CLINICAL MANAGEMENT
Acupuncture for quick relief of asthma symptoms
By Dónal P. O’Mathúna
Editor’s note: Alternative medicine is a booming field in health care today. With more and more asthma patients turning to alternative therapies to supplement, and in many instances, replace traditional pharmacological management, disease management specialists should be aware of the leading options and their effects. Acupuncture, is often touted as symptomatic treatment asthma. Following is a review of the latest clinical information on acupuncture and its effectiveness on asthma exacerbation.
Asthma affects more than 14 million Americans — between 3% and 6% of adults and between 8% and 12% of children1 — and its incidence and severity are increasing.2 In a survey of patients with controlled asthma, 33% reported canceling or rearranging activities within the past month, and 47% missed one or more days of work or school that month because of their asthma; 14% had visited an emergency department within the year, and 5% were hospitalized.2
There has been much interest in the use of alternative and complementary therapies for asthma.3-5 A survey found that 22% of Dutch general practitioners viewed acupuncture as an effective asthma treatment.6 The National Institutes of Health Consensus Statement on Acupuncture stated that acupuncture may be beneficial for asthma but only as part of a comprehensive management program.7
History and methods
The history of acupuncture’s use, and its popular use for smoking cessation, were reviewed recently in our sister publication, Alternative Medicine Alert.8 Acupuncture is administered while patients sit or recline comfortably. Acupuncturists use numerous needle sites for asthma, with the back, neck, and ears used most frequently. Laser acupuncture is becoming more common, since it is painless, avoids needle infection problems, and has had comparable effectiveness to needle acupuncture with some disorders.9,10
The mechanism of action of acupuncture in asthma is unknown. Acupuncture raises levels of endorphins and cortisol in animals.11 One hypothesis suggests that acupuncture could ameliorate a chronic inflammatory disease through circulation of endorphins and corticotrophin, both of which are made from the same prohormone and are released simultaneously from the pituitary.11 Clinical studies have not verified this hypothesis.
Acupuncture has two broad schools of practice: classical and formula. Traditional Chinese Medicine (TCM) acupuncturists use classical acupuncture, evaluating patients individually and varying acupuncture points for the same condition between patients. TCM acupuncturists view acupuncture as inseparable from other aspects of TCM, such as pulse diagnosis, yoga, and herbal remedies.
Other acupuncturists, those of the formula school, use standard acupoints for specific disorders and isolate acupuncture from other TCM therapies. Classical acupuncturists criticize the latter approach as a "recipe book" form of acupuncture, unrelated to real practice.12 (All studies cited other than reference 13 used formula acupuncture.)
Clinical studies — quick relief
Numerous case studies and several uncontrolled trials report dramatic relief of asthmatic symptoms using acupuncture. Zang reported that acupuncture immediately and completely relieved symptoms in 98.9% of 192 asthma patients and that 76.5% of patients had marked long-term improvement.14
The results of controlled studies have been less remarkable. The earliest study found that acupuncture significantly improved three of five pulmonary functions compared to sham acupuncture’s effect (P < 0.05).15
After either type of acupuncture, isoproterenol aerosol (a beta agonist) produced greater improvement in all measures. Tashkin, et al, induced bronchoconstriction using methacholine, followed by either acupuncture, isoproterenol, sham acupuncture, nebulized saline, or no treatment.16
Acupuncture significantly improved all pulmonary functions (P <0.05), though administration of isoproterenol produced markedly greater improvements (P <0.05).
Patients’ perceptions vs. data
Takishima, et al. studied changes in respiratory resistance in 10 patients while they received true and sham acupuncture.17 Significant reductions were found with 38% of true acupuncture treatments, 6% of sham treatments, and 71% of metaproterenol treatments (P < 0.01). Takishima also noted large discrepancies between patients’ subjective reports of changes and objective pulmonary measurements (subjective improvements were reported in 77% of acupuncture treatments).
Luu, et al. found acupuncture significantly (P < 0.05) improved FEV1, but not vital capacity, compared to sham acupuncture.18 However, changes after salbutamol aerosol were significantly better than acupuncture on both measures (P < 0.01). Other studies have found no significant improvements in acute symptoms after acupuncture compared to sham.11,19,20 Another found that true acupuncture protected against exercise-induced asthma (P < 0.01), but so did sham acupuncture, although to a lesser extent (P < 0.02).21
Acupuncture is more commonly used as an adjunct to long-term asthma control. Tashkin, et al. (1985) believed that they were the first to examine repeated acupuncture treatments.11 They found no significant improvements, either short-term or long-term, in pulmonary function, drug use, or subjective reporting. Dias, et al. found that all patients in their control group had better objective results after sham treatments (P <0.01), and eight of the 10 controls felt better, too.22
Christensen, et al. reported limited positive findings for acupuncture.23 After two weeks, treated patients had significantly higher peak expiratory flow rates (PEFR) and lower medication use than the control group (P <0.05). However, initial improvements were gradually lost, despite continued therapy, with no significant differences between the groups for the rest of the study. Tandon, et al. found no significant differences in pulmonary function tests, medication usage, or patients’ subjective reports when using laser acupuncture.10 Another study found that laser acupuncture was not effective in preventing exercise-induced asthma.9
Four systematic reviews concluded that this topic lacks high-quality studies.1,4,6,24 A 1991 review scored the 13 best controlled studies on the basis of 18 predetermined methodologic criteria. Only three of the eight positive studies scored above 50 (out of 100), while all five negative studies scored over 50.6 The highest score was 72 (for reference 11). The variety of pulmonary measures used made meta-analysis impossible, and all the studies used small subject groups.
Jobst’s review identifies problems with the choice of sham acupoints, claiming that many investigators used sham acupoints which TCM uses for various respiratory conditions.4 Jobst then reevaluated the asthma research, finding that acupuncture was more effective than first appeared. However, Jobst included unblinded studies in this reevaluation. Linde, et al. used a panel of physician acupuncturists to evaluate the adequacy of acupuncture in the studies and found little correlation between members’ evaluations.24
There appears to be great diversity in what constitutes good acupuncture therapy. A 1997 review concluded that "no recommendations can be made one way or the other to either patients, their physicians, or acupuncturists on the basis of the available data."1
Adverse effects
Classical acupuncturists forewarn patients that acupuncture will initially exacerbate disease symptoms but will improve them later. In 16 asthma studies, 23 of the 320 subjects (7%) reported side effects such as fainting, ear ache, mild nausea, and dizziness.4 More serious adverse effects from acupuncture, though rare, include pneumothorax and infection.8 Compared to pharmacological asthma treatments, however, acupuncture has fewer side effects of lesser severity.
Unfortunately, avoidable deaths from asthma have been reported when patients refused conventional care, preferring acupuncture.25,26 Increased use of acupuncture has been thought to contribute to increased asthma mortality in France.26 Indeed, the most favorable review of this research still cautions that abandoning conventional treatment "may be dangerous since it controls asthma and chronic bronchitis very effectively."4
Conclusion
Acupuncture for quick relief of asthma has had some positive results, but high-quality studies are lacking. When acupuncture demonstrated significant benefits, standard pharmaceutical approaches gave markedly better improvements. Studies of long-term effectiveness consistently do not find objective pulmonary benefit. However, subjective improvements are often reported but without correlation with objective parameters.
The National Asthma Management Guidelines using conventional therapy are poorly complied with, suggesting that significant benefits in asthma control could be attained through better adherence to well-supported strategies.2 Clinical studies do not warrant adding acupuncture to maintenance therapy such as inhaled steroids. For those already using acupuncture, adverse effects appear infrequent.
However, caution should be exercised lest subjective improvements mask early signs of an exacerbation and delay pursuit of effective treatment"4
Dónal P. O’Mathúna is Professor of Bioethics and Chemistry at Mt. Carmel College of Nursing, Columbus, OH. He acknowledges Joseph G. Lutz, MD, and Robin Lutz, RN, for valuable input in preparing this article.
References
1. Linde K, et al. Acupuncture for the treatment of asthma bronchiale. In: Cates C, et al (eds). Airways Module of The Cochrane Database of Systematic Reviews, [updated March 3, 1997]. Available in The Cochrane Library [database on disk and CDROM]. The Cochrane Collaboration; Issue 2. Oxford: Update Software; 1997.
2. Legorreta AP, et al. Compliance with National Asthma Management Guidelines and specialty care. Arch Intern Med 1998; 158:457-464.
3. Lewith GT, Watkins AD. Unconventional therapies in asthma: An overview. Allergy 1996; 51:761-769.
4. Jobst KA. Acupuncture in asthma and pulmonary disease: an analysis of efficacy and safety. J Alt Complementary Med 1996; 2:179-206. Reprint of Jobst KA. A critical analysis of acupuncture in pulmonary disease: Efficacy and safety of the acupuncture needle. J Alt Complementary Med 1995; 1:57-84.
5. Davis PA, et al. The use of complementary/alternative medicine for the treatment of asthma in the United States. J Invest Allergol Clin Immunol 1998; 8:73-77.
6. Kleijnen J, et al. Acupuncture and asthma: A review of controlled trials. Thorax 1991; 46:799-802.
7. Acupuncture. NIH Consensus Statement Online 1997 November 3-5 [1998, February, 8];15(5):in press. Available at: http://odp.od.nih.gov/consensus/statements/cdc/107/107_stmt.html
8. Udani J, Ofman J. Use of acupuncture in smoking cessation. Alt Med Alert 1998; 1:64-67.
9. Morton AR, et al. Efficacy of laser-acupuncture in the prevention of exercise-induced asthma. Ann Allergy 1993; 70:295-298.
10. Tandon MK, et al. Acupuncture for bronchial asthma? A double-blind crossover study. Med J Aust 1991; 154:409-412.
11. Tashkin DP, et al. A controlled trial of real and simulated acupuncture in the management of chronic asthma. J Allergy Clin Immunol 1985; 76:855-864.
12. Koh CS. Acupuncture for bronchial asthma? Med J Aust 1991; 155:206.
13. Jobst K, et al. Controlled trial of acupuncture for disabling breathlessness. Lancet 1986; 2:1,416-1,419.
14. Zang J. Immediate antiasthmatic effect of acupuncture in 192 cases of bronchial asthma. J Tradit Chin Med 1990; 10:89-93.
15. Yu DYC, Lee SP. Effect of acupuncture on bronchial asthma. Clin Sci Molec Med 1976; 51:503-509.
16. Tashkin DP, et al. Comparison of real and simulated acupuncture and isoproterenol in methacholine-induced asthma. Ann Allergy 1977; 39:379-387.
17. Takishima T, et al. The bronchodilating effect of acupuncture in patients with acute asthma. Ann Allergy 1982; 48:44-49.
18. Luu M, et al. [Spirometric changes after puncture of thoracic pain points in asthma]. [French] Respiration 1985; 48:340-345.
19. Rosenthal RR, et al. All that is asthma does not wheeze. N Engl J Med 1975; 292:372.
20. Tandon MK, Soh PFT. Comparison of real and placebo acupuncture in histamine-induced asthma: A double-blind crossover study. Chest 1989;96:102-105.
21. Fung KP, et al. Attenuation of exercise-induced asthma by acupuncture. Lancet 1986; 2:1419-1422.
22. Dias PLR, et al. Effects of acupuncture in bronchial asthma: Preliminary communication. J R Soc Med 1982; 75:245-248.
23. Christensen PA, et al. Acupuncture and bronchial asthma. Allergy 1984; 39:379-385.
24. Linde K, et al. Randomized clinical trials of acu- puncture for asthma — A systematic review. Forschende Komplementärmedizin 1996; 3:148-155.
25. Ogata M. An asthmatic death while under Chinese acupuncture and moxibustion treatment. Am J Forensic Med Pathol 1992; 13:338-341.
26. Bousquet J, et al. Asthma mortality in France. J Allergy Clin Immunol 1987; 80:389-394.
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