Respiratory system

Scope
Apart from their use to provide non-specific support for recuperation and repair, specific
phytotherapeutic strategies
include the following :
Treatment of:

inflammatory catarrhal conditions of the upper respiratory mucosa (e.g. common cold,
rhinitis, sinusitis, otitis media)
acute bronchial and tracheal infections
allergic rhinitis
nervous coughing patterns.

Management of :
-

chronic obstructive pulmonary diseases (chronic bronchitis, bronchiectasis, emphysema,

silicosis)
asthma
chronic tracheitis
coughing due to persistent local irritation.

Because of its use of secondary plant products, particular caution is necessary in applying
phytotherapy in cases of known allergic reactions to specific medicinal plant products.

Rationale and orientation

To the Chinese, the lungs were the internal organs most in contact with the exterior. So as well as
ascribing to them the
source of the bodys rhythm and the site of the catalysis of vital energies, they were seen to be
the organs in charge of defences. In earlier times the role of the respiratory system was obvious
in all cultures; the first cry was generally taken to
be the first sign of life, the bronchial gasp on the deathbed the last, and a consistent fear
throughout history was the hacking, bloody cough of consumption or tuberculosis, the disease
that once cast its baleful influence over the popular imagination like cancer and AIDS now do, the
constant reminder of how fatal debility followed weakening of the lungs. It was obvious that the
lungs, even more than the stomach, were susceptible to contagion, the conceptual medieval
precursor to viruses and bacteria. In this imagery, the key to resistance lay not in attacking alien
invaders but in strengthening innate resources. Traditional strategies for treating respiratory
disease were notably founded on supportive and tonifying remedies. Given that the modern virus
remains as elusive as it ever was, an emphasis on supporting defences may seem appropriate
again.
Modern interpretations of respiratory illness have shifted in recent years to identifying underlying
inflammatory processes,
involving leukotrienes and cytokines. Given that most pathologies have a strong inflammatory
element, this is a promising avenue of further research for phytotherapy.

This is, however, the one area where the divide between traditional and modern approaches is
not very wide.
Elsewhere, there are very few modern endorsements of early treatment strategies.2 Modern
medical science, which at first

embraced such agents in the earlier part of this century, now sees no role for their use. For
example, modern editions of Martindales Extra Pharmacopoeia claim that: There is little
evidence to show that expectorants are effective. Some modern drugs may have expectorant
activity, such as bromhexine, but they are usually referred to as mucolytic. The impact of
traditional remedies on the respiratory system is relatively poorly researched. Reliable external
measures of change in mucosal function are elusive; many respiratory diseases are either selflimiting or are among some of the most persistent conditions in the clinic. Even in asthma, where
peak flow rates provide a simple measure of benefit, the complexity of the condition and the
usual presence of confounding and violent influences make easy characterisation of the
condition, and the measurement of all but the most powerful across-theboard remedies,
unreliable.
A sense that traditional approaches should be relegated to history is possibly reinforced in the
medical psyche by the
knowledge that one of the most dramatic advances of modern drugs was in controlling at last the
old scourge of tuberculosis. However, this dismissal is not as conclusive as once thought.
Tuberculosis is making a serious come-back on the world stage, attacking first the very
impoverished and malnourished as it always did. As modern drugs struggle with this new
manifestation, there may once again be value in looking at the lessons from the past, that
treatment should be
based on supportive remedies in a regime of convalescence. With the luxury of choice, with the
option of taking modern
drugs where these are necessary, but also being able to select more supportive strategies at
other times, there is real value
in reviewing the treatments forged out of desperate but not always unsuccessful battles with
disease in earlier times. These lessons are fortunately quite well learnt.
The dominant feature of respiratory conditions is how readily changes in their behaviour are
appreciated subjectively. The
often immediate effects of eating and drinking different foods and drinks, of temperature and
humidity changes and of the various treatments used through history have been the main guide
in determining therapeutic strategy. From such experience has come the view of the respiratory
mucosa and musculature as being particularly sensitive to reflex responses, notably from the
upper digestive tract, from the pharynx to the stomach. There is a persistent tradition in many
cultures that respiratory problems are extensions of digestive dysfunctions. Embryology supports
such links, with the bronchial tree originating as a diverticulum of the pharyngeal zone of the
alimentary duct and sharing common vagal innervation, and the association, for example,
between asthma and histamine H2 receptors in the stomach3 add further support to such
connections.

Phytotherapeutics
Part of the problem with expectorants probably arises from confusion over their definition.
Another stems from the difficulties involved with measuring their efficacy.

Overview of expectorants
-

An expectorant is a substance that enhances those physiological mechanisms by which

respiratory tract secretions are cleared from the lungs. In the course of doing this they
often render the consistency of respiratory tract secretions more fluid and/or more
demulcent. They do not necessarily increase the quantity of coughed-up phlegm, nor are
they necessarily antitussive (see below).
Since reflex and warming expectorants act by different mechanisms, and on different
parts of the lung tissue, an effective herbal prescription can combine these two types of
expectorants, but depending on the patients condition as noted above.
The effect and mechanism of action of reflex expectorants have been demonstrated by
scientific experiments. However, since their effect seems to involve vagal stimulation of

secretory glands, there may also be vagal stimulation of smooth muscle tissue in the
lungs. Hence they should be used with caution in asthma, and combined with bronchiolar
spasmolytics (but not anticholinergics that can dry respiratory secretions).
Many lower respiratory tract disorders will benefit from the action of expectorants, but
particularly those where mucus is tenacious and difficult to cough up. However, it
depends on the cause of a cough whether an expectorant action is also antitussive.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning
is only concerned
with the actual oral production of phlegm or sputum. Since the majority of mucus produced from
the lungs is swallowed,
this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are
more useful, but probably the best definition comes from Brunton, a 19th century
pharmacologist. Bruntons functional definition best
explains the various ways in which medicinal plants can act as expectorants.

Definitions of expectorants
-

Oxford Dictionary Promoting the ejection of phlegm by coughing or spitting

Boyd (1954) An expectorant may be pharmacologically defined as a substance which
increases the output of demulcent respiratory tract fluid
Lewis (1960) Expectorants increase the secretions of the respiratory tract and so
reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the
presence of increased quantities of fluid mucus, expectorants produce a productive
cough which is less exhausting and less painful to the patient.
Brunton (1885) Remedies which facilitate the removal of secretions from the air
passages. The secretion may be rendered easier of removal by an alteration in its
character or by increased activity of the expulsive mechanism.

Why expectorants?

Many respiratory conditions are characterised by abnormal mucus (catarrh) that can narrow
airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from
the airways. If expectorants can render this catarrh more fluid and/ or assist in its expulsion, then
a clinical benefit should be achieved.
Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways
(such as tenacious
abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and
larger airways. The sensitivity progressively decreases in the finer airways and in the very fine
airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex,
whereas for tracheitis the stimulus is strong.) By clearing abnormal mucus or by changing its
character and making it more demulcent, expectorants can allay cough and are therefore
antitussive.
In spite of the incomplete scientific case and lack of a consensus orthodox view, traditional
approaches to expectoration
are strong and consistent across cultures and history. They include mechanisms that are rational
and usually immediately apparent.

Stimulating (reflex) expectorants

These are remedies that provoke increased mucociliary activity by reflex stimulation of the upper
digestive wall. The classic examples were originally used as emetics. It was noted that this drastic
action was accompanied by a noticeable
expectoration. In fact, traditional practitioners in Britain used emesis as a technique to clear the
lungs in asthma and chronic bronchitis until quite recent times. Application of these remedies in
sub-emetic doses was thus a consistent feature in all major herbal traditions. Herbs such as
ipecacuanha, squills and Lobelia have been standards in Western medicine. There is some limited

modern investigation of mechanisms involved. For example, ipecac-induced emesis is thought to

be mediated through both peripheral and central 5-HT 3 receptors. Other plants have been used
as stimulating expectorants,
although not used as emetics; members of the Primula, Bellis, Saponaria and Polygala genera are
often included in this category in Western traditions. High saponin levels seem to be a common
feature of this group and saponins are certainly nauseating in high doses.

Plant remedies traditionally used as stimulating (reflex) expectorants

Cephaelis (ipecacuanha), Lobelia inflata (Lobelia), Urginea (squills), Primula veris (cowslip), Bellis
(daisy), Saponaria
(soapwort), Polygala senega (snakeroot)

Indications for stimulating expectorants

-

Cough linked to bronchial congestion, especially where mucus is thick and tenacious or
where there is unproductive cough
Bronchitis, emphysema

Other traditional indications for stimulating expectorants

- In some cases as emetics in higher doses
Contraindications for stimulating expectorants

Although there is no firm evidence of unsuitability, as gastric irritants they can transiently upset
some individuals (immediately relieved by withdrawing or changing the remedy). In addition, the
use of stimulating expectorants should be kept under review in cases of
dry and irritable conditions of the lungs
asthma
young children
dyspeptic conditions

Application

Stimulating expectorants are best taken in hot infusions or as tinctures or fluid extracts, before
food.
Long-term therapy with stimulating expectorants is appropriate in the management of chronic
bronchial conditions as
long as digestive functions are not affected.

Advanced phytotherapeutics

Stimulating expectorants may also be usefully applied in some cases (depending on other
factors) of rheumatic and connective tissue diseases

Warming expectorants (mucolytics)

Many of the spices were highly prized in the cold damp climates of northern Europe for their
apparent ability to counteract
associated chest problems. In particular, ginger had an almost mythical reputation; where this or
imported cinnamon
and cloves were not available, Europeans resorted to fennel, aniseed, garlic, mustard and
horseradish for the same ends.
Later cayenne or chilli peppers were used for this purpose, although generally taken to be too
drying in most cases. The
effect of the pungent spices probably includes increased blood flow to the respiratory mucosa, a
reflex irritation of the upper digestive mucosa (as with the stimulating expectorants) and,
especially in the sulphur-containing garlic and mustard family, a decrease in the thickness of
mucus by altering the structure of its mucopolysaccharide constituents; the sensation usually is
of a clearing of catarrh and the shifting of congestion up from the lungs.5 A simple infusion of

fresh ginger and cinnamon remains one of the most effective home treatments for the common
cold.
Essential oils from various herbs (either administered as essential oils or contained in herbal
extracts or tinctures) are
the most important agents that directly influence goblet cells to secrete more respiratory tract
fluid and mucus. Boyd studied the effects of several essential oils in various experimental models
(see Chapter 2). The most pronounced increase
of respiratory tract fluid was seen after ingestion of oil of anise. Interestingly ingestion of oil of
eucalyptus had a moderate
effect that was not eliminated by cutting afferent gastric nerves. This finding supports the
premise that essential oils do not generally act as reflex expectorants.

Plant remedies traditionally used as warming expectorants

Pimpinella anisum (aniseed), Cinnamomum zeylanicum (cinnamon), Foeniculum (fennel),

Zingiber (ginger), Allium
sativum (garlic), Angelica archangelica (angelica).

Indications for warming expectorants

-

Productive cough associated with cold

l Bronchitis, emphysema
l Profuse catarrhal conditions
l Dry cough, as per Boyd.

Other traditional indications for warming expectorants

-

As aromatic digestives
l Congestive chronic infections and inflammatory conditions.

Contraindications for warming expectorants

The use of warming expectorants may be contraindicated or inappropriate in gastro-oesophageal

reflux.

Traditional therapeutic insights into the use of warming expectorants

There is a close association in traditional medicine between catarrhal congestion and the
digestive/assimilative functions.
The warming remedies were seen to act seamlessly across both respiratory and digestive
functions treating disturbances
in either or both together. Symptoms most often found with catarrhal conditions might include
abdominal distension, loss
of appetite and loose stools.

Applications
Warming expectorants are best taken immediately before meals. They are particularly effective
taken in hot aqueous infusions. Long-term therapy with warming expectorants is usually
acceptable.

Respiratory demulcents
These herbs contain mucilage and have a soothing and anti-inflammatory action on the lower
respiratory tract. Although
the mechanism is not clear, an opposite effect to that of the stimulating expectorants has been
postulated; that is the
effect is a reflex one from the demulcent effect on the pharynx and upper digestive tract, again
involving common embryonic origins and vagal innervation.

The major respiratory demulcent herbs are Althaea officinalis (marshmallow root or leaves) and
other members of
the Malvaceae (mallows), Ulmus spp. (slippery elm), members of the Plantago genus, Cetraria
islandica (Iceland moss)
and Chondrus crispus (Irish moss). Tussilago (coltsfoot) and Symphytum (comfrey) were very
widely popular before concerns about pyrrolizidine alkaloids constrained their sale.
Pronounced antitussive activity has been demonstrated experimentally with oral doses of 1000
mg/kg body weight
of extract of Althaea officinalis (marshmallow), with comparable effects at 50 mg/kg of the
isolated polysaccharides.6
These animal studies might suggest enormous doses necessary for clinical effect but if, as
implied, the effect is a mechanical one, it is likely that only marginal increases in dose would be
necessary to have similar impact in larger animals like humans (see also Chapter 2 under
Mucilages).
Respiratory demulcents were popular for childrens cough and generally for dry, irritable and
ticklish coughing. They
were seen as intrinsically contraindicated in wet, damp chest problems, although they can
sometimes be quite well suited
to these if there is an irritable element.

Plant remedies traditionally used as respiratory demulcents

-

Althaea (marshmallow), Plantago spp. (ribwort and plantain), Verbascum (mullein,

especially leaf), Chondrus (Irish moss), Cetraria (Iceland moss), Glycyrrhiza (licorice).
l

Indications for respiratory demulcents

-

Dry, non-productive, irritable cough

l Coughing in children
l Asthmatic wheezing and tightness.

Other traditional indications for respiratory demulcents

-

As mucilaginous digestive remedies

l The effects of dryness on the respiratory system.

Contraindications for respiratory demulcents

The use of respiratory demulcents may be inappropriate in profuse catarrhal or congestive

conditions of the mucosa (but
see above).

Traditional therapeutic insights into the use of respiratory demulcents

As with other respiratory remedies, there is a close association between effects here and on the
digestive tract. Respiratory
demulcents are at their most appropriate if there are parallel indications in the gut: dry inflamed
conditions such as gastritis
and oesophagitis associated with hyperacidity, dry constipation and its various associated
problems.

Application
Respiratory demulcents are best taken before meals. They are particularly effective taken in cold
aqueous infusions.
However, if gastro-oesophageal reflux is contributing to the pathology, as can be the case in
asthma, they should be taken
after meals.
Long-term therapy with respiratory demulcents is usually well tolerated.

Respiratory spasmolytics

Respiratory spasmolytics relax the bronchioles of the lungs. Traditionally they included the
solanaceous plants (the nightshade family) with powerful atropine-related antiparasympathetic
constituents: Datura, Atropa and Solanum were the prominent antiasthmatics of early history. As
could now be explained pharmacologically, these remedies tended also
to dry up the mucosa and had other less desirable effects, so less powerful remedies were also
popular. Ephedra sinica
(ma huang) from Asia was popular when it reached Europe and works through a
sympathomimetic action. Other gentle
remedies include culinary herbs such as hyssop and especially thyme, horehound, the North
American gumplant, Grindelia camporum and elecampane (Inula helenium).

Plant remedies traditionally used as respiratory spasmolytics

Ephedra (ma huang), Datura stramonium (jimson weed), Atropa belladonna (deadly nightshade),
Solanum
dulcamara (bittersweet), Hyssopus (hyssop), Thymus vulgaris (thyme), Lobelia inflata (lobelia),
Marrubium
vulgare (horehound), Grindelia camporum (gumplant), Euphorbia hirta (pill-bearing spurge),
Coleus forskohlii,
Glycyrrhiza (licorice), Inula (elecampane).

Indications for respiratory spasmolytics

-

Tight, breathless, non-productive coughing

l Wheezing and other asthmatic symptoms.

Other traditional indications for respiratory spasmolytics

-

Many of the gentler remedies were used as relaxants

l The solanaceous plants have potent neuroactive properties.

Contraindications for respiratory spasmolytics

The use of respiratory spasmolytics may be contraindicated or inappropriate in the following
In the case of solanaceous plants: glaucoma, urinary retention, paralytic ileus, intestinal
atony and obstruction
l In the case of Ephedra: appetite disorders, glaucoma, prescription of monoamine oxidase
(MAO) inhibitors.

Application
Respiratory spasmolytics may be taken at any time of the day as required for immediate effect.
Long-term therapy with respiratory spasmolytics is acceptable in the case of the gentler
examples, but not for the solanaceous plants or Ephedra, and in all cases there should be
attention to treatment of underlying causes rather than relying on symptomatic relief.