Acupuncture for Relief of Asthmatic Exacerbation
By Dónal P. O’Mathúna, PhD
Editor’s Note: Dr. O’Mathúna is a Professor of Bioethics and Chemistry at Mount Carmel College of Nursing in Columbus, Ohio. He acknowledges Robin Lutz, RN, and Joseph G. Lutz, MD for valuable input in preparing this article.
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 Among patients with controlled asthma, one-third said their asthma forced them to cancel or rearrange activities within the past month, almost half had missed at least one day of work or school that month because of their asthma; 14% had visited an emergency room within the year, and 5% were hospitalized.2
Unsatisfactory medical control of asthma has generated much interest in the use of alternative and complementary therapies, including acupuncture.3,4 Approximately 10,000 acupuncturists practice in the United States, one-third of whom are physicians.5 Although some states restrict the practice of acupuncture to physicians, interest among nurses is growing.6
Acupuncture is used for many conditions, but the research evidence supporting those uses varies considerably. The National Institutes of Health convened a panel of experts to evaluate acupuncture research. The resulting Consensus Statement concluded that in spite of acupuncture’s popularity, "there is a paucity of high-quality research assessing efficacy."7 The authors found clear evidence of acupuncture’s efficacy for nausea and vomiting, but in relieving pain, some studies showed evidence of efficacy, but others did not. Randomized controlled trials with non-migrainous headaches similarly have conflicting results.8 The Consensus Statement also found evidence that acupuncture is not effective in certain conditions, such as smoking cessation.9 Given such diverse results, acupuncture’s efficacy must be evaluated separately with each condition.
History and Methods
Acupuncture is an integral part of traditional Chinese medicine (TCM). Within TCM, health is believed to require a balanced flow of qi, or life energy.5 This nonphysical energy circulates through the body via invisible channels called meridians. Illness results when the flow of qi is obstructed or unbalanced. Acupuncture needles are inserted into specific locations on the body (acupoints) to restore normal flow of qi through the meridians.
Acupuncture in Western societies has two schools of practice: classical and formula.4 Classical acupuncturists are TCM practitioners who evaluate patients individually and vary acupoints for the same condition between patients. This school views acupuncture as inseparable from other elements of TCM, such as pulse diagnosis, yoga, and herbal remedies.
The formula school uses standard acupoints for specific disorders and isolates acupuncture from other TCM therapies. In treating asthma, numerous needle sites are used, but most commonly ones on the back, neck, and ears.3 Classical acupuncturists criticize the formula school as a "recipe book" form of acupuncture, unrelated to real practice.4 All but one of the research studies in this area used formula acupuncture.
Mechanism of Action
How acupuncture works in general is unclear, and even less is known about its mechanism of action with asthma. Acupuncture raises levels of endorphins and cortisol in animals.10 One hypothesis proposes that acupuncture could ameliorate chronic inflammatory diseases through circulation of endorphins and corticotrophin, both of which are made from the same prohormone and are released simultaneously from the pituitary.10 Clinical studies have not verified this hypothesis.
Clinical Studies
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.11 Clinical observation of 25 hormone-dependent asthmatic patients showed they improved when treated with acupuncture: 14 patients (56%) stopped using their medication, 10 patients (40%) reduced their medication while symptoms improved, and one patient (4%) reported no improvement.12
The results of controlled clinical trials are much less remarkable. A recent British study randomly assigned 23 subjects to receive either acupuncture or a sham procedure in which needles were inserted into the chest at places not recognized as respiratory acupoints.13 All patients were taking beta agonists, and all but two were also taking inhaled steroids. Objective pulmonary measurements showed no improvements in both groups, either 60 minutes or 14 days after acupuncture. How-ever, both groups showed improved scores on the Asthma Quality of Life Questionnaire and reduced use of rescue bronchodilators, with sham therapy consistently showing greater benefits. The authors concluded that either acupuncture for asthma acts through placebo effects, or the needle insertion points are irrelevant.
The lack of correlation between objective respiratory measurements and subjective indexes of improvement has consistently confounded studies in this area. This contrasts with the results of studies comparing the effectiveness of acupuncture against pharmaceutical drugs, where the drugs consistently showed greater improvements on both measures. A small number of early studies for acute relief of asthma found statistically significant improvements in patients receiving true acupuncture compared to controls. More recent studies have not found statistically significant improvements. Controlled studies of acupuncture as an adjunct to long-term asthma control have consistently found no statistically significant improvements in pulmonary function, drug use, or subjective reporting. Results of these studies have been summarized.14
Systematic Reviews
Because of conflicting results arising from individual studies, systematic reviews play an important role in evaluating this research. Four systematic reviews during the 1990s concluded that high-quality studies were lacking in this area.1,4,15,16 A 1991 review scored the 13 best-controlled studies on the basis of 18 predetermined methodological criteria. Only three of the eight positive studies scored above 50 (out of 100), while all five negative studies scored over 50.15 The highest score of 72 (representing the best methodological design) was achieved by Tashkin et al, who found no acute or long-term benefit from acupuncture compared to sham acupuncture.10
The NIH’s National Center for Complementary and Alternative Medicine established and funds a center to evaluate alternative therapies in the treatment of asthma, allergy, and immunology. Researchers there were "struck by and frustrated with the paucity of good, well designed and well done clinical studies" on acupuncture for asthma, in spite of finding over 100 related research publications.3 The most recent 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 The NIH Consensus Statement on Acupuncture stated that acupuncture may be beneficial for asthma but only as part of a comprehensive management program.7
Research Difficulties
Jobst’s review identifies problems with the choice of sham acupoints, claiming that many investigators used sham acupoints which TCM uses for other 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. Another review used a panel of physician acupuncturists to evaluate the adequacy of acupuncture in the studies examined and found little correlation between the acupuncturists’ evaluations.16 There appears to be great diversity in what constitutes good acupuncture therapy, making outcome evaluations even more difficult.
Adverse Effects
Classical acupuncturists forewarn patients that acupuncture will initially exacerbate disease symptoms with improvements coming late.5 In 16 asthma studies, 23 of the 320 subjects (7%) reported side effects such as fainting, earache, mild nausea, and dizziness.4 More serious adverse effects can occur, and a few fatalities have been reported. Although needles are usually inserted a few millimeters into the skin, some are inserted several centimeters and have caused pneumothorax and infection.17 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.17 Increased use of acupuncture has been thought to contribute to increased asthma mortality in France.18 Indeed, the most favorable review of acupuncture research cautioned 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, and patients may be benefiting from placebo effects. However, caution should be exercised lest subjective improvements mask early signs of an exacerbation and delay pursuit of effective treat-ment.
References
1. Linde K, et al. Acupuncture for the treatment of asthma bronchiale. In: The Cochrane Library [database on disk and CD-ROM]. 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. Davis PA, et al. Acupuncture in the treatment of asthma: A critical review. Allergol Immunopathol (Madr) 1998;26:263-271.
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. Cadwell V. A primer on acupuncture. J Emerg Nurs 1998;24:514-517.
6. Plawecki HM, Plawecki JA. Acupuncture: The same difference. J Gerontol Nurs 1998;24:45-46.
7. NIH Consensus Development Panel. Acupuncture. JAMA 1998;280:1518-1524.
8. Vernon H, et al. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complement Ther Med 1999;7:142-155.
9. Udani J, Ofman J. Use of acupuncture in smoking cessation. Alt Med Alert 1998;1:64-67.
10. 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.
11. Zang J. Immediate antiasthmatic effect of acupuncture in 192 cases of bronchial asthma. J Tradit Chin Med 1990;10:89-93.
12. Hu J. Clinical observation on 25 cases of hormone dependent bronchial asthma treated by acupuncture. J Tradit Chin Med 1998;18:27-30.
13. Biernacki W, Peake MD. Acupuncture in treatment of stable asthma. Respir Med 1998;92:1143-1145.
14. O’Mathúna DP. Acupuncture for quick relief of asthmatic exacerbation. Alt Med Alert 1998;1:109-113.
15. Kleijnen J, et al. Acupuncture and asthma: A review of controlled trials. Thorax 1991;46:799-802.
16. Linde K, et al. Randomized clinical trials of acupuncture for asthma—A systematic review. Forschende Komplementärmedizin 1996;3:148-155.
17. Peuker ET, et al. Traumatic complications of acupuncture: Therapists need to know human anatomy. Arch Fam Med 1999;8:553-558.
18. Bousquet J, et al. Asthma mortality in France. J Allergy Clin Immunol 1987;80:389-394.
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