Respiratory Disease

Respiratory Disease is defined as medical conditions which affect the breathing organ and tissues including Inflammatory lung disease, Obstructive lung diseases, Restrictive lung diseases, Respiratory tract infections, trachea, bronchi, bronchioles, alveoli, the nerves and  muscles breathing , etc,.

V. Respiratory tract infections
V. A. Upper respiratory tract infection
Upper respiratory tract infections are considered to be the infection of the airway above the glottis or vocal cords. This includes the nose, sinuses, pharynx, and larynx, including the infection of tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, etc,.
A. Symptoms
The symptoms of include nasal congestion, a runny nose, sneezing, pharyngitis/tonsillopharyngitis, headache, muscle aches (usually severe) sore throat, watery eyes, etc,. Influenza infections may result in different clinical presentations. In the study to determine the clinical differences between circulating influenza strains in a young healthy adult population in the tropics, found that there were no statistical differences between H3N2 and influenza B (p = 0.58). Those with nasal congestion, rash, eye symptoms, injected pharynx or fever were more likely to have H3N2; and those with sore throat, fever, injected pharynx or rhinorrhoea were more likely to have influenza B than H1N1-2009(1). Others in the study of the differing symptom patterns in early pandemic vs seasonal influenza infections, conducted by Department of Laboratory Medicine, National University Hospital, Singapore, found that from the week of June 16 to June 23, 2009, this pandemic influenza A(H1N1/2009) displaced and then replaced the seasonal influenzas (H3N2, H1N1, and B). Of 2683 samples tested during this 12-week surveillance period, 742 (27.6%) were positive for any influenza virus using this assay, with 547 cases of A(H1N1/2009) (20.4%), 167 cases of A(H3N2) (6.2%), 14 cases of A(H1N1) (0.5%), and 12 cases of influenza B (0.4%). Results of multivariate analysis showed that age (P < .001), fever (P < .001), cough (P < .001), sore throat (P = .002), rhinorrhea (P = .001), and dyspnea (P < .001) were significantly different among these groups.(2). According to the study of the symptoms of the common cold and influenza conducted by Cardiff School of Biosciences, Cardiff University, indicated that the effects of cytokines in human beings now helps to explain some of the symptoms of colds and flu that were previously in the realm of folklore rather than medicine-eg, fever, anorexia, malaise, chilliness, headache, and muscle aches and pains. The mechanisms of symptoms of sore throat, rhinorrhoea, sneezing, nasal congestion, cough, watery eyes, and sinus pain(3).

B. Causes and Risk factors
B.1. Causes 
Upper respiratory tract infections are most likely to be caused by viral infection. The sicknesses are
are spread from person to person by spreading from person to person in respiratory droplets through sneezing or coughing and individual are infected with the virus before symptoms arise. It is advised to cover sneezes and coughs, and regular hand washing should provide some protection duringthe season of the common cold and influenza (flu).In the study of the influenza A virus, one of the leading causes of respiratory tract infections in humans, found that various strategies used by influenza A viruses to evade innate immune responses and recognition by components of the humoral and cellular immune response, which consequently may result in reduced clearing of the virus and virus-infected cells(4). Other study indicated that Influenza viruses cause annual outbreaks of respiratory tract infection with attack rates of 5-10%. During attack, strain-specific antibody responses are induced, which exert selective pressure on circulating influenza viruses and which drive antigenic drift of seasonal influenza viruses, especially in the hemagglutinin molecule. This antigenic drift necessitates updating of seasonal influenza vaccines regularly in order to match the circulating strains(5).

B.2. Risk factors
1. Age 
Young children and elder are susceptible to the infection by virus in cold and flu season as a result of immature and weakened immune system, accordingly.

2. Antibiotic resistance
Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The risk factors of being a father, having low education, having immigrant status, being a single parent, having low income, having <2 or >3 children, living in the islands, and being without experience in recurrent URTIs were significantly associated to inadequate knowledge, inappropriate attitudes, and wrong practices(6).

3. Weakened Immune system
People with Weakened Immune system as a result of the chronic illness, may at increased risk of cold and flu. In the study to assess the effects of CHS on host innate immunity and avian influenza virus H5N1 infection in mice, found that The CHS treatment group exhibited reduced local immunity in the respiratory tract, including the number of pulmonary alveolar macrophages and lesions in the nasal mucosa, trachea, and lungs(7).

4. Etc.

C. Types of Upper respiratory infection
1. Rhinitis
Rhinitis is defined as a condition of irritation and inflammation of the nasal mucosa. In most case, it is caused by allergic reaction, with symptoms of  stuffy nose, runny nose, and post-nasal drip. According to the article of Economic Impact and Quality-of-Life Burden of Allergic Rhinitis, the disease affects over 30% of US population(8).

2. Rhinosinusitis or sinusitis
Rhinosinusitis or Sinusitis(9) is defined as a condition of inflammation of the paranasal sinuses,  including frontal, ethmoid, maxillary, and sphenoid of which can develop headache as a result of exposure to a cold or flu virus, or an allergic reaction to pollen, mold, dust or smoke, etc..Sinusitis affects 37 million people each year. The diseases affects more than 24 million population in U.S. annually(10).

3. Nasopharyngitis
Also known as rhinopharyngitis or the common cold s defined as a  Inflammation of the inflammation of the nasopharynx. Symptoms of can be relieved in children, by acetaminophen without any combination is as effective as OTC drugs containing acetaminophen, decongestant, and antihistaminics(11).

4. Pharyngitis 
Pharyngitis,  also known as sore throat is defined as a condition  of inflammation of the pharynx, hypopharynx, uvula, and tonsils. The application of laripront has been reported as the positive outcome of the treatment in children that was especially efficacions in the patients with acute pathologies(12).

5. Epiglottitis (supraglottitis) 
Epiglottitis is defined as a condition of inflammation of the tissue that covers the trachea (windpipe). Epiglottitis, in some some can be misdiagnosed with other disease, such as acute laryngo-tracheo-bronchitis. There is a report of a  the case of a 20-month-old child who required admission to the intensive care with a presumptive diagnosis of acute laryngo-tracheo-bronchitis, for the management of acute upper airway obstruction. This child had received a complete course of Haemophilus influenzae type B (Hib) vaccine. Subsequent events showed that the diagnosis was not laryngo-tracheo-bronchitis but acute epiglottitis(13).

6. Laryngitis 
Laryngitis is defined as condition of inflammation of the larynx. The disease can cause  hoarse voice or the complete loss of the voice as it affects the vocal cords. Antibiotics appear to have no benefit in treating acute laryngitis, but antibiotic such as Erythromycin, could reduce voice disturbance at one week and cough at two weeks when measured subjectively(14).

7. Laryngotracheitis
Laryngotracheitis is defined as conditions of inflammation of the laryngitis and tracheitis. Many practitioners have considered that steroids, with their anti-inflammatory properties, should be efficacious in the treatment of acute laryngotracheitis(15).

6. Tracheitis
Tracheitis is defined as a condition of inflammation of the trachea and subglottic area. Bacterial tracheitis needs a high index of suspicion because of its varied presentations. Certain forms have less severe clinical manifestations. These forms also require aggressive management as they can result in airway obstruction from membranes and edema(16).

D. ARTIs algorithm and diseases associated with Upper respiratory tract infection
D.1. ARTIs algorithm(17)
In teh study to assess the practicability of a new algorithm in decreasing the rate of incorrect diagnoses and inappropriate antibiotic usage in pediatric Acute Respiratory Tract Infection (ARTI), conducted by the Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, indicated that Upper Respiratory Tract Infection, Lower Respiratory Tract Infection, and undifferentiated ARTI accounted for 82%, 14.5%, and 3.5% of 1 209 cases, respectively. Antibiotics were prescribed in 33%; for: Common cold, 4.1%; Sinusitis, 85.7%; Otitis media, 96.9%; Pharyngotonsillitis, 63.3%; Croup, 6.5%; Bronchitis, 15.6%; Pertussis-like syndrome, 82.1%; Bronchiolitis, 4.1%; and Pneumonia, 50%. Implementation of the ARTIs algorithm is practicable and can help to reduce diagnostic errors and rate of antibiotic prescription in children with ARTIs(18).

D.2. Diseases associated with Upper respiratory tract infection
1. Chlamydia infection
 In humans the most common infections are caused by Chlamydophila pneumoniae is Chlamydia trachomatis.These pathogens are mainly responsible for infections of upper respiratory tract, infections of urinary tract and conjunctivitis(19).

2. Acute otitis media (AOM)
Acute otitis media (AOM) occurs as a complication of viral upper respiratory tract infections in young children. AOM and respiratory viruses both display seasonal variation. According to the study leaded by Department of Pediatrics, University of Utah Health Sciences Center, showed that During the study period, 96,418 respiratory viral tests were performed; 46,460 (48%) were positive. The most commonly identified viruses were: RSV (22%), rhinovirus (8%), influenza (8%), parainfluenza (4%), human metapneumovirus (3%), and adenovirus (3%). AOM was diagnosed during 271,268 ambulatory visits. There were significant associations between peak activity of RSV, human metapneumovirus, influenza A, and office visits for AOM. Adenovirus, parainfluenza, and rhinovirus were not associated with visits for AOM(20).

3. Streptococcus pneumoniae serotypes
Streptococcus pneumoniae serotypes associated with colonization of the upper respiratory tract in young children. According to the study by Medical University of Lublin of the 342 pneumococcal isolates, the serotype coverage by PCV-10 or PCV-13 was 73.7% or 80.1%, respectively. Moreover, 92.4% of the isolates belonged to serotypes included in the "old" 23-valent polysaccharide vaccine. A clear picture of the distribution of S. pneumoniae serotypes associated with colonization and/or infection in various geographical areas is needed in a light of recommended or routine vaccination(21).

4. Etc.

E. Preventions
E.1. The do and do not's list
1. Wash your hand thoroughly  with soap and water 15-20 seconds can help to reduce the risk of catching common cold and influrenza. Use alcohol-based hand gels if washing is not possible.
2. Cover sneeze and coughing and  prevent hand-to-hand passage.
3. Enhance your immune function to protect your body against invasion of foreign invasion, including bacteria and virus.
4. Traditional Mediterranean diet
Eating plenty of fruit, vegetables and fish keep lungs healthy. Those who follow a diet closest to this " Mediterranean " ideal are less likely as their peers with eating habits furthest from this pattern to develop chronic lung disease. A good amount of fresh vegetable juices are a good way to start healing, along with adding a variety of spices such as ginger, onions, and garlic. The emphasis should be on eating as healthy a diet as possible(22).
5. Eat your fruit and vegetables
Fruits and vegetables not only are very  nutritional but also contains high amount of antioxidants which can combat against bacteria and virus invasion.
6. Etc.

E.2. Diet to prevent upper respiratory track infection
1. Green tea
In a randomized, double-blind, placebo-controlled trial of 200 healthcare workers conducted for 5 months from November 9, 2009 to April 8, 2010 in three healthcare facilities for the elderly in Higashimurayama, Japan, found that among healthcare workers for the elderly, taking green tea catechins and theanine may be effective prophylaxis for influenza infection(23).

2. Soy
The necessity of introduction soya-based food in a complex treatment of this infection as it enhances processes of detoxication, positevely influences on functional and structural state of the liver, reduces cytolysis, cholestasis symptomes, mesenchymal and inflamation reactions thus increases the tolerance of antimicobacterial agents, according to the study by leaded by Dr. Mel'nyk VP(24).

3. Garlic
In the study of a total of one hundred forty-six volunteers were randomized to receive a placebo or an allicin-containing garlic supplement, one capsule daily, over a 12-week period between November and February, showed that volunteers in the active group were less likely to get a cold and recovered faster if infected. Volunteers taking placebo were much more likely to get more than one cold over the treatment period. An allicin-containing supplement can prevent attack by the common cold virus(25).

4. Etc.

E.3. Phytochemicals and antioxidants to prevent upper respiratory track infection
1. Epigallocatechin gallate
Epigallocatechin gallate is a green tea-derived polyphenol. According to the study by School of Medicine, Wuhan University, reatment with EGCG (20 nmol/L) significantly suppressed the increased ROS level in MDCK cells following influenza A infection. In BALB/c mice infected with influenza virus, oral administration of EGCG (40 mg·kg(-1)·d(-1)) dramatically improved the survival rate, decreased the mean virus yields and mitigated viral pneumonia in the lungs, which was equivalent to oral administration of oseltamivir (40 mg·kg(-1)·d(-1)), a positive control drug(26).

2. Curcumin
Curcumin, in clinically relevant concentrations for topical use, displayed strong antibacterial effect against a facultative upper respiratory tract pathogen by inhibiting bacterial growth, adherence, invasion, and pro-inflammatory activation of upper respiratory tract epithelial cells in vitro, according to the study by Department of Pediatrics, University of Bern, Inselspital(27).

3. Bromelain
Bromelain, a clinically used pineapple extract and natural product, has reported anti-inflammatory and immunomodulatory activities. According to the study by the University of Connecticut, School of Medicine, Bromelain attenuated development of AAD while altering CD4+ to CD8+ T lymphocyte populations. The reduction in AAD outcomes suggests that bromelain may have similar effects in the treatment of human asthma and hypersensitivity disorders(28).

4. Alliin
In a randomly assigned 146 volunteer participants to either a garlic supplement (with 180 mg of allicin content) or a placebo (once daily) for 12 weeks, the trial reported 65 occurrences of the common cold in the placebo group compared with 24 in the garlic intervention group (P < 0.001). The number of days of illness was lower in the garlic group compared with the placebo group (111 versus 366)(29). 

5. Etc. 

F. Diagnosis and tests 
If you are experience some of the above symptoms and if your doctor suspects that you have upper respiratory infection such as common cold, after recording your family history and completing the physical exam, including the examination for any signs of swollen and redness inside wall of the nasal cavity (sign of inflammation), redness of the throat, enlargement of the tonsils, etc.
The test which your doctor orders include.
1. Swap, including nasal swab, throat swab, or sputum
 In most case, upper respiratory tract, is caused infectious bacteria. Swabs must be sent in preservation media, otherwise the detection rate of viable organisms will fall considerably. Transport should therefore be as rapid as possible(30).

2.  Rapid Strep Test (RST), or rapid antigen detection test (RADT)
The test is to determine whether or not a patient has streptococcal pharyngitis, if patients are experience strep throat symptoms


3. Other tests may be necessary depending to the symptoms and the length of the diseases
 X-rays of the neck if suspected case of epiglottitis and CT scans may be necessary if you are experience sinusitis symptoms which  is last more than 4 weeks.

4. Etc.

F. Treatments
F.1. In conventional medicine perspective
1. No specific treatment if the infection is resulted of viral infection, but certain medication can be prescribed to reduce the symptoms, such as
a. Acetaminophen and Nonsteroidal used to reduce fever and body aches.
In the study to evaluate the risk factors for developing allergic reactions to alternative drugs such as acetaminophen and nimesulide in 367 patients intolerant of nonsteroidal anti-inflammatory drugs (NSAID) compared to 243 healthy controls, showed that  test doses (TD) TD was positive in 49 of 367 (14%) NSAID-allergic patients and in one (0.4%) of the controls (P<0.001). No difference was found in age and sex between the TD-positive and TD-negative subjects, although a significantly larger number of females were NSAID allergic (P<0.01)(31).

b. Antihistamines used to decrease nasal secretions and congestion
There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis(32).

c. Nasal ipratropium for diminishing nasal secretions
Rhinorrhea and nasal congestion are simultaneous symptoms associated with the common cold. Both the ipratropium combination treatments had significantly lower tissue use than the xylometazoline treatment group (p < 0.0001). Adverse events were distributed equally between the treatments, except mucus tinged with blood, epistaxis, nasal passage irritation, and nasal dryness, which had a higher incidence in the three groups that received medicines containing ipratropium(33).

d. Cough suppressants to reduce cough
In an observational study on acute cough associated with upper respiratory tract infection (URTI) in children, showed that acute cough disturbs sleep in most children and their parents. Both levodropropizine and central antitussives reduced cough intensity, with levodropropizine producing a higher cough resolution rate(34).


e. Steroids 
Intranasal corticosteroids offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days' duration(35).

f. Etc.

2. Antibiotics
Antibiotics are used only in treating upper respiratory infections caused by bacterial infection. In the study to examine the use of antibiotics and other prescription medications for the common cold in a Medicaid population seen in ambulatory care settings, showed that majority of persons receiving medical care for the common cold are given prescriptions for an unnecessary antibiotic. Unchecked, this practice may lead to greater antibiotic resistance and unnecessary use of health care resources(36).

3.  Inhaled epinephrine
Epinephrine, a hormone and a neurotransmitter,  is sometimes used in children with bronchospasm  to reduce spasm. According to the study by Royal Aberdeen Children's Hospital, Aberdeen, functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions(37).

4. Surgery
Rarely, surgical procedures may be necessary in cases of complicated sinus infections. Maxillary sinus inflammation, when untreated or incorrectly treated, may extend locoregionally, the remaining paranasal sinuses being the first affected anatomical structures. Inflammations of the paranasal sinuses are susceptible to develop complications in certain conditions and threaten the patient's life due to the proximity of vital structures(38).

F.2. In herbal medicine perspective
1. Aromatic essential oils
In a prospective randomized double-blind controlled trial whose aim was to investigate the clinical effects of aromatic essential oils in patients with upper respiratory tract infections with 60 patients participated in the study (26 in the study group and 34 in the control group) conducted by the Faculty of Medicine, Technion-Israel Institute of Technology, showed that spray application of five aromatic plants reported in this study brings about significant and immediate improvement in symptoms of upper respiratory ailment. This effect is not significant after 3 days of treatment(39).

2. Andrographis paniculata (KalmCold)
In a randomized, double blind placebo controlled clinical study was conducted to evaluate the efficacy of KalmCold, an extract of Andrographis paniculata, in patients with uncomplicated upper respiratory tract infection (URTI), researchers at the King George Medical University, found that KalmCold group showed significant reduction (p < or = 0.05) in overall symptom scores as compared to placebo group. In both placebo and KalmCold treated groups, there were only a few minor adverse effects with no significant difference in occurrence (Z = 0.63; p > 0.05). The comparison of overall efficacy of KalmCold over placebo was found to be significant (p < or = 0.05) and it was 2.1 times (52.7%) higher than placebo(40).

3.  Kan Jang
According to the study by Erebuni, Medical Centre, Yerevan, Armenia, in a double blind, placebo-controlled, parallel-group clinical study was carried out to evaluate the effect of an Andrographis paniculata (N.) extract SHA-10 fixed combination, Kan Jang, in the treatment of acute upper respiratory tract infections, including sinusitis of ninety-five individuals in the treatment group and 90 individuals in the placebo group, showed that the individual symptoms of headache and nasal and throat symptoms together with general malaise showed the most significant improvement while cough and eye symptoms did not differ significantly between the groups. Temperature was moderately reduced in the verum group, and concluded that Kan Jang has a positive effect in the treatment of acute upper respiratory tract infections and also relieves the inflammatory symptoms of sinusitis(41). Other study, conducted by Research Institute of Pharmacology of Volgograd Medical Academy, indicated that the symptoms of the disease were less severe in the Kan Jang group. The effect of Kan Jang was particularly pronounced in two objective parameters, amount of nasal secretion g/day and nasal congestion. Kan Jang also accelerated the recovery time, whereas Immunal did not show the same efficacy. The use of standard medication was significantly less in the Kan Jang adjuvant group than in either the Immunal or standard treatment group. Kan Jang treatment was well tolerated and no side effects or adverse reactions(42).

4. Etc.

F.3. In tranditional medicine perspective
1. Jing Fan Bai Du
In the study of the effect of two Chinese herbal medicines (CHMs) formulae in treating acute upper respiratory tract infections (URTIs), diagnosed by Traditional Chinese medicine (TCM) and compared to placebo showed thatn two CHM formulae commonly used for URTIs were not found to be more effective than placebo in either cure or reduction of symptoms of URTIs. However, Jing Fan Bai Du san might be able to improve general health more than placebo for patients with wind-cold syndrome. Both formulae were not associated with any more side effects(43).

2. Herbs for cough such as chuanbei, fangfeng, jiegeng, gancao and baibu
In a randomised, double-blinded, placebo-control study comparing this TCM preparation with a placebo conducted in 82 patients who attended the Family Medicine Training Centre, Prince of Wales Hospital, Hong Kong between November and December, 2003, found that the 62 patients (75.6%) had completed the trial and no adverse effects were reported. Both intervened and control groups had improved in cough score and LCQ in the follow-up period, despite no overall statistical significance was observed in the differences of scores between the two groups. Women taking TCM had significantly fewer problems with sputum production (p = 0.03) and older subjects (>35 years of age) reported a significant improvement in hoarseness (p = 0.05) when compared to those using placebo(44).

3. Other formulas
In the study to assess the efficacy and safety of Chinese herbal medicines for patients with sore throat, found that Six formulations were shown to be superior to the control in improving recovery: Ertong Qingyan Jiere Koufuye was more effective than Fufang Shuanghua Koufuye for acute pharyngitis (odds ratio (OR) 2.52; 95% confidence interval (Cl) 1.11 to 5.74); Yanhouling mixture was more effective than gentamicin atomised inhalation for acute pharyngitis (OR 5.39; 95% CI 2.69 to 10.81); Qinganlan Liyan Hanpian was more effective than Fufang Caoshanhu Hanpian for acute pharyngitis (OR 2.25; 95% CI 1.08 to 4.67); sore throat capsules were more effective than antibiotics (intravenous cefalexin) for acute pharyngitis or acute tonsillitis (OR 2.36; 95% CI 1.01 to 5.51); compound dandelion soup was more effective than sodium penicillin for acute purulent tonsillitis (OR 5.06; 95% CI 1.70 to 15.05); and eliminating heat by nourishing yin and relieving sore-throat methods combined with Dikuiluqan Hanpian was more effective than Dikuiluqan Hanpian alone for children with chronic pharyngitis (OR 2.63; 95% CI 1.02 to 6.79)(45).


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V. B. Lower respiratory tract infection
The lower respiratory tract infection are the infection consisting of the trachea (wind pipe), bronchial tubes, the bronchioles, and the lungs, including the bronchitis and pneumonia. According to  The World Health Report 2004 - Changing History(1), in 2002 lower respiratory track infection were still the leading cause of deaths among all infectious diseases, and accounted for 3.9 million deaths worldwide and 6.9% of all deaths that year.

A. Symptoms
According to the study by Independent Travel Health and Immunization Specialist Nurse, Streptococcus pneumoniae is a cause of significant morbidity and mortality worldwide. There are many different serotypes of the organism which may be carried by up to 50% of children under the age of 6 years, as well as many adults. The organism is associated with both pneumonia and invasive pneumococcal disease, which may result in septicemia or meningitis. It is also a principal cause of otits media and sinusitis, which are not life-threatening, but generate a lot of discomfort, loss of schooling or working days, and around 60 000 GP consultations per year in the UK(2).
1. Shortness of breath, chest pain, abnormal breath sounds and high fever
There is a report of a 65-year-old man with shortness of breath, pleuritic chest pain, and recurrent pneumonia, according to Department of Medical Education.(3). In other study to understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI), showed that logistic regression analysis identified rales, a temperature > 100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea. The presence of abnormal breath sounds and a temperature > 100 degrees F were the best predictors of a diagnosis of pneumonia(4).

2. Other symptoms include
According to the study conducted by Nanxiang Hospital of Jiading District of Shangha, the common symptoms of (human bocavirus infection) HBoV-infected patients included frequent coughing, wheezing and fever(5). Others suggested that CAP is usually characterized by fever, chills, dyspnea, cough, and pleuritic chest pain in association with physical findings suggestive of consolidation in persons who become ill outside of a hospital or chronic-care facility(5).
a. Cough, which may be dry at first, but eventually produces phlegm (sputum)as a result of heat accumulation, according to traditional Chinese medicine.
b. Nausea and vomiting
c. muscle aches
d. weakness
e. fatigue
f. etc.

B. Classification
Two most common types of lower respiratory track infection, include
Bronchitis
Bronchitis is defined as a condition of an inflammation of the mucous membranes of the bronchi, the larger and medium-sized airways that carry airflow from the trachea into the lung parenchyma(7). Most cases of Bronchitis are as a result of recurrent injure to the airways caused by inhaled irritants and cigarette smoking(6). There are 2 types of bronchitis
1. Acute Bronchitis
Short term infection with symptoms of green sputum, chest discomfort or soreness, fever as a result of cold or flu of which only last for a few days.

2. Chronic Bronchitis
Chronic bronchitis is defined as phlegm on most days, at least 3 months per year for ≥ 2 yrs or cough and phlegm on most days, at least 3 months per year for ≥ 2 yrs(7).

A. Causes and Risk factors 
A.1. Causes
A.1.1. Acute brochitis
The most common causes of acute brochitis are as result of the infection due to the invasion of Virus, (influenza and cold). Prolonged activity of the presnece of the virus can have many deteriorative effects.Young adults with underlying medical conditions who are infected with the H1N1 virus are at risk of quickly progressing from mild upper airways infection to severe ARDS within 4 to 5 days after the onset of the illness. According to the study by Dr. Homsi S and the research team, there is a report of a case  a 46-year-old morbidly obese and diabetic woman infected with the H1N1 virus who developed acute bronchitis that lasted for 4 weeks and then progressed to ARDS. The month-long persistence of the H1N1 viral bronchitis and its late progression to ARDS which may reflect prolonged viral activity. Such a prolonged, rather than quick, course of deterioration can cause clinicians to misdiagnose the etiology of the ARDS and may cause the patient to receive a prolonged treatment with steroids to treat bronchitis symptoms(8).
Other in the reviewed study of reported eight cases of influenza A (H1N1) 2009 admitted to themedical intensive care with severe respiratory failure between November and December 2009 and in January 2011. All patients were older than 30 but younger than 50 years, had clinical and radiological evidence of an Acute Respiratory Distress Syndrome (ARDS) and needed invasive ventilatory support. The clinical course of severe cases of influenza A (H1N1) 2009-infection is markedly different from the disease pattern seen during epidemics of seasonal influenza. Most of the patients admitted to our intensive care unit due to influenza A (H1N1) 2009 associated ARDS were previously healthy young people, according to the University Hospital of Muenster(9).

A.1.2. Chronic brochitis
Most common causes of cgronic brochitis are as result of chronical smoking cigarettes, air pollution, dust. toxic gases, etc.
1. Smoking
In the case-control study in Beirut in 2009/2010 to evaluate the relationship: 274 cases of chronic bronchitis and 559 controls without the condition aged > or = 40 years, conducted by Lebanese University Beirut, found that current waterpipe dependence was significantly associated with chronic bronchitis (OR = 3.74, P < 0.001). After adjustment for covariates/confounders, ever waterpipe smoking > 20 WP-years (P < 0.001) was significantly associated with chronic bronchitis(10).
Other study indicated that in a retrospective clinical and morphological study on a group of 17 smoker patients with symptoms of chronic bronchitis, eight non-smokers diagnosed with chronic bronchitis and five non-smokers and asymptomatic subjects. CB developed especially in men of 65-year-old or older, especially in smokers with a median FEV1% at around 71. Histopathologically, patients with symptoms of CB, regardless of smoking status, presented on bronchial biopsies with focal squamous metaplastic change, goblet cell hyperplasia and enlargement of the bronchial gland mass because of the inflammatory process, consisting predominantly of mononuclear cells in the bronchial wall. The statistical testing proved a significant correlation between the densities of different inflammatory cell classes (with the exception of mast cells in the bronchial epithelium) and FEV1% values on epithelium and submucosa regions in all investigated groups(11).

2. Air pollution, dust. toxic gases and other occupational chemical exposures
In the study to ascertain chronic obstructive pulmonary disease (COPD) prevalence among industrial workers in the Russian Federation and determine relative contribution of smoking and occupational factors to COPD of 1,375 workers aged 30 or over, found that those with airfl ow limitation of FEV1/FVC<0.70 were considered having COPD and those with presence of cough and sputum production for at least three months in each of two consecutive years were considered having chronic bronchitis (CB), with no overlapping between these 2 groups. Data on occupational history and VGDF levels in the working area were collected from all participants. In total, 105 cases of COPD and 170 cases of CB were diagnosed in the cohort of examined workers. Occupational exposure to VGDF was twice as often present among COPD patients than among both patients with CB and the control group of healthy workers (p<0.05). More than 40 % of COPD patients were occupationally exposed to VGDF above the value of 3.0 of the occupational exposure limit (OEL) and more than 20 % to 6.0 OEL and higher. Overall odds ratio for COPD development due to occupational VGDF exposure was 5.9 (95 % CI=3.6 to 9.8, p=0.0001). Both smoking and VGDF seem to be important for the development of COPD. Analysis of the combined effect of tobacco smoking and occupational noxious particles and gases on COPD development has shown the following order of risk factors based on the strength of their infl uence: VGDF levels, smoking index, age, and heating microclimate(12).

A.2. Risk factors
1. Tuberculosis and occupational exposures
In the study to determine the prevalence and predictors of chronic bronchitis, found that the pattern of chronic bronchitis in South Africa suggests a combination of risk factors that includes not only smoking but also tuberculosis, occupational exposures in men and domestic fuel exposure in women. Control of these risk factors requires public health action across a broad front(14).

2. Household income adequacy
In the study to determine the prevalence of chronic bronchitis (CB) and associated risk factors in farm and nonfarm rural residents in Saskatchewan, Canada, found that  increasing household income and reducing smoking could be primary, modifiable determinants of CB prevalence(15).

3. Age, low income, allergic, asthma, geographic location
In the study to determine the prevalence (crude and adjusted) of CB and its associated risk factors in Canadian Aboriginal children and youth six to 14 years of age, found that the prevalence of CB was 3.1% for boys and 2.8% for girls. Other significant risk factors of CB were age (OR 1.38 [95% CI 1.24 to 1.52] for 12 to 14 year olds versus six to eight year olds), income (OR 2.28 [95% CI 2.02 to 2.59] for income category <$25,000⁄year versus ≥$85,000⁄year), allergies (OR 1.96 [95% CI 1.78 to 2.16] for having allergies versus no allergies), asthma (OR 7.61 [ 95% CI 6.91 to 8.37] for having asthma versus no asthma) and location of residence (rural⁄urban and geographical location). A significant two-way interaction between sex and body mass index indicated that the relationship between the prevalence of CB and body mass index was modified by sex(16).

3.  Gender
If you are female, you are at inscreased risk to develop brochitis. In the study to analyze the trend of gender gaps in life expectancy (GGLE) in Japan between 1947 and 2010, and explored the correlations of GGLE with gender mortality ratio and social development indices, found that the increased trend of GGLE in Japan could be partly explained by increased disease-specific mortality ratios (male/female), especially those involving chronic bronchitis and emphysema, diseases of the liver, suicide and cancer. The recent decline of GGLE might imply that Japanese women have been catching up with the lifestyle of men, resulting in similar mortality patterns(17).

4. Influenza vaccination coverges and other risk factors
Other researchers in the study of influenza vaccination coverges, found that Socio-economic factors, such as gender, age, educational level, occupational status and macro-region of residence, affect influenza vaccination coverage rates in the Italian general population. In addition, some chronic medical conditions are an obstacle for vaccination(18)

5. Immunodeficiencies
According to the study by Sheffield Children's Hospital, Western Bank, Protracted bacterial bronchitis (PBB) is a disease caused by the chronic infection of the conducting airways. In many children the condition appears to be secondary to impaired mucociliary clearance that creates a niche for bacteria to become established, probably in the form of biofilms. In others, immunodeficiencies, which may be subtle, appear to be a factor. PBB causes persistent coughing and disturbed sleep, and affects exercise tolerance, causing significant levels of morbidity(18a).

5. Other risk factors
Accoring to the University of Saskatchewan, in the study to determine the prevalence of chronic bronchitis (CB) and associated risk factors in farm and nonfarm rural residents in Saskatchewan, Canada, showed that The prevalence of CB was 5.3% among farm residents and 6.4% among nonfarm residents. A greater prevalence of CB is associated with household income adequacy, increasing age, allergies, history of lung disease in a parent, exposure to stubble smoke, obesity, prenatal exposure to smoking, and female sex. Smoking interacted with occupational exposure to wood dust and solvents, and allergic reaction to molds(13).


B. Misiagnosis and diseases associtaed with Bronchitis
B.1. Misdiagnosis
1. Asthma
Protracted bacterial bronchitis (PBB) causes persistent coughing and disturbed sleep, and affects exercise tolerance, causing significant levels of morbidity. PBB has remained largely unrecognised and is often misdiagnosed as asthma(19).

2. Sinus infection
According to the viwer at the Enpow-her in the question of why do doctors misdiagnose phenmonia and bronchitis and assume its sinus infection without proper testing? at indicated that  I have had numerous friends suffering from upper respitory bronchitas or phenmonia symptoms but the doctor has diagnosed "sinus infection". Even after weeks of antibiotics nothing works. Z pac is like a sugar pill. What is the best RX to rid this nasty infection?(20).

3. Whooping cough
According to the article of Bronchitis-like symptoms: Related Misdiagnoses, posted at RD, Jan 13- 2013, The cough symptoms of whooping cough is usually productive initially, but then becomes a persistent dry cough, lasting up to 100 days. Elderly grandparents may also be a reservoir of undiagnosed whooping cough(21).

4. Other Chronic lung diseases
Other Chronic lung diseases may be middiagnosis as brochitis via versa. According to the aboved same article,  Some of the chronic lung diseases are difficult to diagnose. Even the well-knowns conditions such as asthma or lung cancer often fail to be diagnosed early(22).

5. Etc.

B.2. Diseases associated with Brochitis
1. Diabetes mellitus
In the study of 311 patients with chronic occupational bronchitis associated with diabetes mellitus (or diabetes-free) revealed lipid metabolism disorders presenting with overweight, obesity, dyslipoproteinemia. Diabetes mellitus addition to chronic bronchitis increased frequency of lipid metabolism disorders and higher values of lipid state. The revealed lipid metabolism disorders were more marked in the females(23).

2. Upper Respiratory Tract Infection and Flu (Influenza)
In the study to examine the relationship between physician visit time and antibiotic prescribing for children with viral respiratory tract infection (RTI), found that in the 2739 visits from the NAMCS database, representing 119,926 visits nationally, met study criteria. Antibiotics were prescribed at 46,949 (39%) visits-75% with a diagnosis of bronchitis, 54% with bronchiolitis, and 30% with cold or URI. After adjusting for factors related to physician visit time, there was no difference in visit duration when antibiotics were or were not prescribed (13.6 +/- 8.4 and 13.3 +/- 9.6 minutes, respectively, P = 0.24)(24).

3. Lung cancer
In the study to clarify the role of previous lung diseases (chronic bronchitis, emphysema, pneumonia, and tuberculosis) in the development of lung cancer, by conducting conducted a pooled analysis of studies in the International Lung Cancer Consortium,  showed that a history of chronic bronchitis conferred a relative risk of 1.47 (95% CI: 1.29, 1.68 (13 studies)). Tuberculosis (relative risk = 1.48, 95% CI: 1.17, 1.87 (16 studies)) and pneumonia (relative risk = 1.57, 95% CI: 1.22, 2.01 (12 studies)) were also associated with lung cancer risk(25).

4. Gastroesophageal Reflux Disease (GERD)
IAccording to the study inevaluating  the association between the frequency of acid reflux (AR) and weakly acid reflux (WAR) and specific respiratory symptoms (RS) in childhood, showed that a  higher number of AR over WAR events was detected (p < 0.0001) but the WAR-to-AR events ratio progressively decreased with the age of the subjects (p < 0.01). Similar total number of reflux events was found in the three age group and in children with a more prevalent WAR or AR. The most prevalent RS, equally distributed among the three age groups, were persistent and/or nocturnal cough, wheezy bronchitis/asthma, and recurrent lower respiratory tract infections (RLRTI)(26).

5. Emphysema
Pulmonary emphysema, together with chronic bronchitis is a part of chronic obstructive pulmonary disease (COPD).

6. Etc.

C. The complication
1. Increased risk of early viral lower respiratory infections of the new born
There isan increased risk of hospitalisation for acute lower respiratory infection up to age 2 years in children delivered by elective caesarean section. In the study to examine the associations between the number of hospital admissions for bronchiolitis and pneumonia and elective caesarean delivery, showed that Delivery by elective caesarean was independently associated with infant admissions for bronchiolitis but not pneumonia. Elective caesareans or delivery without labour may result in impaired immunity in the newborn leading to increased risk of early viral lower respiratory infections(27).

2. Autoimmune rheumatic diseases
Patients suffering from autoimmune rheumatic diseases have significantly higher risk of developing various infections compared to the healthy population. In the study included patients suffering from systemic lupus erythematosus (n = 30), rheumatoid arthritis (n = 37) or Sjögren's syndrome (n = 32), with stable underlying diseases status. In November 2010, 47 patients, including 35 subjects vaccinated annually during 2006-2010, found that the incidence of influenza or bacterial complications (bronchitis) among vaccinated patients was significantly lower, compared to the non-vaccinated group. Importantly, there was no case of exacerbation of the underlying disease. The last vaccination in 2010 reduced the risk of influenza by 87%, but previous bacterial infections (bronchitis and pneumonia) increased influenza risk significantly(28).

3. Asthma
In the study to investigate whether chronic bronchitis, asthma, or baseline methacholine airway responsiveness can explain the heterogeneity in lung function response to boilermaker work, showed that although chronic bronchitis and asthma were associated with a greater loss in lung function in response to hours worked as a boilermaker, and therefore they acted as effect modifiers of the exposure-lung function relationship, airway hyperresponsiveness did not. However, the high prevalence of airway hyperresponsiveness found in the cohort may be a primary consequence of long-term workplace exposure among boilermakers(29).

4. Bronchiectasis
According to the study of Risk of infections in bronchiectasis during disease-modifying treatment and biologics for rheumatic diseases by Rheumatology B Department, Cochin Hospital, Paris France, lower respiratory tract infectious events are frequent among patients receiving biologics for chronic inflammatory rheumatic disease associated with bronchiectasis. Biologic treatment and pre-existing sputum colonization are independent risk factors of infection occurrence(30).

5. Cystic fibrosis, airway hyperresponsiveness and neutrophilic bronchitis
There is a report of four patients with asthma, airway hyperresponsiveness and neutrophilic bronchitis who harboured abnormal cystic fibrosis transmembrance conductance regulator (CFTR) gene mutations. It serves both to alert clinicians to consider CFTR-related disease in both young and elderly patients with persistent neutrophilic bronchitis, and to highlight the potential utility of future genetic testing for CFTR abnormalities in patients with asthma and recurrent bronchitis or pansinusitis, and the role of nebulized hypertonic saline as a therapeutic option in these patients(31).

6. Recurrent haemoptysis
There is a report of an 8-year-old boy presented with recurrent chest pain and haemoptysis since 3 years of age. He had taken multiple courses of antitubercular treatment without any symptomatic relief. His chest x-ray showed opacity consistent with right sided lung collapse. Further detailed work-up including high-resolution CT scan of thorax, pulmonary angiogram and radionucleide study confirmed intrathoracic gastrogenic cyst(31a).

D. Diagnosis and tests
In the study to assess the practicability of a new algorithm in decreasing the rate of incorrect diagnoses and inappropriate antibiotic usage in pediatric Acute Respiratory Tract Infection (ARTI), by Shahid Beheshti University of Medical Sciences, indicated that upper Respiratory Tract Infection, Lower Respiratory Tract Infection, and undifferentiated ARTI accounted for 82%, 14.5%, and 3.5% of 1 209 cases, respectively. Antibiotics were prescribed in 33%; for: Common cold, 4.1%; Sinusitis, 85.7%; Otitis media, 96.9%; Pharyngotonsillitis, 63.3%; Croup, 6.5%; Bronchitis, 15.6%; Pertussis-like syndrome, 82.1%; Bronchiolitis, 4.1%; and Pneumonia, 50%. Implementation of the ARTIs algorithm is practicable and can help to reduce diagnostic errors and rate of antibiotic prescription in children with ARTIs(32). It is diffiucult in diffentiation between common cold and acute brochtitis in the early of the diseases. If your doctor suspected that you have brochitis, after recoring the family  history and a complete physical examination, the test which your doctor order may include
1. Chest X ray
The aim of the test is to exclude other conditions, such as bronchiectasis, which can mimic the disease clinically.

2. Sputum culture
The purpose of the test is to check for the presence of bacteria in sputum produced when you cough.

3. Pulmonary function test
In the study to evaluate the correlation of 6MWT and spirometric parameters in stable COPD with different severities. 6MWT data assessed included three variables: the 6-minute walk distance (6MWD), 6-minute walk work (6MWORK), and pulse oxygen desaturation rate (SPO(2)%), found that 6MWT correlated with the spirometric parameters in severe and very severe COPD patients. 6MWT may be used to monitor changes of pulmonary function in these patients(33).

Some studies suggested that Children with high pulmonary function would have lower risks on the development of bronchitis and asthma. The protective effect of high pulmonary function would be modified by traffic-related air pollution exposure(34).
According to the study by Dr. Albert RH. at the Hartford Hospital, Hartford,at in the differentiation of acute bronchitis, Cough is the most common symptom bringing patients to the primary care physician's office, and acute bronchitis is usually the diagnosis in these patients. Acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Symptoms of bronchitis typically last about three weeks. The presence or absence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. Viruses are responsible for more than 90 percent of acute bronchitis infections(35).

E. Preventions
E.1. The do and do not's list
1. Wash your hand thoroughly with soap and water 15-20 seconds can help to reduce the risk of catching common cold and influrenza. Use alcohol-based hand gels if washing is not possible.

2. Cover sneeze and coughing and prevent hand-to-hand passage.

3. Enhance your immune function to protect your body against invasion of foreign invasion, including bacteria and virus.

4. Traditional Mediterranean diet
Eating plenty of fruit, vegetables and fish keep lungs healthy. Those who follow a diet closest to this " Mediterranean " ideal are less likely as their peers with eating habits furthest from this pattern to develop chronic lung disease. A good amount of fresh vegetable juices are a good way to start healing, along with adding a variety of spices such as ginger, onions, and garlic. The emphasis should be on eating as healthy a diet as possible(36).

5. Eat your fruit and vegetables
Fruits and vegetables not only are very nutritional but also contains high amount of antioxidants which can combat against bacteria and virus invasion.

6. Stop smoking
As smoking is the main cause of chronic bronchitis.

7. Avoid occpupation and enviroment exposure  to dust, chemical gas, air poplution, etc.
Strong evidances suggested that prolonged period of exposure to dust, chemical gas, air poplution, etc. are associated to the development of chronic bronchitis

8. Etc.

E.1. Diet to prevent bronchitis
According to the study by Olive View Medical Center, Sylmar, Calif. although chronic bronchitis was first named and described in 1808, the disease has been known since earliest time, and numerous drugs have been utilized in its therapy. The basic historic theories of human function have readily been applied to bronchitis; thus in Greek medicine, the disease was appreciated as one of excess phlegm. Early remedies included garlic, pepper, cinnamon, and turpentine, whereas later therapies of choice emphasized coffee, ipecac, and potassium nitrate(37).
1. Garlic
According to Steven Sandberg-Lewis, ND, in the article of Garlic for Bronchitis, indicated that
An inhalation of liquid allicin, an active compound in garlic with antibacterial and antiviral effects or to use liquid allicin, add about 10 drops (my favorite allicin extract is called Allimax Liquid) to the reservoir of a portable nebulizer, which is available at most drugstores. Breathe the mist until all of the extract is gone-about 10 minutes. Repeat the treatment one to three times daily until you're feeling better(38).

2. Green tea
In the study to investigate the Green tea epigallo-catechin-galleate ameliorates the development of obliterative airway disease, suggested that targeting this may offer therapeutic benefits. As a potent anti-inflammatory agent, epigallo-catechin-galleate (EGCG), a green tea catechin, has been very effective in ameliorating inflammation in a variety of diseases, providing the rationale for its use in this study in a murine heterotopic tracheal allograft model of OB(39).

3. Mango ginger
Mango ginger (Curcuma amada Roxb.) is a unique spice having morphological resemblance with ginger but imparts a raw mango flavour. Ayurveda and Unani medicinal systems have given much importance to mango ginger as an appetizer, alexteric, antipyretic, aphrodisiac, diuretic, emollient, expectorant and laxative and to cure biliousness, itching, skin diseases, bronchitis, asthma, hiccough and inflammation due to injuries.According to the study by Department of Biotechnology, Defence Research Laboratory, found that the biological activities of mango ginger include antioxidant activity, antibacterial activity, antifungal activity, anti-inflammatory activity, platelet aggregation inhibitory activity, cytotoxicity, antiallergic activity, hypotriglyceridemic activity, brine-shrimp lethal activity, enterokinase inhibitory activity, CNS depressant and analgesic activity(40).

4. Aromatics 
Aromatics are a commonly used ingredient in a number of proprietary medicines. It is well established that lung mucus clearance is impaired in patients with chronic airways obstruction.  According to the study by Royal Free Hospital and University College Medical School, aromatic treatment significantly enhanced clearance at two time points 30 (p < 0.05) and 60 (p < 0.02) minutes postradioaerosol inhalation but had no demonstrable further effect over the following 5 hours despite further application of the inunction. The clearance improvement (relative to a baseline) observed during the first hour of testing was significantly correlated (p < 0.01) with the concentration level of aromatics(41).

5. Etc.

E.2. Phytochemicals to prevent bronchitis
1. Quercetin
Mucus hypersecretion is a feature of many chronic airway diseases induced by cigarette smoke (CS), and evidence suggests that the antioxidant and anti-inflammatory flavonoid quercetin may protect against CS-induced respiratory pathology. According to the study by State Key Laboratory of Biotherapy and Department of Respiratory Medicine, West China Hospital, Sichuan University, quercetin attenuates CS-induced mucin protein synthesis in rat lung, possibly by inhibiting oxidative stress and inflammation via a mechanism involving NF-κB pathway activation and EGFR phosphorylation. These findings suggest that quercetin has a potential for treating chronic airway diseases(42).

2. Catechin
Catechin found abundantly in Actinidia callosa var. ephippioides extract also had good effects in the antioxidant and anti-inflammatory activities. Catechin might be an important bioactive compound in the stem of ACE. The above experimental data indicated that the stem of ACE is a potent antioxidant medicinal plant, and such efficacy may be mainly attributed to its polyphenolic compounds(43).

3. Eupafolin 
Eupafolin found abundantly in Kalanchoe gracilis (L.) DC stem also had good pharmacological activity in the antioxidant, anti-inflammation and antiproliferative. Eupafolin might be an important bioactive compound in the stem of K. gracilis. The above experimental data indicated that the stem of K. gracilis is a potent antioxidant medicinal plant, and such efficacy may be mainly attributed to its polyphenolic compounds(44).

4. Puerarin
 Puerarin is a major isoflavonoid derived from the Chinese medical herb Radix puerariae (kudzu root), In the study to investigate the myocardial protective effect of puerarin injection (PI) in children with severe pneumonia, conducted by Hospital Affiliated to Weifang Medical College, indicated that
change of serum myocardial zymographic parameters was indirectly proportional to the severity of childrens condition. The reduction of myocardial contractive function was demonstrated by the change of cardiac blood flow parameters in Ultrasound Doppler examination (P < 0.01). Both PI and FDP had the effect in protecting myocardium and improving heart function, showing insignificant difference between their efficacy (P > 0.05), but PI had less stimulation to vessels and without any obvious adverse reaction(45).

5. Etc.

E.3. Antioxidants to prevent bronchitis
1. Antioxidant vitamins C, E and coenzyme Q10 
In the study to to evaluate the effects of antioxidant vitamins (vitamin C and E), Coenzyme Q10 (CoQ10) and dexamethasone (Dxm) in experimental rat models with pulmonary contusion (PC), showed that Administration of CoQ10 resulted in a significant increase in PaO2 values compared with the group I (p = 0.004). Levels of plasma MDA in group II were significantly higher than those in the group I (p = 0.01). Early administration of vitamin C, CoQ10, and Dxm significantly decreased the levels of MDA (p = 0.01). Lung contusion due to blunt trauma significantly decreased SOD activities in rat lung tissue compared with group I (p = 0.01). SOD levels were significantly elevated in animals treated with CoQ10, Vitamin E, or Dxm compared with group II (p = 0.01)(46).

2. Vitamin D
In the cohort  to investigate the association of maternal vitamin D and maternal asthma and infant respiratory infection severity of 70% white, 19% African American, and 21% had asthma, found that
overall, the median maternal vitamin D level was 20 ng/mL (interquartile range, 14-28). Among white women, a 14 ng/mL increase in vitamin D was associated with a decreased odds of asthma (adjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86). Maternal vitamin D was not associated with infant bronchiolitis score(47).

3. Curcumin
Curcumin derived from the rhizome of turmeric has been used for decades and it exhibits anti-inflammatory, anti-carcinogenic, immunomodulatory properties by downregulation of various inflammatory mediators,. according to the study by Panjab University(48)

4. Etc.


F. Treatments
F.1. In conventional medicine perspective
The aim of the treatment is to relive the symptoms, such as cough, pain, breathing, etc.
A. Acute bronchitis
Cough is the most common symptom bringing patients to the primary care physician's office, and acute bronchitis is usually the diagnosis in these patients. Getting more rest,  taking over-the-counter pamedicine to relieve the symptoms, drinking fluids, breathing in warm, moist air. According to the study by Hartford Hospital, Hartford, acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Symptoms of bronchitis typically last about three weeks. The typical therapies for managing acute bronchitis symptoms have been shown to be ineffective, and the U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than six years. The supplement pelargonium may help reduce symptom severity in adults. As patient expectations for antibiotics and therapies for symptom management differ from evidence-based recommendations, effective communication strategies are necessary to provide the safest therapies available while maintaining patient satisfaction(49).

B. Chronic bronchitis
The syndrome of chronic obstructive pulmonary disease (COPD) consists of chronic bronchitis (CB), bronchiectasis, emphysema, and reversible airway disease that combine uniquely in an individual patient. Older patients are at risk for COPD and its components--emphysema, CB, and bronchiectasis. Bacterial and viral infections play a role in acute exacerbations of COPD (AECOPD) and in acute exacerbations of CB (AECB) without features of COPD(50).
Beside over counter medince to reduce symptoms of the disease, prescriptions medication may include
1. Antibiotics
Antibiotics are medication used to fight against the bacetrial invasion. Gemifloxacin is a fluoroquinolone antibiotic with broad spectrum of antibacterial activity. In the study to to evaluate the comparative effectiveness and safety of gemifloxacin for the treatment of patients with community-acquired pneumonia (CAP) or acute exacerbation of chronic bronchitis (AECB), found that gemifloxacin 320 mg oral daily is equivalent or superior to other approved antibiotics in effectiveness and safety for CAP and AECB. The development of rash represents potential limitation of gemifloxacin(51). But other suggested that older patients are at risk for resistant bacterial organisms during their episodes of AECOPD and AECB. Organisms include the more-common bacteria implicated in AECOPD/AECB such as Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae.  Using a risk-stratification approach for elderly patients, first-line antibiotics (e.g., amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline), with a more-limited spectrum of antibacterial coverage, are used in patients who are likely to have a low probability of resistant organisms during AECOPD/AECB. Second-line antibiotics (e.g., amoxicillin/clavulanic acid, second- or third-generation cephalosporins, and respiratory fluoroquinolones) with a broader spectrum of coverage are reserved for patients with significant risk factors for resistant organisms and those who have failed initial antibiotic treatment(52).
Side effects are ot limit to rash, diarrhea, abdominal pain, nausea/vomiting, drug fever, hypersensitivity (allergic) reactions, etc.

2. Blockade of the Epidermal growth factors  receptors (EGFR) therapy
In the study to examine the expression patterns of EGF and their receptors (EGFR1 and c-erbB2) in the bronchial mucosa from the biopsy specimens harvested from smoking and non-smoking CB patients, compared with their expression in normal controls, indicated that blockade of the EGFR pathway can be an alternative successful therapy(53).

3. Surgery
Chronic bronchitis is a common but variable phenomenon in COPD. It has numerous clinical consequences, including an accelerated decline in lung function, greater risk of the development of airflow obstruction in smokers, a predisposition to lower respiratory tract infection, higher exacerbation frequency, and worse overall mortality(54).  Lung reduction surgery can be potential helpful in removing the damage lung area. According to the study by University of Pennsylvania, lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity(55).

4. Etc.

F.2. In Herbal medicine perspective(1)
1. Actinidia callosa var. ephippioides
Oxidative stress and inflammation are related to several chronic diseases including cancer. Actinidia callosa var. ephippioides (ACE) is a special folk medicinal plant from Taiwan. In the study to evaluate the antioxidant, anti-inflammatory, and antiproliferative activities of the methanol extract and fractions from the stem of ACE, showed that  Trolox Equivalent Antioxidant Capacity (TEAC), 1,1-Diphenyl-2-picrylhydrazyl (DPPH) scavenging activity, total phenolic content, flavonoid content, inhibition on nitric oxide (NO) productions by LPS-induced RAW264.7 cell, and on lung cancer cell proliferation were employed. Among all fractions, ethyl-acetate fraction (EA-ACE) showed higher TEAC, DPPH radical scavenging activities, polyphenol and flavonoid contents, respectively. EA-ACE also decreased the LPS-induced NO production and expressions of inducible nitric-oxide synthase (iNOS) in RAW264.7 cells. EA-ACE had the highest antiproliferative activity with an IC(50) (The concentrations required for inhibition of 50% of cell viability) of 469.17 ± 3.59 μg/mL(56).

2. Kalanchoe gracilis (L.) DC stem
In the study to evaluate the antioxidant, anti-inflammatory and antiproliferative activities of the methanolic extract and fractions of the stem of K. gracilis, found that TEAC, total phenolic compound content, total flavonoid content, DPPH radical scavenging activity, reducing power, inhibition of NO production in LPS-induced RAW264.7 cells, and inhibition of cancer cell proliferation were analyzed. Among all fractions, the chloroform fraction showed the highest TEAC and DPPH radical scavenging activities. The chloroform fraction also had the highest content of polyphenols and flavonoids. Chloroform fractions also decreased LPS-induced NO production and expressions of iNOS and COX-2 in RAW264.7 cells(57).

3. Lobelia, coltsfoot, and elecampane
Herbal remedies and herbal teas ease difficult breathing by opening up the inflamed airways, inhibit coughing, and act as antiseptics to treat bronchitis. Lobelia, coltsfoot, and elecampane are all good old fashioned herbal remedies that have been in use for centuries for all kinds of respiratory illnesses. They still work just as well today(58).

4. Etc.

F.3. In traditional Chinese medicine perspective(1)
Chronic bronchitis is chronic non-specific inflammation of bronchial mucosa and its surrounding tissues due to infected or non-infected factors. Except other reasons causing chronic cough, it can be diagnosed from cough and expectoration for 3 months with a history over 2 years. It can be classified as"cough", "dyspnea" and "asthma" in TCM(59). 
Application of herbal medicine to acupoints is to regulate the meridians, yin-yang, and qi and blood for preventing and treating diseases through the pharmacological action of herbal medicines and with their stimulation to the acupoints, including the treatment of hypertension, asthma, chronic bronchitis and allergic rhinitis(60).
1. Jiawei yupingfeng powder
In the study to explore the effect of Jiawei Yupingfeng Powder (JYP) on T-lymphocyte subsets in patients with senile chronic bronchitis in acute onset stage (SCB-AOS), found that Increase of CD3, CD4 and CD4/CD8 (P < 0.05) and decrease of CD8 (P < 0.01) were significantly shown in the treated group after treatment, but no change in the control group. Besides, comparison of the total effective rate in the two groups also showed significant difference (P < 0.05)(61).

2. Kesuning granule
In the study to prove the effect of Kesuning Granule (KSNG) in treating chronic bronchitis in exacerbation (Phlegm-Heat syndrome) and objectively evaluate its safety with a double-blinded, double-dummy and randomized controlled method adopted to observe 120 patients, who were divided into the treated group (n = 60, treated with KSNG 8 g, three times a day) and the control group (n = 60, treated with Jinbei Tankeqing Granule (JBTKQ) 7 g, three times a day). The therapeutic course for both groups was 6 days found that in the treated group, the markedly effective rate was 58.33% and effective rate was 93.33%, while in the control group, they were 51.67% and 91.67% respectively, no significant difference was found between the two groups(62).


3. Jinshui liujun decoction
In the study to assess the effect of Jinshui Liujun decoction (JSL) in treating chronic bronchitis. found that JSL was proved to be efficacious in improving immune function of the body and pulmonary ventilatory function (P < 0.01). JSL could not only increase the secretion of rats' trachea mucosa and dilute sputum, but also increase the motion speed of the pigeons' trachea cilia, thus facilitate the removal of sputum. Compared with the normal saline control group, both animal experiments displayed significant statistical difference (P < 0.01), but without significant difference when compared the JSL group with the positive drug Juhong Tanke Ye control group(63).


4. Yu ping feng powder 
In the study to observe the influence of modified Yu Ping Feng San (MYPFS) on bacterial adhesion of tracheal mucosa, four experiments of bacterial adhesion in pneumatic tract were conducted, in which mice of chronic bronchitis model (CBM) induced by SO2 stimulation and another health control group breathed in aerosol contained Pseudomonas aeruginosa under the same condition, found that theories of traditional Chinese medicine in "strengthening body resistance to eliminate the pathogenic factor", so that they provided experimental evidence for TCM tonics to prevent and treat infection of respiratory tract(64).

5. Etc.

Bronchitis
F.2(a). In Herbal medicine perspective(2)
1.  Jatropha
A number of herbs belonging to the genus Jatropha of Euphorbiaceae family are noted for their medicinal benefits. The genus Jatropha is one of the prospective biodiesel yielding crops. The plants which have been so far explored include J. curcas, J. gossypifolia, J. glandulifera, J. multifida and J. podagrica. Although, the plants of this genus are widely distributed, there is an exiguity of scientific literature proclaiming the medicinal benefits of the plants belonging to genus Jatropha. The present paper is a pragmatic approach to accrue the findings on this very significant genus, according to the study by the Guru Jambheshwar University of Science and Technology-Pharmaceutical Sciences(35).

2. Leucas
Plants of genus Leucas (Lamiaceae) are widely distributed throughout Asia, Africa, and India. The plant is used in traditional medicine to cure many diseases such as cough, cold, diarrhea, and inflammatory skin disorder. A variety of phytoconstituents have been isolated from the Leucas species, which include lignans, flavonoids, coumarins, steroids, terpenes, fatty acids, and aliphatic long-chain compounds. Anti-inflammatory, analgesic, anti-diarrheal, antimicrobial, antioxidant, and insecticidal activities have been reported in the extracts of these plants and their phytoconstituents, according to the study by the Gayatri College of Pharmacy(36).

3. Ochna L
The genus Ochna L. (Gr, Ochne; wild pear), belonging to the Ochnaceae family, includes ca. 85 species of evergreen trees, shrubs, and shrublets, distributed in tropical Asia, Africa, and America. Several members of this genus have long been used in folk medicine for treatment of various ailments, such as asthma, dysentery, epilepsy, gastric disorders, menstrual complaints, lumbago, ulcers, as an abortifacient, and as antidote against snake bites, According to the study by the Institute of Bioconvergence Technology, Dongguk University, crude extracts and isolated compounds have been found to exhibit analgesic, anti-HIV-1, anti-inflammatory, antimalarial, antimicrobial, and cytotoxic activities, lending support to the rationale behind several of its traditional uses(37).

4. Etc.

E.3.  In traditional Chinese medicine perspective(2)
Chronic bronchitis is chronic non-specific inflammation of bronchial mucosa and its surrounding tissues due to infected or non-infected factors. Except other reasons causing chronic cough, it can be diagnosed from cough and expectoration for 3 months with a history over 2 years. It can be classified as"cough", "dyspnea" and "asthma" in TCM(59).
Application of herbal medicine to acupoints is to regulate the meridians, yin-yang, and qi and blood for preventing and treating diseases through the pharmacological action of herbal medicines and with their stimulation to the acupoints, including the treatment of hypertension, asthma, chronic bronchitis and allergic rhinitis(60).
E.3.1. Acute bronchitis
1. Echinacea angustifolia and E. purpurea
Echinacea angustifolia and E. purpureaare commonly used in North America for their anti-bacterial effects. Flos Lonicerae, Radix Scutellaria and Fructus Forsythiae are traditional Chinese medicinal herbs commonly used for the treatment of complaints such as pneumonia, acute upper respiratory tract infection, and acute bronchitis,found that chlorogenic acid is more stable in acidic pH, and hence it is best to keep the extract of E. augustifolia, E. purpurea, Flos Lonicerae, Radix Scutellariae and Fructus Forsythiae in mild acidic conditions at approximately pH 5(38).

2. Shuang-Huang-Lian (SHL)
Shuang-Huang-Lian (SHL), a traditional Chinese formula containing Lonicerae japonicae flos (LJF), Scutellariae radix (SR) and Forsythiae fructus (FF), is commonly used to treat acute upper respiratory tract infection, acute bronchitis and light pneumonia,found that A/%(h(-1)) of forsythoside A in FF+LSF, FF+SR and SHL were all reduced greatly compared with that in FF. However, in pharmacokinetics study, C(max) and AUC(0→1440) of forsythoside A all increased and T(1/2) prolonged in SHL, FF+LJF and FF+SR compared with FF. The results indicated that the different compositions of SHL decreased absorption but increased bioavailability of forsythoside A, which may be related to its metabolism inhibited in intestine or liver(39).

3. Pasting acupuncture with Chinese herbs
According to the study by First Hospital Attached to Harbin Medical University, the clinical observation of pasting acupuncture with Chinese herbs applying in 72 infant acute bronchitis cases and regarding to the humoral immune substances such as IgA, IgM, IgG, Complement C3 shows high cure and improve rate. The curative effect of infantile group is higher than that of childhood one (x2 = 6.501, 0.05 > p > 0.025). All indexes of humoral immune substances, especially IgA, were increased after treatment (t = 10.50, p < 0.01)(40).

4. Ma-xin-shi-gan tang
According to the study bt Affiliated Hospital of Hubei College of TCM, Wuhan, Ma-Xin-Shi-Gan tang (Decoction of Herba Ephedrae, Semen Armeniacae Amarum, Radix Glycyrrhizae and Gypsum Fibrosum) is effective on the immune function of the children with acute lower respiratory tract infection (ALRTI)(61).
According to the study by Sichuan University, in the review to summarise the existing evidence on the comparative effectiveness and safety of Chinese medicinal herbs for treating uncomplicated acute bronchitis, found that there is insufficient quality data to recommend the routine use of Chinese herbs for acute bronchitis. The benefit found in this systematic review could be due to publication bias and study-design limitations of the individual studies. In addition, the safety of Chinese herbs is unknown due to the lack of toxicological evidence on these Chinese herbs, though adverse events are rarely reported. Chinese herbs should be used carefully(62). Other study indicated that TCM is widely used for treating ARTIs. However, none of the identified studies has been well designed or conducted. In this overview, we suggest that clinical trials of TCM for ARTIs need to be re-run in accordance with internationally recognized standards(63).

E.3.2. Chronic bronchitis
Chronic bronchitis is chronic non-specific inflammation of bronchial mucosa and its surrounding tissues due to infected or non-infected factors. Except other reasons causing chronic cough, it can be diagnosed from cough and expectoration for 3 months with a history over 2 years. It can be classified as"cough", "dyspnea" and "asthma" in TCM(64).
1. Acupoint sticking therapy
In the study to assess the therapeutic effect of acupoint sticking therapy for prevention of acute attack of chronic hronchitis, found that acupoint sticking therapy in the three hottest periods of the year has better short-term and long-term therapeutic effects on chronic bronchitis, effectively improving immunological functions and preventing acute attack(65).

2. External application of herbal medicine to acupoints
According to the study by The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, application of herbal medicines to acupoints is one of the important components of TCM, which shows satisfactory effects in treatment of some chronic diseases, including chronic bronchitis(66).

3. Jiawei yupingfeng powder
In the study to explore the effect of Jiawei Yupingfeng Powder (JYP) on T-lymphocyte subsets in patients with senile chronic bronchitis in acute onset stage (SCB-AOS), found that increase of CD3, CD4 and CD4/CD8 (P < 0.05) and decrease of CD8 (P < 0.01) were significantly shown in the treated group after treatment, but no change in the control group. Besides, comparison of the total effective rate in the two groups also showed significant difference (P < 0.05)(67).

4. Kesuning granule
According to the West China Hospital, Sichuan University, In the treated group with Kesuning granule, the markedly effective rate was 58.33% and effective rate was 93.33%, while in the control group, they were 51.67% and 91.67% respectively, no significant difference was found between the two groups. For therapeutic effects on TCM syndromes, the markedly effective rate and effective rate in the treated group was 68.33% and 93.33% respectively and in the control group, 66.67% and 90.00% respectively, also showed insignificant difference. The effect initiative time was earlier in the treated group than that in the control group significantly (P < 0.05). No adverse effect was found in the observation(68).

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Pneumonia
Pneumonia is defined as a condition of the inflammation of the lung as a result of infection, caused by bacteria, such as bacteria Streptococcus pneumoniae or influenza viruses in most cases. Fungi, such as Pneumocystis jiroveci, certain medication such as PPI Stomach Acid Drugs and other conditions such as impaired immune systems can also induced the disease.
 
A. Causes and Risk factors
A.1. Causes
A.1.1. Viral causes of Pneumonia
1. Human bocavirus (HBoV)
According to the study of the clinical characteristics of human bocavirus (HBoV) infection in children, found that Among 843 cases, 90 were HboV positive (10.7%), 131 were respiratory syncytial virus (RSV) positive (15.5%), 117 were influenza virus positive (13.9%), 84 were parainfluenza virus positive (10.0%), 55 were rhinovirus positive (6.5%), 48 were coronavirus positive (5.7%), and 33 were human metapneumovirus positive (3.7%). Of the 90 HBoV infected patients, 45 (50%) showed a co-infection with other respiratory tract viruses. Among them, 33 were infected with one other type of virus (37%), 11 (12%) were infected with two other types of virus, and 1 case (1%) was infected with other three viruses. The HBoV positive rate in children with wheezing was significantly higher than those without wheezing (17.0% vs 9.2%; P<0.01)(8).

2. Legionnaires' disease or HPIV 3
According to the study by Infectious Disease Division, Winthrop-University Hospital, the most common mimics of H1N1 pneumonia are Legionnaires' disease or HPIV 3 in adults, and metapneumovirus or respiratory syncytial virus in children(9).

3. Human metapneumovirus
Human metapneumovirus (hMPV) is a newly identified paramyxovirus causing lower respiratory tract infections (LRTI). According to the strudy by School of Medicine, DPMSC, University of Udine, Italy, during a 15-month study period, 124 children were admitted due to presumptive CAP and, in 116 of them, CAP was radiologically confirmed that hMPV caused 0% to 17.5% of LRTI cases in children in the mini-review. The figure was about 5% in the present and in the only earlier paediatric CAP study. Thus, hMPV is a real but rare cause of paediatric CAP, although seroconversion to hMPV in most children takes place in early childhood(10).

4. Adenovirus
Adenovirus is a frequent cause of mild self-limiting upper respiratory tract infection, gastroenteritis, and conjunctivitis in infants and young children. There is a report of  a case of severe adenovirus pneumonia in a young immunocompetent male who presented with sudden onset respiratory distress that progressed rapidly to respiratory failure and made a successful recovery on supportive measures. Systematic review of the literature identified 14 cases of severe adenovirus pneumonia (defined as respiratory failure requiring ventilatory support at any point during the course of illness) in otherwise healthy immunocompetent adults both in epidemic and community settings(11).

5. Acute respiratory distress syndrome (ARDS)
According to the study by Department of Medicine, University of Manitoba, H1N1 2009 has emerged as an important cause of ARDS in 2009-2010(12).
6. Other virus
Pleural effusion (PE), a complication of community-acquired pneumonia (CAP), is usually attributed to a bacterial infection. According to the study by Federal University of Bahia School of Medicine, found that  in the study bacterial and viral infections among 277 children hospitalized with CAP,  among these children 206 (74%) had radiographic confirmation, of whom 25 (12%) had PE. The aetiology was established in 18 (72%) PE cases: bacterial (n = 5; 28%), viral (n = 9; 50%), and viral-bacterial (n = 4; 22%) infections were found. Infection by rhinovirus (n = 3), enterovirus, Streptococcus pneumoniae (n = 2 each), Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, influenza A virus, and respiratory syncytial virus (RSV) (n = 1 each) were detected as probable sole infections. Parainfluenza virus 1/3 + influenza A virus and RSV + influenza A virus (n = 1 each) were identified as mixed viral-viral infections(13).

5. Etc.

A.1.2. Bacterial causes of Pneumonia
1. Atypical Bacteria
'Atypical' bacteria, especially C. pneumoniae (Legionella pneumophila serogroup 1, C. pneumoniae, Chlamydia psittaci, Coxiella burnetii (phase-2 antigen) and Mycoplasma pneumoniae (IgG and IgM)), are a common cause of community-acquired pneumonia in adults in South Africa. In the study to assess the proportion of cases of community-acquired pneumonia caused by 'atypical' bacteria, including the recently discovered Chlamydia pneumoniae, and to compare the clinical, radiographic and laboratory features of patients with and without 'atypical' bacteria, showed that in the he records of 4 patients could not be traced and 17 patients did not fulfil the inclusion criteria. Thirty-two of these 92 patients (35.9%) were found to be infected with 'atypical' bacteria. The two most common organisms were C. pneumoniae (20.7%) and L. pneumophila (8.7%)(14).

2. Streptococcus pneumoniae and Staphylococcus aureus
Pneumonia is an infection of the lower respiratory tract caused by microbial pathogens. Two such pathogens, Streptococcus pneumoniae and Staphylococcus aureus, are the most common causes of community-acquired and hospital-acquired pneumonia respectively(15).

3. Bacillus anthraxis
There is a report of a case  of rapidly progressive, fatal, anthrax-like pneumonia and the overwhelming infection caused by a Bacillus species of uncertain provenance in a patient residing in rural Texas, according to teh study by Department of Pathology and Laboratory Medicine, The Methodist Hospital System(16).

4. Coxiella burnetii
Coxiella burnetii, the causative agent of Q fever is an intracellular bacterium and a potential weapon for bioterrorism. The widespread throughout the world zoonosis is manifested clinically as a self-limited febrile illness, as pneumonia (acute Q fever) or as a chronic illness with endocarditis being its major complication(17).

5. Legionella pneumophila
Legionella pneumophila, the causative agent of Legionnaires' disease is a facultative intracellular bacterium, which in the course of human infection multiplies in lung macrophages predominantly manifesting as pneumonia(18).

6. Etc.

A.1.3. Fungi and parasites
Although it is less in common, it can happened to people travel to the third world countries. In the study of Pneumonia, one of the most common causes of morbidity in bottlenose dolphins Tursiops truncatus, found that in a retrospective study on 42 dolphins from the US Navy Marine Mammal Program dolphin population was conducted (1980 to 2010), bacterial and fungal pneumonia was present in 42.9 and 28.6% of cases (9 and 6 cases)(19). Other indicated that Pneumocystis species are recognized as major opportunistic fungal pathogens which cause life-threatening pneumonia in severely immunocompromised or weakened mammals. Pneumocystis consists of a heterogeneous group of highly adapted host-specific fungal parasites that colonize a wide range of mammalian hosts(20).

A.2. Risk factors
1.  In Hospitalization
If you are being hospitalized, you are at increased risk to acquire the diseases. According to the study by Shanghai Jiao Tong University School of Medicine, Shanghai, Klebsiella pneumoniae is a member of the family Enterobacteriaceae, opportunistic pathogens that are among the eight most prevalent infectious agents in hospitals. The emergence of multidrug-resistant strains of K. pneumoniae has became a public health problem globally(21).

2. Certain chronical conditions
a. Chronic obstructive pulmonary disease (COPD)
Patients with chronic obstructive pulmonary disease are at inscreased risk of Chlamydia pneumoniae.
There is a correlation between Chlamydia pneumonia (Cpn) infection and chronic obstructive pulmonary disease (COPD), according to the study by Department of Respiratory Medicine of People's Hospital of Jiangyin(22).

b. Asthma
Asthma is a chronic inflammatory disease affecting the air way of the lung with recurring symptoms, such as wheezing, chest tightness, shortness of breath, and coughing. Of 18 controlled epidemiologic studies (over 4000 cases/controls), 15 found significant associations between Cpn infection and asthma using organism detection (polymerase chain reaction (PCR) testing (n = 2 studies) or fluorescent antigen testing (n = 1)), Cpn-specific secretory IgA (sIgA) antibody testing (n = 1), and/or specific serum IgE (n = 2), IgA (n = 4), IgG (n = 3) or other antibody criteria (n = 7). According to the studyby Dean Medical Center, Madison(23).

c. Cystic fibrosis
Cystic fibrosis (SIS-tik fi-BRO-sis), or CF, is an inherited disease of the secretory (see-KREH-tor-ee) glands. Pulmonary infection with Pseudomonas aeruginosa and neutrophilic lung inflammation significantly contribute to morbidity and mortality in cystic fibrosis (CF), according to the study by St. John's University College of Pharmacy and Allied Health Professions(24).

d. Congestive heart failure (CHF) and diabetes
Congestive heart failure (CHF) is defined as a  condition of that the heart's function can enough oxgen to the body. According to the study of the estimation of the economic impact of community-acquired pneumonia (CAP) for adults with asthma, diabetes, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) by Dr. Polsky D, and research team, in adults with certain comorbid conditions have a higher risk of pneumonia than the overall population. If treatment of pneumonia is more costly in certain predictable situations, this would affect the value proposition of populations for pneumonia prevention(25).

e. Sickle cell anemia
Sickle cell anemia is defined as a codition of which the body produces abnormally shaped like a crescent or sickle red blood cells. Patient with sickle cell disease are at high risk of developing an acute infection of the pulmonary parenchyma called community-acquired pneumonia(26).

g. Bronchiectasis
There is a report of a case of a 76-year-old man with a community-acquired pneumonia, in whom both sputum samples and bronchial secretions obtained with bronchoscopic protected catheter brush grew pure culture of N. sicca with abundant polymorphonuclear neutrophils. Bronchiectasis underlying lesions were disclosed by computed tomography. N. sicca should be added to the list of commensal organisms able to cause pulmonary infection(27).

h. Inmune deficiency
Pneumocystis jiroveci pneumonia (PJP) is a potentially fatal fungal infection occurring in immunocompromised patients. There are a number of case reports in the literature, the only collagen vascular disease with an increased incidence of PJP is Wegener granulomatosis.(28).

g. Etc.

3. Smoking
Smoking increases the risk of hospitalization for pneumonia. Tobacco cessation is likely important in reducing hospital admissions for pneumonia, but its benefit depends on duration of smoking cessation and is likely attenuated in the presence of COPD., according to the study of 25,235 participants, whom are identified 6720 current, 13,625 former, and 4890 never smokers(29).

4. Heavy alcohol drinking
Regular moderate alcohol intake is not associated with increased risk of hospitalisation for pneumonia. High weekly alcohol consumption in males and infrequent heavy drinking in both sexes may increase pneumonia risk(30).

5. Enhanced drug users
Epidemic of severe Streptococcus pyogenes infections in injecting drug users in the UK, 2003-2004 were reported and  injecting drug users (IDUs) presented with a wide range of clinical manifestations, including pneumonia(31).

6. Older age
Older ages are at the increased risk to develop as a result of weakened immune system.

7. New born and young children
New and under age children are at the increased risk to develop as a result of immature immune system.

8. Season related
According to the study included 243 patients, 64.6% men and 54.7% over the age of 65. The highest incidence of CAP was in the winter. Streptococcus pneumoniae was the most common causative agent for all seasons except in summer when the main agent was Legionella pneumophila. We observed a significant correlation between the lowest seasonal average temperature and pneumococcal etiology of CAP; inversely, with higher temperatures, Legionella pneumophila was more common. No etiological differences were found by season when related with environmental humidity(32).

9. Certain chemicals exposure
Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by the inhalation of organic substances and certain inorganic chemicals(33).

10. Travellers
According to the investigation of  travel-associated morbidity in European travellers in 2009 in comparison with 2008, with a particular emphasis on emerging infectious diseases with the potential for introduction into Europe,  respiratory illnesses, in particular pandemic A(H1N1) influenza, influenza-like syndromes, and tuberculosis, were also observed more frequently. A significant increase in reported dengue cases in 2009 as compared with 2008 was observed (n = 172, 2.7% vs. n = 131, 1.90%) (p 0.002). The numbers of malaria and chikungunya cases were also increasing, although not significantly. Two deaths were recorded: visceral leishmaniasis and sepsis in a Sudanese migrant, and Acinetobacter sp. pneumonia in a patient who had visited Spain(34).

11. Etc.

B. Misdiagnosis and Diseases associated to pneumonia
B.1. Misdiagnosis
In a study of a total of 518 patients, more patients in 2005 had a hospital admission diagnosis of community-acquired pneumonia (CAP) without radiographic abnormalities compared to 2003 (2005, 91 patients [28.5%]; 2003, 41 patients [20.6%]; p = 0.04), and more patients received antibiotics within 4 h of triage (2005, 210 patients [65.8%]; 2003, 107 patients [53.8%]; p = 0.007). Blood cultures prior to antibiotic administration increased (2005, 220 patients [69.6%]; 2003, 93 patients [46.7%]; p < 0.001). However, the final diagnosis of CAP dropped to 58.9% in 2005 from 75.9% in 2003 (p < 0.001). The mean (+/- SD) antibiotic utilization per patient increased to 1.66 +/- 0.54 in 2005 compared to 1.39 +/- 0.58 in 2003 (p < 0.001). There were no significant differences in PSI or CURB-65 scores, or mortality, according to St. John Hospital and Medical Center, linking antibiotic administration within 4 h of hospital admission (as a quality indicator) to financial compensation may result in an inaccurate diagnosis of CAP, inappropriate utilization of antibiotics, and thus less than optimal care(35).
According to medical malpractic help.com, the misdiagnosis of pneumonia include Influenza, or the flu, Chronic obstructive pulmonary disease, or COPD, Acute bronchiti(36).
1. Coccidioides
There is a report of a case of a 66-year-old man who was status-post bone marrow transplantation for chronic myelogenous leukemia was hospitalized with new onset rash, nausea, and vomiting and subsequently expired. A sputum culture collected on the day of death revealed heavy growth of C. recurvatus 6 days after collection. At autopsy, microscopic examination of the lungs revealed numerous thick-walled, nonbudding spherules ranging in size from 40 to 80 µm. Initial immunohistochemical staining of the formalin-fixed lung tissue was positive for Coccidioides(37).

2. Swine flu
There is a report of a 59-year-old man presented with a severe flu-like illness and widespread pulmonary infiltrates on chest x-ray. A rapid influenza direct test was positive and the patient was nursed in isolation. On subsequent review, a diagnosis of probable atypical pneumonia was made, which was confirmed with positive urinary serology for Legionella pneumophila and treatment with appropriate antibiotics was started(38). Another report of a case of Pneumocystis jiroveci pneumonia (PCP) in a renal transplant patient which was initially misdiagnosed as pandemic influenza H1N1(38a).

3. Tuberculosis
There is a report of a case of misdiagnosis of tuberculosis in a patient with pulmonary lymphogranulomatosis and destructive pneumonia in the presence of AIDS(39).

4. Adult-onset Still disease (AOSD)
Adult-onset Still disease (AOSD) is an uncommon inflammatory condition of unknown origin and pathogenesis. Pulmonary involvement is rare and includes pleuritis and transient radiological infiltrations. There is a report of two cases of AOSD characterized by lung involvement at presentation. Both were misdiagnosed as pneumonia with para-pneumo­nic effusion. We also discuss the difficulties in diag­nosis of AOSD with pulmonary infiltration(40).

4. Etc.

B.2. Diseased associated to pneumonia
1. Sickle Cell Disease
In a study of 335,348 black women with a delivery during 2004-2010, 1,526 had a diagnosis of SCD (0.5 %) and to Compare them with women without SCD who had chronic conditions, found that women with SCD had higher prevalence of deep vein thrombosis, pulmonary embolism, obstetric shock, pneumonia, sepsis, postpartum infection, and transfusions. SCD was also positively associated with acute renal failure, cerebrovascular disorder, respiratory distress syndrome, eclampsia, postpartum hemorrhage, preterm birth, and ventilation when compared with women without SCD and chronic conditions(41).

2. Rheumatoid arthritis 
Although reports of serious infections in clinical trials for rheumatoid arthritis (RA) with tocilizumab, anti-interleukin6 (IL-6) receptor antibody, have been relatively few, there is still some concern about infections. There is a report of 2 case of who developed severe pneumonia during tocilizumab treatment for RA(42).

3. Diabetes
Diabetes mellitus is often identified as an independent risk factor for developing lower respiratory tract infections(43). 

4. Other diseases
According to the study by the University of Washington School of Medicine, patients with a wide variety of disease states, including advanced age, diabetes mellitus, alcoholism, collagen vascular disease, cancer, heart failure, and organ transplantation are potentially at increased risk for pneumonia because of disease-related impairments in host defenses(44).

5. Etc.


A.3. Complications
1. Cardiac complications
In the study of a total of 1343 inpatients and 944 outpatients with community-acquired pneumonia followed up prospectively for 30 days after presentation, showed that incident cardiac complications are common in patients with community-acquired pneumonia and are associated with increased short-term mortality. Older age, nursing home residence, preexisting cardiovascular disease, and pneumonia severity are associated with their occurrence. Further studies are required to test risk stratification and prevention and treatment strategies for cardiac complications in this population(45).

2. Mortality
Community-acquired pneumonia is the most common infectious cause of death in the US. In the study of a  total of 2,654,955 cases of pneumonia from 1987-2005, found that during this period, the proportion treated as inpatients decreased, the proportion aged ≥80 years increased, and the frequency of many comorbidities rose. Adjusted incidence increased to 3096 episodes per 100,000 population in 1999, with some decrease thereafter. Age/sex-adjusted mortality decreased from 13.5% to 9.7%, a relative reduction of 28.1%. Compared with 1987, the risk of mortality decreased through 2005 (adjusted odds ratio, 0.46; 95% confidence interval, 0.44-0.47). This result was robust to a restriction on comorbid diagnoses assessing for the results' sensitivity to increased coding(46).

3. Pleurisy 
Pleurisy is defined as condition of the inflammation of the lining of the pleural cavity surrounding the lungs.There is a report of a 40-year-old female was admitted with right chest pain. SLE was absent from her past history, although she complained of polyarthralgia in winter. Atypical pneumonia/pleuritis was suspected by chest X-ray film, showing a nodular shadow in the right lower field and moderate pleural effusion. Chlamydia pneumonia was diagnosed by elevated anti-C. psittsci antibody, while characteristics of pleural fluid revealed serositis accompanied by SLE because of the high titered anti-DNA antibody and the low titered complement(47).

4. Lung diseases
Acute-onset diffuse interstitial lung disease (AoDILD) in patients with rheumatoid arthritis (RA) has been a serious concern, especially for those under treatment with biological agents which may affect the presentation and outcome of AoDILD, including Pneumocystis pneumonia (PCP)(48).

5. Bacteremia
In the study to determine whether serotype 1 (SP1) invasive pneumococcal disease (IPD) can be distinguished by demographic, clinical and laboratory characteristics from IPD caused by the other most common serotypes (MCS) in the region: 5, 14, 6A, 6B, 19A, 19F, 23F of the study, found that
SP1 was found less frequently than MCS in children with underlying diseases, but was more frequent in older and Bedouin children with IPD. SP1was more frequently associated with bacteremic pneumonia and primary peritonitis than MCS grouped(49).

6. Endocarditis
There is a report of a case of mitral endocarditis caused by Streptococcus pneumoniae in a 43 year old man with history of alcohol abuse and cigarette smoking. The pneumococcal endocarditis was associated with pneumonia, meningitis and brain abscess. Only transesophageal echocardiography could confirm the presence of vegetation(50).

7. Respiratory acidosis
Respiratory acidosis is defined as a condition of which the lungs nolonger cannot remove all of the carbon dioxide produced by the body.
Ventilator-associated pneumonia (VAP) is a common complication of ventilatory support for patients with acute respiratory failure and is associated with increased morbidity and mortality, according to the study by Jawaharlal Nehru Medical College(51).

8. Hypoxemic Respiratory Failure
There is a report a case of severe pneumonia complicated by acute hypoxemic respiratory failure due to primary infection with C. pneumoniae in a previously healthy 46-year-old woman(52).

9. Etc.

D. Diagnosis
Diagnosis is totally dependent to the causes of the diseases by determining whether the cause of CAP is a bacterium, atypical bacterium, or virus. If you are experience some of the above symptoms and if your doctor suspects that you have restrictive lung function, after recording your family history and completing the physical exam, the test which your doctor orders include 
1. Chest X-rays
X-rays can detemine the presence of pneumonia and  the location of the infection. In the study to investigate the relation between physicians' predicted probabilities of pneumonia and their utilities for ordering chest x-rays to detect pneumonia, the authors studied 52 physicians who ordered chest x-rays of 886 patients presenting to an emergency department with fever or respiratory complaints, found that physicians who experienced greater regret over missing a pneumonia than over ordering an unnecessary x-ray estimated lower probabilities of pneumonia for patients for whom they ordered x-rays.(53).

2. Blood test
The aim of the blood test is to measure your white cell count and look for the presence of viruses, bacteria or other organisms of which have caused the infection. According to the study by University of Florida, monitoring WBC concentration is a useful approach for early detection of infected foals on farms with a high prevalence of R equi pneumonia. In contrast, serologic surveillance by use of an AGID assay is of little benefit for that purpose(54).

3. Mucus tests
The aim of the test is to determine types of  microorganism which cause the diseases

4. Etc.

F. Preventions
E.1. The do and do not's list
1. Wash your hand thoroughly with soap and water 15-20 seconds can help to reduce the risk of catching common cold and influrenza. Use alcohol-based hand gels if washing is not possible.
2. Cover sneeze and coughing and prevent hand-to-hand passage.
3. Enhance your immune function to protect your body against invasion of foreign invasion, including bacteria and virus.
4. Traditional Mediterranean diet
Eating plenty of fruit, vegetables and fish keep lungs healthy. Those who follow a diet closest to this " Mediterranean " ideal are less likely as their peers with eating habits furthest from this pattern to develop chronic lung disease. A good amount of fresh vegetable juices are a good way to start healing, along with adding a variety of spices such as ginger, onions, and garlic. The emphasis should be on eating as healthy a diet as possible(55).
5. Eat your fruit and vegetables
Fruits and vegetables not only are very nutritional but also contains high amount of antioxidants which can combat against bacteria and virus invasion.
6. Proctect yourself by preventing to be infected by people with the disease
7. Vaccine
Pneumonia vaccine is now available. Also take the vaccines of other diseases such as Measles, flu, chikenpox, etc. can cause pneumonia.
8. Etc.

F.2. Diet to prevent pneumonia
1. Garlic
Garlic is the natural superfood healer for its natural antibiotic with antiviral, antifungal, anticoagulant and antiseptic properties. Garlic cooked is fine but it loses many of its health-giving powers.
There is a report of a case of a critically ill infant with severe multidrug-resistant Pseudomonas aeruginosa pneumonia and bacteremia who was treated with garlic and antibiotics after in vitro demonstration of a change in the resistance pattern via the disc diffusion method on garlic-treated Mueller Hinton agar. To our knowledge, this is the first report of therapeutic garlic use in a critically ill infant in the literature(56).

2. Green tea
In a population-based cohort study to examine the association between green tea consumption and death from pneumonia in humans, with follow-up from 1995 to 2006., showed that Over 12 y of follow-up, we documented 406 deaths from pneumonia. In women, the multivariate HRs of death from pneumonia that were associated with different frequencies of green tea consumption were 1.00 (reference) for <1 cup/d, 0.59 (95% CI: 0.36, 0.98) for 1-2 cups/d, 0.55 (95% CI: 0.33, 0.91) for 3-4 cups/d, and 0.53 (95% CI: 0.33, 0.83) for > or =5 cups/d, respectively (P for trend: 0.008). In men, no significant association was observed(52).

3. Turmeric
Curcumin derived from the rhizome of turmeric has been used for decades and it exhibits anti-inflammatory, anti-carcinogenic, immunomodulatory properties by downregulation of various inflammatory mediators,. according to the study by Panjab University, Curcumin alone and in combination with augmentin protects against pulmonary inflammation and acute lung injury generated during Klebsiella pneumoniae B5055-induced lung infection in BALB/c mice(58).

4. Citrus fruits, berries
Klebsiella pneumoniae is a ubiquitous opportunistic pathogen that colonizes at the mucosal surfaces in humans and causes severe diseases. Many clinical strains of K. pneumoniae are highly resistant to antibiotics. In the study of flavonols galangin, myricetin, quercetin, and kaempferol, bearing different numbers of hydroxyl substituent on the aromatic rings, to test whethermay inhibit dNTP binding of the primary replicative DnaB helicase of K. pneumoniae (KpDnaB), an essential component of the cellular replication machinery critical for bacterial survival, found that these flavonol compounds may be used in the development of new antibiotics that target K. pneumoniae and other bacteria(59).

5. Etc.

F.3. Phytochemicals to prevent pneumonia
1. Genistein
Genistein, a radioprotective soy isoflavone and protein kinase inhibitor, blocks the invasion of pathogenic bacteria in mammalian epithelial cells. In the study to evaluate the direct effect of genistein on the survival and growth of the probiotic Lactobacillus reuteri and selected opportunistic bacteria in vitro as a prelude to in vivo use for managing postirradiation sepsis, showed that in the CFU assays, significant reductions in CFUs were found for S. aureus and B. anthracis when cultured in the presence of 100 muM genistein. However, L. reuteri, E. coli, S. sonnei, and K. pneumoniae were not altered by in vitro culturing in the presence of 100 muM genistein, according to the Armed Forces Radiobiology Research Institute(60).

2. Puerarin
 Puerarin is a major isoflavonoid derived from the Chinese medical herb Radix puerariae (kudzu root), In the study to investigate the myocardial protective effect of puerarin injection (PI) in children with severe pneumonia, conducted by Hospital Affiliated to Weifang Medical College, indicated that
change of serum myocardial zymographic parameters was indirectly proportional to the severity of childrens condition. The reduction of myocardial contractive function was demonstrated by the change of cardiac blood flow parameters in Ultrasound Doppler examination (P < 0.01). Both PI and FDP had the effect in protecting myocardium and improving heart function, showing insignificant difference between their efficacy (P > 0.05), but PI had less stimulation to vessels and without any obvious adverse reaction(61).

3. Polyphenols
The fermented leaves and stems of Cyclopia intermedia are used to brew Honeybush tea, a herbal tea indigenous to South Africa. The plant is also used to manufacture a sweet herbal infusion used for restorative properties such as soothing coughs and alleviating bronchial complaints including tuberculosis, pneumonia, and catarrh. According to the study by University of the Free State, flavonoids are presumed to contribute significantly toward the scavenging effects of active oxygen species, our results indicate that the tentative claimed health-promoting properties may be attributed to the presence of these and other phenolics in C. intermedia(62).

4. Catechins
Strong evidence of experimental and animal studies have shown the activities of catechins, the main constituents of green tea, against infectious agents. In the study to investigate the association between green tea consumption and the risk of pneumonia in humans, foudn that Green tea consumption was associated with a lower risk of death from pneumonia in Japanese women(63).

5. Resveratrol
Resveratrol is a type of natural phenol in the group of Stilbenoids, produced naturally by many plants when under attack by bacteria or fungi. It has been studied by many researchers for it health benefits in treating chronic diaereses, including cancer, diabetes, heart disease, etc. According to the study by the Chang Gung University, pretreatment with RSV for 3 days markedly increased alveolar macrophage infiltration, elevated NK cell activity, and decreased bacterial burden in the infected lung with a subsequent decrease in mortality. These effects were associated with significantly less-severe inflammatory phenotypes in lung tissue and bronchoalveolar lavage fluid, including reduced neutrophil infiltration of the lungs, reduced phagocytosis activity, and reduced secretion of cytokines such as TNF-alpha, IL-1beta, and IL-6. To further characterize the underlying mechanism responsible for these effects of RSV, LPS derived from S. marcescens was used to induce acute pneumonia in rats, with or without RSV pretreatment. RSV was shown to ameliorate acute pneumonia via inhibition of the NF-kappaB signaling pathway, including inhibition of IkappaBalpha phosphorylation and subsequent NF-kappaB activation(64).

F.34. Antioxidants to prevent pneumonia
1. Hyperbaric oxygenation as antioxidant
In the study to use Hyperbaric oxygenation (HBO) in a complex intensive therapy of 194 children, aged 3 days to 3 years, with severe pneumonias, showed that initially the patients have revealed intensification of free radical processes (FRP) with a simultaneous decrease in the level of enzyme and non-enzyme protection and a drastic increase in gluco- and mineralocorticoid adrenal function. HBO and antioxidants (unithiol and alpha-tocopherol) yielded excellent and good results (a drop in FRP level and activation of enzyme antioxidant protection) in 75.8% of patients. HBO was ineffective in 17% of cases, in 7.2% of patients signs of the developing oxygen intoxication have been revealed(65).

2. Vitamin D
In the study to determine the role of oral vitamin D supplementation for resolution of severe pneumonia in under-five children in Two hundred children [mean (SD) age: 13.9 (11.7) months; boys: 120] between 2 months to 5 years with severe pneumonia, showed that Short-term supplementation with oral vitamin D (1000-2000 IU per day for 5 days) has no beneficial effect on resolution of severe pneumonia in under-five children. Further studies need to be conducted with higher dose of Vitamin D or longer duration of supplementation to corroborate these findings(66).

3. Zinc
Diarrhoeal disorders and acute respiratory infections (ARIs), especially pneumonia, are the most common causes of death in low-income countries.  According to teh study by the Departments of Community Medicine and Child Health, Christian Medical College, zinc supplementation had no overall effect on the duration of hospitalization or of clinical signs associated with severe infection in young children hospitalized for severe pneumonia in southern India. This finding differs from the results of 2 previously reported trials wherein zinc supplementation was associated with a shorter period of recovery from severe pneumonia. Given the conflicting results, further research in representative settings is required to help clarify the role of zinc in the treatment of severe pneumonia(67).

4. Vitamin-A, vitamin C, vitamin E, folic acid and zinc
In a  cross-sectional and controlled clinical trial conducted in under-5 children to compare the effects of supplementation of five micronutrients (vitamin-A, vitamin C, vitamin E, folic acid and zinc) on the morbidity and on the duration of hospital stay in pneumonia, by Rangpur Medical College, found that the average duration of hospital staying was 6.75 days in intervention group and 7.75 days in control group (p<0.01). Chest indrawing and fast breathing disappeared earlier in the intervention group (p<0.01) suggesting that supplementation of micronutrients decrease the morbidity and duration of hospital stay of children suffering from pneumonia(68).

5. Etc.

G. Treatments
Antibiotics are the mosst efective medication used to treat pneumonia. Other medication used conjucntion with antibiotics can be helpful in relieveing breathing and symptoms.
1. Antibiotics
Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. In a review to identify effective antibiotics for community acquired pneumonia (CAP) in children by comparing various antibiotics, conducted by All India Institute of Medical Sciences, Ansari Nagar, indicated that for treatment of ambulatory patients with CAP, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. For severe pneumonia without hypoxia, oral amoxycillin may be an alternative to injectable penicillin in hospitalised children; however, for ambulatory treatment of such patients with oral antibiotics, more studies in community settings are required. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are ceftrioxone, levofloxacin, co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as a second-line therapy69).
Side effects are not limit to soft stools or diarrhea, mild stomach upset, etc.

2. Antivirals
Parainfluenza viruses affect the upper respiratory tract in all age group patients, in children aged 6 months to 3 years in particular. In the study to investigate  the antiviral activity of Ingavirin (2-(imidazole-4-yl) ethanamide of pentandioic-1,5 acid) on a model of parainfluenza infection in Syrian hamsters, showed that the drug was shown to restrict the infectious process in animal lung tissue. This restriction manifested itself as reductions in the infectious titer of parainfluenza virus in the lung tissue, in the degree of pulmonary edema and tissue cell infiltration, and in virus-specific lesion of bronchial epithelial cells(70). Side effects are not limit to dizziness, fatigue, joint or muscle pain, headache, dry mouth, nausea, vomiting, loss of appetite, weight loss, insomnia, etc.
3. Other Supportive treatment  to reduce symptoms, include
Fever and pain reducers such as aspirin, ibuprofen, naproxen or acetaminophen, etc.  and cough medicine.

G.2. In Herbal medicine perspective
1. Crotalaria lachnophora
According to the study by University of Dschang, the 2 new isopropenyl-dihydrofuranoisoflavones, 7,2',4'-trihydroxy-5''-isopropenyl-4'',5''-dihydrofurano[2'',3'':5,6]isoflavone (1) isolated  exhibiting antimicrobial properties have been isolated along with eight known compounds from the Cameroonian medicinal plant Crotalaria lachnophora, showed moderate inhibitory activities against Escherichia coli and Klebsiella pneumoniae(71).

2. Uraria picta
Two isoflavanones, 5,7-dihydroxy-2'-methoxy-3',4'-methylenedioxyisoflavanone (2) and 4',5-dihydroxy-2',3'-dimethoxy-7-(5- hydroxyoxychromen-7yl)-isoflavanone (4) along with six known compounds including isoflavanones, triterpenes and steroids isolated from the roots of Uraria picta, showed the minimum inhibitory concentrations (MIC) found to be in the range of 12.5-200 microg/ml against bacteria (both Gram positive and Gram negative) and fungi(72).

3.  Vitex agnus-castus
A new compound, 6a,11a-dihydro-6H-[1] benzofuro [3,2-c][1,3]dioxolo[4,5-g]chromen-9-ol was isolated from the ethyl acetate fraction of Vitex agnus-castus. The structure of this compound was identified with the help of spectroscopic techniques ((13)C NMR, (1)H NMR, HMBC, HMQC, NOESY and COSY). The compound showed low urease- (32.0%) and chymotrypsin- (31.4%) inhibitory activity, and moderate (41.3%) anti-inflammatory activitym, according to the Center for Biotechnology and Microbiology University of Peshawar(73).

4. Fadogia ancylantha
Communities in Chilumba, Malawi use herbal tea prepared from Fadogia ancylantha Schweinf (Rubiaceae) leaves for the management of diabetes, hypertension and alleviation of symptoms of gastrointestinal disorders and pneumonia. In the study to evaluate the in vitro antidiabetic, anti-oxidant and antimicrobial activities of the crude extracts of the leaves prepared by using three different extraction methods, found that the organic extract (12.5μg/ml) exhibited the highest in vitro glucose uptake increases in Chang cells (181.24±0.29%) and C2C12 muscle cells (172.29±0.32%) while the hot and cold aqueous extracts gave lower uptakes, 145.94±0.37% and 138.70±0.52% in Chang cells respectively. At 100μg/ml, aqueous extracts gave significantly higher (p<0.01) anti-oxidant activity (range 85.78-86.29%) than their organic counterpart (68.16%). The minimum inhibitory concentration (156μg/ml) was obtained in the organic extract against the fungus Aspergillus fumigatus and moderate growth inhibition was observed with other test micro-organisms. The hot aqueous extract inhibited the growth of all test organisms except Pseudomonas aeruginosa. The cold aqueous extract was inactive against Pseudomonas aeruginosa and Candida albicans. The differences in the MIC values between the aqueous extracts seem to suggest that raised temperatures, as traditionally practised, facilitate the extraction of secondary bioactive metabolites(74).

G.3. In traditional Chinese medicine perspective
According to the study by Gansu College of Traditional Chinese Medicine in TCM differentiation of the symptoms and signs, 52 children with presisting pneumonia were divided into the following four types: 1) deficiency of body fluid due to accumulation of heat in the lung, 2) earth failing to generate metal, 3) deficiency of the Ying and Wei systems, and 4) excessiveness of pathogens due to qi deficiency. After treatment for 2-3 weeks, 40-cases were cured, 8 improved, and 4 ineffective(75).
Other in the study to observe the therapeutic effect of traditional Chinese medicine (TCM) and Western medicine (WM) treatments on mycoplasmal pneumonia in children and the changes in the serum cytokines, showed that the total response rate was 93.33% in the treatment group and 73.33% in the control group, showing a significantly better therapeutic effect in the treatment group (P<0.05). The combined treatments also showed better effects in alleviating fever, coughing and rales (P<0.05), and resulted in more obvious reduction in the serum levels of cytokines (P<0.05)(76)

In the study to probe into the mechanism on TCM treatment of infectious atypical pneumonia (severe acute respiratory syndrome, SARS) and evaluate its feasibility and effectiveness in 12 TCM prescriptions of herbal drugs (orally or i.v.) used to treat 16 cases of SARS without using glucocorticoids, anti-viral agents, immune-regulators or antibiotics (in case there was no definite bacterial infections) found that The average fever abatement time was 4.44 +/- 1.46 days and the mean absorption time of gross pulmonary infiltration was 10.87 +/- 2.92 days. No exacerbation occurred during the treatment(77).
1. Qingfei Huatan Quyu method
In the study to observe the therapeutic effect of Qingfei Huatan Quyu method (QHQ, a Chinese medicinal therapy for clearing Fei-heat and dissolving phlegm-stasis) combined with hormone-antibiotic therapy (HAT) on radiation pneumonia (RP), found that QHQ combined with HAT has a definite therapeutic effect on RP. It could efficiently decrease the plasma levels of IL-6 and TGF-beta in patients with RP(78).

2. Qingjin Runfei Decoction
In the study of Patients randomly assigned to two groups, the control group (51 cases) treated with hormone and antibiotic and the treated group (53 cases) with the above therapy plus QRD  conducted by Hangzhou Hospital of Armed Police in Zheijang, found that QRD could enhance the effects of hormone and antibiotic in treating RP, as well as improve QOL of the patients(79).

3. Etc.

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VI. Malignant tumors
VI.A. Lung cancers
Lung is a vital organ of the human being, located near the backbone on either side of the heart with functions of inhaling oxygen from the air then transporting them to the bloodstream to nourish the body cells need and exhaling carbondioxide from the bloodstream.

Lung cancer is defined as a condition of the abnormal growth of the cells in the lung's tissue. Most common form of primary lung cancers are derived from epithelial cells. In Us, Lung cancer is the leading cause of cancer deaths, causing 158,683 people deaths, including 88,329 men and 70,354 women, according to 2007 statistic.

Types of lung cancer
A. Non small cell lung cancer
Non-small cell lung cancer is the most common type of lung cancer. It usually grows and spreads methodically and predictably.Most common types of lung cancers include
1. Squamous-cell carcinoma often found in an outer area of the lung,
2. Large-cell carcinoma found in the center of the lung by an air tube
3. Adenocarcinoma found in any part of the lung.

B. Small cell lung cancer
Small cell lung cancer is a fast-growing type of lung cancer, it can spread to distant parts of the body in a relatively early stage. Most common types of small cell lung cancer include
1. Small cell carcinoma in which the cells are small, round and resemble oats.
2. Mixed small cell/large cell carcinoma in which malignant tumor found in combining of components of small cell lung carcinoma with large cell lung carcinoma.
3. Combined small cell carcinoma in which malignant tumor found in combining of a component of small cell lung carcinoma with components of non-small cell lung carcinoma.

Causes and risk factors
1. Smoking
Smoking is a major cause of lung cancer as it enhances the oxidation stress as the lung inhales oxygen from the air by combining them with cancer causing chemical substances (carcinogens) in the cigarette, leading to the damage of lung's tissue. Normally, our body can withstand and repair this damage, but prolonged exposure your lung to these danger carcinogen can result in cancer development.

2. Second hand smoke
Prolonged exposure to second hand smoke can also increase the risk of lung cancer as mentioned above.

3. Exposure to certain chemicals
There are increased risk of lung cancer for people who inhale or exposing certain industrial chemical such as radon gas, arsenic, chromium, nickel, etc. in the work place.

4. Family history
Risk of lung cancer increased if one of the members of your direct family has lung cancer.

5. Lung disease
Risk of ling can caner increase if you have or previous had certain types of lung disease

6. Excessive drinking
According to the study by Freudenheim et al., R. Curtis Ellison MD suggested that alcohol intake of more than 2 drinks per day is associated with a small increased risk of lung cancer. This study, like others, suggests a weak, positive association between consuming larger amounts of alcohol (>2 drinks a day) and lung cancer risk.

7. Etc.

Symptoms
1. Shortness of breath.
Shortness of breath is one of most common symptoms of lung cancer, as the lung is now no longer function properly due to abnormal growth of some of its cell within it or cancer cells are growth larger enough to block the major airway, or due to fluid accumulation.

2. Coughing up blood.
Cough up blood is another symptoms of lung cancer, it can be caused by breaking off capillary due to cancer invasion or some of malignant cells. Rupture of the tumor can be extreme danger to the patient.

3. Pain
Pain also associated with the lung cancer if the cancer spread to the lung lining and suppress the nerve in the lung.

4. Fluid in the chest
Fluid in the chest may be resulted of blood or pus due to breaking of lung cancer or lung is no longer function properly in expelling mucus and phlegm, leading to shortness of breath.

5. Wheezing and hoarseness
May be due to blocking of major airway

6. Unintentional weight loss
Any unintentional weight loss over 10%

7. Bone pain
If cancer has spread to bone tissue

8. Hormones
Due to small cell lung cancer imitation of some of the body hormones, leading obesity, high blood pressure, nausea, etc.

9. Etc.

Diagnosis and tests
Family history and physical examination are always important for patient with some of above symptoms. Depending to the types of lung cancers, diagnosis and tests may include
1. Chest X ray
Chest X ray is a form of electromagnetic radiation to take image and check for any abnormality of the lung
2. CT Scan (computerized tomography)
A CT scan generates a large series of two-dimensional X-ray images taken around a single axis of rotation, to create a three-dimensional picture of the inside of the body in details.The pictures are viewed by your doctor to see the extent of the tumors abnormalities, such as spreading of cancer to the nearby structure and lymph nodes. CT scan can only review the existence of cancer . but can not tell it is a primary or secondary cancer.

3. MRI (magnetic resonance imaging)
MRI (magnetic resonance imaging) is one of many advanced technology used to visualize internal structures cross sectional imaging of your body used effectively in providing the better details of the metastasis of cancer in the lung and surrounding areas.

4. Sputum Cytology
Sputum Cytology is a test used to examine a sample of mucus under a microscope to check for any abnormal cell.

5. Bronchoscopy
Bronchoscopy is a procedure used to look inside the airways of the lung by inserting a thin, flexible tube called a bronchoscope with a light and small camera that allow your doctor to see the airways and take pictures to check for any abnormality in the trachea and airways, such as infection, inflammation, or malignant tumor, through nose or mouth, down into the airways.

6. Lung Biopsy
In lung biopsy, a sample of liver is taken by a thin, tube-like instrument to examine under microscopy to review the stage of the cancer.

7. Bone scan
With a small amount of radioactive substance, called a tracer injected into a vein, as it travels through the bloodstream it allows a special camera takes pictures of the tracer in your bones. If there is any abnormality in the bone, it will show up in the pictures.

8. Mediastinoscopy
Mediastinoscopy is a surgical procedure to examine the inside of the upper chest between and in front of the lung by inserting of a mediastinoscope through the opening made in the neck just above the breastbone to collect sample to test under microscope for signs of infection, inflammation, or malignant tumor.

9. Positron emission tomography (PET scan)
Positron emission tomography (PET scan) is a type of nuclear medicine imaging with the uses of small amounts of short-lived radioactive material, either injected into a vein, swallowed or inhaled as a gas which will appear in the area of the body being examined, where it gives off energy in the form of gamma rays detected by a camera of positron emission tomography that produces a three-dimensional image or picture of functional processes of the organ in the body.

11. Etc.

Grades of lung cancer
The Grade of lung cancer is depending to the tendency of spreading. Low grade cancers usually grow more slowly and are less likely to spread while high grade cancer indicates otherwise.

Stages of lung cancer
1. Stage 0
Lung caner is classified as Stage 0, if the cancerous cell have not penetrated in deeper tissue but in the surface of the lung lining.
2. Stage I
In stage I, The cancerous cells are no longer in the surface but have invaded into deep lung lining, but still completely inside the lung.
a. Stage IA1
The cancer is ≤ 3 mm (1/8 inch) deep and ≤ 7 mm (1/4 inch) wide.
a.1. Stage IA1: The spreading is < 3mm(1/8 inch) deep and & less than 7mm (1/4 inch) wide.
a.2. Stage IA2: The invasion area is ≥ 3 mm but ≤ 5 mm (about 1/5 inch) deep and & less than 7 mm (about 1/4 inch) wide.
b. Stage IB: The cancer in this stage have invaded the connective tissue, & less than 5mm (1/5 inch).
b.1. Stage IB1: Cancer is 4 cm large (1 3/4 inches).
b.2. Stage IB2: Cancer is ≥ 4 cm (1 3/4 inches) but & less than 5cm (1/5 inch)

3. Stage II
In stage II, the cancerous cells have spread to distant tissues, but is still within the lung.

4. Stage III
n this stage, cancerous cells has spread to the tissues immediately surrounding the lung.

5. Stage IV
In stage IV is the most advance stage of lung cancer as cancerous cells have spread to the distant parts of the body
In this stage, cancerous cells has spread to the tissues immediately surrounding the lung.

Prevention
A. How to avoid
1. Quit smoking
According to statistic, approximate 87% of lung cancer deaths are caused by smoking.
2. Eating more fruits and vegetables
This foods contain high amount of antioxidants which enhance the immune system against the forming of free radicals and prevent the alternation of cell DNA cause of abnormal cell growth.
3. Second smokes
Second smoke contains same amount of carcinogens, exposure to it can increase the risk of lung caner
4. Environment chemicals
avoid exposure to certain industrial chemical such as radon gas, arsenic, chromium, nickel, etc.. In the work place, deal with them by taking maximum pre-cautions and prevention.
5. Alcohol
Researcher found that increased risk of lung cancer for peopne who have >2 drinks a day.

6. Etc,

B. With diet
Traditional Chinese medicine link all foods with white color to lung tonification, taking them are associated reduced risk of lung cancer.
1. Cruciferous Vegetables
Cruciferous vegetables such as cauliflower, broccoli, cabbage, etc. beside contain high amount of antioxidants but also in a study of AACR FCPR 2008: Cruciferous Vegetables Reduce Lung Cancer Risk in Smokers, reseachers found that there is a significant inverse association between consumption of cruciferous vegetables and lung cancer was only seen for squamous or small cell carcinoma, which are the 2 subtypes most strongly associated with heavy smoking.

2. Pomegranate juice
In a recent issue of Cancer Research, researchers led by Hasan Mukhtar, co-leader of the Cancer Chemoprevention Program of the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, demonstrate that drinking pomegranate fruit extract helps slow the growth of lung cancer in mice found that pomegranate fruit continues to show great promise," says Mukhtar, professor of dermatology at the School of Medicine and Public Health and a member of the Carbone Cancer Center. "We have earlier shown that pomegranate fruit contains very powerful skin and prostate cancer-fighting agents. These recent findings expand the possible health benefits of the fruit to the leading cause of cancer death in the country and worldwide: lung cancer."

3. Turmeric
In Molecular Nutritional and Food Research, March 2008, researchers reported that naturally occurring polyphenols in curcumin offer a safer alternative treatment. Curcumin can directly scavenge free radicals such as superoxide anion and nitric oxide, and modulate important signaling pathways. These polyphenols also down-regulate expression of pro-inflammatory mediators, and up-regulate desirable gene expression in the lungs. Researchers concluded that curcumin is a potential therapeutic agent against chronic lung diseases.

4. Apple
In the Article: "Triterpenoids isolated from Apple Peels Have Potent Antiproliferative Activity and May be Partially Responsible for Apple's Anticancer Activity", Rui Hai Liu and Xiangjiu He pointed out that apple consumption has been linked to a reduced risk of chronic health problems such as lung cancer, heart disease, and stroke.

5. Garlic
An analysis of several case-controlled studies in Europe suggests an inverse association between garlic consumption and risk of common cancers.

6. Etc.

C. With nutritional supplements

1. Antioxidants
Antioxidants such free radical scavengers vitamin A, C, E enhance the immune system against the forming of free radicals and prevent the alternation of cell DNA cause of abnormal cell growth.

2. Quercetin
Quercetin is a type of phytochemical, also known as a flavonoid. In cell culture or animal studies, researchers found that quercetin has activity against some types of cancer cells and suggested it may be potential benefits in treating cancer.

3. Naringin
In s study of Intake of Flavonoids and Lung Cancer, researcger found that flavonoids, such as quercetin and naringenin (the aglycone derived from naringin), inhibit certain cytochrome P450 enzymes (CYP1A1 and CYP3A4, respectively) involved in the bioactivation of chemical carcinogens.

4. Selenium
In a study of selenium effects in skin cancer, researchers discovered that it might help prevent lung cancer instead according to the book of 1001 Home Health Secrets for Seniors.

5. Lycopene and 1,25-dihydroxyvitamin D3
In a study of Lycopene and 1,25-dihydroxyvitamin D3 cooperate in the inhibition of cell cycle progression and induction of differentiation in HL-60 leukemic cells, researchers found that The combination of low concentrations of lycopene with 1,25-dihydroxyvitamin D3 exhibited a synergistic effect on cell proliferation and differentiation and an additive effect on cell cycle progression. Such synergistic antiproliferative and differentiating effects of lycopene and other compounds found in the diet and in plasma may suggest the inclusion of the carotenoid in the diet as a cancer-preventive measure.

6. Etc.

Treatments
A. In conventional medicine
A.1. Non small cell lung cancer
1. Surgery
a. The aim of the treatment is to cure the cancer with surgery, if possible. Otherwise, treatments are focused to treat and control the symptoms as long as possible. If the cancer is located in the outer parts of the lung and has not spread to the lymph nodes, then surgery will be effective in curing it.
b. Risks and side effects
b.1. Surgical and anesthesia risks
b.2. Shortness of breath
Due to remove parts of the lung
b. 3. Etc.

2. Radiotherapy
By using high-energy x-rays or other types of radiation, radiation therapy kills lung cancer cells and keep them from growing or regrowing. Depending to stage or grade there are two types of radiation therapy.
a. External radiation
By using a machine outside the body to send direct high-energy x-rays or other types of radiation toward the cancer.
b. Internal radiation
By placing a radioactive substance direct into or near the cancer by a medical instrument with the aim to kill nearby cancer cells.
c. Side effects
c.1.. Fatigue
c.2. Chest pain
c.3. Heart problem
c.4. Short of breath
c.5. Skin discoloration or pinkness, irritation.
c.6. Etc.

3. Chemotherapy
a. Chemotherapy is most use to treat with advance stage of lung cancer, as it has spread to a distant parts of the body by using drugs taken by mouth or injected into a vein or muscle of the patient to stop the growth of or to kill cancer cells.
b. Side effects
b.1. Nausea
b.2. Vomiting
b.3. Hair loss
b.4. Fatigue
b.5. Anemia
b.6. Mouth sores taste and smell changes
b.7. Infection
b.8. Etc.

4. Biological therapy
a. Biological therapy with the use of Iressa, Taceva, target binding agents have contributed significantly in treating non small cell lung cancer by binding to the cancerous site and preventing its activity.
b. Risks and side effects
b.1. Weight gain
b.2. Neutropenia
b.3. Headache,
b.4. Thrombocytopenia
b.5. Anemia
b.6. Nausea
b.7. Rash
b.8. Etc.

A.2. Small cell lung cancer
Small cell ling cancer is behave differently than non small cell lung cancer as it is invasive and has tendency to spread to distant parts of the body, however, it often responds well to the treatments of chemo and radio therapies
1. Chemotherapy
a. Chemotherapy is most use to treat small cell lung cancer, as it has spread to a distant parts of the body by using drugs taken by mouth or injected into a vein or muscle of the patient to stop the growth of or to kill cancer cells.
b. Side effects
b.1. Nausea
b.2. Vomiting
b.3. Hair loss
b.4. Fatigue
b.5. Anemia
b.6. Mouth sores taste and smell changes
b.7. Infection
b.8. Etc.

2. Radiotherapy
By using high-energy x-rays or other types of radiation, radiation therapy kills lung cancer cells and keep them from growing or regrowing. Depending to stage or grade there are two types of radiation therapy.
a. External radiation
By using a machine outside the body to send direct high-energy x-rays or other types of radiation toward the cancer.
b. Internal radiation
By placing a radioactive substance direct into or near the cancer by a medical instrument with the aim to kill nearby cancer cells.
c. Side effects
c.1.. Fatigue
c.2. Chest pain
c.3. Heart problem
c.4. Short of breath
c.5. Skin discoloration or pinkness, irritation.
c.6. Etc.

3. Surgery
It is not very helpful to remove the primary lung tumor because of its spreading tendency, but it can be used to reduce certain symptoms such as enlarged lymph nodes, spleen, etc.

4. Etc.

B. Herbal medicine perspective
1. Grape Seed
In a studies of grape seed extracts in test tubes, researchers suggested that it may prevent the growth of breast, stomach, colon, prostate, and lung cancer cells.

2. Green tea
In some clinical studies researchers suggested that the polyphenols in green tea, may play an important role in the prevention of cancer by killing cancerous cells and stopping their progression.

3. Aloe
in some studies, researchers suggest that some chemical compounds of aloe, such as acemannan, aloeride, and di(2-ethylhexyl)phthalate (DEHP) may have immunomodulating and anticancer effects.

4. Cat's claw
In vitro studies, researchers found that cat's claw demonstrated anticancer effects against several cancer cell lines.

5. Etc.

C. Traditional Chinese medicine perspective
1. Huang Qi
In study of Astragalus-Based Chinese Herbs and Platinum-Based Chemotherapy for Advanced Non–Small-Cell Lung Cancer: Meta-Analysis of Randomized Trials, researchers found that astragalus may increase effectiveness of platinum-based chemotherapy when combined with chemotherapy. These results require confirmation with rigorously controlled trials.

2. Yun Zhi
In a study by by Dr. Kenneth Tsang at the University of Hong Kong's School of Medicine in 1999, on the polysaccharopeptide (PSP) treatment of patients with advanced non-small cell lung cancer, researchers found that after the four-week treatment, there was a significant increase in blood leckocyte and neutrophil levels and body fat compared with pre and post treatment of PSP. Serum IgG and IgM were significantly improved in the PSP treated group compared to the placebo group after four weeks In addition, there were less PSP treated patients who withdrew from the study due to disease progression. Therefore, this study suggests that PSP treatment may be of some benefit in patients with NSCLC.

3. Ling Zhi
In an study of Ling Zhi extracts tested them on three different types of cells: drug-sensitive small-cell lung cancer, drug-resistant small-cell lung cancer, and normal lung cells, researchers found that Ling Zhi killed lung cancer cells. Cancer cells responded to the herb much in the same way as they would react to chemotherapy drugs. Yet unlike chemotherapy drugs, which can also be toxic to healthy cells, herbal extracts were more deadly to cancer cells than to normal cells, indicating that they have some ability to specifically target cancer.

4. Yi Yi Ren
About 20 years ago, a young physician named Dr. Da-Peng Li observed that people in China who ate coix seed as a dietary staple had a surprisingly low incidence of cancer. Research in test tubes, animals and humans by Zhejiang Kanglaite Pharmaceutical Company indicated that The drug from the seed's oil, Kanglaite has been shown to induce apoptosis, or programmed cell death, in various kinds of human tumors, and has a powerful effect on angiogenesis (the formation of new blood vessels to feed the tumor).

5. Etc.

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VI.B. Lymphoma is defined as a condition of cancer in the lymphatic cells (lymphocytes) of the immune system originated in lymph nodes. It represents a group of over 20 types of cancers. Since it is a cancer in the lymph nodes, it tends to begin with several places simultaneously and spread slowly or quickly to distant parts of body, depending to the grade of the cancer.
Lymphocytes are white blood cells in the lymph nodes and bone marrow.

Symptoms
1. Weight loss
Unintentional weight loss over 10% in a short period of time
2. Lumps
As the cancer had or have progressed to the lymph nodes depending to primary cancer.
3. Fever
Infection due to decrease function of the immune system
4. Excessive sweating
Required to change night-ware, it also one of the sign of cancer.
5. Itching
Due to hormone secreting by the malignant tumor.
6. Shortness of breath
If the cancer has spread to the lung
7. Anemia
As the cancer has influenced to the production of red blood cells
9. Loss of appetite
A common symptom of cancer
10. Pain
As a result of the malignant tumor has pressed on the nerves
10. Etc.

Causes and risk factors
Although the exact causes of lymphoma are unknown, but researchers suggested
1. Exposure to certain chemicals
Prolonged exposure to certain chemicals such as solvents, pesticides, herbicides increases risk of lymphoma
2. Certain diseases
Increased risk of lymphoma for people with stomach ulcers or gastritis caused by a kind of bacteria called H. pyelori.
3. HIV/AIDs
People with supression of immune system with HIV/AIDs are at risk to devleop lymphoma.
4. Chemotherapy
People who had previous chemotherapy with certain drugs used, are at risk to develop the disease.
5. Age
The risk of develop of lymphoma increases with age. T he average age of lymphomatic patients are 65 in all cases.
6. Family history
Risk of lymphoma increases if one your immediate relative has it.
7. Viral exposures
Exposure to certain virus are such as Epstein Barr, Hepatitis C, and SV-40 associated with increased risk of lymphoma.
8. Etc.


Grading
The Grade of lymphoma are depending to the tendency of spreading. Low grade cancers usually grow more slowly and are less likely to spread while high grade cancer indicates otherwise.

Staging
Stage I:
The disease is present in only one group of lymph nodes, or, more rarely, in a single organ that does not belong to the lymph system.

Stage II:
Cancer is found in two or more groups of lymph nodes on the same side as the diaphragm. (The diaphragm is a thin muscle below the lungs that helps in breathing and separates your chest from the abdomen). In addition, an organ not in the lymph system may be involved close to the involved nodes.

Stage III:
The disease is present in lymph node groups on both sides of the diaphragm, occasionally with the involvement of other adjacent organs. If the spleen is involved then the disease becomes stage III as well.

Stage IV:
Once the liver, the bone marrow or the lung substance becomes involved, the disease is in stage IV. The same is true if other organs are involved far away from involved nodes.

The letter B in the stage if the patient also affected by the B symptoms (Fever greater than 38°C, drenching night sweats and Unintentional weight loss of >10%). The letter A indicates otherwise
Letter E means the cancer has spread to another organ outside of the lymph . Letter S means spleen has been infected.

Diagnosis and tests
After recording the family history and physical exam, you doctor may order the below tests, if you are found to have some of the above symptoms such as enlaged lymph nodes, excessive night sweat, etc.
1. Blood test
Blood sample is taken from your vein to check the levels of red and white cells and platelets in your blood, and how well your body's organ is working.
2. Chest X ray
Chest X ray is a form of electromagnetic radiation to take image and check for any abnormality of the lung caused by the spreading of the lymphoma.
3. CT Scan (computerized tomography)
A CT scan generates a large series of two-dimensional X-ray images taken around a single axis of rotation, to create a three-dimensional picture of the inside of the body in details.The pictures are viewed by your doctor to see the extent of the tumors abnormalities, such as spreading of cancer to the nearby structure and lymph nodes. CT scan can only review the existence of cancer ,but it can not tell it is a primary or secondary cancer.
4. MRI (magnetic resonance imaging)
MRI (magnetic resonance imaging) is one of many advanced technology used to visualize internal structures cross sectional imaging of your body used effectively in providing the better details of the metastasis of cancer in the lymph nodes and surrounding areas.
5. Lumbar puncture
It is procedure to withdraw a sample of spinal fluid by a thin and tube-like needle. Sample then is examined under microscopy for any abnormal lymphoma cells.
6. Lymph nodes biopsy
In lymphoma biopsy, a sample of liver is taken by a thin, tube-like instrument to examine under microscopy to review the stage of the cancer.
7. Positron emission tomography (PET scan)
Positron emission tomography (PET scan) is a type of nuclear medicine imaging with the uses of small amounts of short-lived radioactive material, either injected into a vein, swallowed or inhaled as a gas which will appear in the area of the body being examined, where it gives off energy in the form of gamma rays detected by a camera of positron emission tomography that produces a three-dimensional image or picture of functional processes of the organs in the body.
8. Immunochistochemistry
Immunochistochemistry is type of the test which provides the pathologist information to determine the type of lymphoma by using antibodies that bind to those antigens.
9. Flow Cytometry
Flow Cytometry isw another type of test which allows the pathologist to examine certain cells by separate them with others with the use of laser light and a fluorescent dye
10. Etc.

Prevention
A. How to avoid
1. Practice safe sex
HIV/AIDs can cause weakened immune system that allow the cells in the lymph nodes to grow with being checked, that can lead to lymphoma.

2. Infection
Prolonged infection cause of cancers are still under further studies, but infection caused by weakened immune system may be a cause of lymphoma.

3. Exposure to radiation
Exposure to radiation increases the risk of lymphoma. Risk of lymphoma increases many times for people lived near the nuclear accident.

4. Avoid Exposing to certain chemicals
Prolonged exposure to certain chemicals such as solvents, pesticides, herbicides increases risk of lymphoma.

5. Etc.

B. Diet
1. Grapes
Resveratrol found in the grape triggers the anti-cancer process in cell and tissue in animal study.
2. Garlic
An analysis of several case-controlled studies in Europe suggests an inverse association between garlic consumption and risk of common cancers.
3. Soy
In laboratory studies, saponins have shown the ability to inhibit the reproduction of cancer cells and slow the growth of tumors in several different tissues.
4. Tomato
Many studies showed that antioxidant lycopene in tomato inhibits cancer cell growth and exhibit apoptosis, causing cell death.
5. Cruciferous vegetables
In a study conducted by University of Leicester researchers and recently presented at the National Cancer Research Conference in Britain found that cruciferous vegetables contains a naturally compound indole-3-carbinol (I3C) which could be a powerful cancer fighter when used in combination with chemotherapy drugs.
6. Etc.

C. Nutritional supplements
1. Antioxidants
Antioxidants such free radical scavengers vitamin A, C, E enhance the immune system against the forming of free radicals and prevent the alternation of cell DNA cause of abnormal cell growth.
2. Vitamin D
In a study presented at the annual meeting of the American Society of Hematology in New Orleans, researcher found that the amount of vitamin D in patients being treated for diffuse large B-cell lymphoma was strongly associated with cancer progression and overall survival.
3. Flavonoids
In a study of flavonoids intake in human, The researchers found that flavonoids’ anticancer property has been proposed to exist via prevention of the formation of cancer-causing metabolites, inhibition of tumor cell proliferation, and stimulation of programmed tumor cell self-destruction (apoptosis).
4. Quercetin
Quercetin is a type of phytochemical, also known as a flavonoid. In cell culture or animal studies, researchers found that quercetin has activity against some types of cancer cells and suggested it may be potential benefits in treating cancer.
5. Lycopene and 1,25-dihydroxyvitamin D3
In a study of Lycopene and 1,25-dihydroxyvitamin D3 cooperate in the inhibition of cell cycle progression and induction of differentiation in HL-60 leukemic cells, researchers found that The combination of low concentrations of lycopene with 1,25-dihydroxyvitamin D3 exhibited a synergistic effect on cell proliferation and differentiation and an additive effect on cell cycle progression. Such synergistic antiproliferative and differentiating effects of lycopene and other compounds found in the diet and in plasma may suggest the inclusion of the carotenoid in the diet as a cancer-preventive measure.

6. Etc.

Treatments
A. In conventional medicine
Treatment of lymphoma are depended on the grades and types
A.1. Indolent lymphomas
Indolent lymphoma is a type of slow grow cancer, with no symptoms in early stage, but by the time it is diagnosed, the diseases in general have spread to distant parts of the body. It is considered a curable lymphoma.
Because of its incurable nature, the aims of the treatment is to control the symptoms with chemotherapy and radiotherapy. Once the symptoms are controlled, the treatments stop.
1. Wait and see approach
If there is no symptom, no treatment. Many studies found that it is a best treatment, there is no evidence that the use chemo and radio therapy can produce any benefits in the early stage of Indolent lymphoma.

2. Chemotherapy
a. Chemotherapy is most use to treat with advance stage of indolent lymphomas, as it has spread to a distant parts of the body by using drugs, such as chlorambucil, with or without steroid agent, prednisone, melphalan, etc. taken by mouth or injected into a vein or muscle of the patient to stop the growth of or to kill cancer cells.
b. Side effects
b.1. Nausea
b.2. Vomiting
b.3. Hair loss
b.4. Fatigue
b.5. Anemia
b.6. Mouth sores taste and smell changes
b.7. Infection
b.8. Etc.

c. Biological therapy
By enhancing the body's own immune or hormonal system to kill cancer cells, while leaving healthy cells relatively intact with the use of antibodies to attack cancer cells or block their activities or interrupting the hormonal or chemical pathways of the cancers with certain drugs composed of small molecules .
b. Side effects
b.1. Allergic reactions,
b. 2. Difficulty breathing, swelling,
b. 3. Nausea,
b.4. Fever or chills, and
b. 5. Dizziness and fatigue
b.6. Etc

d. Radiotherapy
By using high-energy x-rays or other types of radiation, radiation therapy kills lung cancer cells and keep them from growing or regrowing. Depending to stage or grade there are two types of radiation therapy.
a. External radiation
By using a machine outside the body to send direct high-energy x-rays or other types of radiation toward the cancer.
b. Internal radiation
By placing a radioactive substance direct into or near the cancer by a medical instrument with the aim to kill nearby cancer cells.
c. Side effects
c.1.. Fatigue
c.2. Chest pain
c.3. Heart problem
c.4. Short of breath
c.5. Skin discoloration or pinkness, irritation.
c.6. Etc.

e. Radioimmunotherapy
a. In radioimmunotherapy, a tumor-killing dose of a radioactive substance made by identical immune cells that are all clones of a unique parent cell to target and bind selectively to malignant tumor when injected into the body with an aim to kill the cancer cells and prevent damage to the normal cells
b. Side effects
b.1.Fever
b.2. Low blood pressure,
b.3. Diarrhea, and
b.4. Decreased red cell counts
b.5. Etc.

f. Etc.

A.2. High Grade lymphomas
Cancer of high grade lymphomas spread rapidly and steady then indolent lymphomas, if left untreated, it can fatal in a few months but in many cases, it can be cured with intensive therapy.
1. Chemotherapy
a. Chemotherapy is most use to treat with advance stage of indolent lymphomas, as it has spread to a distant parts of the body by using drugs and combination of drugs of cyclophosphamide, doxorubicin (doxorubicin hydrochloride), vincristine (Oncovin) and prednisolone (a steroid), taken by mouth or injected into a vein or muscle of the patient to stop the growth of or to kill cancer cells. The duration of the intensive treatments is depending to the grade of cancer, the higher the grades, the time of treatment are longer
b. Side effects
b.1. Nausea
b.2. Vomiting
b.3. Hair loss
b.4. Fatigue
b.5. Anemia
b.6. Mouth sores taste and smell changes
b.7. Infection
b.8. Low white cell and platelet counts
b.9. Mouth ulcer
b.10. Etc.

2. Biological therapy
a, By enhancing the body's own immune or hormonal system to kill cancer cells, while leaving healthy cells relatively intact with the use of antibodies to attack cancer cells or block their activities or interrupting the hormonal or chemical pathways of the cancers with certain drugs composed of small molecules. Two groups of biological agents (purine analogues and rituximab) found to be very active in use of treating high grade lymphoma.
b. Side effects
b.1. Allergic reactions,
b. 2. Difficulty breathing, swelling,
b. 3. Nausea,
b.4. Fever or chills, and
b. 5. Dizziness and fatigue
b.6. Etc

3. Radiotherapy
Radiotherapy is used mostly in combination with chemotherapy to treat localized types of high grade lymphoma
a. By using high-energy x-rays or other types of radiation, radiation therapy kills lung cancer cells and keep them from growing or regrowing. Depending to stage or grade there are two types of radiation therapy.
a. External radiation
By using a machine outside the body to send direct high-energy x-rays or other types of radiation toward the cancer.
b. Internal radiation
By placing a radioactive substance direct into or near the cancer by a medical instrument with the aim to kill nearby cancer cells.
c. Side effects
c.1.. Fatigue
c.2. Chest pain
c.3. Heart problem
c.4. Short of breath
c.5. Skin discoloration or pinkness, irritation.
c.6. Etc.

4. Radioimmunotherapy
a. In radioimmunotherapy, antibodies armed with radioactive antibodies are also used to target and bind selectively to malignant tumor when injected into the body with an aim to kill the cancer cells and prevent damage to the normal cells
b. Side effects
b.1. Fever
b.2. Low blood pressure,
b.3. Diarrhea, and
b.4. Decreased red cell counts
b.5. Etc.

5. CNS prophylaxis
a. Since some types of high grade lymphoma have a tendency to spread to the central nervous system, therefore, chemo and radio therapies treatment may be recommended to include the CNS even with no indication of their presence, with the injections of drugs into the fluid of brain and spinal cord (Chemo) with or without the use of radiotherapy.
b. Side effects
Side effects of radiotherapy and chemotherapy applied

B. Herbal medicine
1. Asparagus Cochinchinensis
In vitro studies researchers found that curcumin acts as a weak phytoestrogen, exhibits neuroprotective, antiproliferative and preventative effects against cancer

2. Devil's Claw
The extract of Harpagophytum procumbens, commonly known as devil's claw,
In vitro studies, researchers found that cat's claw demonstrated anticancer effects against several cancer cell lines and has been reported to be effective in the treatment of lymphoma cancer, according to a study conducted by K. S. Wilson, M.D., which was published in the journal "Current Oncology" in August 2009.

3. Turmeric
In a study conducted by S. Uddin and colleagues at the Department of Human Cancer Genomic Research at King Faisal Specialist Hospital and Research Center in Saudi Arabia. researchers found that Curcumin in turmeric may inhibit the proliferation of lymphoma cancer by modulating cell cycling and inducing apoptosis.

4. Garlic
An analysis of several case-controlled studies in Europe suggests an inverse association between garlic consumption and risk of common cancers.

5. Green tea
In some clinical studies researchers suggested that the polyphenols in green tea, may play an important role in the prevention of cancer by killing cancerous cells and stoppimg their progression.

6. Etc.


C. Traditional Chinese medicine
1. Huang Qi
In study of Astragalus-Based Chinese Herbs and Platinum-Based Chemotherapy for Advanced Non–Small-Cell Lung Cancer: Meta-Analysis of Randomized Trials, researchers found that astragalus may increase effectiveness of platinum-based chemotherapy when combined with chemotherapy. These results require confirmation with rigorously controlled trials.
According to the American Cancer Society, the substances, licochalcone-A, licocoumarone and glabridin, which are present in licorice root, may prevent mutations in the DNA and kill existing cancer

2. Yi Yi Ren
About 20 years ago, a young physician named Dr. Da-Peng Li observed that people in China who ate coix seed as a dietary staple had a surprisingly low incidence of cancer. Research in test tubes, animals and humans by Zhejiang Kanglaite Pharmaceutical Company indicated that The drug from the seed's oil, Kanglaite has been shown to induce apoptosis, or programmed cell death, in various kinds of human tumors, and has a powerful effect on angiogenesis (the formation of new blood vessels to feed the tumor).

3. Long Kui
Long Kui is also known as wonderberry. The bitter, cold, slightly sweet and toxic herb has been used in TCM as diuretic and antipyretic and to treat acute kidney inflammation, chronic bronchitis, throat cancer, larynx Cancer, uterus cancer as it clears heat, eliminates toxin, improve urination by enhancing the function of liver, kidney and stomach channels. A study was done at the College of Environmental and Chemical Engineering at the Yanshan University in Hebei, China, researcher found that the tumor growth inhibition of long kui polysaccarides might correlate with the reduction of TNF-alpha level of blood serum, which resulted in a massive necrosis (accidental death of cells) in tumor tissues and the up-regulation of Bax and down-regulation of Bcl-2 and mutant p53 gene expression, which triggered apoptosis in tumor cells.

4. Bai Hua She She Cao
Bai Hua She She Cao is also known as spreading hedyotis, The bitter, sweet and cold herb has been used in TCM as anti-bacteria, anti-inflammation, anti-tumor, anti-virus agent and to treat snakebite and enhances immune system as it clears heat, drains dampness, expels toxins and resolves abscesses by enhancing the functions of liver, stomach, large intestine channels.
The Sanjiv Kumar YADAV, Shao Chin LEE(Yong Loo Lin School of Medicine, National University of Singapore researcher results showed that the ethanol extract from Bai Hua She She Cao effectively evokes cancer cell apoptosis, possibly through burst-mediated caspase activation.

6. Etc.

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VI.C. Kaposi's sarcoma
Kaposi's sarcoma is a cancerous tumor of the connective tissue caused by human herpesvirus 8 (HHV8), and is often associated with AIDS, leading to red or purple bumps of abnormal tissue to grow under the skin, in the lining of the mouth, face, torso or limb in a short rime. In fact, it is most commonly appear in the skin, the lining of the digestive tract or the lung and in men more often than in women. Kaposi' sarcoma tends to develop slowly, but in HIV/AIDS patients, though, the disease is aggressive and spread quickly. Kaposi' carcoma can be life threatening, if the cancer invades the to other organs, such as in lung, it can cause difficulty of breathing and in
in liver or digestive tract, it can cause internal bleeding.

Types of Kaposi' sarcoma1. Classic/Mediterranean Kaposi' sarcoma
Classic Kaposi' sarcome is rare cancer developed more common in older men of Mediterranean, Middle Eastern or Jewish descent as it forms one or more lesions on the legs, ankles, or the soles of the feet. The classic Koposi' sarcoma is a slower growth type of cancer because of the progression without weaken immune system and many early diagnosis do not require treatment.

2. Endemic (African) Kaposi sarcoma
Endemic KS is found in parts of Africa due to human herpes virus 8 or herpesvirus infection is more common. It develops more quickly affect men, women and children of all ages, but tends to occur in younger men under age 40.

3. Iatrogenic/transplant-associated Kaposi sarcoma
In this case, Iatrogenic/transplant-associated Kaposi sarcoma occurs to patient with infection of Kaposi's sarcoma-associated herpesvirus (KSHV) due to medication used to suppress the immune system of the body from rejecting the donated organ in transplant, leading to the increased risk of development of the disease.

4. Kaposi sarcoma in HIV negative men having sex with men
Recently report from the above study from Department of Dermatology, Cochin Hospital, APHP, Faculté de Médecine René Descartes, Paris, France, indicated that Kaposi's sarcoma may develop in homosexual or bisexual men without HIV infection. This type of Kaposi's sarcoma has clinical features in common with classical Kaposi's sarcoma but occurs in younger patients.

5. Epidemic/AIDS-related Kaposi sarcoma
Epidemic/AIDS-related Kaposi sarcoma is a common type of Kaposi's in The US occurred in the people with HIV infection cause of weakening or damaging of the immune system. The risk of developing KS is depended to the CD4 count. If the CD4 count is lower, the higher the risk of developing Kaposi's sarcoma.


Symptoms
1. Unexplained weight loss
Any Unintentional weight loss of over 10%
2. Swollen lymph nodes
Due to damage of lymph nodes cause of fluid building up
3. Fever
Sometime it will accompany with fever due to infection
4. Purple, red, or brown blotches or tumors on the skin
Due to blood vessels concentration.
5. Cough and shortness of breath
As the result of the disease have spread to the lung
6. Bleeding from gastrointestinal lesions
As a result of the disease has spread to the gastrointestinal tract
7. Anemia
As a result of internal bleeding
8. Vomiting
Due to the disease has invaded the digestive system.
9. Etc.

Causes and risk factors
1. Sexual Preferences
Homosexual and bisexual males are increased risk of the disease
2. Age
Male between age of 20 - 60 with sexual preferences mentioned above is at high risk of Kaposi's sarcoma, and elder man with weakened immune system is at increased risk of Kaposi' sarcoma.
3. HIV and AID
People infected with HIV and AID have a weakened the immune system and increased risk of developing Kaposi's sarcoma
4. Gender
Kaposi' sarcoma occurs more often in men than in women.
5. Ethic background
while classic Kaposi' sarcoma is more likely to develop in older men of Mediterranean, Middle Eastern or Jewish descent, epidemic/AIDS-related Kaposi sarcoma is a common in The US.
6. Etc.

Diagnosis and Test1. Biopsy
Biopsy is the medical procedure of withdawing removing a skin lesion effected area and vitualize under microsocpe by a pathologist to review nature of the tumors and determine types of cancerous cells by a thin needle by either punch or excisional biopsy.

2. Chest x-ray
A chest X-ray radiograph (X-ray) is impotant for your doctor to visualize tissues, organs and bones that lie beneath the skin of the chest cavity to see if cancer has spread to the lung.

3. Bronchoscopy
In case of patient having a symptoms of shortness of breath or other related to lung symptoms, Bronchosoly may be used to look into the lungs to check for anf lesion of Kaposi' sarcome by using general anesthesia and a tiny, fexible instrument with light inserted through the throat down into the lung.
4. Gastrointestinal endoscopy
In case there is gastrointestinal or related symptoms, gastrointestinal endoscopy is used to determine the nature of the tumors depending to the locations
a. Upper endoscopy
It is a procedure with the use of an endoscopy inserted into mouth to examine the esophagus and the stomach with the help of anesthesia and withdrawn sample by small instrument.
b. Capsule endoscopy
If symptoms are intestine related, capsule endoscopy is helpful by introduce a capsule with light and a camera to the intestine as the patient swalow it. As it travels through the small intestine (it may taken sometime), it takes thousands of pictures which will be viewed by the doctor from a computer.

5. Etc.


Stages of Kaposi's sarcoma
There is no stage in classifying Kasopi's sarcoma but grouped into 5 types of the disease.

Preventions
A. How to void
1. Sexual preference
Men with sexual preference such as homosexual and bisexual preference should practice sex safety to protect against infected HIV or AID virus.
2. Alcohol
Excessive drink can damage liver and suppress immune system function in fighting again infection caused by virus.
3. Get enough nutrients
Nutrients deficiency weakens the Immune system.
4. Toxins
Accumulated toxins over s prolonged period of time can increase the risk of suppression of immune system.
5. Obesity
Obesity can affect the function of white blood cells to produce anti-body and cause a depressed immune system.
6. Over dose of sugar
Study in 1973 showed that found that drinking Eating or drinking 100 grams (8 tbsp) of sugar suppresses the immune system.

7. Etc.

B. Diet
Improve immune system is one the best way to prevent against infected by human herpesvirus 8 (HHV-8) and Kaposi's sarcoma
1. Citrus fruits
Citrus contains high amount of vitamin C, the essential vitamin in boosting immune system but also one of the free radical scavenger and vitamin A persursor.

2. Garlic
Garlic is best known to contain to contain high amount of sulfur and antxidants that not only enhance the immune system but also immune system booster by activating the anti-microbial property infighting against bacteria, viruses, fungi and parasites.

3. Cranberries .
Phytochemicals in canberry under active research for possible benefits immune system, and as anti-cancer agents. Flavonoids found abundat in cranberry, inhibit cander cell in vitro study.

4. Omega 3 fatty acid
Several studies showed that Omega 3 inhibits cancer cells of in certain cancer cells, including breast, prostate, colon cancer cells, etc. Others studies also indicated that benefit cancer patients, improving appetite, weight, and quality of life.


5. Honey
In some studies, Antioxidants in honey have even been associated with reducing the damage done to the colon in colon inflamation diseases. Other study found that particular type of honey may be useful in treating Methicillin-resistant Staphylococcus aureus infections. Honey also contain antimicobrial agent because of low water activity causing osmosis, hydrogen peroxide effect and high acidity.

6. Etc.
C. Nutritional Supplement
1. Vitamin C
Vitamin C increases raised the concentration in the blood of IgA (Ig is an abbrevlatlonfor immunoglobulin), IgM, and the C3 complementcomponent-three key members of the immune system in fighting against foreiger invasion such as bacteria and virus. It is also a powerful antioxidant in scavenging free radicals thus stopping the oxidated damage to the cells DNA.

2. Vitamin E
Another free redical scangering antioxidant and immune booster by producing the protein, interleukin-2, that fights and kills bacteria and viruses in your body.

3. Vitamin E
Vitamin E beside is a powerful antioxidant, it also enhances the rpoduction of B cells guarding our body against foreigner invasion.

4. Beta Carotene
Beta carotene is only another antioxidant, but enhance the production of B-cells in fighting against cancerous cells. An article in the American Journal of Clinical Nutrition (August 1997) showed that increased consumption of beta carotene reduces risk of cancer, inhibits early stages of carcinogenesis, and reduces the risk of cancer in experimental animal models.

5. Bioflavenoids or Flavonoids
Flavonoids found abundat in cranberry, inhibit cander cell in vitro study.

6. Zinc
Zinc, as a antioxidant is essential mineral in ading immune system by enhancing the proper function of T cells which belong to a group of white blood cells known as lymphocytes, in fighting against damaging free radicals. Zinc supplements have been shown to slow the growth of cancer.

7. Selenium
Selenium is one of the powerful antioxidant. In the extracellular space, it helps to influence immune processes by proliferating the response to mitogen, and macrophages, leukotriene.

8. Etc.

Treatments
A. In conventional medicine
The aims of the treatments are to control the disease condition and reduce symtoms due to the nature of arising from or occurring to many locations of Kaposi's sarcoma, depending to the severity of immune deficiency.
1. Radiotherapy
a. Radiation may be used to kill any cancer cells and keep them from growing or regrowing in the body. By using high-energy x-rays or other types of radiation. In Kaposi' sarcoma, lesions of are respond well to radiotherapy treatment even with small dose.
b. Side effects
b.1. Fatigue
b. 2.Chest pain
b.3. Heart problem
b.4. Short of breath
b.5. Skin discoloration or pinkness, irritation
b.6. Etc.

2. Chemotherapy
a. Chemotherapy is most used to treat with advance stage of cancer combined with radio therapy, as it has spread to a distant parts of the body by using drugs taken by mouth or injected into a vein or muscle of the patient to stop the growth of or to kill cancer cells. In Koposi's sarcoma, many drugs have been used such as vinblastine, vincristine, bleomycin, etc. but it is very difficult to give adequate dose because of immune suppression.
b. Side effects
b.1. Nausea
b.2. Vomiting
b.3. Hair loss
b.4. Fatigue
b.5. Anemia
b.6. Mouth sores taste and smell changes
b.7. Infection
b.8. Etc.

3. Biological therapy
a. By enhancing the body's own immune or hormonal system to kill cancer cells, while leaving healthy cells relatively intact with the use of antibodies to attack cancer cells or block their activities or interrupting the hormonal or chemical pathways of the cancers with certain biological agents. In Kapois' sarcoma, the agent modifier alpha-interferon, has been used with good respond to patience with less severe immune suppressive condition.

b. Side effects
1. Allergic reactions
b. 2. Difficulty breathing, swelling
b. 3. Nausea
b.4. Fever or chills
b.5. Dizziness and fatigue
b.6. Etc.

4. Etc.

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VII. Benign tumors
Benign lung tumors, growth from many different structures in the lung, is defined as a conditions of abnormal  cell growth with no tendency of spreading or masses that push normal cells out of the way rather than invading surrounding tissue restricted to a limited area in the lung. Approximately one out of 500 chest radiographs shows the incidental finding of a solitary pulmonary nodule and almost one half of these pulmonary lesions are caused by a tumor. Unfortunately, only 2% to 5% of all lung tumors are of benign origin, e. g. lipoma, fibroma, hamartoma, and chondroma, and the majority are malignant neoplasms, most commonly primary lung cancer followed by metastases of extrapulmonary primary carcinomas. According to the study by Universitätsklinik für Pneumologie(a)
A. Symptoms
Some patients with benign lung tumors are experience no symptoms and most cases of benign lung tumors are found in routine examination, but in some patients the abnormal cells growth have affect the lung fucntion and cause symptoms of wheezing, coughing that lasts or coughing up blood, Shortness of breath, etc. In the study to assess the clinical characteristics, chest imaging, pathology, diagnosis and treatment of clear cell tumor of the lung (CCTL)of  age of the patients was (44 ± 18) years, with equal sex distribution, found that in most of the patients, the lesions were incidentally found during routine examinations. Chest roentgenogram or CT scan showed a homogenous, rounded opacity (solitary nodule) of (3.2 ± 1.4) cm in diameter. Contrast-enhanced CT scans revealed a sign of intense enhancement because of these tumors were highly vascular, containing capillaries and sinusoidal vessels in some patients(1).

B. Types of bengin lung tumors
B.1. Hamartomas
According to the statistic, Hamartomas constitute 8% of solitary lung nodules and 75% of benign nodules. It is defined as a benign tumor-like nodule composed of an overgrowth of mature cells and tissues of  the lung's lining and of fat and cartilage, etc. According to the study by Yenepoya Medical College, there is a report of a case of a 74-year-old male who had a lung mass that did not progress over 4-year on chest radiograph. The CT-guided FNAC smears showed benign bronchial epithelial cells, fibro-myxoid spindle cell stroma and fat spaces that aided the diagnosis of pulmonary hamartoma avoiding surgical intervention(2).

B.2. Bronchial adenomas
Changes in the lung tissue in bronchial adenomas are not dependent on their histological structure, but on the anatomical form of growth, localization and duration of the existence. In relation to the mechanism of the development, lung tissue changes may arise as a result of invasive tumor growth, hypoxia, and impaired drainage function of the bronchi, toxico-immunological disturbances(3).

B.3. Rare neoplasms
Rare neoplasms are benign lung tumors  made up of connective tissue or fatty tissue. Pulmonary papillary adenomas are rare neoplasms that predominantly occur in the periphery of the lung. There is a report of a 24-year-old male with a 6.0-cm spherical mass found incidentally at the periphery of the left upper lobe by imaging. Enucleation of the neoplasm was performed with intraoperative frozen section analysis. The tumor histologically showed papillary proliferations containing fibrovascular cores lined by a single layer of tumor cells that lacked atypia, mitoses, or necrosis(4).

B.4. Etc.

C. Causes
1. Infectious and inflammatory causes of benign lung tumors
a. An infectious fungus such as coccidioidomycosis
Coccidioidomycosis refers to the spectrum of disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Clinical manifestations vary depending upon both the extent of infection and the immune status of the host. Coccidioidomycosis has been reported to involve almost all organ systems; however, pulmonary disease is the most common clinical manifestation. The incidence of coccidioidomycosis continues to rise, and primary coccidioidal pneumonia accounts for 17 to 29% of all cases of community-acquired pneumonia in endemic regions. The majority of patients with coccidioidomycosis resolve their initial infection without sequelae; however, several patients develop complications of disease ranging in severity from complicated pulmonary coccidioidomycosis to widely disseminated disease with immediately life-threatening manifestations, according to the study by the University of California-Davis(5).
Other study report a case of a 61-year-old gentleman presented with shortness of breath, cough, weight loss, but no fever or hemoptysis. His physical exam was unremarkable except for decreased air entry on both lung fields, and axillary and inguinal lymphadenopathies. Computed tomography of the chest showed bilateral cavitary lung lesions, biopsy of which showed non caseating granulomas, and tissue culture showing Histoplasma capsulatum(6).

b. Tuberculosis (TB)
Chordoma is an uncommon tumor initially believed to be benign due to the rarity of its metastasis. Cytological, morphological, and immunohistochemical features of chordoma, relating to its origin from notochordal remnants, allows for its accurate diagnosis. According to the study by University of Saskatchewan, there is a report of a 75-year-old man with a known history of tuberculosis (TB) presented with shortness of breath and a dry cough. A chest X-ray demonstrated a diffuse, infiltrative miliary pattern in both lungs. Bronchial washings submitted for culture and cytological examination did not identify any tuberculous bacilli. Fine needle aspiration cytology (FNAC) showed focal areas of myxoid regions with small, round, uniform mononuclear cells. There was a documented past history of chordoma arising from the L2 vertebrae. Because of the rarity of this lesion in the lung and the limited diagnostic material available with a clinical history of TB and lumbar chordoma, the pathological report rendered on the FNAC was "atypical cells suspicious for metastatic chordoma(7).

c. A lung abscess
Capnocytophaga species are known commensals of the oral cavity of humans and animals (mainly dogs and cats) and are a rare cause of respiratory tract infections. There is a report of a case of cavitary lung abscess caused by a Capnocytophaga species in a patient with a metastatic neuroendocrine tumor, according to the study by Memorial Sloan-Kettering Cancer Center(8).

d. Round pneumonia
The differential diagnose between round pneumonia and a neoplastic process is difficult to make. In this report, all of cases of round pneumonia have resolved clinically and radiographically with antibiotic therapy, according to the study by (9).

e. Parasitic infections
According to the study by Department of Surgery, Mayo Clinic, Multiple benign pulmonary nodules are rare and are from a variety of etiologies. Infectious causes, such as histoplasmosis, tuberculosis, or parasitic infections, usually require biopsy for confirmation(9a).

2. Diseases casues of benign lung tumors
d. Rheumatoid arthritis
In the study to examine the role of lung disease in rheumatoid arthritis from a clinical, epidemiologic, pathophysiologic, and therapeutic perspective, showed that lung disease in rheumatoid arthritis is a heterogeneous and oftentimes serious condition, with a profound impact on patient wellbeing and survival. Advances in the understanding of its etiology and targeted application of available, as well as development of new, more specific therapeutics will be of benefit to patients with rheumatoid arthritis who are suffering from lung disease(10).

e. Wegener granulomatosis
Wegener's granulomatosis is a type of vasculitis, or inflammation of the blood vessels. Wegener's granulomatosis is a systemic vasculitis that primarily involves the upper and lower respiratory tracts and kidneys. Pulmonary Wegener's granulomatosis can present with multifocal lung involvement or solitary lung lesions with no evidence of extrapulmonary disease, according to the study by the research team of Dr. S Uppal.(11).

f. Sarcoidosis
There is a report of a case of a 65-year-old woman with a high initial index of suspicion for lung malignancy. Clinicians should always be aware that sarcoidosis enters the differential diagnosis of patients presenting with a lung mass that encases and narrows bronchial and vascular structures with associated pericardial effusion. Rarely, pleural effusion can be the presenting symptom of disease relapse despite maintenance treatment(12).

g. Leiomyoma
Benign metastasizing leiomyoma, is rare but occurs from a low-grade leiomyoma that most commonly spreads from the uterus(13).

h. Meningiomas
Meningiomas are generally benign tumors, but rarely metastasize outside of the central nervous system. There is a report of a 25-year-old female was admitted to our institute because of an abnormal shadow on her chest x-ray. A computed tomography (CT) scan showed a 3-cm, well- circumscribed mass in the right lower lobe of the lung. We performed thoracotomy and resected three pulmonary tumors at the right lung and diaphragm. Histological examination revealed a benign meningothelial meningioma. Six months later, she complained of heaviness of her head and a head CT scan revealed an intracranial mass(13a).

3. Birth defected causes of benign lung tumors
The relationship between congenital cystic adenomatoid malformation (CCAM) and pleuropulmonary blastoma (PPB), whether causal, correlational, or coincidental, remains controversial. In the study of Seventy-four CCAMs resected over the study period in 129 children diagnosed with CCAM. Five PPBs were diagnosed during the study period. Three of the 5 PPB cases were initially diagnosed as CCAMs. These PPBs were not clinically or radiologically distinguishable from CCAMs, found that asymptomatic cystic lung malformations represent a therapeutic dilemma. In this cohort, the incidence of PPB among apparently benign lung lesions was 4%. No clinical or radiological markers differentiated benign CCAMs from PPBs. Our experience provides further justification for resection of all CCAMs(14).

C. Diagnosis and tests
Most case of lung tumors are found accidentally in chest X ray.
Solitary pulmonary nodule represents 0.2% of incidental findings in routine chest X-ray images. One of the main diagnoses includes lung cancer in which small-cell subtype has a poor survival rate. Recently, a new classification has been proposed including the very limited disease stage (VLD stage) or T1-T2N0M0 with better survival rate, specifically in those patients who are treated with surgery(15).
The aim of the differentiation is to prevent the spreading of the lung nodules if they have become maligancy
1. Comparison chest X ray and repeat chest X ray
The  lung tumor will be compared with chest X ray taken in last year for the potentail of malidnancy.
If lung nodule found in the X ray is new and can not be compared than Repeat chest X ray if your doctor suspected that nodule is likely benign.

2.  Bronchoscopy
In the study in comparison of transbronchial needle aspiration (TBNA) with cytology brush and forceps biopsy, in the diagnosis of a pulmonary mass or coin lesions has been studied by Shure and Wang in the past, found that the needle brush and TBNA have a higher diagnostic yield in malignant lung masses or nodules. The use of regular brush and forceps biopsy did not increase the diagnostic yield in malignancy. Forceps biopsy might be more useful in benign diseases(15a).

3.  Biopsy, Thoracoscopy and neodymium:yttrium-aluminum garnet laser
Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopic stapler alone (72%), neodymium:yttrium-aluminum garnet laser (18%), or both (10%)(16).

4. CT scan
Proposed is a method for statistical analysis for a small sample size, repeated measure experiment with nesting factors. In the original experiment the Student t-test was used for analysis. Using the same data, we modeled the experiment into two groups of mice with benign and malignant primary lung tumors. 4 tumor nodules were selected from each mouse (N= 36). The dependent variables are the volume, diameter, and signal attenuation measured using computed tomography (CT), according to the study by The University of Texas Health Sciences Center at Houston, Houston(17).

5. Radial EBUS navigation
In the study to examine the sensitivity and factors that may impact the diagnostic yield of a similar technology, namely, radial endobronchial ultrasound (EBUS), found that lesion size, distance, presence of a computerized tomography bronchus sign, or lobar location may not impact the diagnostic yield of bronchoscopic biopsy of peripheral lung nodules with radial EBUS navigation(18).

6. Etc.

D. Preventions
D.1. Diet to prevent benign lung tumors
1. Mediterranean diet
Mediterranean diet and more specifically certain meats, fruits, vegetables, and olive oil found in certain parts of the Mediterranean region have been associated with a decreased cardiovascular and diabetes risk. According to the study by University of Illinois at Chicago, showed that one agent in particular, carnosol, has been evaluated for anti-cancer property in prostate, breast, skin, leukemia, and colon cancer with promising results. These studies have provided evidence that carnosol targets multiple deregulated pathways associated with inflammation and cancer that include nuclear factor kappa B (NFκB), apoptotic related proteins, phosphatidylinositol-3-kinase (PI3 K)/Akt, androgen and estrogen receptors, as well as molecular targets(19).

2. White cabbage, green pepper, strawberry, olive, mangoes and grapes
Lupeol, found in white cabbage, green pepper, strawberry, olive, mangoes and grapes was reported to possess beneficial effects as a therapeutic and preventive agent for a range of disorders. Last 15 years have seen tremendous efforts by researchers worldwide to develop this wonderful molecule for its clinical use for the treatment of variety of disorders. These studies also provide insight into the mechanism of action of Lupeol and suggest that it is a multi-target agent with immense anti-inflammatory potential targeting key molecular pathways which involve nuclear factor kappa B (NFkappaB), cFLIP, Fas, Kras, phosphatidylinositol-3-kinase (PI3K)/Akt and Wnt/beta-catenin in a variety of cells(20).

3. Apple peel
Flavonoids and triterpenes are two major groups of bioactive compounds in apple peels. According to the study by the Betulin Institut, the antitumour effects were subsequently confirmed in a series of cancer cell lines from other origins, for example breast, colon, lung and neuroblastoma. In addition, in the last decade many studies have shown further effects that justify the expectation that triterpenes are useful to treat cancer by several modes of action. Thus, triterpene acids are known mainly for their antiangiogenic effects as well as their differentiation inducing effects. In particular, lupane-type triterpenes, such as betulin, betulinic acid and lupeol, display anti-inflammatory activities which often accompany immune modulation. Triterpene acids as well as triterpene monoalcohols and diols also show an antioxidative potential, (21).

4. Cruciferous vegetables, soybean, garlic, tomato, rice, beans, and potatoes
Phytoalexins have been identified in at least 75 plants including cruciferous vegetables, soybean, garlic, tomato, rice, beans, and potatoes suggesting plants may be a rich source of cancer-fighting compounds. According to the study by The University of Arizona, 
Preclinical evidence suggests these compounds possess anticancer properties including an inhibition of microbial activity, cell proliferation, invasion and metastasis, hormonal stimulation, and stimulatory effects on expression of metabolizing enzymes(22a).
D.2. Phytochemicals to prevent benign lung tumors
1.  Flavonoids
In the study to review data from epidemiological and preclinical studies addressing the potential benefits of diets based on flavonoids for cancer prevention, found that flavonoids are subdivided into subclasses including flavonols, flavones, flavanones, flavan-3-ols, anthocyanidins, and isoflavones. Epidemiological studies suggest dietary intake of flavonoids may reduce the risk of tumors of the breast, colon, lung, prostate, and pancreas. However, some studies have reported inconclusive or even harmful associations. A major challenge in the interpretation of epidemiological studies is that most of the data originate from case-control studies and retrospective acquisition of flavonoid intake. Differences in agricultural, sociodemographics, and lifestyle factors contribute to the heterogeneity in the intake of flavonoids among populations residing in the United States, Europe, and Asia. Dose and timing of exposure may influence the anticancer response to flavonoid-rich diets(22). Other study found that in vitro work has concentrated on the direct and indirect actions of flavonoids on tumor cells, and has found a variety of anticancer effects such as cell growth and kinase activity inhibition, apoptosis induction, suppression of the secretion of matrix metalloproteinases and of tumor invasive behavior(23).

2. Triterpenoids and rexinoids
In the study to test the members of two noncytotoxic classes of drugs, synthetic oleanane triterpenoids and rexinoids, both as individual agents and in combination, for the prevention and treatment of carcinogenesis in a highly relevant animal model of lung cancer, found that triterpenoids and rexinoids are multifunctional, well-tolerated drugs that target different signaling pathways and are thus highly effective for prevention and treatment of experimental lung cancer(24).

3.  Glyceollins 
Glyceollins are a novel class of soybean phytoalexins with potential cancer-preventive and antiestrogenic effects.  According to the study by the School of Life Sciences and Biotechnology, College of Natural Sciences, glyceollins, elicited ingredients of soy source, target the signaling pathways mediated by VEGF or bFGF, providing new perspectives into potential therapeutics for preventing and treating hypervascularized diseases including cancer(25).

4. Etc.

D.3. Antioxidants to prevent benign lung tumors
In the study to determine whether vitamins, minerals and other potential agents, alone or in combination, reduce incidence and mortality from lung cancer in healthy people, showed that
1. Zinc and copper 
 Zinc, copper and selenium are important cofactors for several enzymes that play a role in maintaining DNA integrity. However, limited epidemiologic research on these dietary trace metals and lung cancer risk is available. According to the study by, dietary zinc and copper intakes are associated with reduced risk of lung cancer. Given the known limitations of case-control studies, these findings must be interpreted with caution and warrant further investigation(26).

2. Antioxidants vitamin C and vitamin E
In the study to evaluate the evidence of the supplements vitamin C and vitamin E for treatment and prevention of cancer,  identified only 3 studies that reported statistically significant beneficial results: vitamin C (in combination with BCG) was found to be beneficial in a single trial of bladder cancer and vitamin E (in combination with omega-3 fatty acid) increased survival in patients with advanced cancer. In the ATBC trial, in analyses of 6 individual cancers, the prevention of prostate cancer in subjects treated with alpha-tocopherol was statistically significant (RR=0.64, 95% CI: 0.44, 0.94)(27).

3. Selenium
In a systematic review of selenium for lung cancers, and assessed potential interactions with conventional therapies, found that Selenium may be effective for lung cancer prevention among individuals with lower selenium status, but at present should not be used as a general strategy for lung cancer prevention. Although promising, more evidence on the ability of selenium to reduce cisplatin and radiation therapy toxicity is required to ensure that therapeutic efficacy is maintained before any broad clinical recommendations can be made in this context(28).

4. Etc.


E. Treatments
E.1. In conventional medicine perspective 
radiographs may be continued used to monitor the progression of lung nodules, if the tumor does not double in size in less than a year and it does not become cancerous. Other wise surgery may be the only option, but the aim of the surgery is to spare the lung, unless it is absolutely necessary for it to be removed and depending to the patients conditions
1. Endoscopic cryotherapy
In  a systematic review and evaluation of endoscopic cryotherapy of endobronchial tumors, investigating safety and efficacy, found that endoscopic cryotherapy was found to be a safe and useful procedure in the management of endobronchial tumors although its efficacy and appropriate indications have yet to be determined in well-designed controlled studies(29).

2. Bronchotomy
Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. According to the study by the University of Messina, bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring(30).

3. Pulmonary segmentectomy
Pulmonary segmentectomy has been recognized as an operative option for complete resection of early-stage lung cancer in patients with poor pulmonary function. According to the study by, transbronchial indocyanine green injection into the relevant bronchus with the use of an infrared thoracoscope allows identification of intersegmental lines and planes during thoracoscopic segmentectomy(31).

4.  Lobectomy
In the study to assess 14,473 patients who met our inclusion criteria, lobectomy conferred superior unadjusted overall (p < 0.0001) and cancer-specific (p = 0.0053) 5-year survival compared with segmentectomy. Even after adjusting for patient factors, tumor characteristics, and geographic location, we noted that patients who underwent lobectomy had superior overall and cancer-specific survival rates, regardless of tumor size(32).

5. Sleeve resection 
There is a report of a 75-year-old man complained of sputum and was referred to our department. His sputum cytology was class III. Chest X-ray and computed tomography showed no abnormalities, but bronchoscopy revealed an elevated lesion in the membranous portion of the left main bronchus, which was pathologically diagnosed as squamous cell carcinoma in situ. Since bronchoscopy revealed no other lesions in the visible parts of the airway, it was considered to be a solitary, early lung cancer, and sleeve resection of the left main bronchus was performed(33).

6. Completion pneumonectomy (CP)
Completion pneumonectomy (CP) is a difficult operation in which the surgeon must use techniques such as intrapericardial ligation of the pulmonary vessels. There is a case of CP for a patient with recurrent lung cancer. A 63-year-old man was admitted to our hospital for evaluation of abnormal shadows in the right lung field in October 2002. Right middle lobectomy with mediastinal lymph node dissection had been performed in February 1993. Computed tomography (CT) revealed a hilar mass in the right upper lobe the day after admission. Bronchofiberscopic cytology revealed squamous cell carcinoma. Right completion pneumonectomy was performed on suspicion of metachronous multiple lung cancers 4 days later. Histopathologically, resected specimens represented adenosquamous carcinoma similar to the prior lesion from the middle lobe, and examination revealed that the tumor represented a recurrence following middle lobectomy. The patient remains well as of 19 months postoperatively(34).

7. Etc.

E.2. In herbal medicine perspective
1. Roots of Prismatomeris connata
The roots of Prismatomeris connata have been used in traditional herbal medicine to treat many health problems, particularly pneumoconiosis. According to the study by the University of British Columbia,  natural compound PCON6 has relatively selective cytotoxicity against NSCLC growth and represent a concept of developing a novel drug therapy specific for NSCLC based on the roots of C. connata or PCON6(35).

2. Juglans mandshurica Maxim
Juglanthraquinone C (1,5-dihydroxy-9,10-anthraquinone-3-carboxylic acid, JC), a naturally occurring anthraquinone isolated from the stem bark of Juglans mandshurica. Acording to the study by the Northeast Normal University,  JC exhibited the strongest cytotoxicity of all compounds evaluated. Next, we used JC to treat several human cancer cell lines and found that JC showed an inhibitory effect on cell viability in dose-dependent (2.5-10 μg/ml JC) and time-dependent (24-48 h) manners(36).

3. Trichosanthes kirilowii Maximowicz
Trichosanthin (TCS) is a type I ribosome-inactivating protein that is isolated from the root tubers of the Chinese medicinal herb Trichosanthes kirilowii Maximowicz. According to the study by Zhejiang University School of Medicine, recent studies have demonstrated that TCS does indeed induce apoptosis in several tumor cell lines. Although TCS-induced apoptosis of tumor cell lines is now well known, the underlying mechanisms remain to be elucidated(37).

4. Rheum officinale Baill.
Rheum officinale Baill. (Da Huang) is one of the herbs commonly used in traditional Chinese medicine formulae against cancer. According to the study by The Hong Kong Polytechnic University, Da Huang water extract was found to have significant growth inhibitory effects on both A549 and MCF-7 cell lines with IC(50) values 620+/-12.7 and 515+/-10.1 microg/ml, respectively. Growth inhibitory effects were dose- and time-dependent. A significant decrease in cell number, DNA fragmentation and single DNA strand breakages were observed in the Da Huang water extract treated A549 and MCF-7 cells(38).


E.3. In traditional Chinese medicine perspective
1. Emodin extracted from Chinese herbs
In the study to observe emodin-mediated cytotoxicity and its influence on Rad51 and ERCC1 expressionin non-small cell lung cancer (NSCLC), found that emodin exerted a suppressive effect on the proliferation of NSCLC in a concentration dependent manner. Protein and mRNA expression of ERCC1 and Rad51 was also significantly decreased with the dose. Vacuolar degeneration was observed in A549 and SK-MES-1 cell lines after emodin treatment by transmission electron microscopy. Emodin may thus inhibited cell proliferation in NSCLC cells by downregulation ERCC1 and Rad51(39).

2. Shenqi fuzheng
 In China, Shenqi Fuzheng, a newly developed injection concocted from Chinese medicinal herbs has been reported that may increase efficacy and reduce toxicity when combined with platinum-based chemotherapy, but little is known about it outside of China. According to the study by the Nanjing University of Traditional Chinese Medicine, SFI intervention appears to be useful to increase efficacy and reduce toxicity when combined with platinum-based chemotherapy for advanced NSCLC, although this result needs to be further verified by more high-quality trials(40).

3. Astragalus-based Chinese herbs
In the study of 1,305 potentially relevant publications, 34 randomized studies representing 2,815 patients met inclusion criteria. Twelve studies (n = 940 patients) reported reduced risk of death at 12 months (risk ratio [RR] = 0.67; 95% CI, 0.52 to 0.87). Thirty studies (n = 2,472) reported improved tumor response data (RR = 1.34; 95% CI, 1.24 to 1.46). In subgroup analyses, Jin Fu Kang in two studies (n = 221 patients) reduced risk of death at 24 months (RR = 0.58; 95% CI, 0.49 to 0.68) and in three studies (n = 411) increased tumor response (RR = 1.76; 95% CI, 1.23 to 2.53). Ai Di injection (four studies; n = 257) stabilized or improved Karnofsky performance status (RR = 1.28; 95% CI, 1.12 to 1.46). Astragalus-based Chinese herbal medicine may increase effectiveness of platinum-based chemotherapy when combined with chemotherapy. These results require confirmation with rigorously controlled trials, according to the study by the University of California(41).

4. Trichosanthes kirilowii Maxim (Cucurbitaceae)
Tianhua (TH-R) is extracted from Trichosanthes kirilowii Maxim (Cucurbitaceae) containing trichosanthin, a traditional Chinese medicine, which has been locally reported to have good anticancer effects in vivo in both animal and human models. According to the study by Chung Shan Medical University, it has been proven that medicinal herbs such as Tianhua have positive effects against cancer through preventing or inhibiting the process of lung tumorigenesis(42).

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V. Pleural cavity diseases
Pleural cavity diseases is defined as a condition of the below
1. Accumulated air within the pleural cavity, from either the outside or from the lung (Pneumothorax.
2. Accumulated fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume (Pleural effusion).
3.  Abnormal cells growth  on the pleurae (Pleural tumors). It can be benign or malignant.
4.  Accumulated plagues within the pleural cavity as a result of exposure to asbestos.
http://www.thoracic.org/education/breathing-in-america/resources/chapter-14-pleural-disease.pdf
 


VI. Pulmonary vascular diseases

VII. Neonatal diseases