Abstract
Lifestyle Choices
When preparing for cold and flu season, conventional training does not teach clinicians to dive right into a discussion about lifestyle behaviors. Instead, the discussion often moves toward vaccinations, hand hygiene, and staying away from crowded places and people who are sick—all of which may be important information. However, for a patient who is not exercising and who is eating an unhealthy diet and/or living a high-stress life, one of the most important doctor–patient discussions for preventing infection is to discuss lifestyle choices.
There are known risk factors related to lifestyle for colds and other viruses, flu, and pneumonia. Smoking and excessive alcohol consumption each individually increases the risk for colds and other respiratory infections. In fact, smoking increases the risk of viral and bacterial infections, including the common cold, pneumonia, and influenza, and worsens symptoms when a smoker contracts these conditions. 1 Known risk factors for developing the flu include, among other things, obesity, a weakened immune system, and chronic disease, many of which are preventable. Lack of sleep and chronic stress are other significant contributors to respiratory infections. In a recent review, which included more than 20,000 participants, “self-reported short sleep duration, a physician's diagnosis of a sleep disorder, and reported trouble with sleeping was associated with a greater likelihood of a cold or infection or both in the past 30 days.” 2 The authors added that “the bidirectional relationship between sleep and the immune system is well established.” 2
Lifestyle behaviors that contribute to a healthy immune system include regular exercise, adherence to a healthy dietary pattern, seven or more hours of sleep a night for adults, avoidance of smoking and/or secondhand smoke, drinking minimal alcohol, and learning stress management techniques. People who engage in and/or follow these lifestyle choices are less prone to both infections and chronic disease. A recent randomized controlled trial found that compared with a control group, an eight-week mindfulness-based stress reduction (MBSR) training and an eight-week moderate intensity exercise training were each individually associated with a reduced risk of acute respiratory illness. 3 The authors of this study pointed out that MBSR and exercise also confer significant protection against a wide variety of chronic diseases, making adoption of such practices a win–win situation.
The bottom line is that as clinicians, many of us observe that compared to people who have adopted poor lifestyle behaviors, people who practice healthier lifestyle behaviors are simply sick less often. As a result, having a discussion and providing specific direction about healthy lifestyle choices is a positive step in the direction of respiratory illness prevention.
References
Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med 2004;164:2206–2216.
Prather AA, Leung CW. Association of insufficient sleep with respiratory infection among adults in the United States. JAMA Intern Med 2016;176:850–852.
Barrett B, Hayney MS, Muller D, et al. Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial. PLoS One 2018;13:e0197778.
Case Western Reserve University School of Medicine
Cleveland, OH
Western Herbal Medicine
Western herbal medicine offers an effective and safe alternative to antibiotics in viral respiratory infections. Several herbs have proven their value in randomized clinical trials, but their real power comes from the ability to create individualized formulas that address each patient's unique presentation. My general approach to this, highlighting native North American herbs, has been successful in my practice for more than 20 years.
In almost every herbal formula for viral respiratory infections, an immunostimulating and antimicrobial herb will be needed. Echinacea angustifolia or Echinacea pallida (purple coneflower) root fills both of these roles admirably. 1 I frequently add a local Apiaceae family herb to this mix, as they also have both actions. Ligusticum grayi (Gray's lovage) root, Lomatium dissectum (desert parsley) root, and Osmorhiza occidentalis (western sweet cicely) root are good options, with the last tasting the best.
Combining several antimicrobial herbs prevents resistance and maximizes synergy. Along with the herbs mentioned above, Usnea longissima (old man's beard) thallus, Salvia apiana (white sage) leaf, Sambucus cerulea (blue elder) fruit, or the non-native Glycyrrhiza glabra (licorice) root are great options. 2,3 Licorice also helps reduce inflammation and soothe pharyngitis. Anemopsis californica (yerba mansa) is another great antimicrobial herb that relieves symptoms via its astringency. Solidago canadensis (goldenrod) is also helpful at reducing inflammation and thus symptoms.
It is also traditional to include a diaphoretic herb to augment immune function and optimize a fever. Eupatorium perfoliatum (boneset) aerial parts, blue elder flower, Tilia americana (basswood) flower, and Achillea millefolium (yarrow) aerial parts are all good choices. 4 They work best as infusions.
References
Shah SA, Sander S, White CM, et al. Evaluation of Echinacea for the prevention and treatment of the common cold: A meta-analysis. Lancet Infect Dis 2007;7:473–480.
Tiralongo E, Wee SS, Lea RA. Elderberry supplementation reduces cold duration and symptoms in air-travellers: A randomized, double-blind placebo-controlled clinical trial. Nutrients 2016;8:182.
Hubbert M, Sievers H, Lehnfeld R, Kehrl W. Efficacy and tolerability of a spray with Salvia officinalis in the treatment of acute pharyngitis—a randomised, double-blind, placebo-controlled study with adaptive design and interim analysis. Eur J Med Res 2006;11:20–26.
Hensel A, Maas M, Sendker J, et al. Eupatorium perfoliatum L: Phytochemistry, traditional use and current applications. J Ethnopharmacol 2011;138:641–651.
Northwest Naturopathic Urology
Seattle, WA
Faculty, Bastyr University
Kenmore, WA
Traditional Japanese Herbal Medicine
Upper respiratory infections (URIs) are frequently caused by viruses. 1 URIs are common in all ages. Individuals may be affected by several viral URIs annually, 2 which results in personal inconveniences, for example absence from school or work, and increased social burden.
In Japan, viral URIs are commonly treated with traditional Japanese herbal medicine, namely Kampo medicine. Patients with symptoms of URI can access treatment from primary-care physicians; physicians can prescribe Kampo medicine under the national health insurance system. Kakkonto is one of the most commonly used Kampo formulas in Japan. 3 Patients can also buy Kampo medicine for viral URIs via community pharmacies. Some individuals may buy Kampo medicine and keep it at home for use when they become sick. In Japan, Kampo medicine is widely accepted. It is considered to be useful in primary-care settings.
Influenza is one of the most common and burdensome viral URIs. Several basic and clinical studies have reported on the effect of maoto (Ma-Huang-Tang in Chinese), an ancient multicomponent herbal formulation against influenza extracted from four crude drugs: ephedra herb, apricot kernel, cinnamon bark, and glycyrrhiza root. Findings from randomized controlled trials suggest that maoto is anti-pyretic, and its effect is equivalent to neuraminidase inhibitors, such as oseltamivir or zanamivir. 4 Maoto may be administered together with these neuraminidase inhibitors to enhance anti-pyretic and analgesic effects. 5,6 No severe adverse reaction has been reported in previous clinical trials.
Several newer-generation anti-influenza medications have been proposed recently. We are heading to a post-neuraminidase inhibitor era. Maoto and other Kampo formulas are much more cost-effective compared to neuraminidase inhibitors or other new medications. 7 To date, there have been no reports of Kampo-resistant influenza virus. This is because Kampo medicine consists of multiple ingredients and also modulates host immune reactions. 8
Kampo medicine is an effective, inexpensive, and resistance-free treatment for viral URIs.
References
Heikkinen T, Jarvinen A. The common cold. Lancet 2003;361:51–59.
Spector SL. The common cold: Current therapy and natural history. J Allergy Clin Immunol 1995;95:1133–1138.
Katayama K, Yoshino T, Munakata K, et al. Prescription of Kampo drugs in the Japanese health care insurance program. Evid Based Complement Alternat Med 2013;2013:576973.
Nabeshima S, Kashiwagi K, Ajisaka K, et al. A randomized, controlled trial comparing traditional herbal medicine and neuraminidase inhibitors in the treatment of seasonal influenza. J Infect Chemother 2012;18:534–543.
Kubo T, Nishimura H. Antipyretic effect of Mao-to, a Japanese herbal medicine, for treatment of type A influenza infection in children. Phytomedicine 2007;14:96–101.
Saita M, Naito T, Boku S, et al. The efficacy of ma-huang-tang (maoto) against influenza. Health 2011;3:300–303.
Arita R, Yoshino T, Hotta Y, et al. National cost estimation of maoto, a Kampo medicine, compared with oseltamivir for the treatment of influenza in Japan. Tradit Kampo Med 2016;3:59–62.
Nishi A, Ohbuchi K, Kushida H, et al. Deconstructing the traditional Japanese medicine “Kampo”: Compounds, metabolites and pharmacological profile of maoto, a remedy for flu-like symptoms. NPJ Syst Biol Appl 2017;3:1–11.
Center for Kampo Medicine,
Keio University School of Medicine
Tokyo, Japan
Evidence-Based Yoga Therapy
Alternative and complementary therapies are commonly used in the prevention of respiratory infections. Today, yoga therapy is a well-recognized complementary therapy used in hospitals, as well as at comprehensive clinical respiratory care centers. 1,2 Prānāyāma (yogic breathing exercises) have been associated with significant improvements in respiratory function, especially with the measure of vital capacity. Improvements have been seen in healthy individuals, asthmatics, and chronic smokers. 3 In one study in which respiratory changes with yoga were compared to a regular exercise program, 4 the yoga group had an improvement in maximum oxygen uptake and lower perceived exertion after maximal exercise testing. Another study by Bhargava 5 reported that Prānāyāma appears to alter autonomic responses to breath-holding by increasing vagal tone and decreasing sympathetic discharges. Yogic wisdom 1,3,5 suggests that if Prānāyāma is combined with other yogic practices such as Āsana (physical postures) and Dhyāna (meditation techniques), it may produce the best outcomes for patients with respiratory infections.
Based on this yogic wisdom and a systematic review done at Sanchi University of Buddhist-Indic Studies, the suggested evidence-based yoga therapy module for treating respiratory infections may include the following yogic practices
3,5
–7
:
Āsana (postures): Suryanamaskāra (salutations to the sun), Skandha Chakra (shoulder socket rotation), Tādāsana (palm tree pose), Tiryaka Tādāsana (swaying palm tree pose), Kati Chakrāsana (waist rotating pose), and Gomukhāsana (cow's face pose)
Prānāyāma (breathing techniques): Nādi Shodhana Prānāyāma (alternate nostril breathing) and Bhastrikā Prānāyāma (bellows breath)
Bandha (lock): Uddiyāna Bandha (abdominal contraction)
Dhyāna (meditation): Yoga Nidrā (deep relaxation technique) and Āntar Mouna (inner silence)
References
Mishra SK, Singh P, Bunch SJ, Zhang R. The therapeutic value of yoga in neurological disorders. Ann Indian Acad Neurol 2012;15:247–254.
Rudra S, Kalra A, Kumar A, Joe W. Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014. PLoS One 2017;12:e0176916.
Birkel DA, Edgren L. Hatha yoga: Improved vital capacity of college students. Altern Ther Health Med 2000;6:55–63.
Ray US, Sinha B, Tomer OS, et al. Aerobic capacity and perceived exertion after practice of Hatha yogic exercises. Indian J Med Res 2001;114:215–121.
Bhargava R, Gogate MG, Mascarenhas JF. Autonomic responses to breath holding and its variations following prānāyāma. Indian J Physiol Pharmacol 1988;32:257–264.
Satyananda S. Āsana Prānāyāma Mudra Bandha. Munger, Bihar, India: Yoga Publications Trust, 2008.
Visweswaraiah NK, Telles S. Randomized trial of yoga as a complementary therapy for pulmonary tuberculosis. Respirology 2004;9:96–101.
Sanchi University of Buddhist-Indic Studies
Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis
Bhopal, India
Yoga
Various therapies such as yoga, Ayurveda, and Traditional Chinese Medicine have been proved beneficial in improving immune resistance. 1 –3 Yoga is an ancient science and practice on how postures, breathing, and a philosophy can beneficially affect the body and mind. Yoga texts detail the manifestation of psychosomatic diseases, mentioned as Adhija-Vyadhi in the yogic literature. 4 The literature describes the occurrence of physical diseases due to mental afflictions by vitiating the normal vital energy (Prana) patterns of an individual. 4 This in turn is believed to result in immune disorders. 5,6 The literature also describes the reversibility of mind–body diseases through yoga. 4,6
These concepts have served as the principles for prescription of specific yoga modules for diseases. 4 Accordingly, a specific yoga module that includes joint loosening exercises, breathing exercises, yogāsanas (physical postures), prānāyāma (voluntary regulated breathing), guided meditation, and relaxation techniques has been formulated for chronic respiratory infections and for improving immune resilience, as shown in Table 1. Yoganidrā (yogic relaxation technique) has been shown to reduce erythrocyte sedimentation rate when practiced for 30 minutes a day for six months. 7 Yoga has proven to be beneficial as an adjunct to anti-tuberculosis treatment (ATT) in pulmonary tuberculosis patients by reducing symptom scores and improving lung capacities and radiographic images. 8 The yoga group had signicantly more patients showing sputum conversion based on microscopy when compared to the breath awareness group. 8 Sudarshan Kriya Yoga significantly increased natural killer cells at 24 weeks. 9 Yoga has also been shown to have a buffering effect on stress-induced decrease in cellular immunity. 6 Researchers have concluded that yoga seems to act on the hypothalamus and the anterior pituitary via cerebro–cortico–limbic pathways, influencing the hypothalamic–pituitary–adrenal axis to balance the sympathetic and parasympathetic parts of the autonomic nervous system for appropriate immune regulation. 5,6 Thus, yoga acts as potent therapy for building immune resilience to prevent respiratory infections and as an adjunct in acute respiratory infections.
Yoga Module for Chronic Respiratory Infections and for Improving Immune Resilience
References
Patwardhan B, Warude D, Pushpangadan P, Bhatt N. Ayurveda and Traditional Chinese Medicine: A comparative overview. Evid Based Complement Alternat Med 2005;2:465–473.
Morgan N, Irwin MR, Chung M, Wang C. The effects of mind–body therapies on the immune system: Meta-analysis. PloS One 2014;9:e100903.
Mahajan AS. Role of yoga in hormonal homeostasis. Int J Clin Exp Physiol 2014;1:173.
Venkatesananda S. Vasistha's Yyoga. Albany, NY: SUNY Press, 2010.
Arora S, Bhattacharjee J. Modulation of immune responses in stress by Yoga. Int J Yoga 2008;1:45–55.
Gopal A, Mondal S, Gandhi A, et al Effect of integrated yoga practices on immune responses in examination stress—A preliminary study. Int J Yoga 2011;4:26–32.
Kumar K, Pranav P. A study on the impact on ESR level through yogic relaxation technique yoga nidrā. Indian J Tradit Knowl 2012;11:358–361.
Visweswaraiah NK, Telles S. Randomized trial of yoga as a complementary therapy for pulmonary tuberculosis. Respirology 2004;9:96–101.
Kochupillai V, Kumar P, Singh D, et al. Effect of rhythmic breathing (Sudarshan Kriya and Pranayam) on immune functions and tobacco addiction. Ann N Y Acad Sci 2005;1056:242–252.
NIMHANS Integrated Centre for Yoga,
Department of Psychiatry-NIMHANS
Bangalore, India
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