins and vagal innervation.
The major respiratory demulcent herbs are Althaea officinalis (marshmallow root or leaves) and
other members of
the Malvaceae (mallows), Ulmus spp. (slippery elm), members of the Plantago genus, Cetraria
islandica (Iceland moss)
and Chondrus crispus (Irish moss). Tussilago (coltsfoot) and Symphytum (comfrey) were very
widely popular before concerns about pyrrolizidine alkaloids constrained their sale.
Pronounced antitussive activity has been demonstrated experimentally with oral doses of 1000
mg/kg body weight
of extract of Althaea officinalis (marshmallow), with comparable effects at 50 mg/kg of the
isolated polysaccharides.6
These animal studies might suggest enormous doses necessary for clinical effect but if, as
implied, the effect is a mechanical one, it is likely that only marginal increases in dose would be
necessary to have similar impact in larger animals like humans (see also Chapter 2 under
Mucilages).
Respiratory demulcents were popular for childrens cough and generally for dry, irritable and
ticklish coughing. They
were seen as intrinsically contraindicated in wet, damp chest problems, although they can
sometimes be quite well suited
to these if there is an irritable element.
As with other respiratory remedies, there is a close association between effects here and on the
digestive tract. Respiratory
demulcents are at their most appropriate if there are parallel indications in the gut: dry inflamed
conditions such as gastritis
and oesophagitis associated with hyperacidity, dry constipation and its various associated
problems.
Application
Respiratory demulcents are best taken before meals. They are particularly effective taken in cold
aqueous infusions.
However, if gastro-oesophageal reflux is contributing to the pathology, as can be the case in
asthma, they should be taken
after meals.
Long-term therapy with respiratory demulcents is usually well tolerated.
Respiratory spasmolytics
Respiratory spasmolytics relax the bronchioles of the lungs. Traditionally they included the
solanaceous plants (the nightshade family) with powerful atropine-related antiparasympathetic
constituents: Datura, Atropa and Solanum were the prominent antiasthmatics of early history. As
could now be explained pharmacologically, these remedies tended also
to dry up the mucosa and had other less desirable effects, so less powerful remedies were also
popular. Ephedra sinica
(ma huang) from Asia was popular when it reached Europe and works through a
sympathomimetic action. Other gentle
remedies include culinary herbs such as hyssop and especially thyme, horehound, the North
American gumplant, Grindelia camporum and elecampane (Inula helenium).
Application
Respiratory spasmolytics may be taken at any time of the day as required for immediate effect.
Long-term therapy with respiratory spasmolytics is acceptable in the case of the gentler
examples, but not for the solanaceous plants or Ephedra, and in all cases there should be
attention to treatment of underlying causes rather than relying on symptomatic relief.