Respiratory Infections

Integrative Approaches for Cold and Flu

By Luke Fortney, MD, Integrative Family Medicine, Meriter Medical Group, Madison, WI. Dr. Fortney reports no financial relationships relevant to this field of study.

Every year in September throughout the United States, students return to school, and many people return to work from vacation and summer break. As weather cools with the coming fall and winter, people gather in close proximity in colleges, schools, daycares, clinics, and workplaces. Humidity drops and indoor heating leads to dry air. Many experts and laypersons alike have postulated that these and other factors contribute to the rise in acute respiratory infections (ARIs) seen across the population. Also referred to as upper respiratory infection (URI) or the common cold, these infections have considerable overlap with pharyngitis, sinusitis, otitis, bronchitis, and pneumonia. While rhinovirus is the most common agent of infection, influenza is the most dangerous in terms of morbidity and mortality.1

Although the common cold is considered a nuisance illness, it carries considerable cost both in terms of health care dollars and overall negative impact on the economy. Data extrapolated from a United States telephone survey conducted in 2001 suggest that about 500 million non-influenza viral respiratory infections occur every year, resulting in estimated direct costs of $17 billion and indirect costs of $22.5 billion annually.2 On average, adults experience 2.5 colds per year,3 while children experience five per year.4 Furthermore, while URIs are a nuisance illness, they have measurable, significant decrements on quality of life in terms of physical, social, and emotional functioning.5 Accordingly, there has been increased emphasis for researchers to measure the effectiveness of novel URI treatments based on health-related quality-of-life impact.

Integrative Opportunity

Interestingly, there exists no effective cure for ARIs, and treatment options generally have only mild-to-modest effect on symptom reduction. Some patients appear to be more prone to ARIs than others, but the reasons for this are also not completely understood. Although many investigations have failed to identify clear determinants of susceptibility, prevention, and cure, a Cochrane review found that sick-time isolation, hand washing, and use of protective masks play a significant role in preventing the spread of viral respiratory infections.6 In addition to these effective measures, there are other sensible approaches that can be considered for ARI management. Being able to offer patients various safe and effective treatment options helps reduce harm associated with inappropriate use of antibiotics for ARIs.7

Stress has long been recognized as a factor in ARI susceptibility and symptom severity. For example, university health clinics have long observed increases in ARIs among students experiencing increased stress during mid-term or final exams. Research shows that immune function and mood are correlated, with positive affective states resulting in stronger immune function and decreased illness.8 In one study, employees who enrolled in a mindfulness-based stress reduction program demonstrated less anxiety and stress. They also showed significant increases in influenza vaccine titers compared to controls.9 In working with patients, it is always valuable to ask about increased stress and offer helpful suggestions to minimize the burden of stress when possible. Deep breathing exercises, simple mindfulness practices, and a quiet day of rest can be helpful for treating ARI symptoms.10

Tobacco use — cigarette smoking in particular — appears to prolong symptoms and increase frequency of ARIs.11 Accordingly, an integrative medicine approach to treating ARIs should include a quick screening for tobacco use, particularly cigarette smoking. Smokers who present with ARIs present an ideal opportunity for cessation counseling.

Conversely, moderate alcohol intake appears to be protective against ARIs. One study found that 1-2 drinks a day, especially red wine, seems to predict fewer and less severe ARIs compared to teetotallers or heavy drinkers.12 It is postulated that the beneficial effects of beer and wine consumption may be due to the antioxidant and anti-inflammatory effect of polyphenols. However, that the alcohol itself may have a beneficial effect on ARIs cannot be excluded.13

In relation to vitamin D, several randomized, controlled trials (RCTs) suggest that supplementation for the treatment or prevention of URIs may be beneficial.14 People with higher serum levels of 25-OH vitamin D seem to have greater pulmonary function as measured by FEV1 compared to people with lower levels. This may be due to immune-modulating and antimicrobial effects of vitamin D,15 or its ability to remodel lung tissue and improve lung function.16 However, data from the VIDARIS trial, an RCT, published in the Journal of the American Medical Association found that vitamin D supplementation did not reduce the incidence of respiratory tract infections in adults who have sufficient serum levels of vitamin D.17 Nonetheless, for patients who are significantly low in 25-OH vitamin D serum levels (< 30 ng/mL), supplementation with cholecalciferol (vitamin D3) 1000-2000 IU should be recommended.18

Although the cure for the common cold remains elusive, many therapies can improve and possibly shorten the duration of ARIs. A systematic approach that includes choices for patients is ideal. Including patients as active participants in their own health care is beneficial from an integrative medicine perspective. Furthermore, research suggests that having empathetic physicians who are mindfully present and listen to patients with ARIs actually decreases both duration and intensity of symptoms, as well as improves objective measures of illness such as IL-8 and neutrophils.19 The power of placebo in the ARI setting should not be underestimated; rather, it should be viewed as stimulating the natural healing response. One ARI study found that participants who were randomized to a “no-pill” group (meaning they were not given anything in pill form) showed longer and more severe illness than those who received pills. For those participants who believed in and received pills (regardless of whether or not it was placebo), illnesses were substantively shorter and less severe. These findings support the general idea that beliefs about treatments are important and should be taken into consideration when treating patients presenting with ARIs.20 It is with this background in mind that the patient encounter should be approached, with intention to stimulate the healing response through mindful presence and empathy. In this setting, the particular agents to choose from may not be as important, it turns out, as the process of choosing in the presence of a supportive and listening physician.

Other Lifestyle Adjustments During ARI

With ARIs, an integrative approach should begin with hand washing and appropriate hygiene to prevent spreading the infection to others. This effect appears to be, not surprisingly, most robust among children. The highest quality RCTs suggest respiratory virus spread can be prevented by hygienic measures, particularly hand washing, especially among younger children.6 Hand washing is most effective if it is at least 20 seconds in duration (or humming “Happy Birthday” from beginning to end twice). Although hand sanitizer is helpful, it is not as effective as hand washing. If used, enough volume of material should be expressed to cover all surfaces of the hands and fingers and rubbed together until dry.21

Although regular exercise should be encouraged for all patients, intense exercise (such as distance running) should be temporarily halted while a patient is symptomatic with ARIs. There is research showing increased risk of ARIs during excessive cardiovascular exercise.22 In general, patients should be encouraged to stay gently active, such as short walks or light home yoga as examples. Additionally, as in a hospital setting where incentive spirometry is widely used, patients should be encouraged to take slow, deep breaths every 1-2 hours while awake to prevent atelectasis and to improve pulmonary circulation.23

Nutritionally, recommendations should include low sugar (e.g., table sugar, especially high fructose corn syrup) intake during ARIs. Sugar suppresses the immune system by inhibiting the ability of white blood cells to engulf bacteria and viruses.24 Practically, this means avoiding soda, candy, sweets, and desserts. Paradoxically, honey shows promise as a remedy for ARIs. In addition to its demulcent effects, honey has antioxidant and immunomodulating properties that may explain its antimicrobial effects. Research shows that 1-2 teaspoons (5-10 mL) can significantly reduce nighttime cough frequency and severity, as well as improve sleep when compared to placebo in children ages 2 years and older with ARIs.25 Honey is also at least as effective as dextromethorphan or diphenhydramine in children.26 Together with chamomile, licorice, or ginger tea, honey can be a comforting remedy for ARI symptoms.27 There also is evidence to support chicken soup as a remedy for ARIs,28 but it is recommended to use free-range chicken stock and organic ingredients due to the overall health uncertainties in the risk associated with pesticides and other synthetic chemicals.29 Hot toddies also can be considered for adults with no risk or history of alcoholism (e.g., warm tea with honey with a small amount of rum or brandy taken at night). Finally, although the simple therapy of gargling salt water has mixed data, it is safe and can be relieving for associated pharyngitis as well as helping with eustachian tube dysfunction.30

Supplement and Botanical Updates

There is some evidence for a handful of dietary supplements with evidence to support their use. Although the three primary species of Echinacea purpurea may be the most widely recognized cold remedy, recent research findings have been mixed, especially for Echinacea pallida and Echinacea angustifolia. Overall, more than 20 RCTs have been conducted on the three species of echinacea, but more recent, higher-quality studies have shown very modest (such as decreasing cold symptom duration by one-half day over a week) to no benefit.31,32 Other botanicals are on the horizon with data suggesting benefit.

Andrographis paniculata is a plant from Asia that has traditional use in Ayurvedic medicine. Systematic reviews show that, collectively, Andrographis is superior to placebo in treating ARI symptoms,33 and more recent trials have also shown benefit.34 A typical dose is 300 mg (tablet or capsule, standardized to 4% andrographolide) four times a day during early ARI symptoms. This should then be stopped after ARI symptoms subside.

Elderberry (Sambucus nigra) is widespread in the Northern hemisphere, and the syrup extract of the berries may be helpful for ARIs and influenza-like illness. Only one RCT shows benefit in reduction of symptoms among 60 volunteers in a European trial.35 A recent investigation found that elderberry was in fact active against influenza in an in vivo animal study.36 The suggested dose for adults is 1 tablespoon of liquid extract 3-4 times a day.

Pelargonium sidoides (Umckaloabo) is a South African Geranium plant that has been used traditionally in that region for the treatment of ARIs among other things. Six RCTs show benefit, including a positive review in Cochrane Database.37 One commercial product (Umcka) is listed as a 1X homeopathic preparation. Recommended dose is 1 mL 3-4 times a day for the duration of the cold. This particular brand was tested both in vivo and in vitro and found to have antiviral activity with improved outcomes among influenza infected mice.38

Probiotics are an increasingly interesting area of research, particularly with Clostridium difficile gut infections and antibiotic-associated diarrhea. However, it was found incidentally to have some benefit with ARIs. A more recent RCT in 2011 found that taking Lactobacillus plantarum and Lactobacillus paracasei reduced days of ARI symptoms from 8.6 days in controls to 6.2 days in the treatment group. Furthermore, the incidence of ARIs was reduced from 67% in controls to 55% in the probiotic group.39 Practically speaking, it is reasonable to recommend taking a probiotic capsule twice a day either at the onset of symptoms or ongoing for prevention.

Vitamin C and zinc are somewhat controversial and show mixed evidence for relief of ARIs, but they appear to have some benefit. One RCT found that patients with the common cold who took 1000 mg of vitamin C and 10 mg of zinc had significantly reduced symptoms over 5 days of treatment. Vitamin C and zinc are very safe and well tolerated and are good options to recommend for most patients with ARIs.40 However, caution should be used with Zicam, an herbal homeopathic combination over-the-counter nasal spray that can cause long-term olfactory dysfunction and loss of smell. One study found that Zicam was cytotoxic to sinus and olfactory nasal tissue.41

Oscillococcinum is a homeopathic medicine produced in and widely used in France and more than 50 countries for the treatment of influenza. It is an ultra-diluted, homeopathic-prepared remedy comprised of duck liver and heart to a ratio of 1:10400.42 A Cochrane Database review of six studies concluded that although considered very safe, there is insufficient good evidence to recommend Oscillococcinum for the treatment of ARIs. However, this review did not rule out the possibility that Oscillococcinum may be helpful clinically.43 When presenting options to patients diagnosed with influenza and influenza-like illness, it is reasonable to support patients who elect to add Oscillococcinum as an adjunctive therapy.

Summary

Athough ARI is considered a nuisance illness, it is prevalent and widespread, with significant negative effects on quality of life. Treatment recommendations should focus on offering patients choices to create a meaningful health plan that addresses individual concerns using safe therapies. It is important to steer patients away from ineffective and potentially harmful therapies such as antibiotics. It is also important to offer empathy and partner with patients, which itself has a beneficial effect on symptom relief and quality of life.

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