|Year : 2015 | Volume
| Issue : 3 | Page : 429-436
Perioperative acupuncture in asthma patients under general anesthesia
Maha M.I. Youssef MD 1, Amani Abou Zeid2, Laila Ahmed Abou Ismail3
1 Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Department of Chest, Kasr Al Ainy Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Department of Clinical and Chemical Pathology, Head of Women Health Care Unit by Acupuncture, National Research Centre, Cairo, Egypt
|Date of Submission||05-Nov-2013|
|Date of Acceptance||29-Dec-2013|
|Date of Web Publication||29-Jul-2015|
Maha M.I. Youssef
Department of Anesthesia, Intensive Care, and Pain Management, Kasr Al Ainy Hospital, Faculty of Medicine, Cairo University, Cairo 11431
Source of Support: None, Conflict of Interest: None
Background and objective
The incidence of asthma has increased in the last few years. Acupuncture was found to have a bronchodilating effect in asthmatic patients. The aim of this study was to evaluate the perioperative bronchodilator effect of acupuncture in comparison with regular inhalation asthma treatment.
Patients and methods
The study was conducted at Kasr AL Ainy Teaching Hospital. Forty patients of both sexes, aged 20-40 years, classified as ASA 2, with mild partially controlled asthma [determined from forced expiratory volume in the first second (FEV 1 ), forced expiratory volume/forced vital capacity (FEV 1 /FVC), peak expiratory flow rate (PEFR) ranging from 70 to 79%] were allocated to two groups. Group A (n = 20) received preoperative acupuncture for 30 min, and if there was clinical improvement on the basis of spirometer tests patients were allowed to proceed with their operation, followed by intraoperative acupuncture until fully awake. Group B (n = 20) received a 30 min preoperative treatment with 10 drops of nebulized salbutamol (1 mg, 1 ml) and 500 mg ipratropium bromide diluted in 2 ml normal saline inhaled through a nebulizer. FEV 1 , FEV 1 /FVC, PEFR, SPO 2 , and hemodynamic data were collected before treatment T(0) and 30 min after the end of treatment T(30). The onset of bronchodilation as marked by the disappearance of wheezing and improvement in patient symptomatology, the success rate of treatment (improved pulmonary function tests >12%, disappearance of wheezing) recorded at T(30), intraoperative hemodynamic changes, peripheral oxygen saturation, end tidal CO 2 levels, peak airway pressure, and any complications related to the different treatments used were also recorded.
Wheezing disappeared after 9.5 ± 1.67 min, recorded from T(0), in group A compared with 14.4 ± 2.80 min in group B. At T(30), pulmonary function tests improved by more than 12% and wheezing disappeared in 16 (80%) patients in group A and in 18 (90%) patients in group B. This was statistically significant (P < 0.001). There was a statistically significant increase in FEV 1 , FEV 1 /FVC, and PEFR peripheral oxygen saturation (SpO 2 ) within each group compared with T(0). Intraoperatively, the peak airway pressure was clinically comparable in both groups, although it was statistically significant (P = 0.04). In group A there were no complications related to the use of acupuncture. Two (10%) patients in group A and 14 (70%) patients in group B experienced an increase in heart rate by more than 10%.
Perioperative acupuncture seemed to improve respiratory functions without serious side effects.
Keywords: acupuncture, asthma, bronchodilation, general anesthesia, perioperative bronchospasm, pulmonary function tests
|How to cite this article:|
Youssef MM, Zeid AA, Abou Ismail LA. Perioperative acupuncture in asthma patients under general anesthesia. Ain-Shams J Anaesthesiol 2015;8:429-36
|How to cite this URL:|
Youssef MM, Zeid AA, Abou Ismail LA. Perioperative acupuncture in asthma patients under general anesthesia. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jul 22];8:429-36. Available from: http://www.asja.eg.net/text.asp?2015/8/3/429/161727
| Introduction|| |
Hyperactive airway diseases have increased in the general population in the last decade, especially in industrialized countries ,, . In addition, bronchospasm may occur under general anesthesia. Acupuncture has proved its efficacy in the management of asthma , .
Many researchers found a relation between relief of asthma by acupuncture and the neuroregulation of air passages. Increasing the sympathetic tone together with smooth muscle relaxation can be achieved by needling specific acupoints on the back  . Many drugs have been used to control asthma attacks in patients; unfortunately, some may have serious side effects ,, . According to the Global Initiative for Asthma (GINA) guidelines, reversal of bronchoconstriction was acceptable if there was a more than 12% increase in forced expiratory volume in the first second (FEV 1 ) after bronchodilator treatment  .
The shortage of medical resources and funds in our country have propelled researchers and patients to find other ways to control the disease. Acupuncture might be of help in asthmatic patients with contraindication to short B 2 agonist medications.
In the current study, we hypothesized that the use of perioperative acupuncture would relieve bronchospasm, improve lung functions, and dilate the airway passages intraoperatively. This would give the patient a chance to undergo surgery.
Thus, we aimed to investigate the effectiveness and drawbacks of perioperative acupuncture in improving the respiratory functions [FEV 1 and FEV 1 /forced vital capacity (FVC), peak expiratory flow rate (PEFR)] and SpO 2 , and in relief from wheezing in asthmatic patients when compared with inhaled bronchodilators for the treatment of bronchial asthma  .
| Patients and methods|| |
This prospective randomized controlled open labelled study was conducted at Kasr Al Ainy Teaching Hospital, Department of Anesthesia, Cairo University, Egypt, from October 2012 to October 2013. After approval from the local ethics committee and taking informed written consent from the patients, 40 patients of both sexes, aged 20-40 years, of ASA grade II, with mild partially controlled asthma according to the newest classifications of GINA guidelines  and scheduled for minor operations under general anesthesia were enrolled in the study. They were randomly allocated into two groups by means of computer-generated lists of random numbers that were concealed in closed envelopes. Group A (n = 20) received acupuncture and group B (n = 20) received nebulized inhaled bronchodilators. Mild partially controlled asthma patients may present with any of the following: occurrence of daytime symptoms more than twice/week; presence of any limitation of activities; any nocturnal symptoms/awakening; need for reliever/rescue treatment more than twice/week; lung function (FEV 1 , FEV 1 /FVC, PEFR ranging from 70 to 79%) less than 80% of predicted or personal best, if known; and responsive to bronchodilator treatment with an increase of more than 12% in baseline values , .
However, patients with skin infections, coagulation abnormalities, bleeding tendencies, international normalized ratio greater than 1.5, hepatic patients with esophageal varices, recent chest infection, corpulmonale, pulmonary hypertension, hypoxemia, dyspnea at rest, cardiac abnormality, difficulty in communicating, as in deafness, and mental retardation (difficulty in complying with the study regimen) were excluded from the study.
Group A received perioperative acupuncture treatment as the only bronchodilator agent (preoperative 30 min treatment). At the end of the preoperative treatment T(30), if the lung functions improved, as assessed by selected pulmonary function tests (PFTs), and if the wheezing disappeared by auscultation, together with improvement in the SpO 2 , the patient was allowed to proceed with his operation, and acupuncture was continued until adequate recovery, which was confirmed by the Modified Aldrete Score (MAS; score 9-10)  .
Group B received preoperative bronchodilating medications in the form of 10 drops of salbutamol (1 ml) and 500 mg ipratroium bromide diluted in 2 ml saline for 30 min of inhaled nebulizer treatment. In addition to routine investigations, PFTs and evaluation of arterial blood gases were included. PFTs included in the preoperative workout were important to identify patients who were responsive to bronchodilators. However, our baseline PFTs were those carried out before treatment at T(0).
In the preoperative preparation room, an intravenous cannula was inserted for all patients. All patients were fully monitored with routine standard monitors - namely, ECG, noninvasive blood pressure, and pulse oximeter (SpO 2 ). Preoperative chest auscultation was performed in the three lung zones, upper, middle, and lower, in the midclavicular line, midaxillary line, over the back in the midscapular line, and interscapular area for detection of the type, timing, and location of wheezes. The patients were shown how to use the spirometer [Figure 1].
|Figure 1: MIR Spirobank used for pulmonary function tests. Cun, the measuring unit for localization of acupoints on the body surface [13,14].|
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Regarding acupuncture, sterile disposable needles of 0.30-0.32 mm thickness were used.
The main acupoints were GV14, BL12, BL13, BL23, BL43, Dingchuan (Ex-B 1).
Additional acupoints were LU5, LU6, LU7, LU9, PC6, PC3, LI4, and LI11 (situated in the upper extremity), CV4, 17, and GV20 (situated approximately at the top of the head), and ST36, ST40, KI3, SP6, and LIV2 (situated in the lower extremity) ,, [Figure 2] [Figure 3] [Figure 4] [Figure 5].
|Figure 2: Acupoints on the head and back [13,16]. GV14: at C7; Dingchuan (Ex-B 1): 0.5 cun lateral to GV14 (C7); GV20 (situated approximately at the top of the head): 5 cun posterior to the anterior hairline; BL12: 1.5 cun lateral to GV 12, level at T2; BL13: 1.5 cun lateral to GV 12, level with T3; BL23: 1.5 cun lateral to GV 4, level with L2; BL43: 3 cun lateral to the GV line, level with T9.|
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|Figure 3: Conception (CV) and large intestine (LI) meridians [13,16]. CV2: at pubic symphysis; CV4: 2 cun above CV2; CV17: midway between the nipples at the level of the fourth intercostal space; LI4: in the middle of the second metacarpal bone on the radial side; LI11: at the lateral end of the transverse cubital crease midway between LU 5 and the lateral epicondyle of the humerous.|
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|Figure 4: Lung, and pericardium meridian acupoints [13,16]. LU5: at the cubital crease on the radial side of the biceps brachii tendon; Lu7: 1.5 cun above the wrist crease, superior to the styloid process of the radius; LU9: at the wrist crease on the radial side of the radial artery; Lu6: 7 cun above LU9 on the line joining LU5 and LU9; PC3: on the transverse cubital crease on the ulnar side of the biceps brachii tendon; PC6: 2 cun above the wrist crease between the tendons of palmaris longus and flexor carpi radialis.|
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|Figure 5: Lower limb acupoints [13,16]. ST36: 3 cun below ST35; ST40: 8 cun below ST35, one finger width lateral to ST38, one finger width lateral from the anterior border of the tibia, two finger width lateral to the anterior border of the tibia; KI3: in depression midway between the tip of the medial malleolus and the attachment of the Achilles tendon; SP6: 3 cun directly above the tip of the medial malleolus on the posterior border of the tibia; LIV2: on the dorsum of the foot between the first and second toes, proximal to the margin of the web at the junction of the red and white skin.|
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Under complete aseptic conditions, with the patient in the sitting position, the back was exposed and specific selected acupoints were needled. Each point was stimulated manually by needle rotation in clockwise direction for 5 s repeatedly over a total period of 5 min. Then the needles were removed and the patient was allowed to lie down in a semisitting position. The rest of the points were needled. CV17, ST36, LU5, and LU6 acupoints were stimulated electrically until the patient experienced the 'De Qi' feeling in the form of a characteristic numbness, soreness, or slight spreading pain , . If acupuncture succeeded in producing adequate improvement in the PFTs by more than 12% and to bring relief from wheezing, at the end of the preoperative treatment T(30), the patient was allowed to proceed with his surgery. Acupuncture needles were kept in place and electrostimulation was continued all through the operative time and until full recovery of conscious level in the early postoperative period (defined as the time from the end of operation until the patient is fit for discharge with MAS 9-10). Then, the needles were removed and the patient was transferred to his ward.
FEV 1 , FEV 1 /FVC, PEFR, and hemodynamic data were collected before the treatment ['pretreatment' T(0)] and at the end of the treatment ['post-treatment' T(30)]. For both groups, after starting the treatment, auscultation of the chest was carried out every 5 min until disappearance of wheezing to record the onset of bronchodilation. It was defined as the time elapsing from the start of the treatment at T(0) until disappearance of wheezing.
At T(30) after treatment time, the number of patients who fulfilled the inclusion criteria clinically and on the basis of PFTs in both groups was recorded to calculate the success rate. If there was no improvement in the chest condition after 30 min in either group, the patient was sent to his ward to continue his regular medications.
While using a spirometer, the patients were encouraged to take a deep inhalation, followed by maximum forced expiration, and then a second deep inhalation, to perform the flow volume loop. The maneuver was repeated twice. The highest FEV 1 value from each set of measurements and percentage change in FEV 1 (%) were used for analysis. PFTs were carried out with a portable spirometer (Spirobank, SN: A23-04003997; MIR, Rome, Italy)  by an experienced chest physician  [Figure 1].
At T(30) after treatment time, data on auscultation, FEV 1 , FEV 1 /FVC, PEFR, SPO 2 , and hemodynamic changes were collected. Patients fulfilling the inclusion criteria were allowed to proceed with their surgery; general anesthesia was achieved using intravenous 0.02 mg/kg midazolam, 1 mg/kg lidocaine, 2 mg/kg fentanyl, 2 mg/kg propofol, and 0.15 mg/kg cis-atracurium. Surgical levels of anesthesia were achieved by inhalation of sevoflurane with concentrations of 1.5-2% adjusted for age.
After adequate muscle relaxation, which was confirmed by train of four (TOF) (0), a laryngeal mask airway of proper size selected on the basis of body weight (LMA classic; Teleflex, Philadelphia, Pennsylvania, USA) was inserted to secure the airway according to the manufacturer's recommendations. Intraoperatively [T(IO)], the ventilator settings were adjusted to keep preoperative normocapnea. Intravenous fluids were given to maintain hemodynamic stability.
Intraoperatively, as a measure of airway obstruction, the peak airway pressure (PAWP) was selected to gauge the airway resistance. The PAWP was studied by recording the readings on the pressure gauge of the ventilator, and the mean PAWP for each patient was recorded together with ETCO 2 and SPO 2 at 10 min intervals. At the end of the operation, after adequate reversal of muscle relaxant (2.5 mg neostegmine and 1 mg atropine diluted to 10 ml solution with normal saline and given slowly) confirmed by TOF (0.9), the LMA was removed. After regaining full consciousness (MAS 9-10)  , chest auscultation was performed to ensure patent airways (in group A electroacupuncture was stopped, and the needles were removed) and the patients were sent to their wards.
All medications needed for emergency treatment of bronchial asthma were available and kept in hand for the treatment of asthma if it occurred at any time during the study. If any patient needed extra treatment he was managed accordingly and was excluded from the study.
The patients were followed up for 3 h postoperatively; auscultation of the chest was carried out at 15 min intervals for the first hour and then at 30 min intervals to record the onset of recurrence of wheezes.
Any complications due to the use of acupuncture (fainting, infection, needle break, pneumothorax)  and inhaled B2 agonists (increase heart rate, tremors, or nausea) were also recorded.
We planned to enroll 20 patients per study group to achieve a power of 80% to detect a 12% or more improvement in the FEV 1 within either group, assuming a noncentrality parameter of 3, and based on a previously published study  , assuming a = 0.05 (two tailed), b = 0.2, and effect size dz of 0.668.
Data were collected and analyzed using SPSS version 19 (IBM Corp, Armonk, NY, USA). FEV 1 , FEV 1 /FVC, PEFR, and SpO 2 were measured by paired and unpaired t-tests to measure within-group and between-group data, respectively. Mean heart rate (MHR) and mean blood pressure (MBP) were measured by repeated-measures analysis of variance and the unpaired t-test to measure within-group and between-group data, respectively. Categorical data were compared by means of the χ2 -test. Ordinal data were expressed as mean ± SD, whereas categorical data were expressed as frequency (%). P less than 0.05 was considered statistically significant.
| Results|| |
There were no statistically significant differences between the two groups regarding the demographic characteristics of age, sex, body weight, surgical time (the time between induction of anesthesia until removal of LMA from the patient's mouth in the operating room) [Table 1].
Pretreatment recordings at T(0)
All studied data were collected and recorded and were comparable between the two groups [Table 2]. On auscultation, wheezing was seen to have disappeared completely within 9.5 ± 1.67 min after starting acupuncture treatment in group A, and within 14.5 ± 2.80 min in group B after starting the bronchodilator treatment. This finding was statistically significant (P < 0.001) [Table 3].
Post-treatment at T(30)
The bronchodilator treatment was successful in 16 (80%) patients in group A and in 18 (90%) patients in group B (increase in PFTs >12%, disappearance of wheezing by auscultation, and improvement of peripheral oxygen saturation by SpO 2 ). There was no statistically significant difference between the studied groups regarding mean FEV 1 , FEV 1 /FVC, and SPO 2 . There was a statistically significant increase in mean PEFR in group B compared with group A (P = 0.005). However, within the same group, comparison at different time intervals showed a high statistically significant increase in FEV 1 , FEV 1 /FVC, PEFR, and SPO 2 when they were compared with T(0) findings [Table 2].
Regarding hemodynamic changes, there was a statistically significant increase in MHR and MBP in group B when compared with group A (**P < 0.001 and P = 0.04, respectively). Within-group comparison showed statistically significant decrease in MHR in group A (ͷP < 0.05), whereas there was a high statistically significant increase in MHR and MBP in group B when compared with T(0) (ͷͷP < 0.005) [Table 4].
Intraoperative data collection T(IO)
Under general anesthesia, the data were collected at 10 min intervals until the end of operation. The mean values of SpO 2 , ETCO 2 , and PAWP were recorded for each patient [Table 5]. However, SpO 2 was taken under 100% oxygen with no statistically significant difference between the two studied groups. The mean PAWP showed a statistically significant increase in group B compared with group A (P = 0.04). However it was clinically insignificant. The mean ETCO 2 readings were comparable between groups, with no statistically significant difference [Table 5]. There was a greater statistically significant increase in MHR in group B compared with group A. This increase in heart rate was secondary to bronchodilator administration (**P < 0.001). Regarding group A, within-group comparison showed a statistically significant decrease in MHR and in MBP when data were compared with T(0) (ͷP < 0.05 and ͷͷP < 0.005, respectively). Furthermore, there was a highly significant decrease in MBP (‡‡P < 0.005) when data were compared with T(30) [Table 4].
With regard to within-group comparisons in group B, a highly significant increase in MHR (ͷͷP < 0.005) was seen when data were compared with T(0) and a highly significant decrease in MHR and MBP (‡‡P < 0.005) when data were compared with T(30) [Table 4].
With regard to hemodynamic changes, although there were statistically significant differences within groups, clinically those differences were not significant.
None of the subjects needed extra treatment with rescue bronchodilators.
Early postoperative period
The early postoperative period was defined as the time from removal of LMA out of the patient's mouth until adequate recovery with full conscious level confirmed by the MAS (9-10) [Table 6].
When fully recovered (MAS 9-10)  [Table 6], the chest of patients in group A was auscultated before removal of acupuncture needles to confirm the presence of clear airway passages. The patients were followed up for 3 h after recovery. The time of recurrence of the wheezes and reappearance of patient symptomatology (defined as the time elapsing from full recovery until recurrence of wheezes) was recorded for both groups and showed highly significant difference between the two groups (P < 0.001). There were no complications in group A related to the use of needles. However, 2 (10%) and 14 (70%) cases in group A and group B, respectively, experienced increase in heart rate of more than 10% from prestudy baseline value. This was highly significant (<0.005). No other complications were encountered during the study in either group [Table 3].
| Discussion|| |
The treatment of asthma is a challenge to physicians all over the world. Asthma is a serious incapacitating health problem. Bronchodilators decrease airway inflammation and bronchial hyper-reactivity and produce bronchodilation. The use of several medications to control the chest condition and the serious side effects have directed many patients toward seeking complementary medicine to improve the patient's health status  .
Acupuncture practice has been increasing worldwide. Clinical trials have found that repeated acupuncture treatment results in reduction of bronchospasm, production of pulmonary vasodilatation, bronchial smooth muscle relaxation, and ease of breathing  .
Patients were diagnosed as having mild partially controlled asthma according to GINA guidelines (FEV 1, FEV 1 /FVC, and PEFR are between 70 and 79% of predicted value for age, sex, and body weight), which improved by 12% or more on bronchodilators as shown in their preoperative workout , .
A recent meta-analysis found that acupuncture resulted in short-term bronchodilation but was not efficient in long-term treatment for asthma , . Thus, in the current study, the needles were kept in place until full recovery to ensure adequate bronchodilation all through the perioperative time.
We found that perioperative treatment with acupuncture led to rapid bronchodilation as marked by the disappearance of wheezing and improvement in the chest condition. This was confirmed by selected PFTs. In our study, the acupuncture succeeded in 80% of cases in group A, whereas the bronchodilator treatment was successful in 90% of cases in group B. The effect of acupuncture was comparable to that of bronchodilator therapy regarding the PFTS, except for PEFR, which showed statistically significant increase in group B compared with group A after treatment at T(30). At T(30), the FEV1, FEV1/FVC, PEFR, and SpO 2 data were significantly increased in each group when compared with T(0). In accordance with our study are the studies conducted by Zang  in which the patients were treated at points Kongzui (Lu 6) and Yuji (Lu 10). Immediate bronchodilation occurred in about 98.9% of cases. This was accompanied by relief from cough and wheezing, improvement in lung functions, and decrease in the remission rate to 76.5%. In the current study, 14 (70%) patients experienced more than 10% increase in MHR from the prestudy baseline in group B. This finding was consistent with many studies performed on the adverse effects of long-term use of bronchodilating drugs ,, .
Confirming the results of our study, Fung et al.  have concluded that the use of real-points acupuncture in asthmatic patients resulted in significant improvement in their condition when compared with placebo points or sham acupuncture. Another study presented by Tashkin et al.  concluded that real acupuncture succeeded in relieving stress catecholamine-induced bronchospasm in comparison with sham or placebo acupuncture, which failed to relieve stress.
The study presented by Hu  showed that the bronchodilating effect of acupuncture was apparent after a single treatment and remained for sometime after termination of the treatment. This finding was similar to ours, as the wheezes reappeared within 42.5 ± 6.17 min in group A after the removal of acupuncture needles in comparison with 136.1 ± 23.03 min in group B.
In contrast to our study, another study conducted by Chu et al.  found that acupuncture is less effective than inhaled bronchodilators in the management of acute attacks. They reviewed the results of a prospective controlled crossover trial examining the acute bronchodilation effect of acupuncture in patients with persistent but suboptimally controlled asthma. There was no clinical difference in the percentage of predicted FEV 1 after real acupuncture. The difference from our results might be due to the difference in the type of asthma, which was persistent and suboptimally controlled.
Furthermore, Shapira et al.  in a study on patients with moderate persistent asthma, concluded that a short course of acupuncture treatment resulted in no change in lung functions, bronchial hyper-reactivity, or patient symptoms. However, they tried to personalize the line of treatment for all patients and concluded that the failure might have been due to personalization and short-term acupuncture treatment.
The main limitation of our study was that the assessors could not be blinded to the technique. Another limitation of the study is that we selected only mild cases of partially controlled asthma. Further investigations are needed on a larger number of patients to confirm our results and to study the effect of perioperative acupuncture in more severe cases status asthmaticus not responding to drugs and in chronic obstructive pulmonary disease patients.
| Conclusion|| |
Perioperative acupuncture seems to improve respiratory functions as much as perioperative inhaled bronchodilators, without serious side effects.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Hansen EF, Rappeport Y, Vestbo J, Lange P. Increase in prevalence and severity of asthma in young adults in Copenhagen. Thorax 2000; 55: 833-836.
Beasley R, Keil U, Mutius E, Pearce N. Worldwide variation in prevalence of symptoms of asthma, allergic rhino conjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351:1225-1232.
Braback L, Hjern A, Rasmussen F. Trends in asthma, allergic rhinitis and eczema among Swedish conscripts from farming and non-farming environments. A nationwide study over three decades. Clin Exp Allergy 2004; 34:38-43.
Mitchell P, Wells JE, Box PO. Acupuncture for chronic asthma: controlled trial with six months follow-up. Am J Acupunct 1989; 17:5-13.
Chen J, Wu Ll, XS Lai. Clinical observation on treatment of allergic asthma. External application of herbal drug on acupoints. J Acupunct Tuina Sci 2005: 3:13-15.
Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2003; 4.
Lulich KM, Goldie RG, Ryan G, Paterson JW. Adverse reactions to beta 2-agonist bronchodilators. Med Toxicol 1986; 1:286-299.
Thompson PJ, Gibb WR, Cole P, Citron KM. Generalised allergic reactions to aminophylline. Thorax 1984; 39:600-603.
Dahl R. Systemic side effects of inhaled corticosteroids in patients with asthma. Respir Med 2006; 100:1307-1317.
Pellegrino R, Viegi G, Brusasco V, et al.
Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948-968.
McGrath B, Chung F. Postoperative recovery and discharge. Anesthesiol Clin North America 2003; 21:367-386.
Spirobank spirometer. Available at: http://alt.menzl.com/mir_spirobank.htm.
[Last accessed on 2013 Nov 4].
World Health Organization. A standard international acupuncture nomenclature: memorandum from a WHO meeting. Bull World Health Organ 1990; 68:165-169.
Waqar MA, Khan M, Hasnain SM, Saleem A, Shaukat S, Sarwar F, Mahmood Y. Prevalence of allergy and asthma in school children of Islamabad, Pakistan. World Appl Sci J 2009; 6:426-432.
Elmar T Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture. therapists need to know human anatomy. Arch Fam Med 1999; 8:553-558.
Chu KA, Wu YC, Ting YM, Wang HC, Lu JY. Acupuncture therapy results in immediate bronchodilating effect in asthma patients. J Chin Med Assoc 2007; 70:265-268.
Braman SS. The global burden of asthma. Chest 2006; 130:4S-12S.
Zwolfer W, Keznickl-Hillebrand W, Spacek A, Cartellieri M, Grubhofer G. Beneficial effect of acupuncture on adult patients with asthma bronchiale. Am J Chin Med 1993; 21:113-117.
Takishima T, Mue S, Tamura G, Ishthara T, Watanabe K. The bronchodilating effect of acupuncture in patients with acute asthma. Ann Allergy 1982; 42:44-49.
Martin J, Donaldson ANA, Villarroel R, Parmar MKB, Ernstz E, Higginson IJ. Efficacy of acupuncture in asthma: systematic review and meta analysis of published data from 11 randomized controlled trials. Eur Respir J 2002; 20:846-852.
Zang J. Immediate anti-asthmatic effect of acupuncture in 192 cases of bronchial asthma. J Tradit Chin Med 1990, 10:89-93.
Fung KP, Chow OK, So SY. Attenuation of exercise-induced asthma by acupuncture. Lancet 1986; 2:1419-1422.
Tashkin DP, Kreoning RJ, Bresler DE, Simmons M, Coulson AH, Kerschner H. A controlled trial of real and simulated acupuncture in the management of chronic asthma. J Allergy Clin Immunol 1985; 76: 855-865.
Hu J. Clinical observation on 25 cases of hormone dependent bronchial asthma treated by acupuncture. J Tradit Chin Med 1998; 18:27-30.
Shapira MY, Berkman N, Ben-David G, Avital A, Bardach E, Breuer R. Short-term acupuncture therapy is of no benefit in patients with moderate persistent asthma. Chest 2002; 121:1396-1400.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]