Focus on Alternative and Complementary Therapies
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Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2003; 8: 385–91
Chronic obstructive pulmonary disease (COPD) is an entity that is relatively obscure to the public, particularly when compared with the general familiarity with the similar pulmonary disorder, asthma. Most of the disease conditions that are categorised as being COPD entities are regarded as dreaded illnesses with little prospect of satisfactory outcome with the use of orthodox therapies. The major disease in the COPD spectrum is bronchitis, which is similar to asthma but is characterised by more coughing and sputum production accompanied by progressive incapacity that may eventually necessitate end-of-life care on ventilator support. The other major entity is emphysema, which is more ‘silent’, but is especially relentless. For practical purposes, the majority of patients with bronchitis or emphysema are labelled as having COPD, since they have components of bronchitis (airway damage) and emphysema (alveolar destruction), often in association with an asthmatic element (bronchospasm), perhaps with some chronic infection associated with persisting damage due to bronchiectasis.
When treating COPD, the main emphasis is on relieving the asthmatic or bronchitic airway smooth-muscle spasm, using various bronchodilators: beta-sympathomimetics, anticholinergics and theophylline. However, COPD is less likely to respond to anti-inflammatory therapy with corticosteroids or antileukotrienes, or other immunomodulators. Furthermore, although bronchitis is characterised by a productive cough, orthodox mucus modifying agents, which may work, are still considered to be of doubtful value.1 There is similar doubt about the value of antibiotics in preventing or treating COPD exacerbations, unless there is clear evidence of a superimposed bacterial infection rather than a virus causing the acute deterioration.2
To many patients, the above summary paints a gloomy perspective of the range of orthodox therapeutic options for treating early or moderately advanced COPD. Patients who realise that they have early COPD, or are diagnosed as such, are likely to be distressed when they contemplate the treatment protocols. They will have to use aerosols of albuterol or salmeterol to relieve bronchospasm and will also require aerosolised ipratropium or tiotropium, the prime drugs that exist for treating COPD. When the disease advances, they may need to use theophylline and possibly steroids; both classes of drugs have worrisome side-effects. In practice, many patients resolve the problem by becoming non-compliant with their prescribed orthodox agents.
The bleak prospect of advancing COPD and the limited range of safe, although very effective, therapeutic options provided by orthodox medicine lead to another option: CAM. Patients and their physicians readily accept CAM for COPD without necessarily realising it, since many of the second-line treatments have their parallels in ancient therapies that still exist or have evolved into CAM. Thus, most over-the-counter cough and cold medicines and simple agents for improving breathing are the traditional agents used for centuries to treat catarrhs, abnormal mucus, ‘pectoral grieves’ (coughs), and heavy breathing (dyspnoea).3
Although non-physician practitioners of CAM are enthusiastic about many alternatives, several reviews suggest that there is little evidence that most of the popular ones are of significant benefit in serious airway disorders.4–8 The important categories of alternative remedies include herbs, aromatic aerosols or fumes, diet, homoeopathy, acupuncture, exercises, and unestablished surgical procedures.
Most of the herbs that are used to treat COPD are traditional agents that were used by ancient Roman physicians, such as Dioscorides who was the great pharmacology authority in the first century AD.3 When one tries to evaluate his recommendations, and the scores of additional herbs that have been described for lung disorders subsequently, it is evident that the vast majority lack any specific value. The main function of such herbs might be to provide a non-specific gastric irritating effect, which is less severe than the similar emetic effect of nauseating agents. A sub-emetic nauseant activates a gastropulmonary reflex leading to increased production of a lower-viscosity mucus in the respiratory tract. Through this mechanism, the typical herbal remedy might have an expectorant effect. Unfortunately, there is little evidence that any of the numerous traditional remedies that are used today result in any measurable outcome or discernible clinical benefit.9,10 This is not surprising, since orthodox expectorants that physicians prescribe have undergone surprisingly little evaluation, and they lack adequate laboratory or clinical evidence of a useful effect on mucociliary clearance.
Many CAM herbs are described as expectorants or mucolytics.11 Various explanations are given for their supposed actions, although most of them are emetic agents used in sub-emetic dosage to stimulate the ‘gastro-pulmonary mucokinetic reflex’ through the vagus nerve. Nauseating herbs such as ipecacuanha act in this way, as do expectorant salt solutions such as ammonium chloride or potassium nitrate. Saturated solution of potassium iodide (SSK1) has been one of the most popular orthodox expectorants, and it probably acts through this mechanism. Seaweed or kelp, which contain iodide, are sometimes used as the equivalent botanical remedies. However, despite the long history of usage of SSKI, and its frequent prescription by orthodox physicians, it has never been examined for its effectiveness in an appropriately controlled study. In the USA, an organic iodide, iodinated glycerol, was removed from the market by the FDA a few years ago because its value could not be proved.
Some of the more popular cough medicines for treating mucus include phenolic and other organic chemicals obtained from plants such as beechwood and pine trees. The best known of these products used to be terpene hydrate, but it has become less available in recent years since its value has never been proved. In contrast, guaifenesin remains very popular although few studies have been carried out to assess its effectiveness in COPD, and the exact mechanism that might enable it to serve as an expectorant remains undetermined. The German Commission E lists 34 herbs as having expectorant or secretolytic properties, and suggests that they could be useful for ‘catarrhs’, thus implying a benefit in COPD.12 A German proprietary drug, Bronchipret, is popular for treating bronchitis, and the manufacturers have made strenuous efforts to demonstrate both its laboratory and its clinical effectiveness, but the overall effectiveness that has been reported needs to be confirmed. The product contains ivy, a traditional treatment for cough, and thyme. It is of interest that thyme is generally regarded as a mucus loosening herb, and is the only one of the dozen of such botanical remedies that is consistently listed in herbal texts. However, there is no good evidence that thyme has any substantial specific effect or is of clinical value in bronchitis. There are many other herbal remedies used in China, India, South America and other major regions,13 but it is difficult to evaluate the reliability of favourable reports in journals from these regions. Overall, herbal medicines are of limited value in asthma14 and are unlikely to be more useful in COPD.
There is not doubt that pungent spices, such as wasabi and Tabasco pepper, can cause sneezing, coughing and expectoration. The active capsicum pepper chemical, capsaicin, can act on sensory nerves in the lung and can liberate then deplete substance P. It is used as a laboratory tool for evoking cough and mucus production. Despite this, no evidence is available to confirm the clinical value of pepper products in COPD. Similarly, horseradish, mustard, black pepper and garlic are also used as CAM therapies but their value is undetermined, although subjective impressions justify their use in such time-honoured recipes as spicy chicken soup. Garlic is probably the favoured spice for treating mucus problems, and it is used for a variety of other indications, including hypertension and hypercholesterolaemia. Studies that demonstrate benefit are balanced by others that show no significant effect, and thus the value of garlic is controversial. The fact that it is excreted in the breath might suggest it could have some pharmacological effect on the lung.
Modifications of diets are very popular in CAM. Dietary manipulations include the following: elimination diets, caloric reduction (or, for undernourished patients, an increase), detoxification, acidity control, antioxidants and dietary prostaglandin or leukotriene modifiers. There is no clear evidence of significant or continuing benefit with calorie control. Elimination of food allergens may help some asthmatic subjects with specific allergies to peanuts, shellfish and other foods, but these are less likely to be factors in older subjects with COPD. Milk products are often claimed to make mucus more viscous, but there is no evidence that this old belief is correct.
Some evidence was published a few years ago suggesting that antioxidants such as vitamins A, C and E, and selenium may benefit COPD.15 Although there has been limited follow-up of these encouraging reports16, there is emerging evidence in favour of carotenoids, catechols, flavones and flavonols that are found in fruits.17,18 The previously reported value of omega-3 fatty acids in COPD requires substantiation.19,20 Magnesium supplementation has been reported to be of value in asthma, but there is no evidence of it resulting in improvement in COPD. Many patients with COPD take cysteine as a food supplement, since it could serve as a mucolytic and antioxidant, but its value has not been studied, although the related orthodox drug, acetylcysteine, has been shown to be of some value.21 A compound in garlic, S-allyl-L-cysteine, is similar in chemical structure to N-acetyl-L-cysteine (Mucomyst or Fluimucil, which is used in many countries as a mucolytic), and this further justifies the use of the herb. Although nutritional support using proprietary food substitutes is popular, a meta-analysis failed to find benefit.22 The value of some other modalities, such as anabolic steroids, is now being investigated. It is noteworthy that carotene supplementation in smokers has been reported to increase the likelihood of subjects developing cancer, while the value of vitamin E is disputed. Such findings suggests that any advocated supplement must be viewed with an open mind as being potentially useful or perhaps neutral or possibly harmful until adequate evidence for a definite benefit is obtained.
The use of aromatic oils derived from odiferous flowers, leaves and spices is very popular for hedonistic health enhancement. It is probable that many aromatic vapours, or even their perfumed smell, can act on airways to increase mucus output and thereby improve expectoration. A variety of commercial mixtures have long been popular for treating bronchitis, such as Vick’s VapoRub, Tiger Balm, Friars’ Balsam and Ozothin. Some patients rely on the separate components such as eucalyptus oil (cineole), benzoin, camphor, methylsalicylate (wintergreen), menthol (from mint) and thymol (from thyme). Numerous other aromatic herbs are used around the world, with extracts of cinnamon, cloves, nutmeg, aniseed and fennel being popular. Recently, a study that compared Vick’s VapoRub with placebo given by inunction on the chest showed that the medication significantly improved mucociliary clearance over the next hour.23 However, the study involved only 12 patients with bronchitis, and the effect was small and short-lasting. Furthermore, the investigators suggest the benefit was attributable to menthol, since this single agent is known to have an antitussive effect and it may attenuate capsaicin-induced bronchoconstriction. Overall, menthol appears to be one of the most effective alternative respiratory medications, but there is insufficient evidence to suggest it can provide a significant role in COPD, other than as a mild antitussive.
Although aromatherapy using essential oils in massages may make most people feel better, it may have a more limited role in respiratory disorders. Some patients with hyperactive airways develop bronchospasm when they inhale aromas, and thus they may have an adverse reaction to aromatherapy. Similarly, some individuals are allergic to herbs such as ragweed, and they may exhibit cross-sensitivity to related plants. Spice dusts may also evoke bronchospasm when inhaled by people with susceptible lungs. Asthmatics sometimes derive benefits from being confined to the non-allergenic atmosphere of caves, but COPD patients simply need to avoid cigarette smoke and chemical pollutants – and perhaps many aromatherapies.
Patients that seek out alternative therapies to relieve bronchospasm hope that these will be safe as well as effective. Ephedra and other herbal agents are often used in complex mixtures in Chinese and Kampo (Japanese) traditional products, but the sparse evidence for their effectiveness in bronchospasm is based on occasional reports that lack adequate controls.9 Inappropriate use of Ephedra (Ma huang) and similar decongestant medications can be very dangerous. In India, the herbal remedy forskolin (colforsin) has long been recommended for its ability to enter cells and increase cycle 3′,5′-adenosine monophosphate, but no recent evidence of benefit in bronchospasm has been published. In Europe and South America, many herbal remedies are described as being useful but none of these has shown outstanding qualities. In the USA, extracts of Lobelia inflata have long been favoured by herbalists, who recommend that the herb or its extract, lobeline, be taken orally or used in smoking mixtures. The herb was strongly promoted in the past for bronchospastic disorders and as an aid to quitting smoking, but it has largely been abandoned as ineffective and toxic. Similarly, atropinic cigarettes and powders, or belladonna given by various means, are occasionally preferred as alternatives to the more effective and less toxic ipratropium and tiotropium aerosols. Individuals who are partial to the use of smoking agents strongly advocate marijuana: this does have a slight bronchodilator effect, but its value is very limited. No oral marijuana derivative has been formulated for use in treating asthma, and smoking of the herb is contraindicated in COPD because the smoke may irritate the airways.8
Reports of double-blind, placebo-controlled trials of homoeopathic preparations in the management of asthma have been reviewed, and some positive findings have been noted.7,8 The work of the team in Glasgow, Scotland is particularly relevant,24 since these investigators have shown evidence of a benefit from a homoeopathic pill based on allergens. However, this is an artificial finding, since typical homoeopathic remedies are not based on allergens. Overall, studies on homoeopathy in asthma are suggestive of some benefit, but more studies will be required from expert investigators to help determine its true value. Furthermore, studies on asthma cannot necessarily be extrapolated to COPD, and there is a lack of information to suggest homoeopathic remedies would be of specific value in COPD.
There is unsatisfactory evidence of acupuncture being of significant benefit in asthma, although several good studies suggest a trend towards improvement.8,25,26 The main problems with acupuncture are the lack of standardisation of technique, the variation in capability of the practitioners, the marked placebo effect, and the hazard of adverse outcomes. Although complications are rare, needling the chest has caused pneumothorax in several cases, and may be an increased risk in patients with COPD who have hyperinflated lungs. At present, acupuncture cannot be recommended in COPD and, if used, needling the chest or neck should be avoided. Acupuncture is used for smoking cessation, as are laser therapy and electro-stimulation; however, there is no clear evidence of benefit.27 Other variants of acupuncture, including electro-acupuncture, moxa, cupping, reflexology and shiatsu, have not been adequately evaluated in COPD.
Various breathing exercises and physical therapy modalities have been used for many years in the management of respiratory disorders. Most of these techniques have been abandoned in hospitals specialising in chest diseases because evidence for benefit did not emerge from numerous studies.28 Deep breathing exercises after major surgery is still used in orthodox medical practice, but the additional value of more complex instruments, such as incentive spirometry, has not been clearly shown and is questionable. Moreover, prior techniques that were highly valued in the past – such as intermittent positive pressure breathing – have been abandoned.
Techniques that have gained in popularity include physical exercise, posture correction, yoga, tai chi, qi gong and Buteyko exercises.29,30 Since their use might help motivate patients to feel an increased commitment to self-care, they may have value in asthma, but these techniques require further study in COPD.29,31 In contrast, well-organised rehabilitation programmes, that emphasise economy of exercise and breathing techniques, have been shown to be useful.32,33 Nevertheless, many authorities question their cost-effectiveness, and there are debates as to whether the programmes do anything other than motivate patients to persist in exercising and to take their medications appropriately.32 There is no doubt that psychological support and motivation can help selected asthmatics, and COPD will probably benefit from such attention, provided that the patient is interested and cooperates.34
This category includes surgical procedures, osteopathic, chiropractic and body work techniques. Numerous impressive therapies have been promoted. An example includes bilateral carotid body resection, which was shown to result in a decrease in dyspnoea in COPD. However, patients could become more hypoxic, and some were susceptible to sudden death. This procedure has essentially been abandoned. Currently, lung reduction surgery is being studied, and evidence is emerging that it can benefit selected patients. The cost of such an intervention will preclude most candidates from obtaining this help. Chiropractic in childhood asthma proved to be no more effective than a sham procedure, and there is less likelihood of chiropractic being of measurable benefit in COPD.35 Other procedures have not been adequately studied to demonstrate their potential benefit in breathing disorders.
A host of less invasive variants has been used.7,8 These include speleologic (cave) treatments or the use of other controlled atmospheres, spas or camps, group therapy, the use of simple or complex equipment, magnetic stimulation, ultrasonic therapies, and so forth. Such treatments may be similar to hypnotism:36 they may impress patients and their relatives and result in a subjective sense of benefit. However, there is inadequate evidence of any sustained value unless the individual uses these as adjuvant motivational techniques in a well-organised rehabilitation programme that provides continuing follow-up.
Vaccines have long been used to protect patients from infectious complications in COPD. Although influenza and Pneumococcus are accepted forms of prophylaxis, other vaccines, such as that for Hemophilus influenzae, have not become established, although there is greater interest in Europe in using such modalities. Vaccines, such as OM-85BV, prepared from flora in a patient’s sputum, are used in some countries; although evidence in their favour is limited, such therapies may prove to be useful.6,37,38 Various biological materials are derived from the thymus and are used to stimulate immunity to infection.39 There have been a few favourable reports, but more evidence for effectiveness is required. It is important to recall that the value of antibiotics in treating acute exacerbations in COPD has not been convincingly proved.2
Other approaches to reducing infections that can aggravate COPD are relevant. However, no studies have been carried out in COPD patients to assess the value of measures such as large doses of vitamins, special antioxidant products, or amino acid supplements. Immunomodulating herbs such as codonopsis, cordyceps, astragalus and Japanese Kampo remedies are being used, but their values have not been adequately investigated in general, or for COPD in particular.7,9 Probiotics and other longevity measures that are supposed to decrease aging or to help rejuvenate the immune system have not been subjected to orthodox evaluation.
It is difficult to draw a distinction between therapeutic modalities and hedonistic measures in health care. Experiences such as massages, mud baths, relaxation therapy, writing journal therapy, music therapy, animal-pet therapy, hypnotism, meditation, and so on, may make participants feel better, and may even improve lung function temporarily. Getting an anxious patient to relax may be a challenge, but it could be of benefit.39,40 Whether or not such popular modalities should be regarded as true medical therapies, or reimbursed by insurance third-party payers, is arguable. However, if the patient can afford them – or find a volunteer to provide them – there is no reason that they should not be tried without waiting for future publication of convincing evidence of effectiveness or for the decision of health insurance advisers to make such modalities reimbursable.
Very few CAM measures have been evaluated for COPD. Some have been shown to be of possible value in asthma, and it is likely that they could be helpful if appropriately adapted to COPD. It is disappointing that, despite optimism over the last decade, no totally new valuable treatments have emerged for bronchitis or emphysema, although lung reduction therapy may help some patients with the latter condition. It is important to recognise that many orthodox therapies, such as inhaled steroids, have not yielded incontestable evidence of benefit in COPD despite numerous carefully controlled studies. Moreover, the most basic constituent of COPD, mucus, has demonstrated itself to be very resistant to evaluation through convincing therapeutic investigations. Thus, many modalities of CAM that are alleged by practitioners or patients to be of value may be useful, although it may be extremely difficult to obtain convincing proof of their effectiveness. Most of the evidence for respiratory modalities in CAM has been sought using asthmatic subjects. However, the evidence that has so far emerged demonstrates common faults in CAM investigations: there are too few studies reported, inadequate numbers of patients are studied, and non-standardised techniques or inadequate controls are often employed.
It will be more difficult to measure significant outcomes in COPD since it is less responsive than asthma to any therapy whether orthodox or alternative. However, even a dubious benefit in COPD may be a meaningful one to the patient, and may lead to an improved quality of life (QOL). Thus, the only relevant measure of improvement in COPD may be one that is based on a QOL questionnaire or visual analogue measurement, rather than on the standard studies of pulmonary function that are so useful for evaluating treatment outcomes in asthma.
A personal comment may be worth considering with respect to COPD, and to other illnesses that are not curable by conventional medical therapies. Physicians and other health advisers often suggest or prescribe the use of medications that lack evidence of effectiveness. For example, most expectorants fit into this category, yet it is noteworthy that a huge variety of these medications are used throughout the world. Undoubtedly, both the patient and the prescribing adviser feel that the medication offers some benefit: it is not the case of the prescriber knowingly advising that an inactive ‘placebo’ be used. When both parties are in agreement that a medication is effective despite objective lack of effectiveness, the token prescription can be called a ‘placebit’ meaning ‘it will please’ both the prescriber and the user. Much of the CAM used in COPD may be placebit therapy, and objective evidence of benefit from such agents is unlikely to be found. Perhaps proof of value is not required provided that the treatment is not harmful, not expensive and not ludicrous, since various forms of placebit therapy will continue to please both prescriber and prescribee. Placebit therapy in both orthodox medical practice and in CAM will remain popular for COPD whatever emerges from any new studies that provide evidence of effectiveness, or lack thereof.
