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Chronic obstructive pulmonary disease (COPD)

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Related Terms
  • Alpha-1-antitrypsin deficiency (AAt), Arterial blood gases (ABGs), bronchial tubes, bronchitis, bronchodilators, chronic bronchitis, corticosteroids, cutis laxa, dyspnea, emphysema, inhaled steroids, leukotriene modifiers, lung disease, lung transplant, Marfan syndrome, plethysmograph, pulmonary disease, pulmonary function tests, pulse oximetry, PFTs, respiratory failure, shortness of breath (SOB), smoking cessation, spirometry test, sputum examination, supplemental oxygen.

Background
  • Chronic obstructive pulmonary disease (COPD) is a type of lung disease that involves damage or obstruction to the airways of the lungs, making it difficult to breathe. COPD is an overall term referring to a group of chronic lung conditions, most commonly including chronic bronchitis and emphysema, and possibly asthma or asthmatic bronchitis. While chronic bronchitis and emphysema may occur separately, it is common for patients to have both diseases at the same time.
  • Chronic bronchitis is characterized by an ongoing, mucus-producing cough that that occurs most days of the month, three months a year for two consecutive years or more. Constant coughing causes the bronchial tubes to become inflamed. Eventually, the airways become scarred. Long-term irritation also leads to the production of mucus, which further irritates and blocks the bronchial tubes. As a result, less oxygen is able to enter the airways.
  • In addition, the excessive mucus in the bronchial tubes provides an environment for disease-causing bacteria to grow. Therefore, lung infections are common complications of chronic bronchitis.
  • Emphysema is an incurable illness that occurs when the walls between the air sacs (alveoli) in the lungs lose their ability to stretch and recoil, causing shortness of breath (SOB).
  • The Centers for Disease Control (CDC) report that COPD affects up to 24 million Americans, and according to the American Lung Association, is the fourth leading cause of death in the United States. COPD patients typically die from complications, such as severe lung infections, heart problems, or lung cancers.
  • The main risk factor for COPD is smoking. Researchers estimate that smoking causes 80-90% of COPD deaths. According to the American Lung Association, female smokers are nearly 13 times more likely to die from COPD than females who have never smoked. Male smokers are nearly 12 times more likely to die from COPD than males who have never smoked.
  • There is currently no cure for COPD. Instead treatment focuses on reducing the symptoms and complications of the disease. Treatment varies, depending on the specific condition. It can range from medication and oxygen supplementation to transplant surgery. Bronchodilators are commonly used to relax the bronchi muscles in the lungs that can cause bronchospasms and restrict the airways.

Signs and symptoms
  • General: Symptoms of chronic obstructive pulmonary disease (COPD) usually develop gradually over many years. They typically worsen over time. Some patients may suffer from either chronic bronchitis or emphysema, while other may have both diseases.
  • Patients who have had COPD for many years may develop bluish discoloration of the lips and nail beds (cyanosis). This occurs when there is not enough oxygen in the blood. Some patients may develop headaches in the morning because they are unable to remove carbon dioxide from the blood. Many people with COPD also experience weight loss because their body requires more energy to breathe than the average person.
  • Chronic bronchitis: Symptoms of chronic bronchitis include chronic cough, increased mucus that is yellow-greenish in color, frequent clearing of the throat, wheezing, and shortness of breath (SOB). Patients typically experience fatigue because the body has to work harder to get enough oxygen.
  • Emphysema: Shortness of breath (dyspnea), especially during activity, is one of the earliest symptoms of emphysema. As the disease progresses, shortness of breathe becomes constant, even during rest. An individual is likely to feel tired both because it is more difficult to breathe and because the body is getting less oxygen.
  • Other symptoms include distress resulting from the inability to get enough air, wheezing, chronic mucus production, exhaling through pursed (puckered) lips or grunting before exhaling, and needing to lean forward to breathe while sitting. Individuals with emphysema are often thin and have very pink skin. Individuals with advanced disease may have the characteristic barrel chests from the increase in lung size.

Diagnosis
  • Pulmonary function tests (PFTs): Pulmonary function tests (PFTs) can detect chronic obstructive pulmonary disease (COPD) before symptoms are seen. These noninvasive tests measure how much air the lungs can hold and the flow of air in and out of the lungs. They can also measure the amount of oxygen and carbon dioxide exchanged in the lungs. They include a spirometry test and lung volume test.
  • In a spirometry test, a person breathes into mouthpiece that is connected to an instrument called a spirometer. The spirometer records the amount and the rate of air that is breathed in and out over a specified time. Some of the test measurements are obtained by normal, quiet breathing, and other tests require forced inhalation or exhalation after a deep breath.
  • Lung volume measurement detects restrictive lung diseases. In this set of diseases, a person cannot inhale a normal volume of air. Restrictive lung diseases may be caused by inflammation or scarring of the lung tissue (interstitial lung disease) or by abnormalities of the muscles or skeleton of the chest wall.
  • Lung volume measurement can be performed in two ways. The most accurate way is for an individual to sit in a sealed, transparent box called a body plethysmograph. This box looks similar to a telephone booth. The patient then breathes in and out a mouthpiece while inside the plethysmograph. Changes in pressure inside the box allow determination of the lung volume. Lung volume can also be measured when an individual breathes nitrogen or helium gas through a tube for a specified period of time. The concentration of the gas in a chamber attached to the tube is measured, allowing estimation of the lung volume.
  • Chest X-ray: A chest X-ray may be performed to rule out other lung problems, such as lung cancer. Even in the advanced stages of emphysema, chest X-rays are often normal.
  • Blood tests: Arterial blood gases (ABGs) measure how well the lungs transfer oxygen to the bloodstream and how effectively they remove carbon dioxide from the bloodstream. A blood test for the alpha-1-antitrypsin (AAt) gene, which is found in some individuals with emphysema, may also be used.
  • Pulse oximetry: This test involves use of a small device that attaches to the fingertip to measure the amount of oxygen in the blood. To help determine whether or not the individual needs supplemental oxygen, the test may be performed at rest, during exercise, and overnight.
  • Sputum examination: A healthcare provider may take a sample of the patient's mucus (sputum) to help determine the cause of some lung problems. If disease-causing microorganisms (e.g. bacteria) are present, there is infection. If there is blood in the sputum, this may indicate lung damage or lung cancer.
  • Computerized tomography (CT) scan: A CT scan allows a healthcare professional to see the organs in two-dimensional images or "slices." Split-second computer processing creates these images as a series of very thin X-ray beams are passed through the body. A CT scan can detect emphysema sooner than an X-ray can, but it cannot assess the severity of emphysema as accurately as a pulmonary function test.

Complications
  • Death: Individuals with chronic obstructive pulmonary disease (COPD) may die from complications of the disease. Causes of death may include lung cancer, lack of blood flow and oxygen to the brain (stroke), respiratory failure, lung infections, and heart attack.
  • Heart problems: For unknown reasons, COPD increases risk of developing heart disease, including heart attacks. The heart may become enlarged because it is strained. COPD may cause high blood pressure in the arteries that bring blood to the lungs.
  • Infections: Patients with COPD may suffer from frequent infections, including the common cold, flu, and pneumonia. Lung infections make breathing even more difficult for COPD patients. Infections also cause even more irreversible damage to the lung tissue. Patients should talk to their healthcare providers about recommended vaccines. The flu shot is usually recommended in non-allergic COPD patients.
  • Lung cancer: Smokers with chronic bronchitis have a higher risk of developing lung cancer than smokers who do not have chronic bronchitis.
  • Quality of life: People with advanced emphysema are often incapacitated. They experience shortness of breath even when resting or sitting in a chair or bed. Patients should consult their healthcare providers if they experience feelings of sadness, low self-esteem, loss of pleasure, apathy, and sometimes, difficulty functioning for two weeks or longer, with no known underlying cause. These may be signs of depression.

Treatment
  • General: There is currently no cure for chronic obstructive pulmonary disease (COPD). Treatment focuses on reducing symptoms and preventing complications. Patients should take their medications exactly as prescribed to help prevent life-threatening complications, such as heart attack, from occurring. Patients should also tell their healthcare providers if they are taking any other drugs (prescription or over-the-counter), herbs, or supplements, because they may interact with treatment.
  • Smoking cessation: Smoking cigarettes may worsen symptoms of COPD. Therefore, Patients are encouraged to stop smoking. Nicotine replacement products, including the patch (Habitrol®, Nicoderm CQ®, Nicotrol®), chewing gum (Nicorette®), lozenges (Commit®), inhalers (Nicotrol Inhaler®), nasal sprays (Nicotrol NS®), and the antidepressant bupropion (Zyban®), may help patients quit smoking. These drugs work in part by continuing to release low levels of a brain chemical called dopamine. In this way, these smoking cessation medications decrease the craving for nicotine and reduce the signs and symptoms of withdrawal.
  • Varenicline (Chantix®) is a newer drug that works in a similar way. Chantix® stimulates the release of low levels of dopamine in the brain to help reduce the signs and symptoms of withdrawal. In addition, Chantix® blocks nicotine receptors in the brain. The U.S. Food and Drug Administration (FDA) has approved the course of Chantix® treatment for 12 weeks. Individuals who successfully quit smoking during Chantix® treatment may continue to use Chantix® for an additional 12 weeks to further increase the likelihood of long-term smoking cessation. Side effects of Chantix® include changes in taste, nausea, vomiting, gas, and insomnia (inability to sleep).
  • Bronchodilators: Medications called bronchodilators may help relieve coughing, shortness of breath, and difficulty breathing by opening constricted airways. Bronchodilators relax the muscles around the airways, making it easier to breath. Patients typically use an inhaler to take bronchodilators, but tablets are also available for some. Depending on the severity of the disease, a patient may need a short-acting bronchodilator before physical activities, a long-acting bronchodilator that is used every day, or both. Commonly prescribed bronchodilators include albuterol (Ventolin® or Proventil®), metaproterenol (Alupent®), terbutaline (Brethine®), theophylline (Theo-Dur® or Slo-bid®), and perbuterol (Maxair®).
  • Steroids: Steroids are used to prevent and reduce airway swelling, as well as decrease the amount of mucus in the lungs. Steroids may either be inhaled with an inhaler or taken by mouth. Examples of inhaled steroids include beclomethasone (Beclovent® or Vanceril®), budesonide (Pulmicort Respules®), flunisolide (Aerobid®), fluticasone (Flovent®), and triamcinolone (Azmacort®). Inhaled steroids seem to have fewer side effects than steroids that are taken by mouth. These drugs are typically used to treat moderate or severe COPD. Prolonged use of inhaled steroids may weaken the bones and increase the risk of cataracts, diabetes, and heart disease, including high blood pressure, high cholesterol levels, chest pain, and heart attack.
  • Commonly prescribed corticosteroids that are taken by mouth include prednisone (Prednisone Intensol®, Sterapred®, or Sterapred® DS), and triamcinolone (Aristocort®).
  • Liquid corticosteroids, such as Pediapred® or Prelone®, are available for children. These medications can be used short-term for severe symptoms, such as extreme shortness of breath.
  • Leukotriene modifiers: Leukotriene modifiers, such as zafirlukast (Accolate®) or montelukast (Singulair®), are a new type of long-term control medication. They help prevent airway inflammation and swelling. They also help decrease the amount of mucus in the lungs.
  • Supplemental oxygen: Patients who have extreme difficulty breathing may benefit from supplement oxygen. Various forms of oxygen are available, as well as different devices to deliver them to the lungs. A healthcare provider will help the patient set up oxygen for home use.
  • Lung transplant: Patients with severe emphysema may benefit from lung transplantations. Usually just one lung is transplanted because the survival rate has been proven to be higher for individuals with single-lung transplants than for individuals with double-lung transplants.
  • Surgery: In a procedure called lung volume reduction surgery (LVRS), surgeons remove small pieces of damaged lung tissue. The extra space that is created in the lungs after surgery appears to help the remaining lung tissue work more efficiently.
  • Pulmonary rehabilitation program: A key part of COPD treatment involves a pulmonary rehabilitation program, which combines education, exercise training, and behavioral intervention to help restore the individual with emphysema to the highest possible level of independent living.

Integrative therapies
  • Good scientific evidence:
  • Boswellia: Boswellia has been proposed as a potential therapy for asthma. Future studies are needed to assess the long-term efficacy and safety of boswellia and to compare the efficacy of boswellia to standard therapies. Boswellia should not be used for the relief of acute asthma exacerbations. Boswellia is generally believed to be safe when used as directed, although safety and toxicity have not been well studied in humans. Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease (GERD). Use cautiously if taking lipid-soluble medications, agents metabolized by the liver's cytochrome P450 enzymes, or sedatives. Use cautiously with impaired liver function or liver damage or lung disorders. Use cautiously in children. Avoid if pregnant due to potential abortifacient effects or if breastfeeding.
  • Buteyko breathing technique: The Buteyko breathing technique (BBT) consists of breathing techniques, relaxation exercises, and asthma education. The technique aims to reduce hyperventilation. Studies have shown reduced use of rescue inhalers among patients receiving BBT. Improvements in other measures of asthma severity have not been shown. Additional study is warranted.
  • BBT is generally considered safe. Avoid with asthma that changes suddenly ("brittle asthma"). BBT may interact with asthma medications and should be used with caution when decreasing asthma medication. Asthma should be treated by a qualified healthcare professional and patients should always carry a rescue inhaler. Avoid if pregnant or breastfeeding.
  • Choline: Choline is possibly effective when taken orally for asthma. Choline supplements seem to decrease the severity of symptoms, number of symptomatic days and the need to use bronchodilators in asthma patients. There is some evidence that higher doses of 3 grams daily might be more effective than lower doses of 1.5 grams daily. Choline is generally regarded as safe and appears to be well-tolerated. Avoid if allergic/hypersensitive to choline, lecithin, or phosphatidylcholine. Use cautiously with kidney or liver disorders or trimethylaminuria. Use cautiously with a history of depression. If pregnant or breastfeeding it seems generally safe to consume choline within the recommended adequate intake (AI) parameters; supplementation outside of dietary intake is usually not necessary if a healthy diet is consumed.
  • Coleus: There is a lack of sufficient data to recommend for or against the use of coleus in the treatment of bronchial asthma. Preliminary data appears to be promising. However, larger, randomized, controlled trials are needed to confirm the safety and efficacy of coleus in bronchial asthma. Coleus is generally regarded as safe, as very few reports have documented adverse effects. However, only a few short-term trials have assessed its safety in a small sample size of patients. Avoid if allergic to Coleus forskohlii and related species or with bleeding disorders. Avoid if pregnant or breastfeeding.
  • Ephedra: Ephedra contains the chemicals ephedrine and pseudoephedrine, which are bronchodilators (expand the airways to assist in easier breathing). It has been used and studied to treat asthma and chronic obstructive pulmonary disease, such as asthmatic bronchoconstriction, in both children and adults. Other treatments such as beta-agonist inhalers (for example, albuterol) are more commonly recommended due to safety concerns with ephedra or ephedrine. However, the U.S. Food and Drug Administration (FDA) has collected thousands of reports of serious toxicity linked to ephedra (including over 100 deaths). Ephedra products are banned from dietary supplements because of serious health risks, including heart attack, heart damage, breathing difficulties and fluid retention in the lungs. Avoid ephedra if pregnant or breastfeeding.
  • Psychotherapy: Family psychotherapy may slightly improve wheezing and thoracic gas volume for asthma in children, according to several studies.
  • Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.
  • Pycnogenol: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster spp. atlantica), which is grown in coastal south-west France. Pycnogenol may offer clinical benefit to both children and adults with asthma. Additional study is needed before a conclusion can be made. Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.
  • Yoga: Multiple human studies report benefits of yoga (such as breathing exercises), when added to other treatments for mild-to-moderate asthma (such as standard drug therapy, diet, or massage). Better research is needed before a firm conclusion can be drawn.
  • Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Unclear or conflicting scientific evidence:
  • Acupressure, shiatsu: Preliminary research suggests that acupressure may be of benefit in improving quality of life in asthma. Further well-designed studies are needed before firm conclusions can be drawn. A combination of acupressure and massage may reduce dyspnea (labored breathing) and anxiety in patients with chronic obstructive pulmonary disease (COPD) who use prolonged mechanical ventilatory support. Further study of acupressure alone is needed before a recommendation can be made. A small study of patients undergoing pulmonary rehabilitation reported acupressure to be beneficial for decreasing dyspnea. Larger, well-designed studies are needed before clear conclusions can be drawn.
  • With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
  • Acupuncture: Some research suggests acupuncture may help prevent exercise-induced asthma and that it may reduce the perceived level of breathlessness associated with asthma or emphysema. However, reviewers agree that the available studies are small, poorly designed, and insufficient for making recommendations. A few studies have found no support for the use of acupuncture for asthma. Overall there is insufficient evidence on which to base recommendations for acupuncture to treat breathlessness in chronic obstructive pulmonary disease (COPD).
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. There is currently not enough scientific evidence to make a strong recommendation for the use of the Alexander technique in chronic asthma patients. More study is needed in this area. There is a lack of high-quality research describing the effect of the Alexander technique on respiration. No serious side effects have been reported with use of the Alexander technique. It has been suggested that the technique may be less effective with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.
  • Applied kinesiology: Applied Kinesiology (AK) is an assessment technique that uses muscle strength testing with the aim to identify nutritional deficiencies and health problems. It is based on the concept that weakness in certain muscles corresponds to specific disease states or body imbalances. Study results are mixed in regards to bronchial asthma. Further research is needed before conclusions can be drawn. Applied kinesiology techniques in themselves are harmless. However, medical conditions should not be treated with AK alone, and should not delay appropriate medical treatment.
  • Aromatherapy: Early evidence suggests that aromatherapy may aid mucus clearance in chronic obstructive pulmonary disease (COPD). More studies are needed before conclusions about this application of aromatherapy can be made. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid if history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Ayurveda: There is early evidence that daily supplementation with gum resin of Boswellia serrata, known in Ayurveda as Salai guggal, may reduce dyspnea (shortness of breath), rhonchi, and the number of attacks in bronchial asthma. Another herb, Devadaru (Cedrus deodara), may have antispasmodic effects and reduce symptoms in bronchial asthma, particularly for patients with shorter histories of asthma and lower frequencies of attacks. Further research is needed in this area before a recommendation can be made.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before use of any herbs or supplements. Use guggul cautiously with peptic ulcer disease. Avoid sour food, alcohol, and heavy exercise. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia hebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
  • Belladonna: Belladonna may improve the prevention of airway obstruction and reduce the amount of mucus produced. However, due to a lack of high-quality human research in this area, there is not enough evidence to form a clear conclusion.
  • Avoid if allergic to belladonna or plants of the Solanaceae(nightshade) family (bell peppers, potatoes, eggplants). Avoid with history of heart disease, high blood pressure, heart attack, abnormal heartbeat (arrhythmia), congestive heart failure, stomach ulcer, constipation, stomach acid reflux (serious heartburn), hiatal hernia, gastrointestinal disease, ileostomy, colostomy, fever, bowel obstruction, benign prostatic hypertrophy, urinary retention, glaucoma (narrow angle), psychotic illness, Sjögren's syndrome, dry mouth (xerostomia or salivary gland disorders), neuromuscular disorders such as myasthenia gravis, and Down's syndrome. Avoid if pregnant or breastfeeding.
  • Beta-carotene: The prevalence of bronchitis and shortness of breath in male smokers with chronic obstructive pulmonary disorder (COPD) seems to be lower in those patients who consume a diet containing high amounts of beta-carotene. However, beta-carotene supplements have not been proven to benefit COPD and may actually increase cancer rates in smokers. Based on preliminary evidence, taking a mixture of beta-carotene isomers orally may prevent exercise-induced asthma. However, because synthetic beta-carotene has not been well tested for this indication, the difference between the activities of the two supplements cannot be deduced. Further research is needed before a strong recommendation can be made. Avoid if sensitive to beta-carotene, vitamin A or any other ingredients in beta-carotene products.
  • Black tea: Research has shown caffeine to cause improvements in airflow to the lungs (bronchodilation). However, it is not clear if caffeine or tea use has significant clinical benefits in people with asthma. Better research is needed in this area before a conclusion can be drawn.
  • Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.
  • Borage seed oil: The flowers and leaves of borage (Borago officinalis) are often pressed to produce oil very high in gamma-linolenic acid (GLA). Preliminary evidence suggests that gamma linolenic acid (GLA) may have some immunosuppressant activity that may be helpful in reducing asthma symptoms. Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.
  • Bromelain: Bromelain is a digestive enzyme extracted from the stem and the fruit of the pineapple plant (Ananas comosus, family Bromeliaceae). There is currently not enough information to recommend for or against the use of bromelain in chronic obstructive pulmonary disorder (COPD). Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or other members of the Bromeliaceaefamily. Use cautiously with a history of bleeding disorders, stomach ulcers, heart disease, liver, or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
  • Butterbur: Historically, butterbur has been used to treat asthma. Pre-clinical studies report anti-inflammatory and leukotriene inhibitory properties, which may lead to clinical effects. Initial human research suggests possible benefits. However, controlled trials with adequate sample sizes are necessary in order to clarify whether there are true benefits in humans. Use caution if allergic or sensitive to Petasites hybridus or other plants from the Asteraceae/Compositae family (like ragweed, marigolds, daisies, and chrysanthemums). Raw, unprocessed butterbur plant should not be eaten due to the risk of liver or kidney damage or cancer. Avoid if pregnant or breastfeeding.
  • Chiropractic: Several studies report the effects of chiropractic spinal manipulative therapy on breathing indices and quality of life in children and adults with asthma. Results are variable, and in the studies with positive results, mostly subjective but not objective (lung function test) changes are reported. Due to methodological problems and variable results, no clear conclusions can be drawn in this area. There is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of chronic obstructive pulmonary disorder (COPD).
  • Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
  • Coenzyme Q10: CoQ10 may benefit asthma patients when added to other therapies. Further research is needed. Asthma should be treated by a qualified healthcare provider. Allergy has not been associated with Coenzyme Q10 supplements, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs, or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.
  • Coleus: Coleus species have been used in the Asian traditional medicine to treat angina, asthma, bronchitis, epilepsy, insomnia, skin rashes, and a wide range of digestive problems. Pretreatment with coleus may be beneficial as a breathing aid for intubation, especially for middle-aged smokers. More research is needed.
  • Coleus is generally regarded as safe, as very few reports have documented adverse effects. However, only a few short-term trials have assessed its safety in a small sample size of patients. Avoid if allergic to Coleus forskohlii and related species or with bleeding disorders. Avoid if pregnant or breastfeeding.
  • Cordyceps: Cordyceps may reduce some asthma symptoms. Additional studies are needed to make a firm recommendation. There is currently insufficient evidence from clinical study to draw a conclusion on the use of cordyceps for other respiratory disorders.
  • Avoid if allergic or hypersensitive to cordyceps, mold, or fungi. Use cautiously with diabetes or bleeding disorders or if taking anticoagulant medications. Use cautiously with prostate conditions, if taking immunosuppressive medications, or if on hormonal replacement therapy or oral contraceptives. Avoid with myelogenous-type cancers. Avoid if pregnant or breastfeeding.
  • Creatine: It is unclear if creatine may help treat chronic obstructive pulmonary disease (COPD). Study results are mixed. More clinical trials are needed before a conclusion can be made. Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.
  • Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. Better studies are needed in which danshen is compared with more proven treatments for asthmatic bronchitis before a clear conclusion can be drawn.
  • Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin or hypotensives including ACE inhibitors such as captopri, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure and following cerebal ischemia. Avoid if pregnant or breastfeeding.
  • English ivy: Currently, there is insufficient available information to recommend for or against the use of English ivy in treating asthma in children or in treating chronic obstructive pulmonary disease COPD). Additional study is needed.
  • Avoid if allergic or hypersensitive to English ivy (Hedera helix), its constituents, or members of the Araliaceae family. In addition, crossreaction or cross-senstivity has been noted between Hedera helix and Dendropanax trifidus, Schefflera arboricola, dandelion (Taraxacum officinale), false ragweed (Ambrosia acanthicarpa), giant ragweed (Ambrosia trifida), short ragweed (Ambrosia artemisifolia), sagebrush (Artemisia tridentata), wild feverfew (Parthenium hysterophorus), yarrow (Achillea millifolium), and tansy (Tanacetum vulgare), and some Dahlia species. Use cautiously with cancer or taking antineoplastic (anticancer) agents. Avoid if pregnant or breastfeeding.
  • Eucalyptus oil: Further research is needed to confirm anti-inflammatory and mucolytic activity of eucalyptus oil before it can be recommended in upper and lower airway diseases, such as asthma. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
  • Gingko: Ginkgo biloba has been used medicinally for thousands of years and is currently one of the top selling herbs in the United States. Ginkgo may reduce symptoms in patients with asthma. More study is needed to make a conclusion. Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergy to mango rind, sumac, poison ivy or oak or cashews exists, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.
  • Ginseng: Limited research suggests that ginseng has positive effects on breathing, such as its proposed role as a bronchodilator. Ginseng was reported to improve lung function and exercise capacity in patients with chronic obstructive pulmonary disease COPD). Several studies have also looked at the effects of ginseng in a variety of lung conditions. Early results are promising, but many studies have used combination products, making it difficult to evaluate the effect of ginseng. More research using ginseng alone is needed in this area. Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
  • Goji: In traditional Chinese medicine (TCM), herbs are almost always administered in combination formulas consisting of several herbs that balance each other's effects and enhance the success of the treatment. A case study provides some initial objective data on the formula "Invigorating Kidney," which includes wolfberry together with six other herbs. This herbal decoction showed that it may be possible to reverse airway obstruction for patients convalescing from asthma.
  • Use cautiously in patients who are taking blood-thinning medications, such as warfarin. Use cautiously in asthma patients and in patients with sulfite sensitivities. The New York Department of Agriculture has detected the presence of undeclared sulfites, a food additive, in two dried goji berry products from China. Avoid in patients who are allergic to goji, any of its constituents, or to members of the Solanaceae family.
  • Green tea: Research has shown caffeine to cause improvements in airflow to the lungs (bronchodilation). However, it is not clear if caffeine or tea use has significant benefits in people with asthma. Better research is needed in this area before a conclusion can be drawn. Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.
  • Green-lipped mussel: Limited evidence suggests that green-lipped mussel supplementation may help allergic diseases, such as atopic asthma. Additional research is needed before a recommendation can be made. Green-lipped mussel is generally considered safe. Use cautiously with anti-inflammatory agents. Use cautiously with asthma. Avoid in patients with liver disease. Avoid with allergy or sensitivity to green-lipped mussel or other shellfish. Avoid if pregnant or breastfeeding.
  • Guided imagery: A small study reports increased outcomes of relaxation in chronic obstructive pulmonary disease (COPD) with use of guided imagery techniques. Additional research is needed to confirm these results. Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery.
  • Hydrotherapy: There is preliminary evidence that daily breathing exercises in a warm pool may improve lung function measurements in patients with chronic obstructive pulmonary disease (COPD). It is not clear if this technique is superior to breathing exercises alone. Evidence from controlled trials is necessary before a clear conclusion can be drawn.
  • Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
  • Hypnotherapy, hypnosis: Preliminary research for the use of hypnosis for the management of asthma symptoms does not provide clear answers. Anxiety associated with asthma may be relieved with hypnosis. Additional research is needed before a firm conclusion can be drawn. Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Kiwi: Currently data on the therapeutic benefit of kiwi as a preventative for lung conditions is lacking. A survey study suggests that kiwi and other fruits high in vitamin C may be effective for the prevention of respiratory problems in children, especially wheezing. However, properly controlled studies are lacking at this time. More research is warranted before a recommendation can be made.
  • Avoid if allergic or hypersensitive to kiwi, latex, birch pollen, banana, chestnut, fig, flour, melon, poppy seeds, rye grain, sesame seeds and related substances. Kiwi is generally considered safe when taken in amounts naturally found in foods. Use cautiously with anti-platelet drugs like aspirin, cilostazol or clopidogrel. Use cautiously with hormone therapies or serotonergic drugs. Avoid if pregnant or breastfeeding because there are no clinical trials that have tested its safety in supplemental doses. The amount found in foods appears to be safe in most people.
  • Lactobacillus acidophilus: Lactobacillus acidophilus has been suggested as a possible treatment for asthma. However, further research is necessary before a firm conclusion can be made. Acidophilus may be difficult to tolerate if allergic to dairy products containing L. acidophilus. Avoid with a history of an injury or illness of the intestinal wall, immune-disease, or heart valve surgery. Avoid with prescription drugs, like corticosteroids, because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus. Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid®), esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.
  • L-Carnitine: Currently there is insufficient evidence to support the use of carnitine for respiratory distress in adults. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Lutein: There is early evidence of a role of carotenoids in lung function and severity of respiratory infections. However, there is no association between levels of lutein in the blood and illness severity in the elderly or in lung function in adults. More information is required in this field before a strong recommendation can be made. Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.
  • Lycopene: Laboratory research suggests that lycopene, like other carotenoids, may have antioxidant properties and may be helpful in the prevention of exercise-induced asthma. There is limited, poor-quality research in this area, and further evidence is needed before a firm conclusion can be made. Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.
  • Massage: Promising initial evidence suggests that massage therapy may improve lung function in children with asthma. Additional research is necessary before a firm conclusion can be drawn. Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: Preliminary research of transcendental meditation® for asthma reports benefits. However, due to unclear design or study description, these results cannot be considered definitive.
  • Sahaja yoga, which incorporates meditation techniques, may have some benefit in the management of moderate to severe asthma. Further studies of meditation alone are needed before any a firm conclusion can be drawn.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Melatonin: Based on preliminary research, melatonin may improve sleep in asthma. Further studies that evaluate the long-term effects of melatonin on airway inflammation and bronchial hyper-responsiveness are needed before a firm conclusion can be made. Based on available studies and clinical use, melatonin is generally regarded as safe in recommended doses for short-term use. Available trials report that overall adverse effects are not significantly more common with melatonin than placebo. However, case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with overdose.
  • Mistletoe: Studies of Iscador® document improved clinical symptoms and markers of immune function in children with recurrent respiratory disease (RRD) exposed to the Chernobyl nuclear accident. There is currently insufficient evidence to recommend for or against mistletoe therapy for RDD in general. Avoid if allergic or hypersensitive to mistletoe or to any of its constituents. Anaphylactic reactions (life threatening, shock) have been described after injections of mistletoe. Avoid with acute, highly febrile, inflammatory disease, thyroid disorders, seizure disorders or heart disease. Use caution with diabetes, glaucoma or with cholinergics.
  • Nasal irrigation: Early research suggests that hypertonic saline aerosol may benefit chronic obstructive pulmonary disease (COPD), by enhancing the clearance of lung secretions. More studies are needed. Nasal irrigation is generally well tolerated. Use cautiously with history of frequent nosebleeds. If the irrigation liquid is hot, the nose may become irritated.
  • Omega-3 fatty acids, fish oil, alpha linolenic acid: Several studies do not provide enough reliable evidence to form a clear conclusion on the use of fish oil for asthma. Because most studies have been small without clear descriptions of design or results, the results cannot be considered conclusive.
  • Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
  • Para-aminobenzoic acid: Although limited available clinical study suggested that oral PAMBA (para-aminomethylbenzoic acid) administration helped to prevent asthma exacerbation following bronchoprovocation challenge, further studies are needed to confirm this effect.
  • Avoid oral use in children and pregnant or nursing women. PABA must be used with caution in patients with renal disease because of its predominantly renal route of excretion. Abnormalities of liver function tests have been noted in patients taking PABA. Monitoring may be indicated for higher doses (>8g per day). Blood sugar monitoring may be warranted in diabetics or patients at risk for hypoglycemia who are taking PABA systemically. Discontinue use if rash, nausea, or anorexia occurs. Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision.
  • Peppermint: There is currently not enough available scientific evidence on the use of peppermint for asthma. Use cautiously in patients with gastroesophageal reflux disease or achlorhydria due to lower esophageal sphincter relaxing effects and reports of dyspepsia. Peppermint oil should be used cautiously by people with G6PD deficiency or gallbladder disease. Use cautiously in patients with hiatal hernia or kidney stones. Avoid injection of peppermint oil, as it may result in pulmonary edema and acute lung injury. Avoid topical use of peppermint oil around the facial or chest areas of infants and young children, especially around the nose, because the menthol constituent can induce apnea, laryngeal and bronchial spasm, acute respiratory distress with cyanosis, or respiratory arrest if applied directly to these areas.
  • Perilla: Preliminary evidence suggests some benefit of perilla oil for symptoms of asthma. Further clinical trials are required before a definitive conclusion can be reached. Avoid if allergic/hypersensitive to perilla or members of the Lamiaciae/Labiatae family. Use cautiously with cancer, low HDL-cholesterol and immune disorders. Use cautiously if taking NSAIDS or barbiturates. Avoid if pregnant or breastfeeding.
  • Physical therapy: There is currently inconclusive evidence on the use of physical therapy for lung function. Chest physical therapy and physiotherapy breathing retraining have been studied in both children and adults to improve quality of life and improve lung function in severe and acute asthma. Early evidence is mixed. Studies often include combination treatment with drug therapy or are not well-designed, which make it difficult to assess the magnitude of benefit, if any, of physical therapy alone. More research is warranted.There may be a beneficial effect of respiratory rehabilitation in terms of improved tolerance to exercise and improved quality of life for chronic obstructive pulmonary disease (COPD) patients. Studies have investigated the use of physical therapy with drugs, as well as the difference between manual and mechanical techniques; few studies have compared respiratory physiotherapy to control groups. Additional study is warranted.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
  • Pomegranate: It is unclear whether pomegranate juice is helpful for chronic obstructive lung disease (COPD). In theory, pomegranate may be beneficial because of its antioxidant effects, but studies in humans do not support this theory. Additional studies in this area are warranted.
  • Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.
  • Probiotics: Laser acupuncture plus probiotics may help prevent asthma attacks in school-aged children with intermittent or mild persistent asthma. More research with probiotics alone is needed. Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
  • Psychotherapy: Psychotherapy for patients with chronic obstructive pulmonary disease (COPD) may decrease anxiety and depression, but it does not seem to improve physical performance. Supportive psychotherapy may reduce psychiatric symptoms of patients with emphysema. More research is needed in this area.
  • Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.
  • Qi gong: Qi gong is a type of traditional Chinese medicine (TCM) that is thought to be at least 4,000 years old. Some research suggests that the regular practice of internal Qi gong over several months may improve breathing in asthma. Further research is needed to confirm these results. Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.
  • Relaxation therapy: Preliminary studies of relaxation techniques in individuals with asthma report a significant decrease in asthma symptoms, anxiety and depression, along with improvements in quality of life and measures of lung function. Further large trials in humans are needed to confirm these results. Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
  • Sanicle: Sanicle (Sanicula europaea, Sanicula europa), a perennial plant in the Apiaceae family, has been studied for use in asthma. More evidence is needed before a recommendation can be made. Avoid if allergic or sensitive to sanicle. Use cautiously with stomach problems. Use cautiously if taking blood pressure-lowering or diuretic drugs. Avoid if pregnant or breastfeeding.
  • Selenium: Preliminary research reports that selenium supplementation may help improve asthma symptoms. Further research is needed to confirm these results. Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Spiritual healing: It is not clear whether spiritual healing has any effect on symptoms or quality of life in asthma patients. Further research is needed. Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.
  • Tai chi: Tai chi practice may help improve lung function after lung removal. More study is needed in this area. Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while practicing tai chi may increase the risk of injury.
  • Thymus extract: Preliminary evidence suggests that thymus extract may be useful for asthma symptom reduction and for reducing disease exacerbations and hospital admission related to chronic obstructive pulmonary disease (COPD). More clinical trials are required before recommendations can be made involving thymus extract for these uses.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
  • Traditional Chinese medicine: Laser acupuncture and probiotics provided a beneficial clinical effect in children with asthma. Further studies are needed to confirm these findings. Herbs used with Traditional Chinese medicine (TCM) have been reported to improve symptoms and improve immune function in chronic obstructive pulmonary disease (COPD) patients. Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Tylophora: Available studies of Tylophora for asthma show conflicting results. Methodologically weak trials make extrapolation to clinical practice difficult. Therefore, efficacy remains unproven. Avoid if allergic or hypersensitive to tylophora.
  • Vitamin B6: Preliminary research suggests that children with severe asthma may have inadequate pyridoxine status. Theophylline, a prescription drug used to help manage asthma, seems to lower pyridoxine levels. Studies of pyridoxine supplementation in asthma patients taking theophylline yield conflicting results. Further research is needed before a conclusion can be drawn. Avoid vitamin B6 products if sensitive or allergic to any of ingredients in product formulations. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Use cautiously if pregnant or breastfeeding.
  • Vitamin C: It has been suggested that low levels of vitamin C (or other antioxidants) may increase the risk of developing asthma. The use of vitamin C for asthma has been studied since the 1980s (particularly exercise-induced asthma), although the evidence in this area remains inconclusive. Additional research is necessary before a clear conclusion can be drawn.
  • Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.
  • Fair negative scientific evidence:
  • Evening primrose oil: Small studies do not show evening primrose oil to be useful in the treatment of asthma. Further research is needed.
  • Lycopene: A daily dose of lycopene for one week does not seem to affect lung function after exercise and does not provide any protective effect against clinical difficulty in breathing in young athletes.
  • Reflexology: Reflexology is based on the concept that areas of the feet correspond to other parts of the body, and stimulation of these areas on the feet can affect the associated body part. In addition to the feet, some practitioners perform reflexology of the ears and hands. So far, studies have shown that reflexology is no better than placebo at treating asthma.
  • Vitamin E: There is preliminary evidence that vitamin E does not provide benefits in individuals with asthma.
  • Strong negative scientific evidence:
  • L-arginine: Although it has been suggested that arginine may be a treatment for asthma, studies in humans have actually found that arginine worsens inflammation in the lungs and contributes to asthma symptoms. Therefore, taking arginine by mouth or by inhalation is not recommended in people with asthma.

Prevention
  • Smoking cessation: The primary cause of chronic obstructive pulmonary disease (COPD) is smoking. Patients who do not smoke are less likely to develop COPD than patients who do.
  • Patients who have COPD should not smoke. Smoking cigarettes may worsen symptoms of COPD.
  • Avoidance of respiratory infections: Avoid being around crowds during the cold and flu season (colder months). Washing the hands frequently, along with carrying a small bottle of hand sanitizer, helps keep viruses and bacteria away. Touching the nose or rubbing the eyes increases a patient's risk of developing viral or bacterial infections. Patients should talk to their healthcare providers about recommended vaccines.
  • Control breathing: Patients should talk to their healthcare providers or respiratory therapists to about breathing techniques that may help manage symptoms. Therapists may recommend relaxation exercises that may make it easier to breath. These breathing techniques may also help reduce symptoms of anxiety or distress, which occur in patients who have difficulty breathing.
  • Drink fluids: With COPD, mucus tends to collect in the air passages and can be difficult to clear. Drinking plenty of fluids, such as water or 100% fruit juices, help to keep secretions thin and easy to bring up.
  • Eat healthy foods: A healthy diet may help COPD patients maintain their strength and improve energy. Patients who are underweight should talk to their healthcare providers to determine whether or not they need nutritional supplements.
  • Regular exercise: Regular exercise can significantly increase the capacity for physical activity. Simple breathing techniques (deep breathing) may also help.
  • Visit the doctor: Patients should visit regularly visit their healthcare providers to have their lung function monitored.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Lung Association. .
  2. Bateman ED, Feldman C, O'Brien J, et al. Guideline for the management of chronic obstructive pulmonary disease (COPD): 2004 revision. S Afr Med J. 2004 Jul;94(7 Pt 2):559-75. .
  3. Cazzola M, Donner CF, Hanania NA. One hundred years of chronic obstructive pulmonary disease (COPD). Respir Med. 2007 Jun;101(6):1049-1065. Epub 2007 Mar 23. .
  4. Centers for Disease Control. .
  5. Holzgrabe U, Muth M. [Chronic obstructive pulmonary disease.] [Article in German.] Med Monatsschr Pharm. 2007 May;30(5):168-76; quiz 177-8. .
  6. La Vecchia C, Fabbri LM. Prevention of death in COPD. N Engl J Med. 2007 May 24;356(21):2211-2; author reply 2213-4. .
  7. National Emphysema Foundation. .
  8. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2010.
  9. Omron E. Inhaled corticosteroids and mortality in COPD. Chest. 2007 Mar;131(3):939; author reply 940. .
  10. Yohannes AM, Hardy CC. Treatment of chronic obstructive pulmonary disease in older patients: a practical guide. Drugs Aging. 2003;20(3):209-28. .

Causes
  • Smoking: The single greatest risk factor for chronic obstructive pulmonary disease (COPD) is smoking. COPD is most likely to develop in cigarette smokers, but cigar and pipe smokers and marijuana smokers also are susceptible. The risk of COPD increases with the number of years and amount smoked.
  • Exposure to secondhand smoke, also known as passive or environmental tobacco smoke, also increases risk of developing COPD. Secondhand smoke is smoke that is inadvertently inhaled from someone else's cigarette, pipe, or cigar.
  • Age: Although the lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 50-60.
  • Exposure to pollution: An individual breathing fumes from certain chemicals, such as chlorine or pesticides, dust from grain, cotton, wood, or working around toxic fumes has an increased risk of developing COPD. Breathing indoor pollutants, such as fumes from heating fuel, as well as outdoor pollutants, such as car exhaust, increases the risk of COPD.
  • Heredity: A rare, inherited deficiency of the protein, alpha-1-antitrypsin (AAt), can cause emphysema, especially before age 50, and even earlier if the individual smokes.
  • Connective tissue disorders: Some conditions that affect connective tissue (provides body framework and support) are associated with emphysema. Connective tissues are the supporting tissues of the body, such as tendons, ligaments, bone, and cartilage. These conditions include cutis laxa (a rare disease that causes premature aging) and Marfan syndrome (a disorder that affects many different organs, especially the heart, eyes, skeleton and lungs).

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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