THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 15, Number 2, 2009, pp.

183186 Mary Ann Liebert, Inc. DOI: 10.1089/acm.2008.0379

Treatment of Pneumothorax Following Acupuncture: Is a Closed Thoracostomy Necessary for a First Choice of Treatment Modality?
Eung-Soo Kim, M.D., Ph.D.,1 Jong-Yael Kang, M.D.,1 Chang-Hae Pyo, M.D., Ph.D.,2 and Gwang-Woo Rhee, M.D.3

Abstract

Background: Acupuncture is currently the most popular of all forms of complementary and alternative medicine, and acupuncture is not dangerous in the hands of a trained practitioner. However, complications of acupuncture including pneumothorax have been reported. Objectives: Despite the use of fine needles in acupuncture, the lung-collapsed degree of acupuncture pneumothorax is relatively high. In general, the treatment modality of acupuncture pneumothorax is closed thoracostomy with a chest tube of larger diameter. However, the treatment of acupuncture pneumothorax frequently faces controversy concerning the necessity of a standard chest drain insertion. Design: This was a retrospective study from March 1994 to February 2004. Subjects: Nine (9) patients were admitted due to pneumothorax following acupuncture from March 1994 to February 2004 in Hanil General Hospital, KEPCO Medical Foundation (Seoul, Republic of Korea). Results: Five (5) patients had a moderate degree of pneumothoraces, while 4 patients had a severe degree of pneumothoraces. Four (4) patients were treated by closed thoracostomy with a standard chest drain and the other four patients were treated by the percutaneous chest drainage with a narrow-bore central venous catheter. One (1) patient with a mild degree of pneumothorax was treated only by nasal oxygen inhalation. One (1) patient was treated by video-assisted thoracic surgery after the closed thoracostomy due to continuous air leak. Conclusions: We treated the acupuncture pneumothorax by making a choice between the closed thoracostomy and the percutaneous chest drainage based on a smoking history and chest radiographic findings. In the absence of smoking history and pulmonary emphysema or bullae, we got favorable results, not by the closed thoracostomy but only by the percutaneous chest drainage with a narrow-bore central venous catheter.

Introduction

of acupuncture including pneumothorax have been reported in the medical literature. Materials and Methods A retrospective study was performed on 9 patients who had acupuncture pneumothorax and who had been treated from March 1994 to February 2004. We analyzed many factors such as the sex and age distribution, the affected site,

cupuncture is an ancient procedure that has been practiced in Asia for thousands of years, and currently is the most popular of all complementary alternative medicines. Acupuncture in the chest is not dangerous because of needling onto a bone (rib) in the hands of a trained doctor, Oriental medical doctor, or acupuncturist. However, these favorable conditions are not always met, and complications

1Department 2Department 3Department

of Thoracic and Cardiovascular Surgery, Hanil General Hospital, KEPCO Medical Foundation, Seoul, Republic of Korea. of Emergency Medicine, Hanil General Hospital, KEPCO Medical Foundation, Seoul, Republic of Korea. of Diagnostic Radiology, Hanil General Hospital, KEPCO Medical Foundation, Seoul, Republic of Korea.

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184 TABLE 1. Sex/age F/82 F/23 F/58 F/32 F/42 F/83 M/38 F/50 F/56 Rt/Lt (%) 25/ 50/ 30/ 30/40 20/ 30/ 80/10 70/ 70/ Tx (Rt/Lt) CTS/ PCD/ CTS/ PCD/PCD O 2/ CTS/ CTS, VATS/O2 PCD/ PCD/ DEMOGRAPHY Tbc
OF

KIM ET AL. PATIENTS Smoking 30 py Practitioners OMD Acu Doctor Acu OMD OMD OMD Doctor OMD Combined disease DM, HT, CHF Anemia

Bullae

30 py

Asthma, HT, CVA

Rt/Lt, right/left; Tx, treatment; Tbc, pulmonary tuberculosis; CTS, closed thoracostomy; py, pack-year; OMD, Oriental medical doctor; DM, diabetes mellitus; HT, hypertension; CHF, congestive heart failure; PCD, percutaneous chest drainage with a central venous catheter; Acu, acupuncturist; O2, nasal oxygen inhalation; CVA, cerebrovascular accident; VATS, video-assisted thoracic surgery.

clinical symptoms, the degree of lung collapse and treatments, and others. Results Sex and age distribution Nine (9) patients were admitted to our hospital due to pneumothorax following acupuncture; only 1 patient was male while others were female. Their ages ranged from 23 to 83 years, and the average age was 51.6 years (Table 1). Clinical symptoms The affected sites of all patients were on the right side. Two (2) patients (nos. 4 and 7) had bilateral pneumothoraces. Except one patient (no. 3), all patients had acupuncture performed at the shoulder and the paraspinal region between

the scapula and the thoracic vertebrae. Symptoms of acupuncture pneumothorax were similar to those of spontaneous pneumothorax. Pain and discomfort of the chest were the initial symptoms in all patients, and dyspnea also appeared in 6 (nos. 2, 4, 6, 7, 8, 9) of the patients. Past history, computed tomography findings, and combined diseases In all cases, none had a history of pneumothorax before the acupuncture pneumothorax occurred. Only 1 patient had a history of pulmonary tuberculosis. The other 8 patients had at least any evidence that the patient suffered from tuberculosis shown in the chest radiograph or a high-resolution computed tomography scan of the lung. Two patients (nos. 1 and 6) smoked about 30 pack-years between the two of them. Four patients (nos. 1, 3, 6, 7) were found to have multiple

FIG. 1. Comparison of the chest radiographs between a closed thoracostomy (A, patient no. 6) and a narrow-bore percutaneous chest drainage (B, patient no. 8). In the absence of smoking history and pulmonary emphysema or bullae, favorable results were obtained only by percutaneous chest drainage with a narrow-bore central venous catheter as a modified thoracentesis method without the closed thoracostomy.

TREATMENT OF ACUPUNCTURE PNEUMOTHORAX bullae and pulmonary emphysema in a high-resolution computed tomography scan of the lung. Three (3) patients were receiving medical treatments for hypertension, diabetes mellitus, bronchial asthma, anemia, congestive heart failure, and other conditions. The practitioners of acupuncture were Oriental medical doctors (5 patients), doctors, and acupuncturists (2 patients each). Degree of lung collapse and treatments According to the classification of Rhea et al.,1 the degrees of collapsed lung are divided into mild (below 20%), moderate (20%-40%), and severe (more than 40%). Five (5) patients had moderate degree of pneumothoraces, while 4 patients had severe degree of pneumothoraces. Four (4) patients were treated by closed thoracostomy with a standard chest drain (Fig. 1A) and the other 4 patients were treated with percutaneous chest drainage with a narrowbore central venous catheter (Fig. 1B). One (1) patient with a mild degree of pneumothorax was treated only by nasal oxygen inhalation. One (1) patient was treated by video-assisted thoracic surgery after the closed thoracostomy due to continuous air leak. We treated the acupuncture pneumothorax by choosing between either the closed thoracostomy or the percutaneous chest drainage, based on smoking history and chest radiographic findings. In the absence of smoking history and pulmonary emphysema or bullae, we chose the percutaneous chest drainage. Discussion Acupuncture is an ancient Asian system of healing. It is now one of the most popular complementary alternative therapies not only in Asia but also in a large part of the world. Traditional acupuncture, now called dry needling, involves the insertion of stainless steel needles into various body regions. In addition, low-frequency current may be applied to the needles to produce greater stimulation, the socalled intramuscular stimulation (IMS). Other procedures, used separately or together with acupuncture, include injection of a liquid material through the inserted needles, which is called prolotherapy; the permanent placement of needles in the body, so-called gold dry needling; laser puncture; and others. In recent years, adverse effects of acupuncture have been discussed more intensively than ever before.2 Complications include delays in diagnosis due to the treatment of pain without proper diagnostic studies, introductions of infection and emotional trauma due to pain or scarring, and punctures of body cavities with associated complications.3 Those papers reported serious complications in some; the death of an asthmatic patient that might have been associated with the emotional stress of the first-time acupuncture treatment4; spinal cord injury5; delayed cardiac tamponade and hemothorax caused by self treatment6; the pseudoaneurysm7; needle in the paraspinal muscle and the retroperitoneal hematoma due to rupture of a pseudoaneurysm; and others provide examples from these findings. Pneumothorax due to perforation of the lungs by needle insertion into the thoracic cavity is most common of these serious complications.8,9 However, it is rare, occurring only twice in nearly a quarter of a million treatments.3,10 In general, practitioners perform acupuncture with a bone (rib)

185 touch, so the danger of pneumothorax is very low. Sometimes, the pneumothorax following acupuncture would occur during the IMS, due to needle migration. However, the needles used in acupuncture are so fine that pneumothorax due to acupuncture usually is not fatal. Some reports of bilateral pneumothoraces after acupuncture were seen.11 An autopsy case10 of bilateral tension pneumothoraces after acupuncture was reported. A study has reported a case of an acupuncture needle left in the abdomen that was recovered years later after having migrated to the chest wall and causing chronic pain.12 In the Norwegian survey of Norheim and Fonnebo, adverse effects from acupuncture were reported from 12% of doctors and 31% of acupuncturists. Pneumothorax was cited as the most common organ injury.9 In our report, 22% of doctors and 55.6% of Oriental medical doctors and 22% of acupuncturists reported as such. We treated the acupuncture pneumothorax by choosing between the closed thoracostomy and the percutaneous chest drainage based upon a smoking history and chest radiographic findings. In the absence of smoking history and pulmonary emphysema or bullae, we obtained favorable results only by percutaneous chest drainage with a narrowbore central venous catheter as a modified thoracentesis method without the closed thoracostomy. Consequently, in acupuncture pneumothorax that is without definite causes or underlying diseases, a percutaneous chest drainage method is recommended due to less possibility of scarring and less pain. Conclusions We report 9 patients who presented to the Departments of Thoracic and Cardiovascular Surgery and Emergency Medicine related to pneumothorax following acupuncture. Four (4) patients were treated by closed thoracostomy, and the other 4 patients were treated by the percutaneous chest drainage with a narrow-bore central venous catheter. One (1) patient with a mild degree of pneumothorax was treated only by nasal oxygen inhalation. We treated the acupuncture pneumothorax by making a choice between the closed thoracostomy and the percutaneous chest drainage based on a smoking history and chest radiographic findings. In the absence of smoking history and pulmonary emphysema or bullae, we got favorable results, not by closed thoracostomy but only by percutaneous chest drainage with a narrow-bore central venous catheter. Disclosure Statement No competing financial interests exist. References
1. Rhea JT, Deluca SA, Greene RE. Determining the size of pneumothorax in the upright patient. Radiology 1982;144: 733. 2. Yamashita H, Tsukayama H, White AR, et al. Systemic review of adverse events following acupuncture: The Japanese literature. Complement Ther Med 2001;9:98104. 3. Ernst E, White AR. Prospective studies of the safety of acupuncture: A systemic review. Am J Med 2001;110:481 485.

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4. Ogata M, Kitamara O, Kubo S, Nakasono I. An asthmatic death while under Chinese acupuncture and moxibustion treatment. Am J Forensic Med Pathol 1992;13:338341. 5. Kita Y, Naritom H, Sawada T, et al. Cervical spinal cord injury caused by acupuncture. Arch Neurol 1988;45:831. 6. Hasegawa J, Noguchi N, Yamasaki J, et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology 1991;78:5863. 7. Fugiwara T, Tanohata K, Nagase M. Pseudoaneurysm caused by acupuncture: A rare complication. Am J Roentgenol 1994; 162:731. 8. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122133. 9. Norheim AJ, Fonnebo V. Adverse effects are more than occasional case reports: Results from questionnaires among 1135 randomly selected doctors, and 197 acupuncturists. Complement Ther Med 1996;4:813. 10. Iwadate K, Ito H, Katsumura S, et al. An autopsy case of bilateral tension pneumothorax after acupuncture. Legal Med 2003;5:170174.

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11. Kao CL, Chang JP. Bilateral tension pneumothorax after acupuncture. J Emerg Med 2002;22:101102. 12. Carron H, Epstein BS, Grand B. Complications of acupuncture. JAMA 1974;228:15521554.

Address reprint requests to: Eung-Soo Kim, M.D., Ph.D. Department of Thoracic and Cardiovascular Surgery Hanil General Hospital KEPCO Medical Foundation 388-1 Ssangmun-3-Dong Dobong-Gu Seoul, 132-703 Republic of Korea E-mail: earth916@hotmail.com