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Chapter 10 Medicinal and aromatic plants used in respiratory diseases 373
day intervals after the treatment, parameters such as asthma severity, symptom frequency, and lung function were evaluated. In the two evaluations after the treatment,
patients given Nigella sativa plant seed extract experienced a decrease in asthma severity,
frequency of recurrence, and chest wheezing, while lung functions also improved. This
situation caused a decrease in the need for medication in patients, while no change was
reported in the placebo group. It has been suggested that these findings indicate that Ni-
gella sativa plant seeds may contribute to the prevention of asthma [36]. The Echinodorus
scaber Rataj plant is used as a medicinal plant among the public, especially in the treat-
ment of respiratory tract diseases where inflammation is present. It has been reported
that the hydroethanolic extract of the leaves of the Echinodorus scaber Rataj plant has
pharmacological effects through its anti-inflammatory effects in asthma. In a study investigating the effects of the plant leaf extract on an ovalbumin-induced allergic asthma
mouse model, it was determined that it reduced the number of immune-related cells
such as eosinophils, neutrophils, leukocytes, and mononuclear cells. It has also been reported that the Echinodorus scaber Rataj plant leaf extract caused a decrease in the levels
of IL-5, IL-13, and IL-4 cytokines in the bronchoalveolar lavage fluid and IgE levels in the
blood plasma, which increased after the allergic asthma model in mice. The antiinflammatory effect of the Echinodorus scaber Rataj plant leaf extract has been attributed
to these biochemical changes [37]. Zataria multiflora Boiss is a plant traditionally used to
treat cough and respiratory disorders. In addition to its antioxidant properties, it also has
anti-inflammatory properties. In a study conducted to reveal the role of the Zataria multi-
flora Boiss plant’s leaf and stem extract in asthma, it was determined that it improved
respiratory function in asthmatic patients and increased lung function. It was reported
that the Zataria multiflora Boiss plant’s leaf and stem extract induced a decrease in patients’ inflammation-related cells and had a therapeutic effect for asthmatic patients due
to these properties [38]. In another study investigating the effects of hydroethanolic extract of Curcuma longa and curcumin on asthma model rats, it was shown that Curcuma
longa and curcumin have anti-inflammatory and antioxidant properties. It has been suggested that Curcuma longa and curcumin may have a therapeutic effect in the treatment
of asthma through their anti-inflammatory properties [39].
10.4 Pneumonia
Magnolia officinalis is a medicinal plant. Magnolia officinalis bark extract is used especially in the treatment of fever, cold, cough, and bronchitis. In a study investigating
the therapeutic properties of Magnolia officinalis bark extract in a mouse pneumonia
model induced by influenza virus A, it was determined that the expression levels of
inflammation factors such as IL-6, nitric oxide, and TNF-α in the serums of animal
given the plant extract, decreased. In addition, it has also been reported that Magnolia
officinalis bark extract has a suppressive effect on pneumonia in mice. In particular,
374 Serkan Kapancik, Atteneri López Arencibia, and Burak Tuzun
it has been determined that it is effective in reducing the proximity of cells in these
tissues to apoptosis by mediating a decrease NF-κB and TLR3 expression in the tissues
infected with influenza virus A of mice. In this respect, it has been suggested that
Magnolia officinalis bark extract can be used effectively in the treatment of pneumonia through its anti-inflammatory roles and its effects on suppressing apoptosis [40].
Moringa oleifera is a tree species that plays a role in suppressing inflammation with
the help of its rich phytochemicals. Moringa oleifera is a powerful antioxidant, in addition to its roles in preventing inflammation. The therapeutic roles of the Moringa
oleifera leaves ethanolic extract in inflammation of lung cells induced by lipopolysaccharide in mice were examined in vitro in W138 cells. It was determined that the ethanolic extract of plant leaves suppressed IL-6 and IL-1β levels in lung cells. Since the
suppression of these inflammation-related cytokines by the ethanolic extract of plant
leaves may also play an inhibitory role in inflammation occurring in pneumonia, it
has been reported that Moringa oleifera plant can be used in diseases related to inflammation and these study results support its traditional use [41]. Green chemistry
synthesis was performed with the help of copper ions from the water extract of Alhagi
maurorum plant, and the effectiveness of this synthesized green chemistry synthesis
product in pneumonia was investigated. For this purpose, a pneumonia model was
first used in BALB/c mice. For the pneumonia model, the disease was created in mice
by injecting mycoplasma pneumonia. The effects on inflammatory factors such as,
TNF-α, IL-8, IL-1, IL-6, and TGF were examined. It was determined that the product
obtained as a result of green chemistry synthesis had suppressive properties on inflammation-related factors, and thus, it produced inflammatory inhibitory effects in
pneumonia model mice. It also mediated decreases in the number of inflammationrelated cells. As a result of this study, it was reported that green chemistry synthesis,
with the help of copper ions from the water extract of Alhagi maurorum plant, exhibited healing effects in pneumonia mouse model [42]. Acute pneumonia is especially
fatal in elderly individuals and children with weakened immune systems. Acute pneumonia is an inflammation-related pathological condition, resulting from inflammation
of the lung tissue. The therapeutic efficacy of Symplocos prunifolia extract was investigated in A549 and RAW264.7 cells after inflammation induced by lipopolysaccharide.
In this in vitro study, it was determined that Symplocos prunifolia extract reduced nitric oxide in RAW 264.7 cells stimulated with lipopolysaccharide. In addition, this
plant extract reduced the cyclooxygenase-2 enzyme and nitric oxide synthase enzyme
expression levels. However, it was determined that Symplocos prunifolia extract suppressed the expressions of cyclooxygenase-2, inducible nitric oxide synthase, and inflammation-related proteins in LPS-stimulated A549 cells. It has been suggested that
Symplocos prunifolia extract suppresses the activation of NF-κB, MAPK, and PI3K/Akt
signaling pathways in order to suppress inflammation, and therefore it is a candidate
for therapeutic efficacy in acute pneumonia [43].
Chapter 10 Medicinal and aromatic plants used in respiratory diseases 375
10.5 Lung cancer
Lung cancer is a disease that is frequently seen and has a high mortality rate. Despite
technological developments, the frequency of deaths due to lung cancer has increased, while the mortality rate has remained high. The increase in life expectancy
in lung cancer depends on the effectiveness of treatment. Therefore, many studies are
being conducted on the therapeutic effects of medicinal plants in lung cancer. If we
talk about these studies, we will first discuss the role of the extracts of Erythrophleum
succirubrum, Croton oblongifolius, and Bridelia ovata plants, extracted with 50% ethanol and ethyl acetate, in the treatment of lung cancer. In the study conducted on
A549, it was determined that ethyl acetate extracts of Erythrophleum succirubrum,
Croton oblongifolius, and Bridelia ovata plants had cytotoxic effects on cell lines. In
addition, it was determined that the ethanolic extract of Erythrophleum succirubrum
plant had cytotoxic effects on lung cancer cells. In addition, when these plant extracts
were combined with chemotherapy drugs currently used for cancer treatment, they
also mediated an increase in the synergistic effectiveness of these drugs. It was determined that the cytotoxic effect of the extracts of Bridelia ovata, Croton oblongifolius,
and Erythrophleum succirubrum plants was achieved by inducing apoptosis. It was
also determined that these plant extracts had anticancer effects on samples taken
from tumor tissues of lung cancer patients. Based on these data, it was suggested that
the ethyl acetate extracts of Erythrophleum succirubrum, Croton oblongifolius, and
Bridelia ovata plants and the ethanolic extract of Erythrophleum succirubrum plant
have significant potential in the treatment of lung cancer [44]. Another plant whose
therapeutic activity in lung cancer has been investigated is the Teucrium polium
plant. Teucrium polium is a medicinal plant that has been used among the public for a
long time for complaints such as diabetes and indigestion. In the study investigating
the effectiveness of the Teucrium polium plant in non-small cell lung cancer, H322 and
A549 lung cell lines were used. The effect of the plant extract on cell cycle and apoptosis in these lung cell lines was examined. It was determined that the extract of the
Teucrium polium plant suppressed proliferation and de-regulated the progression of
the cell cycle in H322 and A549 lung cell lines. Therefore, it was stated that the extract
of the plant is a good therapeutic that it can be used for the treatment of lung cancer
[45]. It is known that Luffa acutangula and Lippia nodiflora plants have different biological activities for many diseases. In particular, it is suggested that they have anticancer activity. Research on Lippia nodiflora and Luffa acutangula plants has shown
that leaf extracts of these plants can contribute to the treatment of lung cancer. In
this study, when Lippia nodiflora and Luffa acutangula plant leaf extracts were applied to NCI-H460 lung cancer cell lines, dramatic changes occurred in the proliferation of these cells. In addition, mitochondrial depolarization occurred in these cells.
In addition, it was determined that Luffa acutangula and Lippia nodiflora plant leaf
extracts induced apoptosis in NCI-H460 lung cancer cells [46]. Scutellaria barbata is a
plant in the class of medicinal plants used among the public. It is especially used in
Figure 10.5: Lung cancer xenograft nude mouse model created by implantation of lung cancer cell lines
(created via BioRender.com) (Mouse A: mouse dies because it does not receive treatment; Mouse
B: mouse that can survive after treatment with medicinal and aromatic plant extracts).
376 Serkan Kapancik, Atteneri López Arencibia, and Burak Tuzun
suppressing inflammation and as a diuretic. Scutellaria barbata extracts have been
shown to have anticancer activity in different types of cancers. The effects of Scutel-
laria barbata extracts on lung cancer was also examined in A549. It was determined
that Scutellaria barbata ethanol extracts significantly suppressed the proliferation of
A549. It did this by revealing cytotoxic effects and inducing apoptosis in lung cancer
cells. In addition, it was determined that Scutellaria barbata ethanol extracts mediated changes in the expressions of many genes involved in DNA damage, cell cycle
control mechanisms, regulation of nucleic acid binding, and protein phosphorylation.
It has been reported that expression changes in these genes mediate the death of lung
cancer cells. In this respect, the effectiveness of the Scutellaria barbata plant in lung
cancer has been demonstrated by molecular mechanisms [47]. It has been shown that
the extract of Kalanchoe tubiflora in n-butanol has an inhibitory effect on cell proliferation. It has been determined that the water extract of Kalanchoe tubiflora mediates
cell cycle arrest in A549 lung cancer cells. The in vivo effects of the water extract of
Kalanchoe tubiflora have also been investigated on nude mice. In this study, A549xenografted nude mouse models were created by implating A549 cells into nude mice,
as in Figure 10.5.
It was found that the water extract of Kalanchoe tubiflora caused the shrinkage of
lung cancer tumors generated by A549 non-small cell lines in these nude mice. Based
on these results, it was reported that Kalanchoe tubiflora plant has antitumor activity
for lung cancer [48]. Salvia miltiorrhiza Bunge is a medicinal plant that contains
many components and is used especially for the treatment of cardiovascular patients,
Chapter 10 Medicinal and aromatic plants used in respiratory diseases 377
but also has anti-inflammatory, anticancer, and anti-allergic effects. The effects of
methanol extract of plant roots on proliferation and apoptosis in A549 were investigated for its role in lung cancer. It was determined that methanol extract of plant
roots inhibited the proliferation of non-small cell lung cancer cells in a dosedependent manner, and also induced early and late apoptosis in these cells, as analyzed by flow cytometry. It caused interruption in the G2/M phase of the cell cycle. It
was determined that methanol extract of Salvia miltiorrhiza Bunge roots mediated an
increase in the expression of p53, PARP1, p21, and caspase-3/9. Bcl-2, one of the apoptosis-related proteins, has been shown to induce cell apoptosis by causing a decrease in
Bcl-xl expression and an increase in Bax expression. In light of these results, it has
been said that methanol extract of plant roots has the ability to induce apoptosis in
lung cancer cells and may be a complementary treatment method to inhibit tumor
growth [49]. Another study investigating the effectiveness of Morinda citrifolia vegetable leaves as a complementary treatment in the treatment of lung cancer compared
the anticancer activity of the plant with erlotinib to reveal its anticancer activity in
lung cancer. For this purpose, a BALB/c mouse model was used, in which lung cancer
was induced in vivo. It was determined that the ethanol extract of Morinda citrifolia
vegetable leaves inhibited tumor growth in a lung cancer animal model at a dosedependent level that could be considered significant. It also caused an increase in the
immune cells in lung cancer model mice and a decrease in the levels of EGFR, which
has an important biological role in lung cancer, as shown in Figure 10.6. The extract
of Morinda citrifolia vegetable leaves also showed an effect on inflammation and mediated a decrease in the levels of cyclooxygenase 2, an enzyme associated with inflammation. As a result, it was stated that 50% ethanol extract of Morinda citrifolia vegetable leaves strengthened immunity and suppressed cell proliferation, thus showing
anticancer activity against lung cancer [50].
Therapeutic activity of Punica granatum leaf extract against non-small cell lung
cancer was also investigated on cell lines. For this study, A549 and H1299 were used,
while anticancer activity study of Punica granatum leaf extract was also performed on
LL/2. Punica granatum leaf extract was shown to suppress cell proliferation in lung cancer cell lines in a dose-dependent manner. In cell cycle analyses performed by flow cytometry, it was determined that Punica granatum leaf extract inhibited the cell cycle in
G2/M phase in H1299 cell lines in a dose-dependent manner. In addition, it was determined that Punica granatum leaf extract caused an increase in apoptosis, mediated by
mitochondria, and could prevent cell migration and cell invasion of H1299 cells. Based
on these anticancer effects of Punica granatum leaf extract application on lung cancer
cell lines, it has been indicated that this plant can be used safely and effectively in the
treatment of lung cancer [51]. Nigella sativa is also used by humans in traditional medicine for the treatment of many diseases. It is known that Nigella sativa extracts have
high antioxidant properties and anti-inflammatory effects. The relationship between
plant seed extract and seed oil and lung cancer was investigated in vitro in lung cancer
cell lines. In this study conducted on lung cancer cells without A549 small cells, it was
Figure 10.6: EGFR signaling pathway and biological effects in lung cancer (created via BioRender.com).
378 Serkan Kapancik, Atteneri López Arencibia, and Burak Tuzun
determined that after the application of Nigella sativa seed extract and seed oil, A549
cells lost their typical morphological appearance and appeared smaller than they
should be. It was revealed with the help of viability tests that Nigella sativa seed extract
and seed oil dramatically reduced the viability of lung cancer cells [52]. Artemisia juda-
ica L. has a high antioxidant capacity and active effects in suppressing inflammation. In
addition, it has roles related to apoptosis. Therapeutic effects of Artemisia judaica
L. plant extract in lung cancer were evaluated in vitro and in vivo. It was determined
that Artemisia judaica L. plant extract caused cytotoxic effects at a good IC50 dose compared to doxorubicin in A549 cells. In addition, in the analysis performed on cell cycle,
it was determined that it caused cell cycle to arrest in G2/M phase. It caused a decrease
in the expression of proteins with anti-apoptotic effect and an increase in the protein
expression with apoptotic effect. It was determined that Artemisia judaica L. plant extract dramatically reduced tumor size in mice with xenograft lung cancer model. When
this antitumor effect is compared with the antitumor effect caused by doxorubicin, it
has been shown that it causes a tumor suppression of 54% compared to doxorubicin
treatment in the xenograft model. In this study, in the docking study conducted on the
Figure 10.7: Lung model on a microfluidic chip with 3D lung cancer model (created via BioRender.com).
Chapter 10 Medicinal and aromatic plants used in respiratory diseases 379
active components of the plant extract of Artemisia judaica L., it has also been shown
that the active components of the plant bind to the active site of the epidermal growth
factor receptor [53]. Curcumin, obtained from the Curcuma longa plant, has anticancer
activity in many different types of cancers. The effectiveness of the Curcuma longa
plant extract, from which curcumin is obtained, on A549 was also investigated. For this
purpose, three different n-hexane, dichloromethane, and methanol extracts of the Cur-
cuma longa plant were prepared and applied to A549 cancer cells. It was determined
that the n-hexane extract of the plant had dose-related cytotoxicity in A549 cells. In addition, it was shown that the n-hexane extract of the Curcuma longa plant also inhibited
telomerase activity. It has been suggested that the n-hexane extract of the plant is a potential source for drug studies in lung cancer due to its cytotoxic effect and telomerase
inhibitory roles [54]. Asparagus racemosus plant has shown anticancer effects in many
types of cancer. The therapeutic roles of Asparagus racemosus root methanol and chloroform extracts in lung cancer were also investigated in A549. There was a change in
the morphology of A549 lung cancer cells, to which the root extracts of the plant were
applied. A549 cells changed from their standard shape to round and small. In addition,
it has been shown that Asparagus racemosus root methanol and chloroform extracts
have cytotoxic effects on A549 cells. In this respect, it has been suggested that Asparagus
racemosus root extract may be a candidate for drug development studies since it mediates a decrease in cell growth in lung cancer [55]. There are rapid developments in the
development of in vitro disease models in lung cancer studies. With the development of
organoid technology, organs are being re-developed on microfluidics and biomaterials,
as in Figure 10.7, and these models are used for the treatment of diseases [56].
380 Serkan Kapancik, Atteneri López Arencibia, and Burak Tuzun
The efficacy of Eleutherine bulbosa bulbs against lung cancer was also investigated in
a 3D in vitro cell line model created, as in Figure 10.5.3, in addition to 2D as a result of
technological developments. First, ethyl acetate, chloroform, and n-hexane extracts of
Eleutherine bulbosa bulbs were obtained. It was determined that chloroform extract
created higher levels of cytotoxic effects compared to other extracts. In addition, it
was reported that chloroform extract of Eleutherine bulbosa bulbs prevented the formation of colonies in A549 and caused an increase in apoptosis levels in A549 cells.
Chloroform extract suppressed the formed spheroid size, mediated a decrease in the
stem cell ratio as a result of inducing apoptosis and caused the cell cycle to pause in
the S phase. As a result of the study, it was determined that the chloroform extract of
Eleutherine bulbosa bulbs suppressed cell proliferation in a 2D and 3D in vitro lung
cancer model, created with the help of A549 cells for lung cancer. Therefore, it was
reported that the chloroform extract of Eleutherine bulbosa bulbs could be an agent
that can be used in lung cancer [57]. Another technique used effectively for lung cancer is nanotechnological methods. In another study where copper nanoparticles were
synthesized with the help of Thymus fedtschenkoi leaf extract and their effectiveness
in lung cancer was investigated, it was determined that these nanoparticles were antiproliferative for lung cancer cell lines. It was also determined that these particles did
not cause any cytotoxicity up to high doses in HUVECs, which are human umbilical
cord endothelial cells and not cancer. For these reasons, it is anticipated that these
nanoparticles, synthesized with the help of Thymus fedtschenkoi leaf extract, can be
used as a drug for lung cancer after in vivo studies are carried out [58]. Tagetes erecta
is a medicinal plant with anticancer effects. The effectiveness of Tagetes erecta plant
in lung cancer was investigated with the help of hydroalcoholic extracts obtained
from the flowers and leaves of the plant. It was determined that the flower extract of
Tagetes erecta plant has cytotoxic effects on lung cancer cells. In addition, anticancer
activities were examined in vivo in a lung cancer mouse model. For this purpose,
first, LLC lung cancer cells were implanted into C57BL/6 mice to create a xenograft
lung cancer model. The administration of Tagetes erecta plant flower extract to this
lung cancer mouse model mediated a decrease in tumor growth. In the microscopic
analysis of tumor tissues removed from the animals, a decrease in mitosis was detected, while an increase in necrotic areas was observed [59]. Melissa officinalis has
antitumor properties. When aqueous, methanolic, ethanolic, hydromethanolic, and
hydroethanolic extracts of this plant were applied to lung cancer cells, it was found
that the proliferation of lung cancer cells was suppressed. When compared to other
types of extracts, it was determined that the ethanolic extract of the plant had the
strongest anticancer activity. It was shown that plant ethanolic extract affected the
cell cycle in lung cancer cells, causing a decrease in pro-caspase3 levels and an increase in P53 levels in these cells [60].
Chapter 10 Medicinal and aromatic plants used in respiratory diseases 381
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