Acupuncture for Quick Relief of Asthmatic Exacerbation
October 1998; Volume 1: 109-113
By Dónal P. O'Mathúna, PhD
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 room 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 NIH 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 this publication.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
Mechanism of Action
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 Schools of Practice
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).
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
Clinical Studies-Repeated Use
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
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
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.
The author 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.