Bronchitis and pneumonia

Diagnostic summary: Bronchitis

• •Diagnosis of acute bronchitis: rule out other causes of acute cough—pneumonia, common cold, acute asthma, exacerbation of chronic obstructive pulmonary disease.
• •For presumed diagnosis of acute bronchitis, viral cultures, serologic assays, and sputum analyses should not be routinely performed; responsible organism is rarely identified.
• •With acute cough and sputum suggestive of acute bronchitis, absence of the following findings reduces likelihood of pneumonia sufficiently to eliminate need for chest radiograph: (1) heart rate above 100 beats per minute; (2) respiratory rate above 24 breaths per minute; (3) oral body temperature higher than 38°C; and (4) chest examination findings of focal consolidation, egophony, or fremitus.

Diagnostic summary: Pneumonia

Diagnosis of pneumonia is usually made by physical examination and confirmed by chest radiographs. Common physical examination findings include the following:

• • Rales: bubbling or crackling sound. Rales on one side of chest and rales heard while patient is lying down are strongly suggestive of pneumonia.
• • Rhonchi: abnormal rumblings indicating presence of thick fluid.
• •
  Percussion: dull thud instead of healthy hollow-drum–like sound; indicates conditions suggesting pneumonia:

  • 1.
    Consolidation (lung becomes firm and inelastic)
  • 2.
    Pleural effusion (fluid buildup in space between lungs and lining around it)

    

• • Sputum suggestive of infection: bloody; thick, opaque; yellow, green, or brown; positive Gram stain. Sputum culture and sensitivity are not always helpful in identifying cause of pneumonia owing to contamination with throat or mouth bacteria.
• • Urine test (Alere BinaxNOW, Alere, Scarborough, ME) can detect Streptococcus pneumoniae or Legionella pneumophila antigens within 15 minutes. It may identify 77% of pneumonia cases and may rule out infection in 98% of patients who do not have S. pneumoniae. However, the test is not useful diagnosing S. pneumoniae pneumonia in children because the organism is common in this population whether or not they have pneumonia. L. pneumophila causes legionnaires’ disease and sometimes pneumonia.
• • Chest x-ray study: to confirm diagnosis of pneumonia, but it need not be positive for clinical diagnosis to be made. Positive chest radiograph for pneumonia may reveal lung infiltrates or complications (e.g., pleural effusions).

Special considerations with pneumonia

More than 100 types of bacteria, viruses, and fungi cause bronchitis or pneumonia. The three most common forms of pneumonia are viral, mycoplasmal, and pneumococcal types.

Viral pneumonia

• •Most often caused by adenovirus, influenza, parainfluenza, and respiratory syncytial virus
• •Develops as complication of viral upper respiratory infection

Clinical summary for viral pneumonia

• •People at risk for more-serious viral pneumonia are often immunocompromised.
• •Antibiotics are of no value.
• •Symptoms often begin slowly and may not be severe at first.
• •
  Most common symptoms:

  • 1.
    Cough (may cough up mucus or even bloody mucus)
  • 2.
    Fever: mild or high
  • 3.
    Shaking chills
  • 4.
    Shortness of breath (may occur only when climbing stairs)

Mycoplasmal pneumonia

• •Caused by Mycoplasma pneumoniae. Mycoplasma is a genus of bacteria lacking cell walls.
• •“Walking pneumonia.”
• •Antibiotics are usually not necessary but may speed recovery. Effective classes of antibiotics: macrolides, quinolones, and tetracyclines.

Clinical summary for mycoplasmal pneumonia

• •Most commonly occurs in children or young adults
• •Insidious onset over several days
• •Nonproductive cough, minimal physical findings, temperature below 102^°F
• •Headache and malaise: common early symptoms
• •White blood cell count: normal or slightly elevated
• •X-ray pattern: patchy or inhomogeneous

Pneumococcal pneumonia

• •Pneumococcal pneumonia (S. pneumoniae): most common bacterial pneumonia and most common cause of pneumonia hospitalization.
• •Careful clinical judgment must be used to determine severity of disease and status of patient’s immune system. Antibiotics or hospitalization is often necessary, especially for the elderly or immunocompromised.
• •Resistance rates to antibiotics and resistant strains are increasing.
• •Consider natural treatments in cases resistant to antibiotics or as adjunct to strengthen immune response and increase therapeutic effect.

Clinical summary for pneumococcal pneumonia

• •Preceded by upper respiratory infection.
• •Sudden onset of shaking, chills, fever, chest pain.
• •Sputum: pinkish or blood-specked at first, then rusty at height of infection; finally yellow and mucopurulent during resolution.
• •Gram-positive diplococci in sputum smear.
• •Rapid urine test (BinaxNOW) for S. pneumoniae antigens is positive.
• •Initially, chest excursion is diminished on involved side; breath sounds are suppressed; fine inspiratory rales.
• •Later, classic signs of consolidation: bronchial breathing, crepitant rales, dullness.
• •Leukocytosis,
• •Radiograph: lobar or segmental consolidation.

General considerations

• • Bronchitis: inflammation of mucous membranes of bronchi, airways carrying airflow from trachea into lungs.
• • Pneumonia: inflammation of lungs.
• •Both are characterized by cough with or without sputum.
• •Acute bronchitis often occurs during acute viral illness—common cold or influenza. Viruses cause 90% of cases of acute bronchitis.
• •Pneumonia is usually seen in immunocompromised individuals—for example, drug and alcohol abusers—leading to nosocomial and opportunistic pneumonias with high mortality rates. Acute pneumonia is the seventh leading cause of death in United States and is particularly dangerous in the elderly.
• •In healthy people, pneumonia follows an insult to host defenses: viral infection (influenza), exposure to cigarette smoke or other noxious fumes, impairment of consciousness (which depresses the gag reflex, allowing aspiration), neoplasms, and hospitalization (Textbook, Bronchitis and Pneumonia).
• •In immunocompetent, nonelderly adults, cigarette smoking is the strongest independent risk factor for invasive pneumococcal disease.
• •The airway distal to the larynx is normally sterile. Mucus-covered ciliated epithelium that lines the lower respiratory tract propels sputum to larger bronchi and trachea, evoking the cough reflex. Respiratory secretions contain substances that exert nonspecific antimicrobial actions: alpha₁-antitrypsin, lysozyme, and lactoferrin. Potent alveolar defense mechanisms include alveolar macrophages, rich vasculature for rapidly delivering lymphocytes and granulocytes, and efficient lymphatic drainage network.

Therapeutic considerations

Regardless of the form of bronchitis or pneumonia the basic approach involves use of (1) expectorants, (2) mucolytics, and (3) immunosupportive nutrients. Antibiotics are of limited value in acute bronchitis, but they are useful in pneumonia.

Expectorants

Impaired cough reflexes are thought to contribute to recurrent bronchitis and pneumonia. Botanical expectorants increase quantity, decrease viscosity, and promote expulsion of secretions of respiratory mucous membranes. Many have antibacterial and antiviral activity. Some expectorants are antitussives; however, Lobelia inflata promotes cough reflex. Thus Lobelia clears lungs better than other expectorants when cough is productive. Other expectorants include Glycyrrhiza glabra (licorice), Pelargonium sidoides (South African geranium), Hedera helix (ivy), and wild cherry bark.

Pelargonium sidoides (South African geranium)

P. sidoides is a medicinal plant in the geranium family native to South Africa. The common name, umckaloabo, is close to the Zulu word for “severe cough.” Intricate groupings of thick dark-red rhizomes and tubers underground withstand grass fires in its habitat. An extract from rhizomes and tubers—ethanolic extract EPs 7630 (Umcka) is an approved drug for acute bronchitis in Germany. Primary active ingredients include highly oxygenated coumarins (e.g., umckalin) and polyphenolic compounds. Umcka uses a three-pronged approach in acute bronchitis: it (1) enhances immune function; (2) is antimicrobial—antimycobacterial and antiviral—and inhibits attachment of bacteria and viruses to mucous membranes of respiratory tract; and (3) acts as an expectorant. EPs 7630 at 100 mcg/mL interferes with replication of seasonal influenza A virus strains (H1N1, H3N2), respiratory syncytial virus, human coronavirus, parainfluenza virus, and coxsackievirus, but not highly pathogenic avian influenza A virus (H5N1), adenovirus, or rhinovirus. EPs 7630 induces reduction in Bronchitis Severity Score (BSS), which includes coughing, expectoration, chest pain, dyspnea, and wheezing from baseline versus after 7 days of treatment. In clinical studies with Umcka in 2500 adults and children, adverse events occurred on par with placebo and involved mild gastrointestinal complaints and skin rashes. There were no known drug interactions.

Hedera helix (ivy)

Extracts from leaves of ivy relieve cough and asthma. More than 80% of herbal expectorants prescribed in Germany consist of ivy extracts. Ivy leaf contains saponins that show expectorant, mucolytic, spasmolytic, bronchodilatory, and antibacterial effects. Mucolytic and expectorant action is based on indirect beta₂ adrenergic effects, as a result of the saponins alpha-hederin and hederacoside C, the latter being metabolized to alpha-hederin when ingested. An indirect effect is that alpha-hederin inhibits intracellular uptake of beta₂ receptors and leads to increased beta₂ adrenergic response of the cell. Ivy is often a monopreparation with good safety, compliance, and efficacy in acute and chronic bronchitis. A combination of ivy and thyme (Thymus vulgaris) for acute bronchitis induced a 50% reduction in coughing fits from baseline 2 days earlier than placebo. Treatment was well tolerated with no difference in frequency or severity of side effects between thyme-ivy combination and placebo.

Mucolytics

Mucolytics are used to improve quality of mucous secretions to promote expectoration. Guaifenesin (glycerol guaiacolate) is a derivative of a compound isolated from beech wood. Guaifenesin is an approved over-the-counter expectorant and mucolytic. Alternatives include N-acetylcysteine (NAC) and bromelain.

N-acetylcysteine (NAC)

NAC has an extensive history as a mucolytic for acute and chronic lung conditions. It directly splits sulfur linkages of mucoproteins, reducing viscosity of bronchial and lung secretions. NAC improves bronchial and lung function, reduces cough, and improves oxygen saturation in the blood. NAC is helpful in all lung and respiratory disorders (e.g., chronic bronchitis and chronic obstructive pulmonary disease). Oral NAC reduces risk of exacerbations and improves symptoms in patients with chronic bronchitis compared with placebo. NAC can increase manufacture of glutathione, a major antioxidant for the entire respiratory tract and lungs. The dose is 200 mg t.i.d.

Bromelain

Bromelain is used as adjunctive therapy for bronchitis and pneumonia because of its fibrinolytic, anti-inflammatory, and mucolytic actions and its enhancement of antibiotic absorption. Its mucolytic activity provides efficacy in pneumonia, bronchitis, and sinusitis.

Vitamin C

• •Before the advent of pharmaceutical antibiotics, many controlled and uncontrolled studies demonstrated 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. If administered later, it only lessens severity of disease.
• •In pneumonia, white blood cells take up large amounts of vitamin C.
• •Vitamin C therapy in elderly patients with pneumonia leads to better clinical outcomes. The benefit of vitamin C is most obvious in patients with the most severe illness, many of whom tend to have low initial plasma and white blood cell levels of vitamin C.

Vitamin A

• •Vitamin A is especially valuable in children with measles, perhaps owing to the increased rate of excretion of vitamin A during severe infections.
• •Patients with fever excrete more retinol than those without fever. A remarkable 34% of patients studied excreted a quantity of retinol equivalent to 50% of the U.S. recommended daily allowance.
• •This may be particularly important for children. In children with measles (average age 10 months), providing 400,000 international units (IU) (120 mg of retinyl palmitate), one half on admission and one half a day later, reduced death rate by 50% and duration of pneumonia, diarrhea, and hospital stay by 33%.
• • Zinc and vitamin A: In children aged 6 months to 3 years, those given initial high doses of vitamin A followed by 4 months of elemental zinc (10 mg/day for infants and 20 mg/day for children older than 1 year) exhibited reduced incidence of pneumonia, not seen in with vitamin A alone.

Vitamin E

Patients with influenza complicated by pneumonia experience a sharp rise in lipid peroxidation (LPO) products, especially those who are seriously ill. Administrating alpha-tocopherol decreases LPO products and results in a more-benign clinical course.

Garlic (allium sativum)

• •Garlic has broad-spectrum antibiotic activity against both gram-positive and gram-negative bacteria.
• •Garlic is an effective antibacterial agent against S. pneumoniae; consider it in cases of antibiotic resistance or as adjunct to antibiotic therapy.
• •Alternatively, berberine-containing plants (e.g., Hydrastis canadensis [goldenseal]) may be helpful.

Bottle blowing and salt pipes

• •In adults hospitalized for community-acquired pneumonia, patients instructed to sit up and take 20 deep breaths 10 times daily or to sit up and blow bubbles in a bottle containing 10 mL of water through a plastic tube 20 times on 10 occasions daily experienced a significantly reduced length of hospitalization. The number of days with fever was lowest with bottle-blowing.
• •Early mobilization itself decreases hospital stay in pneumonia patients.
• •Despite positive clinical results, C-reactive protein levels, peak expiratory flow, and vital capacity were not affected.
• •Changes in respiratory pressure associated with bottle blowing may provide an environment for more-efficient bacterial clearance.
• •Decreased impairment of pulmonary function and increased total lung capacity manifests in patients who have undergone coronary artery bypass. This modality or a similar activity (e.g., playing a wind instrument) may decrease frequency and duration of respiratory events in patients vulnerable to respiratory infections.
• •An alternative to bubble blowing is use of a salt pipe. These inhaler-type devices contain tiny salt particles said to ease breathing. The practice originated in central Europe, where respiratory patients spent time in salt caves or mines to relieve breathing problems.

Therapeutic approach

The basic approach involves expectorants, mucolytics, and immunosupportive nutrients. Helpful general physical modalities and measures are as follows:

• •Diathermy to chest and back: 30 minutes q.d.
• •Mustard poultice: once q.d.
• •Lymphatic massage: t.i.d.
• •Postural drainage: t.i.d.
• •Bottle-blowing therapy: blowing bubbles in a bottle containing 10 mL water through a plastic tube 20 times on 10 occasions a day
• •Plenty of rest
• •Optimal hydration
• •Humidifier

Expectorants

Choose one or more of the expectorants listed here.

Lobelia inflata

• •Dried herb: 0.2 to 0.6 g t.i.d.
• •Tincture: 15 to 30 drops t.i.d.
• •Fluid extract: 8 to 10 drops t.i.d.

Glycyrrhiza glabra

• •Powdered root: 1 to 2 g
• •Fluid extract (1:1): 2 to 4 mL (0.5 to 1 tsp)
• •Solid (dry-powdered) extract (4:1): 250 to 500 mg

Pelargonium sidoides

Dosage for EPs 7630 or equivalent preparation:

• •Adults: 1.5 mL t.i.d. or 20-mg tablets t.i.d. for up to 14 days.
• •Children: age 7 to 12 years, 20 drops (1 mL) t.i.d.; age 6 years or younger, 10 drops (0.5 mL) t.i.d.

Hedera helix

Ivy leaf is available primarily in tincture and fluid extract and dry powdered extract in capsules and tablets. Daily doses of dried herbal substance should deliver an amount equal to the following:

• •1 to 5 years: 150 mg; 6 to 12 years: 210 mg; older than 12 years: 420 mg
• •Typical dose for adults and children older than 12 years for a 4:1 dried powdered extract: 100 mg q.d.

Mucolytics

Choose one or more of the mucolytics listed here.

Guaifenesin

• •Adults and children age 12 years and older: 200 to 400 mg every 4 hours. Avoid taking more than 2400 mg in a 24-hour period.
• •Children age 6 to 11 years: 100 to 200 mg every 4 hours; no more than 1200 mg in a 24-hour period.
• •Children age 2 to 5 years: 50 to 100 mg every 4 hours; no more than 600 mg in 24 hours.
• •Not recommended for children under age 2 years.

N-acetylcysteine

• •200 mg t.i.d.

Bromelain

• •1200 to 1800 milk clotting units [MCU]
• •500 to 750 mg t.i.d. between meals

Supplements

• •Vitamin A: 50,000 IU/day for 1 week or beta-carotene 200,000 IU/day (vitamin A should not be used in women of childbearing age owing to possible teratogenic effects)
• •Vitamin C: 500 mg every 2 hours
• •Vitamin E (mixed tocopherols): 200 IU q.d.
• •
  Choose one of the following:

  • —
    Bioflavonoids (mixed citrus): 1000 mg q.d.
  • —
    Grapeseed (Vitis vinifera) extract (95% procyanidolic oligomers) 150 to 300 mg q.d.
  • —
    Pine bark extract (Pinus pinaster) 150 to 300 mg q.d.
• •Zinc: 30 mg elemental zinc q.d.

Additional recommendations for pneumococcal pneumonia

Choose garlic, H. canadensis, or both.

Garlic

Daily dose is equal to at least 4000 mg of fresh garlic, which translates to at least 10 mg allicin or a total allicin potential of 4000 mcg.

Hydrastis canadensis

Standardized extracts are recommended. The following doses are given t.i.d.:

• •Dried root or as infusion (tea): 2 to 4 g
• •Tincture (1:5): 6 to 12 mL (1.5 to 3 tsp)
• •Fluid extract (1:1): 2 to 4 mL (0.5 to 1 tsp)
• •Solid (powdered dry) extract (4:1 or 8% to 12% alkaloid content): 250 to 500 mg