NMT150 wk2

Upper Respiratory Tract Infection (URTI)

• Involves an infection of the nose, sinuses, pharynx, larynx, and large airways
• Viral causes: rhinovirus (most common), adenovirus, parainfluenza virus, enterovirus, and respiratory syncytial virus (RSV)
• Diagnosis: typically a clinical diagnosis, but nasal and nasopharyngeal swabs/aspirates can be used
• Complications: pneumonia, sinusitis, otitis media, coinfection with bacterial agents, and exacerbation of preexisting medical conditions (asthma & COPD)

Common Cold

• Typically mild and self-limited
• Symptoms: nasal mucosal erythema and edema, rhinorrhea, and nasal congestion, sore throat, cough, and sneezing, headache, and low-grade fever
• Onset of symptoms usually begins one to three days after exposure and can last 7-10 days or persist up to 3 weeks

Botanical Treatment Strategies

• Enhance the immune system's first and second lines of defense
• Choose herbs with tissue and microbial specificity
• Relieve common symptoms such as sore throat, congestion, and rhinorrhea
• Prevent recurrence

Herbal Actions

• Antivirals / antimicrobials
• Immune stimulants
• Deep immune tonics
• Adaptogens
• Anti-catarrhals / mucolytics
• Expectorants
• Diaphoretics
• Demulcents
• Lymphatics
• Anti-inflammatories

Baptisia Tinctoria

• Pharmacy: decoction, tincture, and dried herb
• Actions: anti-microbial, immune stimulant, anti-inflammatory, diaphoretic, and lymphatic
• Safety: can cause nausea, vomiting, anorexia, hypersalivation, tachypnea, tachycardia, and respiratory paralysis with toxic doses internally; contra-indicated in long-term use or high doses, pregnancy, and lactation

Echinacea Angustifolia / Purpurea

• Pharmacy: decoction, tincture, and powdered extract
• Actions: anti-microbial, immunomodulator, immune stimulant, anti-inflammatory, diaphoretic, lymphatic, vulnerary, and anti-catarrhal
• Pharmacology: activates immune response via enhanced granulocyte chemotaxis, macrophage phagocytosis, and increased levels of TNF, IL-1, Ig binding, and neutrophils
• Safety: high doses may cause nausea, throat irritation, and skin irritation; caution in Asteraceae allergy; selectively modulates CYP 3A4 substrates – potential for interactions

Zingiber Officinale (Ginger)

• Pharmacy: infusion, tincture, dry herb, and fresh herb
• Actions: anti-oxidant, anti-inflammatory, anti-microbial, diaphoretic, carminative, and anti-spasmodic
• Pharmacology: sesquiterpenes in ginger have specific anti-viral effects against rhinoviruses and RSV; fresh ginger may stimulate mucosal cells to secrete IFN-β to counter viral infection
• Safety: caution with ulcers, GERD, gallstones, kidney disease, bleeding disorders, and those with sensitive stomachs; additive effect with anticoagulant medication

Herbal Pharmacy

• Herbal selection: Echinacea angustifolia, Baptisia tinctoria, and Zingiber officinale
• Pharmacy and posology: tincture, ratio, and dosage
• How to make an herbal lozenge: using demulcent herbs like Althea officinalis, Glycyrrhiza glabra, Verbascum thapsus, and/or Ulmus fulvus
• Steam inhalations: using Eucalyptus, Thyme, and/or Peppermint essential oils to relieve cough and congestion

Other Considerations

• Rest, hydration, and nutrition
• Food as Medicine: adding garlic, onion, ginger, thyme, oregano, sage, or mushrooms to soups or stews for immune support
• Immune Support Soup recipe
• Preventing recurrence: using adaptogens and deep immune tonics long-term to support HPA axis and strengthen immune system

Adverse Childhood Experiences (ACEs)

• ACEs are strongly associated with 9 of the 10 leading causes of death in the US:
  • Heart disease
  • Cancer
  • Accidents/unintentional injuries
  • Chronic lower respiratory disease
  • Stroke
  • Alzheimer's disease or dementia
  • Diabetes
  • Kidney disease
  • Suicide

Relationship Matters

• Human beings are social creatures, neurologically designed to be in relationships with others
• Social engagement, active listening, and compassionate presence can create a safe space for patients
• The relational experience we can provide to patients can have a significant impact on their health and well-being

Bruce Perry's Reflections

• Human beings are designed to be in relationships with others, which affects our brain and body physiology
• Consistent, predictable, nurturing caregiving can shape our worldview and create a sense of safety and trust
• Inconsistent, unpredictable, chaotic interactions can lead to maladaptive behaviors and a view of the world as unsafe

Attachment and Adaptations of Self

• Secure attachment is the foundation of subconscious perceptual systems
• Secure attachment is associated with:
  • Meeting discomfort and distress with reliable, loving care
  • Soothing the baby/young child and establishing CNS patterns of trust, security, and comfort
  • Predicting lifelong health outcomes (biological, social, psychological)
• Insecure attachment styles include:
  • Anxious style: preoccupied with relationships, seeking safety in the presence of others
  • Avoidant style: equating intimacy with loss of independence, seeking safety in disconnection
  • Disorganized style: no template for safety, resulting in chronic tension between connection and disconnection

The Common Denominator

• Insecure attachment styles are rooted in shame, a belief that one is flawed and unlovable

Your Attachment Style Can Influence

• Your adult relationships and behaviors in relationships
• Your beliefs about yourself
• The way you explain the events of your life
• Your physical health
• Your subconscious triggers
• How you perceive stress, adversity, and challenge
• How you react to and recover from adversity

Relational Tensions vs Relational Security

• Relational security is associated with trust and security in self and others
• Relational tensions can be shifted through conscious awareness and intention

Attending

• Attending is an important skill for cultivating relational security and bringing to our patients
• Tracking autonomic states involves noticing and describing physical/sensory experiences of different states

Authenticity Can Heal Trauma

• Authenticity and connection can be a powerful tool for healing trauma
• Gabor Maté, MD, discusses the underlying causes of physical and emotional suffering and connects them to the pressures of modern-day living

Clean Needle Technique

• Definition: "Use of techniques designed to reduce the risk of infection of patients, practitioners, and office personnel by killing or reducing the strength of pathogens, thereby reducing the chances for contact between the pathogens"
• Includes: Clean Field, Sterile Needles, Universal Precautions, Contraindications, Needle Insertion, Needle Manipulation, and Management of Problems

Anatomy of a Needle

• Consists of: Handle, Root, and Body/Shaft

Clean Field

• Definition: "The area that has been prepared to contain the equipment necessary for acupuncture, in such a way as to protect the sterility of the needles"
• Setup: Use a paper towel or folded gauze pad, place packaged needles, cotton, and alcohol-soaked cotton on the clean field
• Important: The clean field is 3-dimensional, and non-sterile items must not be passed over it

Sterile Needles

• All pre-packaged needles come sterilized from the manufacturer
• Each needle has an expiry date and method of sterilization indicated on the box
• The inside of the bubble package is considered sterile
• Handle the needle shaft carefully to maintain sterility

Universal Precautions

• Assume all patients are infected with HBV or HIV and take non-discriminatory precautions to protect yourself
• Pertains to: Blood, body fluid containing visible blood, semen, vaginal secretions, tissues, CSF, synovial fluid, pleural fluid, peritoneal fluid, and amniotic fluid

Contraindications

• Absolute: alcohol intoxication, exhaustion, severe fear
• Relative: sexual intercourse, overeating, hunger, excessively thirsty, strenuous exercise

Needle Insertion

• Steps:
  1. Wash hands
  2. Prepare clean field
  3. Locate and mark points to be needled
  4. Cleanse each point with alcohol
  5. Inspect needle
  6. Place tube over cleansed area and allow needle tip to fall to the surface of the skin
  7. Tap the top of the needle handle to penetrate the skin
  8. Remove tube and ensure needle doesn't fall over
  9. Gently yet firmly insert the needle to the desired depth

Needle Manipulation

• Techniques: leaving needles in for 15 minutes, tapping and flicking, tonifying methods, holding Channel Qi, and moving Qi

Problems with Needling

• Needle-stick Injury: inform instructor, encourage bleeding from the site, and follow testing protocol
• Stuck Needle: gentle traction, relaxation, or oppositely rotating the needle
• Bent Needle: gentle removal, correcting patient position, and avoiding strong manipulation
• Broken Needle: remain calm, remove broken portion with forceps or locking hemostats, and seek medical attention if necessary
• Fainting: stop needling, lie the patient down, keep them warm, and consider needling GV 26, St 36, Pc 6, and Kd 1 or moxa GV 20, CV 4 or 6
• Arterial Puncture: apply direct pressure with ice, contact emergency services immediately, and allow blood to flow back toward the heart

Types of Needles

• Filiform needle: standard solid needle, comes in different materials (Chinese, Japanese, Korean)
• Ear Tacks: small needles with adhesive backing, used for auricular acupuncture
• Grain Type needles: small needles for sub-cutaneous insertion and covered with tape

Deficiency

• Characterized by emptiness of the Upright Qi and the absence of a pathogenic factor
• Types of deficiencies:
  • Qi deficiency: pale face, weak voice, slight sweating, slight shortness of breath, fatigue, loose stools, poor appetite
  • Yang deficiency: bright pale face, cold limbs, absence of thirst, desire for hot drinks, frequent pale urination
  • Yin deficiency: heat in the afternoon, dry throat at night, night sweats
  • Blood deficiency: dull-pale face, pale lips, dry hair, blurred vision, tiredness, poor memory, insomnia, scanty periods

Yin Deficiency

• Decrease in Yin produces heat symptoms
• Symptoms: red cheeks, dry stools, anxiety at night, night sweats, hot flushes, 5 Centre Heat, thirst for cold drinks in sips

Yin Excess

• Excess Yin produces cold symptoms
• Symptoms: abdominal pain better with warmth, dysmenorrhea better with warmth, local pain better with heat, chills

Yang Deficiency

• Decrease of Yang produces cold symptoms
• Symptoms: tired after bowel movement, low libido, edema, fatigue

Yang Excess

• Excess Yang produces heat symptoms
• Symptoms: feeling hot all day, red face, thirst for cold drinks (gulps)

Qi

• Qi is the root of the human body
• Qi functions: promoting, warming, defending, checking, nourishing
• Qi deficiency: fatigue, insomnia, poor digestion, cold hands and feet, shortness of breath, little to no appetite, frequent infections, weak immune system

Stagnation

• If Qi stagnates in the meridians, symptoms include: stiffness, heaviness, numbness or tingling of the limbs, migrating pain in the limbs

Blood

• Formed from Food Qi, which is acted upon by Yuan Qi
• Blood is not complete until it is sent to the Heart, where it is turned red
• Blood functions: nourishment, moisture, circulation with Ying Qi, determining menstruation
• Blood deficiency: long cycles, short luteal phase, scanty menstrual blood, amenorrhea, fatigue, anxiety, insomnia, poor memory, cold hands and feet, abdomen, low back, floaters in eyes, slow recovery, pale
• Blood stasis: oppression or pain in the chest, coughing up dark, clotted blood, purple, deep, stabbing pain

Excess

• Characterized by the presence of a pathogenic factor while Upright Qi is relatively intact and actively fighting against the pathogenic factor
• Symptoms: pain worse with pressure, pain that is acute in onset, irritability, restlessness, strong voice

Naturopathic Therapeutics - Putting it Together

• Learning objectives for this week's session include active learning, collaboration, and applying preventative care and lifestyle advice to the case study.
• Considerations for a comprehensive Naturopathic treatment plan include 3 treatment recommendations, nutritional guidance, lifestyle guidance, collaborative care, medical guidance, and follow-up considerations, all requiring informed consent.

Informed Consent

• Informed consent must be obtained and documented for every intervention, including obtaining case history, performing physical exams/testing, treatments, and collecting health information.
• This is in accordance with regional privacy acts and the CONO Standard on Consent.

Record Keeping

• Accurate record keeping is essential to meet regulatory requirements, as outlined in the CONO Standard for Record Keeping.
• Records must be communicated to the patient and noted in their chart.

Lifestyle, Prevention, and Health Promotion

• Basic hygiene practices for healing and prevention include rest, staying home when sick, washing hands, avoiding touching face and eyes, coughing into elbows, and keeping up-to-date with vaccinations.
• Nasal saline irrigation (Neti pot) can help relieve symptoms of URTI, reduce viral load, and reduce reliance on medications, but requires proper technique and equipment.
• Traditional Ayurvedic practice recognizes the importance of Jala Neti as a holistic practice.

Scenario: Treatment Plan Design

• Work in groups to design a treatment plan for this week's case, considering 3 EBM treatment suggestions that are appropriate for the patient.
• Considerations include treatment recommendations, nutritional guidance, lifestyle guidance, collaborative care, and follow-up considerations, all within the framework of informed consent.

Nutrition for Immune Support and Healthy Function

• Learning objectives for nutritional guidance include considering Vitamin C, Zinc, and Probiotics in relation to case presentation.

Treatment Goals

• Address presenting symptoms and improve patient comfort
• Support full and speedy recovery to return to regular activities
• Patient education
• Monitor and prevent sequelae

Natural Medicines Database

• Vitamin C:
  • Data supports use of Vitamin C in treatment of common cold
  • Consider bowel tolerance with dosing and potential for osmotic diarrhea and GI upset
  • May precipitate kidney stones for those susceptible (40% increased risk with 1 gram/day supplement)
• Zinc:
  • 30-50 mg/day for adults (75 mg in study) for specific, limited time period to avoid copper deficiency
  • Take with food to avoid GI upset
  • GI upset and N&V are most likely side-effects
  • Avoid taking at same time as antibiotics to avoid interference with absorption

Our Role/Advice

• Provide appropriate and specific product and formula
• Recommend safe and appropriate therapeutic dose
• Screen for allergies and potential interactions
• Advise on cautions, concerns, and possible side-effects

Colds and Coughs

• Colds and coughs can be treated with herbal medicine, which involves the use of herbal actions to combat the infection.

Herbal Actions

• Immunostimulant: activates the immune system to fight infections
• Diaphoretic: induces sweating to help remove toxins
• Antitussive: soothes and relieves coughs
• Antispasmodic: relaxes smooth muscles to reduce inflammation
• Expectorant: liquefies respiratory secretions to facilitate the expulsion of phlegm and mucous
• Mucolytic: breaks down mucous and loosens thick bronchial secretions
• Demulcent: soothes irritated mucous membranes
• Antimicrobial: destroys or inhibits the growth of microorganisms
• Antiadherence: prevents microorganisms from attaching to and infecting mucous membranes
• Antipyretic: reduces fever
• Lymphatic: promotes the proper functioning of the lymphatic system

Phytochemicals

• Polysaccharides: immunostimulants found in Echinacea, Asian ginseng, Canadian ginseng, and Siberian ginseng
• Alkylamides: immunostimulants found in Echinacea
• Saponins: expectorants found in Ivy, Licorice
• Steroidal saponins: adaptogens, immunomodulators found in Asian ginseng, Canadian ginseng, and Siberian ginseng
• Mucilage: demulcent found in Marshmallow
• Essential oils: antispasmodics found in Thyme, Oregano, and Eucalyptus
• Diterpene lactones: immunomodulators, antispasmodics found in Andrographis

Echinacea

• Main indications: prevents and treats the common cold, flu, and upper respiratory tract infections (URIs), vaginal candidiasis, and urinary tract infections
• Actions: immunostimulant, antimicrobial
• Phytochemicals: alkylamides, phenolics, polysaccharides, glycoproteins, ketoalkenes
• Safety: caution in autoimmune disease, safe in pregnancy and lactation

Ginseng

• Main indications: stress, fatigue, cold and flu treatment and prevention, low immunity
• Actions: adaptogen, immunostimulant, immunomodulator, antiviral, aphrodisiac
• Phytochemicals: steroidal saponins, polysaccharides
• Safety: caution in high blood pressure, Korean ginseng is considered safe in pregnancy and lactation

Homeopathic Remedies for Upper Respiratory Tract Infections

• Dros era: #1 remedy for whooping cough; respiratory illnesses such as laryngitis, bronchitis, and tuberculosis
• Dros era Cough: Tormenting cough with short paroxysms, ringing cough, must hold the chest to cough, inability to cough due to pain
• Dros era Characteristics: < evening, after midnight, after drinking, exertion, singing, smoking; cough after measles; > walking

Rumex Crispus

• Rumex Characteristics: Nervous, restless, sad, and depressed; aversion to mental work
• Rumex Symptoms: Dry tickling cough, copious discharge from mucosa of nose, eyes, and whole respiratory tract
• Rumex Modalities: < cold air, touch or pressure on throat/larynx, temperature changes, morning, and before 11 pm; > drinking, sucking on candy

Spongia

• Spongia Characteristics: Sensitive, anxious, and fearful; "sssh" or "sshh" sound when inhaling
• Spongia Symptoms: Dry, raw, or sore throat, hoarseness, asthmatic cough, and blood circulation problems
• Spongia Modalities: < before midnight, dry cold wind, cold drinks, warm room, and heat; > eating, drinking, warm things, and resting
• Spongia Use in Croup: Bönninghausen used Aconitum, Spongia, and Hepar sulphuris calcareum to cure croup; can be used in alternating order with Aconitum and Hepar

Ipecacuanha

• Ipecacuanha Characteristics: Persistent nausea and vomiting; spasmodic irritation in the chest and stomach
• Ipecacuanha Symptoms: Shortness of breath, gastric disturbances, bright red hemorrhage, and convulsions
• Ipecacuanha Modalities: < warmth, damp warmth, warm room, overeating, and motion; > open air, rest, pressure, and closing the eyes
• Ipecacuanha Mentals: Irritable, contemptuous, anxious during fever and coughing; intolerant to noise, and tranquil after anger

Acute Otitis Media (AOM)

• AOM is typically a pediatric condition, but can also affect adults.
• It can be caused by both bacteria and viruses, and co-infection is common.
• The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Preventative Factors

• Vaccination (influenza and S.pneumoniae) can reduce the risk of AOM.
• Public health measures may reduce virus transmission, leading to a decrease in AOM cases.
• Avoiding exposure to tobacco smoke and breastfeeding can also help prevent AOM.

Watchful Waiting

• Spontaneous resolution is seen in a number of cases caused by the top 3 bacterial pathogens:
  • S.pneumoniae: 20%
  • H.influenzae: 50%
  • M.catarrhalis: 75%
• Withhold antibiotic prescriptions for 48 hours in children over 6 months of age if they have:
  • Nonsevere illness (mild pain and fever < 39°C)
  • Uncomplicated AOM (no episode in the preceding month, no acute facial nerve palsy, mastoiditis, meningitis, or labyrinthitis)
• No craniofacial abnormalities, immunodeficiencies, cardiac or pulmonary disease, Down syndrome, or history of complicated AOM.

Exceptions

• Infants under 6 weeks of age should be immediately referred to the nearest emergency department.
• Patients aged 6 weeks to 6 months should begin antibiotic therapy immediately.
• Patients with 3 or more episodes in 6 months or 4 or more within a year should begin antibiotic therapy immediately.

Antibiotic Therapy

• Antibiotic resistance is common among the three pathogens.
• S.pneumoniae resistance is due to the alteration of penicillin-binding cell wall proteins, leading to decreased drug affinity.
• This is overcome by doubling the dose of amoxicillin.
• H.influenzae and M.catarrhalis produce beta-lactamases, which confer resistance.
• This is overcome by using a beta-lactamase inhibitor called clavulanate.
• When antibiotics are used, treatment failure should be considered if symptoms do not improve after 72 hours of treatment.

Antibiotic Options

• Amoxicillin is considered first-line therapy in the treatment of AOM.
• The combination of amoxicillin and clavulanate is typically used for treatment failure or recurrence.
• Cefuroxime axetil and Cefprozil are second-generation cephalosporins and have reasonable activity against H.influenzae and M.catarrhalis.
• Azithromycin and Clarithromycin are macrolides and should be reserved for patients with type 1 hypersensitivity reactions to beta-lactam antibiotics.
• Clindamycin is a lincosamide and can be used for patients with type 1 hypersensitivity reactions to beta-lactam antibiotics.

Supportive Therapy

• Antibiotics do not reduce pain within the first 24 hours of therapy and do little in the following days compared to placebo.
• Analgesics are recommended during watchful waiting and with antibiotic therapy.

Analgesics

• Acetaminophen: 10-15 mg/kg every 4-6 hours to a maximum of 75 mg/kg/day and not to exceed 4000 mg/day.
• Ibuprofen: 10 mg/kg every 6-8 hours to a maximum of 40 mg/kg/day and not to exceed 2400 mg/day.
• Aspirin should never be given to children or teenagers recovering from chickenpox or with flu-like symptoms due to the risk of Reye syndrome.