Wei Yu-ting (魏玉婷), Yan Xing-ke (嚴(yán)興科)

School of Acupuncture and Tuina, Gansu University of Chinese Medicine, Lanzhou 730000, China

Asthma, also known as bronchial asthma (BA), is a common chronic inflammatory disease of the airways involving multiple cells and cytokines. Common symptoms include recurrence of wheezing, coughing,chest tightness and shortness of breath[1]. Research has shown that the incidence of asthma is rising by the rate of 20%-50% every 10 years[2]. Medicine treatment is the most common therapy currently, though with major adverse reaction and strong tolerance. As a physical therapy, acupuncture can adjust pulmonary ventilation to improve pulmonary function, alleviate clinical symptoms and thus control asthma, so it is widely used in clinical treatment for asthma in recent years.Pulmonary function examination can reflect the real time pulmonary function in asthma patients, providing objective indicators for diagnosis and therapeutic evaluation[3], such as forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), and forced vital capacity (FVC). PEF can detect the obstruction status in airways, especially major ones in early stage,and FEV1 can reflect the severity of the disease[4]. We have summarized the clinical studies in the recent 10 years of acupuncture for pulmonary functions of asthma patients, and the results are as follows.

1 Materials and Methods

1.1 Inclusion criteria

Clinical studies on acupuncture in treating BA between 2005 and 2016 (including personal experience and academic thesis); treatment methods included acupuncture plus medicine (Chinese or Western medicine) or acupuncture plus cupping; evaluation methods were based on indexes reflecting pulmonary function (FEV1, PEF, etc.); only one representative article was included among similar articles with the same points selection of the same first author, but included all if the points selection were different.

1.2 Exclusion criteria

Animal experiment and review articles were excluded.

1.3 Literature filtration

Two independent researchers filtrated original literature separately. If there were any doubts,discussion was allowed between two persons or asked for help of the third researcher to determine inclusion.A total of 3 268, 52 and 39 articles were retrieved from China National Knowledge Infrastructure (CNKI),Wanfang Academic Journal Full-text Database (Wanfang)and PubMed. By reading abstract and whole text, 3 314 articles were excluded and 45 were finally included.

2 Results

Points selection, needling techniques and acupuncture manipulations were analyzed to summarize the influence of acupuncture on pulmonary functions in asthma patients.

2.1 Influence of points on pulmonary function in asthma patients

As a traditional Chinese medicine (TCM) treatment approach, acupuncture emphasizes points selection in intervening pulmonary functions in asthma patients. In the principle of TCM pattern differentiation, points selection can be classified as single point and multiple points; and besides acupuncture alone, acupuncture plus medicine is also used according to different circumstances.

2.1.1 Single-point acupuncture on pulmonary function

Empirical single-point selection for asthma has the merit of applying less points and quick onset. Treatment of single-point acupuncture for asthma can improve pulmonary function and alleviate clinical symptoms,mainly used in acute stage of asthma.

Acupuncture alone: Cai ZH,et al[5]observed the therapeutic function of puncturing Qingchuan (Extra)[between Lianquan (CV 23) and Tiantu (CV 22), in the sunken below the medial front of cricoid cartilage, a feeling of contradiction when pressing with hand] for asthma, during which lifting-thrusting method was used,and compared with ordinary acupuncture at Dingchuan(EX-B 1), with no reinforcing or reducing manipulation.The result showed that instant wheezing time was shorter in the treatment group, and the improvement of PEF was superior in the treatment group, showing a statistical difference (P＜0.01). It’s indicated that puncturing Qingchuan (Extra) can rapidly relieve wheezing symptom in acute stage of asthma and improve pulmonary function, and the mechanism included reducing airway resistance and increasing pulmonary ventilation. Li W,et al[6]observed electroacupuncture (EA) at Feishu (BL 13) for asthma,and compared it with oral administration of sulpiride.The result showed that both methods can improve PEF,FEV1, FVC and FEV1% to different degrees, but the effect in the treatment group was better than that in the control group, showing a statistical significance(P＜0.05). It indicated that EA at Feishu (BL 13) has the dual function of improving airway obstruction and decreasing airway resistance, and has a better function than regular Western medicine treatment in relieving clinical symptoms and improving pulmonary functions for asthma patients in the acute stage.

Acupuncture plus Western medicine: Han J[7]observed the effect of puncturing bilateral Yuji (LU 10)on the basis of oxygen inhalation and azithromycin anti-infection treatment, in which lifting-thrusting reinforcing-reducing manipulation was applied, and compared it with routine treatment plus salbutamol aerosol inhalation treatment. The result showed that instant FEV1, PEF and FEV1% were improved in the treatment group, while indicators in the control group were significantly improved 5 min after inhalation,indicating that puncturing Yuji (LU 10) had immediate effect in relieving asthma, and such effect was better than salbutamol aerosol. As the Xing-Spring point of the Lung Meridian, Yuji (LU 10) can unblock yang, purge heat and thus relieve asthma, for both cold and heat wheezing, and it can also increase cyclic adenosine monophosphate (cAMP) and cAMP/cyclic guanosine monophosphate (cGMP) ratio in lung tissues, relieve bronchial spasm and improve pulmonary venticulation[8], which may be its mechanism in treating acute asthma.

2.1.2 Multiple-points acupuncture on pulmonary function

Multiple-points acupuncture for asthma largely conforms to pattern differentiation and symptomatic point selection principle, and common points combination rules in clinical practice. Compared with single-point acupuncture, it is more widely used in clinical and mechanism studies. Multiple-points acupuncture can improve pulmonary function and alleviate symptoms of all stages and varying severities,and thus control symptoms of asthma.

Acupuncture alone: Xie YL,et al[9]used yangwarming and qi-tonifying acupuncture to treat chronic persistent asthma, eight points including Dazhui (GV 14),Feishu (BL 13), Taixi (KI 3), Zusanli (ST 36), Danzhong(CV 17), Dingchuan (EX-B 1), Zhigou (TE 6) and Jianshi(TE 6) were used. Lifting-thrusting and twirling reinforcing manipulation was applied to the former 4 points, and lifting-thrusting and twirling reducing manipulation was applied to the latter 4 points. It was compared with seretide inhalation. The result showed that the improvements of all pulmonary function indicators were better in the observation group. Besides,clinical symptoms score and immunoglobulin E (IgE)level decreased in both groups, but with better improvements in the observation group, showing statistical significances (P＜0.05), indicating that yangwarming and qi-tonifying acupuncture can regulate immune reaction, relieve airway inflammation,decrease airway reaction and thus control symptoms in chronic persistent asthma and improve pulmonary functions. Therefore, it’s worth clinical popularization.Chu KA,et al[10]found that acupuncture at Lieque (LU 7),Hegu (LI 4), Fenglong (ST 40) and Neiguan (PC 6) could instantly improve FEV1 in asthma patients, while such effect was inferior to inhalation of bronchodilator. Pai HJ,et al[11]proved that acupuncture could alleviate inflammation reaction and improve lung’s capacity in asthma patients. They also found that sham acupuncture had the same effect as acupuncture but with shorter course of treatment, and noted that sham acupuncture could not be taken as a control group when acupuncture was the primary intervention method. Wechsler ME,et al[12]also proved that when salbutamol inhalation treatment was adopted in the treatment group, sham acupuncture in the control group, the latter one could improve FEV1, and thus,sham acupuncture was not recommended for placebo treatment.

Acupuncture plus medicine: Zhang ZL,et al[13]used qi-regulating and phlegm-resolving acupuncture combining routine treatment to intervene pulmonary functions of asthma patients. The result showed that the effect was better than that of routine treatment alone, and proved that such needling technique could improve pulmonary function and alleviate clinical symptoms by positive feedback of Th1 cell subset,negative feedback of Th2 cell subset, reduction of inflammatory factors and airway hyper-responsiveness.

Shao SJ,et al[14]used Shao’s five needling therapy combining oxygen and aerosol inhalation to treat asthma patients in acute attack stage, and observed its influence on pulmonary functions. The result showed a better efficacy compared to oral intake of theophylline sustained tablets combining synthesis therapy.Experimental research showed that Shao’s five needling therapy can decrease the thickness of bronchial wall and smooth muscle, reduce the expression of transforming growth factor-β1 (TGF-β1) in small airways of rats, facilitate reconstruction of airway and improve the respiratory function, and thus control asthma[15].Wu JH[16]observed the combination therapy of acupuncture and medicine for asthma, which showed a better improvement of pulmonary function than Western medicine alone. It’s indicated that basic Western medicine treatment plus acupuncture could adjust humoral immune response and nerves functions to build up defense, reduce allergic reaction, and produce a better effect in treating asthma and improving pulmonary functions[17]. Zhang WP[18]observed the effect of lung-dispersing, spleenstrengthening and kidney-tonifying acupuncture combining anti-asthma drug on pulmonary functions of asthma patients with different severities. The result showed that the combination therapy was better than anti-asthma drug alone, and the mechanism might relate to autonomic nerve regulation. Modern research has showed that the adjustment function of acupuncture on viscera was linked with autonomic nerves system[19]. Asthma can cause the imbalance between sympathetic and parasympathetic nerve in governing lung and main bronchia, while acupuncture can mobilize organ structure and function, activate sympathetic nerve and inhibit parasympathetic nerve,control gland secretion, release bronchia spasm,alleviate asthma and improve pulmonary function.

The included literature showed that the selection of points in acupuncture therapy intervening asthma patients’ pulmonary function is crucial in clinical practice, especially in the case when multiple points are used. The combination of points is not a simply sum of points, but an coordinated integrity on the basis of mastering specialties of identity and rules of integration,which is the key to improving clinical efficacy[20].Meanwhile, acupoint is also the foundation of acupuncture manipulation. From massive clinical reports, empirical single point and points combination are widely used in improving pulmonary functions of asthma patients (Table 1).

Table 1. Point selection rules of common single and group points (major points ≤5) for pulmonary functions in asthma patients

2.2 Influence of needling technique on pulmonary function in asthma patients

Needling techniques are rooted in TCM theory,summarized from visceral, meridian, eight principle syndrome differentiation and clinical experience. The selection of points is conformed to syndromes or pattern differentiation or clinical experience. In this essay, we have summarized different needling techniques on pulmonary functions of asthma patients in clinical practice in Table 2.

Table 2. Summary of needling technique for pulmonary functions in asthma patients

2.3 Influence of acupuncture manipulation on pulmonary function in asthma patients

Acupuncture manipulation is closely linked with clinical efficacy. Different acupuncture manipulations at the same point will exert different qualities and quantities of stimulation to human body, and disparate influence on visceral organic metabolism and functions[28]. Selection of manipulation should be based on deficiency and excess characteristics of disease and points to generate the most appropriate stimulation,and thus improve clinical efficacy.

When using acupuncture to intervene pulmonary function of asthma patients, common acupuncture manipulations include lifting-thrusting and twirling reinforcing and reducing method, and even reinforcing-reducing manipulation. The selection of manipulation should be also based on individuals and characteristics of diseases. For example, Feishu (BL 13)is the Back-Shu point of the Lung Meridian which can reflect deficiency and excess status of internal organs,and also the location to treat the relevant diseases.Therefore, such point is the main point to treat lung diseases no matter in the case of deficiency or excess[14]:for acute onset, applying reducing method can dredge lung, resolve phlegm and relieve asthma; in remission stage, applying reinforcing method to such point can tonify lung qi, reinforce the healthy qi and eliminate the pathogenic factors. Therefore, when intervening pulmonary functions with acupuncture, the selection of reinforcing or reducing manipulation should be based on the sequence of symptoms and characteristics of diseases, to exert the best efficacy for pulmonary function and control of symptoms (Table 3).

Table 3. Rules of different acupuncture manipulations

3 Mechanism of Acupuncture in Intervening Pulmonary Function in Asthma

Acupuncture can exert a benign two-side stimulation to human body, and it brings regulation on organs and systems from multiple levels and approaches. Generally,it’s manifested as reduction of inflammatory factors,decrease of airway inflammation and airway hyperresponsiveness, release of bronchial spasm, and reduction of airway resistance and increase of pulmonary ventilation volume. However, the respective long-term effect of single and group points on pulmonary functions in asthma patients still requires further investigation. The detailed mechanism is summarized in Table 4.

Table 4. Summary of mechanism of acupuncture on pulmonary functions in asthma

4 Conclusion

By summarizing clinical literatures of acupuncture in intervening pulmonary functions of asthma patients, we can conclude that acupuncture has certain clinical effect in improving pulmonary functions of asthma patients. In which, the selection of points, the needling techniques and manipulation are the manifestation of pattern differentiation principle of TCM, and the key to a satisfactory clinical effect. Modern researches have also provided solid objective proof for acupuncture treatment. Meanwhile, there are still some limitations,e.g. the interval, time and course of treatment are not unified, which will all decrease the feasibility of acupuncture treatment. Besides, Scheewe S,et al[33]found that acupuncture can intervene instant PEF in asthma patients. After certain courses of acupuncture treatment, patients’ anxiety score was decreased, while the treatment showed no improvement in FEV1/FVC.Choi JY,et al[34]also found that acupuncture had no obvious efficacy on pulmonary functions in asthma patients, which might be caused by limited treatment courses failing to generate an accumulated effect,incorrect pattern differentiation, poor acupuncture operation and error during pulmonary function measurement, etc. Therefore, future research needs to investigate acupuncture of different intervals, durations,times and courses to build up a treatment protocol on the one hand, and conduct laboratory research on the other hand to provide theoretical basis for such method.By doing this, after constant summing of experience, an integrated standard acupuncture treatment method can be developed from clinical practice, and provide guidance for asthma treatment.

Conflict of Interest

The authors declared that there was no potential conflict of interest in this article.

Acknowledgments

This work was supported by Level 2 Workstation Project of Gansu University of Traditional Chinese Medicine,Henan Inheritance Office of Shao’s Acupuncturemoxibustion School of State Administration of Traditional Chinese Medicine in 2016 (2016年度國家中醫(yī)藥管理局河南邵氏針灸流派傳承工作室甘肅中醫(yī)藥大學(xué)二級工作站項目資助, No. LP0116036-Z8).

Received: 16 August 2017/Accepted: 19 September 2017

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