Related Terms

• ACE inhibitor-associated cough, acute respiratory distress syndrome, airway obstruction, asbestosis, asthma, bronchial congestion, bronchiolitis, chest X-ray, common cold, congestion, cough, croup, decongestant, dyspnea (shortness of breath), eucalyptus aromatherapy, expectorant, FBD, functional breathing disorder, hypoxia, laryngitis, lower respiratory infection, lung cancer, lung infections, nasal congestion, nasopharyngitis, pharyngitis, pulmonary conditions, pulmonary hypertension, recurrent sneezing, respiration, respiratory disease, respiratory distress, respiratory infection, respiratory problems, respiratory syncytial virus, respiratory tract infection, rhinitis, rhinopharyngitis, runny nose, sarcoidosis, sinus congestion, sore throat, strep throat, stuffy nose, tonsillitis, upper respiratory tract infection, vasodilator.

Background

• Respiratory illnesses are conditions affecting the upper respiratory tract, producing symptoms mainly in the nose and throat. Upper respiratory infections include conditions such as colds, laryngitis, pharyngitis, rhinitis, and sinusitis. Additionally, respiratory conditions include infections of the lower respiratory tract, which may affect the windpipe, airways, and lungs. Lower respiratory tract infections include conditions such as asbestosis, asthma, and sarcoidosis.

• The respiratory system consists of organs that process air in the body, including the nose, throat, and lungs. The nose is the entrance to the respiratory tract. The throat is the hollow tube inside the neck that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes to the stomach). The lungs are the organs that make it possible for people to breathe; their principal function is to transport oxygen from the atmosphere into the bloodstream and to release carbon dioxide from the bloodstream into the atmosphere.

• During a normal day, the average person breathes nearly 25,000 times, taking in large amounts of air. According to the American Lung Association, approximately 342,000 Americans die from lung diseases each year; lung disease is the number three cause of death in the United States, responsible for one in seven deaths.

• Many factors, including genetics, pollutants and irritants, and infectious diseases, may affect the health of the respiratory system.

Risk Factors

• Smoking is one of the leading risk factors for developing a cough and other respiratory disorders. Additionally, women tend to have more sensitive cough reflexes making them more likely to develop a cough. Exposure to allergens such as dust and pollen may make a person more susceptible to developing a cough.

• Children who are five years old or younger or who were born prematurely are more likely to develop croup (a disease of infants and young children characterized by harsh coughing, hoarseness, fever, and difficult breathing).

• People most at risk for developing asbestosis (scarring of the lungs that results in difficulty breathing) include those who have had at least 10 years of moderate to severe exposure to asbestos, such as workers involved in mining, milling, manufacturing, or installation of asbestos products.

• Viral infections are the main cause of colds. They include: rhinoviruses, coronaviruses, adenoviruses, echoviruses, respiratory syncytial viruses (RSV), and coxsackieviruses, which can infect the upper respiratory system. Although over 100 different viruses may cause colds, 30-50% of colds are caused by rhinoviruses.

• The majority of patients hospitalized for RSV are under six months of age. For infants and children born prematurely (35 weeks gestation or less), RSV may cause serious respiratory tract disease or even death.

Types of the Disease

• Asbestosis: Asbestosis is a lung condition caused by breathing in asbestos fibers. Usually, when particles in the air are breathed in, they are filtered out by the nose or the upper airways of the lungs. But asbestos particles are very thin and light and sometimes are not filtered out before they reach the lungs. Asbestos can damage lung tissue and is responsible for causing several serious diseases, including cancer.

• Asthma: According to the American Lung association, approximately 20 million Americans have asthma, which causes about 5,000 deaths each year. Asthma is a chronic, inflammatory lung disease. The air passages within the lungs are constantly swollen, restricting the amount of air allowed to pass through the trachea. Asthmatics have recurrent breathing problems and a tendency to cough and wheeze.

• Common cold: The common cold, or acute viral nasopharyngitis, is an upper respiratory tract infection caused by a virus, which may involve the nose, throat, sinuses, Eustachian tubes (connects the ears to the throat), trachea (windpipe), larynx (voice box), and bronchial tubes (airways). Colds are one of the leading causes of doctor visits and missed days from school and work. According to the Centers for Disease Control and Prevention (CDC), 22 million school days are lost annually in the United States as a result of the common cold. Over the course of a year, people in the United States suffer one billion colds, according to some estimates.

• Cough: Coughs can either be classified as acute or chronic. Acute coughs usually begin suddenly and are often due to a cold, flu, or sinus infection. Acute coughs generally go away within two to three weeks. However chronic coughs last longer than two to three weeks.

• Croup: Croup is a viral infection that causes the upper part of the windpipe (larynx) to swell and is usually caused by one of the cold viruses.

• Laryngitis: Laryngitis is an inflammation of the voice box (larynx) usually associated with hoarseness or loss of voice. Laryngitis may be classified as acute (lasting for a short amount of time) or chronic (long-lasting).

• Pharyngitis: Pharyngitis or sore throat is an inflammation of the pharynx, the passageway that connects the oral and nasal cavities. Most cases of pharyngitis occur during the colder months and often spread among family members. Infections of the pharynx usually involve the tonsils (fleshy tissue in the back of the throat that are part of the body's immune defense), and tonsillitis (inflammation of the tonsils) was once a common name for infectious pharyngitis. Infectious pharyngitis accounts for approximately 10 million visits to the doctor's office each year.

• Pulmonary hypertension: According to the Pulmonary Hypertension Association, over 100,000 people suffer from pulmonary hypertension. Pulmonary hypertension occurs when there is high blood pressure in the lungs. Pulmonary hypertension results from constriction or tightening of the blood vessels that supply blood to the lungs. As a result, it becomes difficult for blood to pass through the lungs, making it harder for the heart to pump blood forward. This leads to enlargement of the heart and eventually fluid may build up in the liver and tissues, such as the in the legs.

• Respiratory distress syndrome (adults): Adult respiratory distress syndrome (ARDS) is a life-threatening lung condition. It is a form of breathing failure that can occur in very ill or severely injured people. It is not a specific disease. It starts with swelling of tissue in the lungs and buildup of fluid in the tiny air sacs that transfer oxygen to the bloodstream. This leads to low blood oxygen levels.

• Respiratory distress syndrome (infants): Respiratory distress syndrome is life threatening and one of the most common lung disorders in premature babies. Additionally, nearly all babies born before 28 weeks of pregnancy develop respiratory distress syndrome. According to the American Lung Association, infant respiratory distress syndrome was the seventh leading cause of death in infants under one year of age in the United States, accounting for 3.2 percent of all infant deaths.

• Respiratory syncytial virus (RSV): RSV is a virus that causes infection of the lungs and breathing passages and is most common among infants and children under one year of age.

• Rhinitis: Rhinitis affects over 50 million people and is considered one of the most common illnesses in the United States. Rhinitis is the medical term for inflammation of the nose and can be classified as either allergic or non-allergic. Allergic rhinitis occurs when the body's immune system overreacts to an airborne substance (allergen) that is normally harmless, such as mold, pollen, animal dander, or dust mites. Once the allergen is inhaled through the nose, white blood cells of an allergic individual produce an antibody called immunoglobulin E (IgE). This immunoglobulin attaches to the allergen, which triggers the release of histamine and other inflammatory chemicals that cause allergic rhinitis symptoms, such as runny nose and nasal congestion.

• There are two types of allergic rhinitis: seasonal allergic rhinitis and perennial allergic rhinitis. Seasonal allergic rhinitis, also called pollinosis, hay fever, or nasal allergies, is characterized by several symptoms, predominantly in the nose and eyes. Symptoms occur after airborne allergens like dust, dander, or pollen are inhaled. When pollens cause the allergic symptoms, the allergic rhinitis is commonly referred to as "hay fever." According to the American Lung association, an estimated 26.1 million Americans have hay fever symptoms each year; 14.6 million Americans have asthma, which often accompanies hay fever. Perennial allergic rhinitis is an allergic reaction to allergens (substances that can cause an allergic reaction) that is not seasonal. Instead, symptoms are persistent and generally less severe than seasonal allergic rhinitis. Non-allergic rhinitis usually affects adults and causes year round symptoms, but the immune system is not involved. Several causes of non-allergic rhinitis include the following: infections, irritants (e.g. dust, secondhand smoke, perfumes), weather changes, emotional or physical stress, hormonal changes, certain foods and beverages, certain medications (e.g. aspirin, ibuprofen ), and long-term use of decongestant nasal sprays.

• Sarcoidosis: Sarcoidosis is commonly found in the lungs and is characterized by the presence of granulomas, small areas of inflamed cells. This may lead to loss of lung volume (the amount of air lungs can hold) and abnormal lung stiffness. Sarcoidosis is most common among African Americans and northern European whites. Additionally, the disease usually affects people between the ages of 20 and 40.

• Sinusitis: There are three classifications of sinusitis: acute, chronic, and recurrent. Acute sinusitis lasts for less than six months, and it is usually caused by a bacterial infection. Most cases of sinusitis are acute. When symptoms last between four and eight weeks, the condition is considered to be subacute. Symptoms of chronic sinusitis last eight weeks or longer and the severity varies. Symptoms for acute and chronic sinusitis are very similar, except chronic sinusitis symptoms last longer and often cause more fatigue. According to the CDC, chronic sinusitis affects nearly 35 million people in the United States. When an individual suffers from three or more episodes of acute sinusitis per year, the condition is referred to as recurrent sinusitis.

Causes

• Asbestosis: Inhaling asbestos fibers may cause scar tissue to develop inside the lungs.

• Asthma: Individuals who are sensitive to environmental factors (e.g. air pollutants, smoke, chemicals, etc.) and have a family history of asthma are more likely to develop the condition.

• Common cold: A cold is caused by a viral infection. Viruses that may cause a cold include rhinoviruses, coronaviruses, adenoviruses, echoviruses, respiratory syncytial viruses (RSV), and coxsackieviruses. Although over a hundred different viruses can cause colds, 30-50% are caused by rhinoviruses.

• Cough: Asthma is a common cause of chronic cough in adults and a leading cause in children. Gastroesophageal reflux disease (GERD) is a common condition where stomach acid flows back into the tube that connects the stomach and the throat (esophagus). This causes constant irritation which may lead to chronic coughing. Blood pressure drugs, such as angiotensin converting enzyme inhibitors (ACE inhibitors), have also been known to cause cough in approximately 20% of patients taking them.

• Croup: Children may develop croup after breathing respiratory droplets infected with the virus. Croup is usually caused by parainfluenza viruses (viruses causing upper respiratory infections (colds) or lower respiratory infections (pneumonia)).Virus particles may survive on toys or other surfaces.

• Laryngitis: Laryngitis is usually caused by a virus. Additionally, laryngitis may also be caused by a bacterial infection or the common cold, bronchitis, flu, or pneumonia.

• Pharyngitis: Viruses (such as those that cause the common cold) and bacteria (which can cause many illnesses such as strep throat) may cause a sore throat. The bacteria group A streptococci causes pharyngitis in 5-15% of adults and 15-30% of children. However, approximately 85% of cases of pharyngitis are caused by a virus.

• Pulmonary hypertension: Pulmonary hypertension may be caused by diseases of the heart and the lungs, such as chronic obstructive pulmonary disease (COPD) or emphysema, sleep apnea (a sleeping disorder characterized by pauses in breathing), failure of the left heart ventricle, and recurrent pulmonary embolism (blood clots traveling from the legs or pelvic veins obstructing the pulmonary arteries), or underlying diseases such as scleroderma (scar tissue in the organs).

• Respiratory distress syndrome: Respiratory distress syndrome results from the absence of the liquid coating inside a baby's lungs (called surfactant) that keeps them open so that he/she can breathe in after birth.

• Respiratory syncytial virus: Individuals may develop respiratory syncytial virus by inhaling respiratory secretions from people coughing or sneezing. Additionally, direct contact (e.g. shaking hands) with infected individuals may spread respiratory syncytial virus.

• Rhinitis: Airborne substances, known as allergens, may cause allergic rhinitis. These allergens are usually harmless and only cause allergic symptoms in some people.

• Sarcoidosis: Research is being done to determine the causes of sarcoidosis. Scientists believe that sarcoidosis may develop when the body's immune system responds to something in the environment, such as bacteria, viruses, dust, or chemicals, resulting in inflammation. In this case, there may be a malfunction in the body's natural defense system causing it not to work properly and overreact.

• Sinusitis: Bacterial infections are usually the cause of acute sinusitis. When the sinuses are blocked for a long time, a secondary bacterial infection may develop, causing sinusitis.

Signs and Symptoms

• Asbestosis: The effects of long term exposure to asbestos typically don't show up for at least 20 to 30 years following initial exposure. Symptoms may include the following: shortness of breath, decreased tolerance for physical activity, coughing, and chest pain.

• Asthma: Symptoms of asthma may include the following: bronchospasm (abnormal contraction of the bronchi causing airway obstruction), coughing, wheezing or whistling sounds when exhaling, shortness of breath or rapid breathing, chest tightness or chest pain, and fatigue.

• Common cold: Symptoms of a common cold usually appear about one to three days after exposure to a cold virus. Signs and symptoms of a common cold may include runny or stuffy nose, itchy or sore throat, dry cough, facial pressure due to sinuses (hollow bones in the front of the face), slight body aches or a mild headache, sneezing, itchy watery eyes, low-grade fever (less than 102 degrees Fahrenheit), and mild fatigue (tiredness). Nasal discharge may become thicker as a common cold runs its course. What makes a cold different from other viral infections (such as influenza) is that the individual generally will not have a high fever or colored sputum. They are also unlikely to experience significant fatigue from a common cold. Colds last for approximately one week. Mild colds may last only two or three days while severe colds may last for up to two weeks. Cough due to a cold can last for hours or days.

• Cough: Some coughs are dry (nonproductive) while others are considered productive. A productive cough is one that brings up mucus.

• Croup: Croup features a cough that sounds like a seal barking. Most children have a mild cold for several days before the barking cough occurs. As the cough becomes more frequent, labored breathing or stridor (a harsh, crowing noise made when breathing in) may occur. Croup is usually worse at night and lasts for five or six nights. In severe cases, the upper airway may become swollen to the point that it is blocked off (airway obstruction). When croup lasts longer than one week, a doctor should be contacted. Children younger than five years of age are more likely to become infected with croup.

• Laryngitis: Patients may experience hoarseness, weak voice, sore throat, dry throat, or cough when they have laryngitis. If symptoms last for more than two weeks in an adult or one week in a child, then a doctor should be consulted as this may be a sign of a more serious condition.

• Pharyngitis: With pharyngitis, patients may experience sore throat, fever, headache, runny nose, difficulty swallowing, and rarely, difficulty breathing. Pharyngitis usually goes away without complications. However, if the sore throat does not go away after several days, then a doctor should be contacted. Symptoms should go away in approximately one week in patients with viral pharyngitis. In patients with strep throat, symptoms should go away a couple of days after beginning antibiotics. It is important for patients to finish taking their entire antibiotic even if they feel better. Strep throat generally presents as more severe, redder in coloration, more painful, and frequently involves swollen glands.

• Pulmonary hypertension: Patients with pulmonary hypertension may experience the following signs and symptoms: chronic fatigue, shortness of breath (dyspnea), chest pain (angina), palpitations, fainting, swollen ankles and legs (edema), and fluid in the abdomen (ascites). These are also symptoms for other diseases such as congestive heart failure; therefore, physicians should rule out other diseases before making a diagnosis of pulmonary hypertension. Unfortunately, these symptoms may affect a person's ability to perform daily tasks such as walking, dressing oneself, and cleaning.

• Respiratory distress syndrome: Signs and symptoms of respiratory distress syndrome usually appear at birth or within the next few hours and include the following: rapid, shallow breathing, sharp pulling in the chest below the ribs with each inhale, grunting sounds during exhaling, and flaring of the nostrils during breathing.

• Respiratory syncytial virus: Symptoms of respiratory syncytial virus may include cough, stuffy or runny nose, mild sore throat, fever, and irritability. Between 0.5% and 2% of infants and young children require hospitalization. However, most recover from the illness in 8-15 days with oxygen therapy or sometimes mechanical ventilation.

• Rhinitis: Symptoms of allergic rhinitis vary greatly among individuals. Common symptoms include: cough, headache, itchy nose, itchy mouth, itchy throat, itchy skin, nosebleeds, impaired smell, watery eyes, sore throat, wheezing, fever, cross-reactivity allergy to some fruits, pink eye (conjunctivitis), nasal congestion, post-nasal drip, runny nose, and swelling of the nasal tissues (may cause headaches). Some patients, especially those suffering from vasomotor rhinitis, sneeze when moving from a cold room to a warmer one.

• Sarcoidosis: Patients may experience a dry cough (without sputum), shortness of breath (dyspnea), or chest pain. Additionally, there may be more general symptoms such as fatigue, weakness, fever, and weight loss.

• Sinusitis: Patients with sinusitis generally experience symptoms that may affect the nose, eyes, or middle ear including thick nasal drainage, bad-tasting postnasal drip, plugged-up nose, cough, difficulty breathing, head congestion, headache, facial swelling, toothache, constant fatigue, tender cheeks, swollen eyelids, pain between the eyes, neck pain and occasionally fever. Individuals suffering from chronic sinusitis may also have nasal polyps, which are abnormal tissue growths (polypoidal masses) found in the mucous membranes of the nose and paranasal sinuses. Since nasal polyps often block the nasal passages and sinuses, breathing problems may develop.

Diagnosis

• Asbestosis: A chest X-ray may be used to diagnose asbestosis. Asbestosis appears as excessive whiteness in the lungs.

• Asthma: Spirometry is a noninvasive way to evaluate the air capacity of the lungs. Physicians are able to measure the volume of air exhaled before and after a bronchodilator (inhaler) is used.

• Cold: Colds are usually diagnosed clinically by the presence of typical symptoms including runny or stuffy nose, itchy or sore throat, dry cough, nasal congestion, facial pressure (sinuses), slight body aches or a mild headache, sneezing, itchy, watery eyes, low-grade fever (less than 102 degrees Fahrenheit), and mild fatigue (tiredness).

• Croup: The doctor will look for signs such as a barking cough and stridor (squeaking sound on inhaling). Additionally, the child will be checked for fever and cold symptoms and the doctor will determine whether there is a prior history of croup or airway problems.

• Pharyngitis: A rapid strep test can be done within 20 minutes in the doctor's office. If the results are positive, then the doctor will start an antibiotic. If the rapid strep test is negative, then a culture to grow the bacteria should be done to confirm the results. A throat culture is more accurate than the rapid strep test but takes several days to get the results.

• Pulmonary hypertension: An echocardiogram may be used to determine whether a patient has pulmonary hypertension. This test is noninvasive and uses harmless sound waves so that the doctor may see the heart without making an incision. A picture of the heart is recorded, and the doctor may determine the size and thickness of the heart muscle.

• Respiratory distress syndrome: Blood samples are taken to determine whether a baby has enough oxygen in the blood, which may help diagnose respiratory distress syndrome.

• Respiratory syncytial virus: The doctor will usually listen to the lungs with a stethoscope to check for signs of wheezing. Additionally, fluid may be taken from the nose with a cotton swab to identify the virus.

• Rhinitis: An allergen-specific immunoglobulin E (IgE) test, commonly often referred to as radioallergosorbent test (RAST®), is a type of blood test that can help determine if a patient who experiences allergy symptoms, such as runny nose, watery eyes, and hives, is allergic to particular substances called allergens. The in vitro test (performed outside of the body in a laboratory setting) exposes a blood sample to suspected allergens (like dust mites, pollen, or animal dander) to determine whether the patient has developed allergen-specific immunoglobulin E (IgE) antibodies. Antibodies are proteins that recognize and bind to specific antigens. During the procedure, a sample of blood is taken from the patient. The blood is then sent to a laboratory that performs specific IgE blood tests. An allergen-antigen complex is bound to a paper disc called an allergosorbent and the patient's blood is added. If the blood contains antibodies to the specific antigen, it will bind to the "tagged" immunoglobulins. RAST® is less accurate than a skin test. However, if the patient has a severe skin disease (such as eczema or psoriasis) that is present on large areas of skin on the arms or back, a skin test may not be possible. This is because the skin test may only be performed on the arms and back, and there may not be enough unaffected skin to perform a conclusive test. For these patients, an allergen-specific IgE test is the preferred diagnostic method.

• Sarcoidosis: When enlargement of the lymph glands in the center of the lungs is seen on X-ray, sarcoidosis is suspected.

• Sinusitis: Allergy testing may be conducted to detect specific allergens that might be causing sinusitis. Computerized tomography (CT) scans, which produce detailed images of the sinus cavities, may be used to identify inflamed areas. Cultures (blood tests) may be used to detect a bacterial or fungal infection. An endoscopic examination may be performed. During this procedure, a narrow, flexible fiber-optic scope is inserted into the nasal cavity through the nostrils. The physician is then able to see where the sinuses and middle ear drain into the nose. Blood tests may be conducted to rule out other conditions that may be associated with sinusitis, like an immune deficiency disorder or cystic fibrosis.

Complications

• Bronchitis and pneumonia: The common cold poses a risk for bronchitis and pneumonia in nursing home patients and other people who may be susceptible to infection. Some experts believe that the rhinovirus may play a more significant role than the flu in causing lower respiratory infections in such individuals.

• Bronchiolitis: Bronchiolitis is an infection of the airways of the lungs and usually occurs in young children between three and six months of age. RSV causes more than half of all bronchiolitis cases.

• Cough complications: Patients may develop headache, dizziness, and fractured ribs from a chronic cough.

• Lung cancer: Patients may have an increased risk of developing lung cancer if they have asbestosis. Additionally, both asbestosis and smoking put patients at an even higher risk for cancer.

• Untreated strep throat: Untreated strep throat may lead to serious complications such as glomerulonephritis (kidney disorder) and rheumatic fever (a potentially life-threatening illness that may damage the heart valves).

Treatment

• Antibiotics: The doctor will prescribe a 10-day treatment of penicillin or amoxicillin (Amoxil®, Trimox®) to treat strep throat. Patients allergic to penicillins may be given erythromycin, azithromycin (Zithromax®), or clarithromycin (Biaxin®). Patients should finish all of the medication even if they start to feel better.

• Cough medicines: Over-the-counter medicines such as Robitussin DM®, which includes the two medications dextromethorphan and guaifenesin, may be used to relieve cough symptoms. However, according to the American College of Chest Physician's Guidelines, over the counter cough syrups contain drugs in too low a dose to be effective. Additionally, patients may delay treatment for more serious coughs. An antihistamine with a decongestant is the recommended treatment.

• Combined therapy medicine: Combined therapy involves both a controller (e.g. corticosteroids or long acting beta agonists) and a reliever (e.g. corticosteroids or short acting beta agonists such as Albuterol®). This therapy is used to manage asthma symptoms for long-term therapy.

• Corticosteroids: Doctors may prescribe corticosteroids such as dexamethasone or prednisone to reduce the upper airway swelling that may occur with croup. Additionally, corticosteroids may be prescribed to keep the lungs working and relieve symptoms in patients suffering from sarcoidosis.

• Endothelin receptor antagonist (ERA): Letairis® (ambrisentan) was recently approved in 2007 for the treatment of pulmonary hypertension. Ambrisentan works by blocking the effects of a substance called endothelin, which is made by the body in increased amounts in patients with pulmonary hypertension. Endothelin causes blood vessels to narrow (constrict). It also causes overgrowth of the muscle in the walls of the blood vessels in the lungs. By blocking the action of endothelin, ambrisentan can reduce blood pressure in the lungs and improve activity level and well-being in patients. Common side effects of ambrisentan include the following: swelling of the lower extremities, nasal congestion, sinusitis, flushing, palpitations, abdominal pain, and constipation.

• Medication change: Patients who develop a cough from ACEIs may be switched to other blood pressure medications, such as angiotensin receptor blockers (ARBS), which have a lower incidence of cough and work in a similar way.

• Nasal decongestants: Nasal decongestants are useful medications for the common cold. Nasal decongestants help dilate (open) swollen mucous membranes of the nasal passages so the individual can breathe easier. Nasal decongestant dosage forms include tablets, sprays, inhalers, and nose drops. Nasal decongestants include the oral decongestant pseudoephedrine (Sudafed®), the nasal sprays oxymetolazone (Afrin®) and phenylephrine (Neo-Synephrine®), and the nasal inhalers propylhexedrine (Benzedrex®) and levmetamfetamine (Vicks Vapor Inhaler®). Nasal sprays containing a decongestant should be used for no longer than 72 hours due to the risk of rebound congestion (nasal spray addiction). They are safe for most patients, but they do have many side effects and conditions in which they should not be used, including in people with heart disease, high blood pressure, thyroid disease, glaucoma (increased pressure in the eyes), diabetes, seizure disorders, enlarged prostate, or by individuals using a monoamine oxidase inhibitor (MAOI, a type of antidepressant). Stinging, burning, sneezing, increased nasal discharge, drying of the nostrils, and altered taste may occur. If these effects continue or become bothersome, a doctor should be consulted. Other side effects include rapid or pounding heartbeat, dizziness, trouble sleeping, shaking of the hands, and tremors. Healthcare professionals recommend not using decongestants while pregnant or breastfeeding. If symptoms get worse, a doctor may need to evaluate the situation.

• Products containing pseudoephedrine can be purchased without a prescription. However, the products are placed behind the pharmacy counter with limits to the amount that may be purchased in a single day and month. These efforts were established since there is widespread abuse of pseudoephedrine as a drug to make methamphetamine.

• Pain relievers: Throat pain may be relieved by taking over-the-counter medications such as ibuprofen (Advil®, Motrin®), acetaminophen (Tylenol®), or aspirin (in adults only). Acetaminophen may also be used in patients who have the croup to lower fever, which may improve the child's breathing.

• Saline nasal drops: Isotonic saline nasal drops are recommended for infants. Healthcare professionals recommend 1-2 drops in each nostril 15 to 20 minutes before feeding and bedtime and repeated 10 minutes later. Adults and children may also use saline nasal drops (Ocean® nasal spray) to relieve dry and inflamed nasal passages.

• Surfactant replacement therapy: Surfactant may be given right after birth in the delivery room to prevent or treat respiratory distress syndrome. Surfactant is a liquid that coats the inside of the lungs and keeps them open so that the baby can breathe in air once he or she is born. The baby is given surfactant through a tube attached to a breathing machine until the lungs have developed enough to start making their own surfactant.

Integrative Therapies

• Strong scientific evidence:

• Andrographis: Andrographis (Andrographispaniculata) has been widely used in Indian (Hindu) folk medicine and Ayurvedic forms of medicine. A combination of andrographis with Siberian ginseng or eleuthero (Eleutherococcus senticosus) called Kan Jang® may be effective for upper respiratory tract infection treatment. In clinical study, this treatment was given for five days, and was shown to improve fever, muscle soreness, cough, sore throat, and headache.

• Several cases of anaphylactic reactions, including shock, have been reported to the World Health Organization Collaborating Center for International Drug Monitoring as of June 2003. Avoid with infertility or patients actively trying to conceive. Use cautiously with diabetes, bleeding disorders, or high or low blood pressure or medications used for these conditions. Avoid if pregnant or breastfeeding.

• 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.

• Bromelain: Bromelain has been studied in various clinical studies for sinusitis with mixed results. Further research is necessary.

• Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with history of bleeding disorder, 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.

• 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.

• Butterbur: Good scientific evidence suggests that butterbur may be effective for allergic rhinitis prevention in susceptible individuals. Comparisons of butterbur to prescription drugs, such as fexofenadine (Allegra®) and cetirizine (Zyrtec®), have reported similar efficacy. Additional studies are warranted before a firm conclusion can be made.

• Avoid if allergic or hypersensitive to Petasites hybridus or other plants from the Asteraceae/Compositae family (such as 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.

• 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.

• Echinacea: Preliminary studies suggest that echinacea may not be helpful for prevention of upper respiratory tract infections in adults and children or treatment of upper respiratory tract infections in adults. Study results are conflicting and further research is needed to make a conclusion in this area.

• Avoid if allergic to echinacea, its constituents, or any members of the Asteraceae/Compositae family (ragweed, chrysanthemums, marigolds, daisies). Use cautiously in patients prone to atopic reactions and in those with hemochromatosis and diabetes. Some natural medicine experts discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus). Use parenteral preparations of echinacea(no longer approved for use in Germany) cautiously. Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole. Avoid in patients presenting for anesthesia. Use cautiously 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.

• 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.

• Nasal irrigation: There is good evidence from clinical studies to recommend the use of nasal irrigation in the treatment of allergic rhinitis. One study demonstrated that reflexology massage may be equally effective; however, the advantage of irrigation (i.e. inexpensive, performed at home, minimal adverse side effects) makes the technique beneficial. Methodological and statistical reporting are lacking in some of these trials. A well-conducted, randomized controlled trial, fully reporting data would make the case for allergic rhinitis stronger.

• Early research suggests that nasal irrigation may help treat chronic sinusitis, with improvements in sinus-related quality of life, decreases in symptoms, and decreases in medication use. Further study is needed before a conclusion can be made.

• Nasal irrigation is generally well tolerated. Use cautiously with history of frequent nosebleeds. If the irrigation liquid is hot, the nose may become irritated.

• Probiotics: Use of probiotic Enterococcus faecalis bacteria in hypertrophic sinusitis (sinus inflammation) may reduce frequency of relapses and the need for antibiotic therapy. Further research is necessary before a firm conclusion can be made.

• Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

• 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.

• Sage: Sage mouthwashes and gargles have been approved for use against sore throat in Germany by the German Commission E. Additional study is needed comparing sage to standard therapies for acute pharyngitis (inflammation of the pharnyx).

• Avoid if allergic or hypersensitive to sage, its constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use essential oil or tinctures cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.

• Vitamin C: Vitamin C, or ascorbic acid, is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits, such as oranges. Scientific studies generally suggest that vitamin C does not prevent the onset of cold symptoms. However, in a subset of studies in people living in extreme circumstances, including soldiers in sub-arctic exercises, skiers, and marathon runners, significant reductions in the risk of developing colds by approximately 50% have been reported. Additional study is needed to better determine the effectiveness of vitamin C for common cold prevention in extreme environments.

• 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. Large doses (greater than 2 grams) may cause diarrhea and gastrointestinal upset. 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.

• Yoga: Human study exists for yoga in the treatment of lung diseases, such as bronchitis, fluid around the lungs (pleural effusion), or airway obstruction. 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).

• There is currently insufficient available evidence on which to base recommendations for acupuncture in non-allergic rhinitis. However, studies suggest that it may offer possible benefits. Additionally, more studies are needed of stronger design to determine whether or not acupuncture offers benefit in sinusitis.

• 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 a lack of high-quality research describing the effect of the Alexander technique on respiration and chronic asthma. More study is needed in this area.

• Serious side effects have not 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.

• Andrographis: Based on clinical evidence, andrographis may be effective for upper respiratory tract infection prevention. Additional high-quality clinical study is needed to reach a conclusion.

• Several cases of anaphylactic reactions, including shock, have been reported to the World Health Organization Collaborating Center for International Drug Monitoring as of June 2003. Avoid with infertility or patients actively trying to conceive. Use cautiously with diabetes, bleeding disorders, or high or low blood pressure or medications used for these conditions. Avoid if pregnant or breastfeeding.

• 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 considered to be harmless. However, medical conditions should not be treated with AK alone, and should not delay appropriate medical treatment.

• Arginine: Early study suggests that arginine supplements may decrease the risk of respiratory infections. Large, well-controlled studies are needed to clarify this relationship.

• Avoid if allergic to arginine, with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control blood sugar levels.

• 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. Despite widespread use in over-the-counter agents and vapors, there is not enough scientific evidence to recommend use of eucalyptus oil as a decongestant-expectorant (by mouth or inhaled form).

• Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with 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.

• Astragalus: Astragalus is often used in Chinese medicine as a part of herbal mixtures to prevent or treat upper respiratory tract infections. Due to a lack of well-designed research, firm conclusions cannot be drawn at this time.

• Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplants, or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.

• 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.

• Boneset: Boneset (Eupatorium perfoliatum) is native to eastern North America and was used by Native Americans to treat fevers. Boneset is used homeopathically in very dilute amounts for colds. Homeopathic boneset was found in limited available study to decrease the symptoms associated with a cold. Homeopathic medicines do not have side effects due to the very small amount of substance, such as boneset, used in their preparation.

• Avoid if allergic or hypersensitive to boneset (Eupatorium perfoliatum), any of its constituents, or related members of the Asteraceae/Compositae family such as dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously in small children, elderly individuals, or individuals suffering from a chronic condition. Use cautiously even in the amounts recommended by manufacturers, as boneset may promote sweating, the production of urine, and catharsis. Avoid with known liver or kidney conditions and in patients who ingest moderate to large amounts of alcohol. Avoid if pregnant or breastfeeding.

• 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.

• Bovine colostrum: Bovine colostrum has shown potential for immune stimulation. However, early evidence has not shown any benefit for reducing upper respiratory tract infection duration, although bovine colostrum may reduce symptoms. Further studies are required before a conclusion can be made.

• Avoid if allergic to dairy products. Use cautiously because toxic compounds, such as polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), and dichlordiphenyldichloroethylene (DDE), have been found in human colostrum and breast milk. Thus, it is possible that these agents may be found in bovine colostrum. Avoid with, or if at risk for, cancer. Use cautiously with immune system disorders or atherosclerosis (hardening of the arteries). Use cautiously if taking medications, such as anti-diarrheal agents (e.g. Imodium®), insulin, or CNS agents (such as amphetamines, caffeine).

• 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.

• Chamomile: Chamomile (Matricaria recutita) has been used medicinally for thousands of years, and is widely used in Europe. It is a popular treatment for numerous ailments, including sleep disorders, anxiety, and digestion/intestinal conditions. In early study, inhalation of steam with chamomile extract was reported to help relieve symptoms of the common cold. Further research is needed to confirm these results. Caution is advised when taking chamomile supplements, as adverse effects including drowsiness are possible.

• Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash may cause allergic conjunctivitis (pinkeye). 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 machinery. Avoid if pregnant or breastfeeding.

• Chiropractic: There is currently not enough reliable scientific evidence to conclude the effects of chiropractic techniques for respiratory tract infections. 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 also 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.

• Choline: Oral tricholine citrate (TRI) effectively relieved allergic rhinitis symptoms in limited available study. Further research is needed before a firm conclusion can be made.

• Choline is generally regarded as safe and appears to be well tolerated. Avoid if allergic to choline, lecithin, or phosphatidylcholine.

• 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.

• Elderberry and elder flower: Elder (Sambucus nigra) has been reported to have antiviral and antibacterial activity in laboratory studies. There is a small amount of research on the combination herbal product Sinupret®, a German product that contains elder and several other herbs, in patients with bronchitis. This formula contains elder flowers (Sambucus nigra) as well as gentian root, verbena, cowslip flower, and sorrel. Although benefits have been suggested, due to design problems with this research, no clear conclusion can be drawn either for Sinupret® or elder in the management of bronchitis. Elder may also offer benefits for bacterial sinusitis, such as reducing excessive mucus secretion. Herbal preparations containing elder may result in less swelling of mucus membranes, better drainage, milder headache, and decreased nasal congestion.

• Cyanide toxicity is possible with consumption of elder. Avoid if allergic to elder or to plants related to honeysuckle. Some reports exist of allergies from contact with fresh elder stems. Use caution with diabetes, high blood pressure or urinary problems, or with drugs used for any of these conditions. Use caution with anti-inflammatory agents, diuretics ("water pills" for high blood pressure), or laxatives. 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.

• Ephedra: Preliminary study suggests that ephedrine nasal spray may help treat allergic rhinitis. Additional research is needed before a recommendation can be made.

• Ephedra taken by mouth can cause serious side effects, including heart attack, seizure, and stroke. Therefore, ephedrine nasal sprays should only be used in the nose. 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 with history of high blood pressure, abnormal heart rate, heart attack, stroke, seizure, eating disorders, anxiety, prostate disease, mental illness, kidney disease, stomach ulcers, heart disease, eye disease, depression, diabetes, thyroid disease, or sleep problems. 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 asthma and upper respiratory tract infections and as a decongestant-expectorant.

• 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.

• Euphorbia: Limited available clinical study involving senior patients with chronic bronchitis showed a significant effect of Euphorbia helioscopia. Larger trials are needed to evaluate the effect of Euphorbia helioscopia in a wider range of patients.

• Avoid if allergic or hypersensitive to pollen from Euphorbia fulgens. Use cautiously with history of Epstein Barr virus infection or stomach conditions. Avoid if pregnant or breastfeeding.

• Evening primrose oil: There is evidence that primrose oil, in combination with thyme, may have some benefits in the treatment of acute bronchitis. However, it is unclear if primrose alone is useful in treating bronchitis. More studies are needed to examine the effectiveness of primrose oil alone as a therapy for bronchitis.

• Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with drugs used for mental illness. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

• Garlic: Garlic (Allium sativum) may improve the immune system's ability to fight off infection, such as a cold virus, and may reduce the severity of upper respiratory tract infections. However, this has not been demonstrated in well-designed human studies.

• Caution is advised when taking garlic supplements, as adverse effects including an increase in bleeding and drug interactions are possible. Garlic supplements should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.

• 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: Several studies have looked at the effects of ginseng in a variety of lung conditions. Limited research suggests that ginseng has positive effects on breathing, such as its proposed role as a bronchodilator. Ginseng was also reported to improve lung function and exercise capacity in patients with chronic obstructive pulmonary disease COPD). Additionally, the ginseng preparation CVT-E002 may be effective for preventing respiratory infections caused by the respiratory syncytial virus. More research is needed to confirm the effects of ginseng for these indications.

• 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.

• Goldenseal: Goldenseal (Hydrastis canadensis) has become a popular treatment for the common cold and upper respiratory tract infections, and is often added to Echinacea in commercial herbal cold remedies. Animal and laboratory research suggests that the goldenseal component berberine has effects against bacteria and inflammation. However, due to the very small amount of berberine in most goldenseal preparations, it is unclear whether goldenseal contains enough berberine to have the same effects.

• Caution is advised when taking goldenseal supplements, as adverse effects including drug interactions are possible. Goldenseal supplements should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.

• 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.

• In humans, preliminary data suggests that a specific formulation of green tea may be effective for common cold prevention. Further well-designed clinical trials are needed to confirm these results.

• 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.

• Preliminary research in children suggests that stress management and relaxation with guided imagery may reduce the duration of symptoms due to upper respiratory tract infections, including colds. More research is needed.

• 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.

• Honey: Currently, there is insufficient human evidence to recommend honey for the treatment of rhinoconjunctivitis.

• Avoid if allergic or hypersensitive to honey, pollen, celery or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

• Horseradish: Horseradish may have antibiotic activity, and has been used in combination with other herbs to treat bronchitis and sinusitis. However, additional studies are needed that use horseradish as a single therapy before a conclusion can be made.

• Avoid if allergic or hypersensitive to horseradish (Armoracia rusticana), its constituents, or members of the Brassicaceae family. Large oral doses may provoke allergic reactions. Use cautiously with clotting disorders, hypotension (low blood pressure), thyroid disorders, kidney disorders, kidney inflammation, gastrointestinal conditions, ulcers, and stomach ulcers. Use cautiously if taking anticoagulants or antiplatelets (blood thinning agents), antihypertensives (blood pressure-lowering agents), anti-inflammatory agents, or thyroid hormones. Use cautiously if undergoing treatment for cancer. Avoid medicinal amounts of horseradish if pregnant or breastfeeding, as glucosinolates from horseradish are considered a toxin that can be excreted through breast milk and may pose a toxicity hazard. Also, based on herbal textbooks and folkloric precedent, horseradish has been used to induce abortion.

• 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.

• There is also preliminary evidence that daily showers with warm water followed by cold water, or cold water alone, may reduce the duration and frequency of common cold symptoms. Additional research is needed in this area 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.

• It has also been suggested that hypnotherapy may be effective for treating hay fever. However, further research is necessary.

• 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. Limited available study also suggests that the Lactobacillus acidophilus (L. acidophilus) strain L-92 (L-92) may be effective for the treatment of Japanese cedar-pollen allergy. Further research is needed to confirm these results.

• 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.

• Licorice: Historically, licorice has been used for its expectorant and anti-tussive effects. The herbal combination product, KanJang®, has been studied for the treatment of uncomplicated upper respiratory tract infections. Results are mixed, and additional study is needed.

• Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid licorice with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.

• 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 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.

• Moxibustion: Moxibustion is the application of heat to variouspoints on the body. It is widely used traditionally in China for treatment of upper respiratory tract infections in children. However, at this time evidence is insufficient.

• Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, the face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or taking a hot bath or shower. Use cautiously with elderly people with large vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.

• MSM: According to preliminary clinical study, MSM reduces symptoms associated with seasonal allergic rhinitis (SAR). However, larger controlled trials are needed to confirm these findings.

• Avoid if allergic or hypersensitive to MSM. Long-term effects of supplementation with MSM have not been examined. Avoid if pregnant or breastfeeding.

• Nasal irrigation: Early research suggests that hypertonic saline aerosol may benefit chronic obstructive pulmonary disease (COPD), by enhancing the clearance of lung secretions. There is also promising early evidence for using nasal irrigation in treating the common cold, respiratory symptoms from occupational exposure, and in post-operative care following sinus or nasal surgeries. 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).

• Papain: Papain has shown some benefits in reducing symptoms of sore throat. More high-quality studies are needed in this area.

• Use cautiously in patients sensitive to papain. Use cautiously in patients being treated for prostatitis. Use Wobenzym®, which contains papain, cautiously, especially in those with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously with radiation therapy. Avoid in patients with gastroesophageal reflux disease or in patients using immunosuppressive therapy.

• 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. Menthol, a constituent of peppermint oil, is sometimes included in inhaled preparations for nasal congestion, including "rubs" that are applied to the skin and inhaled. High quality research is lacking in this area.

• Essential oils are not intended for internal use. 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 and various lung conditions. 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. 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. Respiratory therapy has been used in the treatment of chronic bronchitis, and the FLUTTER device has been studied for its beneficial effects. Results are unclear and additional research is needed.

• 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.

• Propolis: There is some evidence that propolis may help prevent infections with the virus that causes the common cold. Propolis nasal sprays have been suggested as a treatment for runny nose, congestion, and fever in children with nose or throat infections. However, there is currently not enough clinical evidence to support the use of propolis for these indications.

• Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.

• 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: Because selenium is proposed to have a role in immune function, selenium supplementation has been studied in patients with various infections. Some evidence suggests that selenium may promote recovery from bronchitis and pneumonia caused by the respiratory syncytial virus (RSV). Although selenium may correct selenium deficiency in patients with bronchitis, more studies are needed to show its effectiveness in treating respiratory infections.

• 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.

• Slippery elm: Slippery elm (Ulmus fulva) is commonly used to treat sore throat, most typically taken as a lozenge. While anecdotally reported to be effective, supporting evidence is largely based on traditional evidence and the fact that components of slippery elm appear to possess soothing properties for the throat. Scientific evidence is necessary in this area before a clear conclusion can be drawn.

• Slippery elm throat lozenges are safe in recommended dosages. Avoid if allergic or hypersensitive to slippery elm. Avoid if pregnant or breastfeeding.

• Sorrel: Sorrel, in combination with other herbs, may have beneficial effects for acute bronchitis, sinusitis, and allergic rhinitis, but it is not clear what dose is safe or effective. Sorrel alone has not been adequately studied for these indications.

• Avoid large doses of sorrel because there have been reports of toxicity and death. This may be because of the oxalate found in sorrel. Many tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.

• 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.

• Spirulina: Anti-inflammatory properties of spirulina may help improve symptoms of allergic rhinitis. However, further high-quality studies are needed to confirm these findings.

• Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; of if consuming a high-protein diet. Avoid in children or if pregnant or breastfeeding.

• Stinging nettle: For many years, a freeze-dried preparation of Urtica dioica has been prescribed by physicians and sold over-the-counter for the treatment of allergic rhinitis. Clinical trials demonstrating statistical significance over placebo and/or equivalence with other available treatments are needed to support the use of nettle in the treatment of allergic rhinitis.

• Avoid if allergic or hypersensitive to nettle, the Urticaceae family or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, and/or low sodium levels in the blood. Use cautiously with diuretics and anti-inflammatory drugs. The elderly should also use nettle cautiously. Avoid if pregnant or breastfeeding.

• 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.

• Thyme: Thyme has traditionally been used for the treatment of respiratory conditions including bronchitis and cough. The German Commission E (expert panel), has approved thyme for use in bronchitis. However, due to a lack of available data evaluating thyme alone (not in any combination products), additional study is needed to make a conclusion.

• Avoid with known allergy/hypersensitivity to members of the Lamiaceae (mint) family or to any component of thyme, or to rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury, or in atopic patients. Use cautiously in patients with gastrointestinal irritation or peptic ulcer disease. Use cautiously in patients with thyroid disorders. Avoid if pregnant or breastfeeding.

• Thymus extract: Preliminary evidence suggests that both intramuscular and oral thymus extract may be useful for reducing symptoms of respiratory tract infections. Additional study is needed in this area.

• Early evidence also 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 for 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.

• Vitamin E: Supplementation with oral vitamin E may be beneficial for respiratory infection prevention and for reducing the nasal symptoms of allergic rhinitis. Additional research is warranted.

• Caution is advised when taking vitamin E supplements, as adverse effects and drug interactions are possible. Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Avoid if pregnant or breastfeeding, unless otherwise directed by a doctor. Use cautiously with bleeding disorders or if taking blood thinners.

• Wild indigo: Preliminary evidence has shown immunostimulative properties in wild indigo extracts. However, available clinical studies have been conducted using the combination called Esberitox N (Echinaceae purpureae et pallidae radix, Baptisiae tinctoriae radix and Thujae occidentalis herba). Additional study is needed using wild indigo alone to better determine effectiveness for respiratory tract infections.

• Avoid if allergic or hypersensitive to wild indigo, its constituents, or members of the Fabaceae family. Use cautiously if taking immunosuppressive agents. Avoid if pregnant or breastfeeding.

• Yerba santa: Chumash Native Americans and other California tribes have used yerba santa (Eriodictyon californicum) and other related species (Eriodictyon crassifolium, Eriodictyon trichocalyx) for many centuries in the treatment of pulmonary conditions, saliva production, and to stop bleeding of minor cuts and scrapes. There is also clinical history of the use of Eriodictyon extracts in influenza, bacterial pneumonia, asthma, bronchitis, and tuberculosis. However, additional study is needed.

• Avoid if allergic or hypersensitive to Eriodictyon species. Use cautiously in children. Avoid if pregnant or breastfeeding.

• Zinc: Zinc lozenges are advertised as decreasing the symptoms, length, and severity of a cold. However, there are contradictory results regarding the efficacy of zinc formulations in treating duration and severity of common cold symptoms. Although zinc may be beneficial in the treatment of cold symptoms, more studies are needed to clarify which zinc formulations may be most effective, which rhinoviruses are affected by zinc, and if nasal sprays provide a useful alternative application route for zinc treatment. A recent study found no significant differences between zinc nasal spray and placebo.

• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

• Fair negative scientific evidence:

• Echinacea: Initial research suggests that echinacea may not be helpful for upper respiratory tract infection treatment in children, possibly because parents are not able to recognize the onset of common cold symptoms soon enough to begin treatment, or because the dose of echinacea for use in children is not clear. There are fundamental differences in causes of upper respiratory tract infections in children versus adults (bacterial versus viral causes; different viruses; different sites of infection; etc). Until additional research is available, echinacea cannot be considered effective in children for the treatment of upper respiratory infections. Furthermore, development of rash has been associated with echinacea use, and therefore the risks may outweigh the potential benefits for children.

• Avoid if allergic to echinacea, its constituents, or any members of the Asteraceae/Compositae family (ragweed, chrysanthemums, marigolds, daisies). Use cautiously in patients prone to atopic reactions and in those with hemochromatosis and diabetes. Some natural medicine experts discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus). Use parenteral preparations of echinacea(no longer approved for use in Germany) cautiously. Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole. Avoid in patients presenting for anesthesia. Use cautiously if pregnant or breastfeeding.

• Evening primrose oil: Small studies do not show evening primrose oil to be useful in the treatment of asthma. Further research is needed to confirm this conclusion.

• Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

• Grape seed: Grape seed has been used to treat immune system disorders due to its antioxidant effects. However, a well-designed human study of allergic rhinitis sufferers showed no improvement in allergy symptoms with administration of grape seed extract ingredients.

• Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's "cytochrome P450" enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or breastfeeding.

• 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.

• Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

• Vitamin C: More than 30 clinical trials including more than 10,000 participants have examined the effects of taking daily vitamin C on cold prevention. Overall, no significant reduction in the risk of developing colds has been observed. In people who developed colds while taking vitamin C, no difference in severity of symptoms has been seen overall, although a very small significant reduction in the duration of colds has been reported (approximately 10% in adults and 15% in children). Additionally, numerous studies have examined the effects of starting vitamin C for common cold treatment after the onset of cold symptoms. Overall, significant benefits have not been observed. Initial evidence reports possible benefits with high doses of vitamin C taken at the onset of symptoms, but without additional evidence this remains indeterminate. Therefore at this time, the scientific evidence does not support the use of vitamin C for either common cold prevention in general or common cold treatment.

• 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. Large doses (greater than 2 grams) may cause diarrhea and gastrointestinal upset. 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.

• Vitamin E: There is preliminary evidence that vitamin E does not provide benefits in individuals with asthma.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

• 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.

• Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) or blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Prevention

• The diphtheria, Haemophilus influenzae (Hib), and measles vaccines protect children from some of the most dangerous forms of croup.

• Individuals should not smoke and should stay away from second hand smoke to prevent developing a cough.

• People working with asbestos products should monitor their exposure levels and wear protective gear, such as face masks.

• Children and adults need to understand the importance of hand washing. Healthcare professionals recommend carrying a bottle of alcohol-based hand rub containing at least 60% alcohol for times when soap and water are not available. These gels kill most germs and are safe for older children to use themselves. Use cautiously as the overuse of antibacterial cleansers can cause damage to normal bacteria that live on the skin.

• Synagis® (palivizumab) is used to prevent serious lower respiratory tract diseases caused by respiratory syncytial virus in high risk children. A recent study showed that Synagis® may reduce recurrent wheezing in premature infants by almost half.

• Patients may also receive the flu vaccination, which is effective for one year. It may be injected into the patient or sprayed into the nose. A prescription is needed for both types of flu vaccines. They are available at a doctor's office or at a flu clinic in the local area. The flu shot is an inactivated vaccine (containing killed virus) that is given with a needle. The flu shot is approved for use in people six months of age and older, including healthy people and people with chronic medical conditions such as diabetes, asthma, and heart disease. The flu shot is recommended in children ages six months to five years, adults that are in close contact with children ages six months to five years (such as teachers and daycare workers), people 50 years of age and older, healthcare workers, all care givers of high risk people (such as those with HIV/AIDS or cancer), and people with chronic health conditions (e.g. asthma), as well as pregnant women. The nasal-spray flu vaccine (FluMist/LAIV®) is a vaccine made with live, weakened flu viruses that does not cause the flu (sometimes called LAIV for "Live Attenuated Influenza Vaccine"). The nasal flu vaccine is approved for use in healthy people 5- 49 years of age who are not pregnant. Patients who have weakened immune systems (e.g. HIV patients or chemotherapy patients) should not receive the nasal spray vaccine because it contains a weakened form of the live influenza virus. Although rare, it is possible for the weakened virus to cause an infection in immunocompromised patients.

Author Information

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

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Family Physicians. www.aafp.org.

2. American Lung Association. www.lungusa.org.

3. MedlinePlus. www.nlm.nih.gov.

4. Neumours Foundation. www.kidshealth.org.

5. National Heart Lung and Blood Institute. www.nhlbi.gov.

6. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

7. Pulmonary Hypertension Association. www.phassociation.org.

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9. Barrett B, Harahan B, Brown D, et. al. Sufficiently important difference for common cold: severity reduction. Ann Fam Med. 2007 May-Jun;5(3):216-23. View Abstract.

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13. Bolser DC. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):238S-249S. View Abstract.