Note: In addition to reviewing the integrative interventions described here, readers are encouraged to review those described in the Immune Senescence protocol. Immune senescence is an important risk factor for pneumonia, and, therefore, natural compounds shown to combat immune senescence may help reduce pneumonia risk. Similarly, because colds and the flu are risk factors for pneumonia, the Common Cold and Influenza protocols should be consulted as well.
When hospitalized patients require assisted ventilation for 48 hours or more, their risk of developing hospital-acquired pneumonia increases (Liu 2012). Meta-analyses of randomized controlled trial data have concluded that probiotics may prevent hospital-acquired pneumonia in critically ill patients (Liu 2012; Barraud 2013; Petrof 2012; Bo 2014) and lessen the incidence and duration of upper respiratory tract infections in healthy adults and children (Hao 2015; King 2014; Saeterdal 2012). A double-blind placebo-controlled clinical trial on more than 200 healthy subjects tested whether probiotic formulas impacted the rate and severity of respiratory illness over three winters. The trial used formulas containing multiple strains of Lactobacilli (including Lactobacillus plantarum LP 02-LMG P-21020), as well as Bifidobacterium lactis BS 01-LMG P-21384. The frequency, severity, and duration of respiratory illnesses during cold and flu season were significantly reduced in the probiotic group compared with the placebo group (Pregliasco 2008). Since many cases of bacterial pneumonia are preceded by upper respiratory tract infections (Musher 2012), preventing these milder infections may reduce pneumonia risk. Probiotics are also useful in minimizing side effects of antibiotic therapy, including diarrhea and Clostridium difficile infection (Urben 2014; Maziade 2015).
Ganoderma lucidum, commonly known as reishi or lingzhi, has a long history of use for treating conditions related to inflammation and low immune function (Suarez-Arroyo 2013; Wachtel-Galor 2011; Patel 2012; Batra 2013). Because of its balancing effect on immune activity, reishi is considered an immune modulator (Bhardwaj 2014). Reishi polysaccharides have been found to stimulate infection-fighting immune cells (Tsai 2012; Zhu 2005).
Cistanche deserticola has been used historically in traditional Chinese medicine to stimulate immunity in the elderly. Cistanche glycosides, including the compound echinacoside, as well as a cistanche polysaccharide have demonstrated immune-enhancing effects (Xuan 2008; Wu 2005; He 2009). An extract of cistanche was found to increase lifespan and stimulate immune cell activity in mice with immune senescence. Because immune senescence plays a key role in pneumonia susceptibility in older individuals (Krone 2014; McElhaney 2012; Murray 2015; Zhang 2014), cistanche holds promise as a pneumonia preventive in the elderly.
Pu-erh tea has been used traditionally in China for centuries for a wide range of health benefits. Pu-erh tea was found to enhance immune cell activity while decreasing the inflammatory cytokine interleukin-6 in mice with immune senescence (Zhang 2012). This immune-modulatory effect gives pu-erh tea potential as a pneumonia preventive in aging individuals.
Data from the National Health and Nutrition Examination Survey III showed occurrence of community-acquired pneumonia was higher in people with low vitamin D status (Quraishi 2013). In another study that followed over 1400 people between the ages of 53 and 73 for an average of almost 10 years, those with the lowest vitamin D levels were 2.6 times more likely to develop pneumonia compared with those with the highest vitamin D levels (Aregbesola 2013). Very low (< 15 ng/mL) 25-hydroxyvitamin D levels have been associated with 2.6-fold greater odds of hospitalization for community-acquired pneumonia (Jovanovich 2014). Furthermore, vitamin D deficiency may increase the risk of death in hospitalized patients with community-acquired pneumonia (Kim 2015; Leow 2011). An ongoing randomized, placebo-controlled, double-blind clinical trial, called the Lung VITAL study, is examining whether supplementing with 2000 IU vitamin D plus 1 g omega-3 fatty acids from fish per day can reduce pneumonia risk (Gold 2016). An analysis of randomized controlled trial data found vitamin D supplementation reduced the odds of respiratory infections by over 40% (Charan 2012).
These benefits may be partly explained by vitamin D’s ability to increase antimicrobial immune activity (Borella 2014; Youssef 2012). Also, vitamin D deficiency is associated with fewer immune cells in the blood, increasing susceptibility to infection (Dogan 2009; Youssef 2012). Vitamin D is also an immune modulator, involved in stimulating innate immune activity and regulating tissue-damaging inflammation (Youssef 2012; Lin 2016; Calton 2015).
Poor zinc status, a common finding in the elderly, is associated with impaired immune function, decreased defenses against microbes, increased duration and incidence of pneumonia, and greater use of antimicrobial treatments. Low zinc levels are also associated with an increased rate of death from all causes in the elderly. Because zinc is needed for normal cell division and development, it is especially important to cells that replicate rapidly, such as immune cells (Barnett 2010).
In a one-year study, nursing home residents with lower zinc status were found to have almost twice the risk of pneumonia as those with normal zinc status. In addition, pneumonia lasted longer and more antibiotics were used in the low-zinc residents compared with their normal-zinc counterparts. Study subjects with adequate zinc levels were at a significantly lower risk of dying from any cause (Meydani 2007). In an animal model, mice fed a zinc-deficient diet were dramatically more likely to die of infection with Streptococcus pneumoniae, and to have evidence of lung infection with Streptococcus pneumoniae, compared with mice fed zinc-adequate diets (Strand 2001).
Zinc supplements may reduce the duration and severity of upper respiratory tract infections. In one trial, volunteers with recent onset of cold symptoms were treated with 13.3 mg zinc, in the form of an oral zinc acetate lozenge, or placebo every 2–3 hours during the day. Zinc-treated subjects had less severe symptoms and recovered an average of 3.1 days sooner than placebo-treated subjects (Prasad 2008). In a similar trial, taking a lozenge providing 12.8 mg zinc acetate every 2–3 hours, beginning within 24 hours of developing a cold, was associated with decreased severity of symptoms and a 3.6-day reduction in duration of symptoms (Prasad 2000). Zinc may also be useful in prevention. A randomized controlled clinical trial in adults aged 55–87 found daily supplementation with 45 mg zinc gluconate for 12 months was associated with lower incidence of infections compared with placebo (Prasad 2007). Since pneumonia is often a complication of an upper respiratory tract infection (Musher 2012), preventing colds or reducing their severity may help protect against pneumonia.
In a one-year controlled clinical trial, over 600 elderly nursing home residents were treated daily with 200 IU vitamin E or placebo. Those receiving vitamin E experienced fewer common colds (Meydani 2004). Another study following elderly patients hospitalized with community-acquired pneumonia found taking vitamin E supplements was associated with 63% lower odds of re-hospitalization after discharge (Neupane 2010). Based on work in animal models of susceptibility to infection in the elderly, vitamin E appears to exert its protective effect against bacterial pneumonia through modulation of immune function (Bou Ghanem 2015).
Vitamin E is not a single compound, but rather comprises several related compounds called isoforms (Abdala-Valencia 2013). A combination of natural tocopherols may possess greater health-promoting properties compared with isolated alpha-tocopherol. Gamma-tocopherol in particular seems to be an important contributor to some of vitamin E’s health benefits (Peh 2016; Mathur 2015; Devaraj 2008; Lee 2009; Wu 2007).
Green tea is rich in polyphenolic compounds called catechins (Taylor 2005). A major catechin in green tea, epigallocatechin gallate or EGCG, has demonstrated antiviral action against influenza virus (Ling 2012) and has been shown to activate antibacterial immunity against Legionella pneumophila in vitro (Matsunaga 2002; Yamamoto 2004). Green tea catechins have demonstrated important antimicrobial activity against oral pathogens that cause periodontal disease, which may be a risk factor for development of bacterial pneumonia (Taylor 2005; Raghavendran 2007).
A study that followed older subjects for 12 years found that women who drank one or more cups (averaging about 3.5 fl oz per cup) of green tea per day were 41–47% less likely to die from pneumonia than women who drank less than one cup of green tea per day (Watanabe 2009). Drinking 1–5 cups of green tea daily was found in another study to reduce the risk of influenza, a common prelude to pneumonia, in schoolchildren (Park 2011; Chan 2016).
In a controlled clinical trial in nearly 200 healthcare workers, a green tea extract providing 378 mg per day of green tea catechins and 210 mg per day of the green tea-derived amino acid theanine was compared with placebo. Subjects in the green tea extract group had 75% fewer influenza infections over a five-month period (Matsumoto 2011). Gargling with a catechin-rich green tea extract may also be an effective way to prevent respiratory infections, including influenza. In a 3-month study, 148 nursing home residents were assigned to gargle regularly with either a solution containing green tea catechins or a catechin-free control solution. Only 1.3% of residents in the catechin group contracted influenza, while 10% of those in the control group became ill with the flu (Yamada 2006).
N-acetylcysteine and L-cystine
N-acetylcysteine (NAC) is a precursor to glutathione, one of the body’s essential oxidative stress modulators, and has been studied in bronchitis, cystic fibrosis, and other lung conditions because of its expectorant and mucus-thinning actions (van Zandwijk 1995; Tirouvanziam 2006; Roxas 2007; Chen 2013). NAC supplementation increases the body’s stores of glutathione, and evidence indicates that NAC improves immunity and modulates inflammation (McCarty 2015). In a six-month trial with 262 participants, most of whom were 65 or older, only 25% of those taking 600 mg NAC twice daily developed influenza symptoms compared with 79% of those in the placebo group. NAC treatment significantly decreased the severity and frequency of influenza-like episodes, and reduced time spent recovering in bed (De Flora 1997). Influenza often precedes community-acquired pneumonia (Musher 2012), suggesting that NAC might offer some protection against pneumonia in older adults.
A combination of L-cystine and another amino acid, L-theanine (found in green tea), may also protect against viral infections that could lead to pneumonia (Jain 2016; Soboleva 2004; Boros 2016). Taken daily for 14 days prior to vaccination, 700 mg L-cystine plus 280 mg L-theanine improved immune response to the influenza vaccine to a greater degree than placebo in nursing home residents (Miyagawa 2008). In another trial, healthy men taking 350 mg L-cystine plus 140 mg L-theanine twice daily had 58% fewer colds in a 35-day period than those taking placebo (Kurihara 2010).
Echinacea is an immunomodulator that can stimulate antimicrobial immune function but inhibit overly inflammatory immune activity (Zhai 2007; Goel 2005). A rigorous analysis of randomized controlled trials of echinacea preparations concluded that echinacea use can prevent repeated respiratory infections and their complications, including pneumonia. The analysis also determined that using higher doses of echinacea during infections improved its efficacy (Schapowal 2015).
Preliminary research suggests early treatment of cold symptoms with echinacea may speed recovery (Lindenmuth 2000; Goel 2005). Early treatment of influenza with an echinacea preparation was found to be as effective as the antiviral medication oseltamivir (Raus 2015).
Individuals at high risk of pneumonia due to chronic respiratory conditions may benefit from the use of echinacea. In a pilot trial, adults with pre-existing chronic respiratory conditions were treated with either influenza vaccine, a standardized echinacea extract, or both. Those treated with the echinacea extract, with and without the flu shot, experienced fewer flu-like symptoms and had fewer respiratory complications during the study period compared with those who received only the vaccine (Di Pierro 2012).
Some trials have found a benefit of vitamin C supplementation in the prevention of pneumonia, and a review of trials of vitamin C for the common cold found a reduction in severity and duration of colds (Hemila, Chalker 2013; Hemila, Louhiala 2013). Serum levels of vitamin C have been found to be lower in patients with pneumonia than in healthy people (Bakaev 2004). Even a modest dose of 200 mg per day has been shown to raise serum levels and improve the symptomatic condition of individuals with acute respiratory infections (Hunt 1994). Vitamin C has been shown to reduce oxidative stress and levels of inflammatory biomarkers in a preclinical model of severe community-acquired pneumonia (Chen 2014).
In a controlled clinical trial lasting 12 weeks during winter, volunteers taking a garlic supplement had fewer and shorter colds than volunteers taking a placebo (Josling 2001). In another randomized controlled trial, healthy subjects taking an aged garlic extract reported fewer and less severe cold and flu symptoms, and less school and work days missed, during the 3-month study period compared with placebo. Furthermore, blood tests after 45 days showed superior immune cell proliferation in the garlic extract group compared with placebo (Nantz 2012). In a preclinical study, garlic extract demonstrated antibacterial action against both Streptococcus pneumoniae and a less common cause of pneumonia, Klebsiella pneumoniae (Dikasso 2002). A randomized controlled trial published in 2016 investigated the effect of aged garlic extract supplementation on the incidence and severity of colds and the flu. Participants (n=120) were randomized to receive aged garlic extract (2.56 g daily) or placebo for 90 days during cold and flu season. After 45 days, specialized cytotoxic T cells called gamma-delta T cells and NK cells from the garlic recipients proliferated better and were more activated than those from placebo recipients. After 90 days, those who received aged garlic extract reported reduced cold and flu severity, fewer symptoms, and less absenteeism from work and school (Percival 2016).
Coenzyme Q10 (CoQ10) is found in all metabolically active cells of the body. Supplemental CoQ10 may benefit people with pneumonia by inhibiting inflammation, improving cellular energy metabolism, and modulating oxidative stress. In one randomized controlled clinical trial, older adults hospitalized with community-acquired pneumonia were given either 200 mg CoQ10 daily or placebo, in addition to antibiotics, for 14 days. At the end of the trial, it was noted that fevers had resolved more quickly, hospital stays were shorter, recovery rates were higher, and treatment failure rates were lower in the CoQ10 group compared with the placebo group (Farazi 2014).
Disclaimer and Safety Information
This information (and any accompanying material) is not intended to replace the attention or advice of a physician or other qualified health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a physician or other qualified health care professional. Pregnant women in particular should seek the advice of a physician before using any protocol listed on this website. The protocols described on this website are for adults only, unless otherwise specified. Product labels may contain important safety information and the most recent product information provided by the product manufacturers should be carefully reviewed prior to use to verify the dose, administration, and contraindications. National, state, and local laws may vary regarding the use and application of many of the treatments discussed. The reader assumes the risk of any injuries. The authors and publishers, their affiliates and assigns are not liable for any injury and/or damage to persons arising from this protocol and expressly disclaim responsibility for any adverse effects resulting from the use of the information contained herein.
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