Pneumothorax Using Bladder 14
Thye K. Leow, MB (MD)
This case report describes an adverse event, pneumothorax, resulting from the use of acupuncture point Bladder 14. The pneumothorax resolved without surgical intervention.
Acupuncture, Pneumothorax, Bladder 14, Adverse Event
Acupuncture treatment for musculoskeletal conditions, especially in cases where conventional treatment has failed, is increasingly being utilized. Although relatively innocuous when properly performed,1,2 the insertion of needles in the chest wall or at the base of the neck is not devoid of complications.3
This is my case of pneumothorax following acupuncture of the back in a patient with a whiplash neck and upper thoracic injury. There may not be a previously documented case of pneumothorax following needling of this particular acupuncture point, Bladder 14 (BL 14) in the literature.
The patient was a 21-year-old woman with past history of mild asthma, occasional use of salbutamol through inhalers, and a non-smoker with no history of pneumothorax prior to this event. She has a fair complexion, fine skin, average amount of muscular tissue, and little adipose tissue. Her habitus can be described as ectomorphic.
Following a motor vehicle collision resulting in a whiplash injury to her neck and upper back, the patient had 5 sessions of physiotherapy treatment before opting for acupuncture as her condition deteriorated.
Consent was obtained and the patient was treated with acupuncture 18 days following her injury. The needles used were sterile single-use, stainless steel filiform with dimensions of 0.25 mm X 40 mm. The acupoints selected were BL 10 and BL 14 bilaterally, as well as GV 14. Needles were inserted between 1.5 and 2.0 cm deep, and counterclockwise manipulation performed. Needles (Taichi, Morgan and Aickin Co, Auckland, New Zealand) remained in place 30 minutes.
The patient had a near syncopal attack 10-15 minutes following the insertion. She complained of pain with deep breathing following the prompt removal of the needles. She was not breathless and was discharged to home following a period of observation.
She reported back to the clinic about 18 hours later complaining of worsening pleuritic chest pain with deep breathing associated with breathlessness overnight. Chest x-rays revealed that the patient had a moderate-sized left pneumothorax. She was immediately admitted to the hospital for observation and oxygen. No intercostal chest drain was inserted and she was discharged the next day.
The most frequent serious adverse effect following acupuncture is pneumothorax. Rosted4 commented that a clear lack of anatomical knowledge is one of the causes of pneumothorax. However, the number of reported adverse effects are remarkably low throughout the world.
A recent study in Japan did not show any case of pneumothorax in 30,338 acupuncture treatments.5
The usual causes of pneumothorax from acupuncture are acupuncture needles placed in the chest wall for conditions such as bronchial asthma,6,7 neck pain, weakness, and herpes zoster.8,9 The reasons why a left-sided pneumothorax occurred in this case could be due to any or a combination of reasons. The needle on the left side was inadvertently placed deeper than expected. Bodily movement during the dizzy phase of presyncopal attack could be another reason, although this would have instead pushed the needle out. Other factors include poorly developed parathoracic musculature, thinning of visceral pleura from previous use of inhaled steroid medication or simply from being asthmatic.
Perhaps this incident should serve as a warning to all acupuncturists of the potential for a much more serious incident. Yellow flags should be raised for any ectomorphic patients taking steroids who have never had acupuncture in the past, and needles along the medial line of the thoracic bladder channel need to be placed much more superficially. Needles placed in the region of the lateral line of the thoracic bladder meridian (BL 41 to BL 54) should be placed rather superficially, as the surface of the lung is about 15-20 mm beneath the skin.10
However, depending on the thickness of the needles and the tissue resistance, a variable degree of compression of the soft tissue takes place, and the actual puncturing depth may be considerably greater than the length of the needle. Nevertheless, the patient should be warned of the risk even though discussed (as reported by Rotchford11), adverse events such as pneumothorax are rare and the incidence of pneumothorax secondary to acupuncture is impossible to assess accurately. Further studies are cited depicting the possibility of having a spontaneous pneumothorax as a result of acupuncture11; thus exists the possibility of a case of spontaneous pneumothorax being inaccurately attributed to acupuncture. In my 11-year experience of some 30,000 needlings, this has been the only severe case of an adverse event with acupuncture.
It is a major concern that needling a relatively safe acupoint such as BL 14 has the potential of causing a severe adverse reaction such as pneumothorax. This case highlights the need for acupuncture practitioners to be vigilant, able to recognize these events, and then take the appropriate steps following such events. Needles placed in the region of both the lateral and medial lines of the thoracic bladder mer-idian should be inserted much more superficially, especially in cases of ectomorphic patients.
- Millman BS. Acupuncture: context and critique. Ann Rev Med. 1977;28:223.
- Lee KP, Anderson WT, Moddell HJ, Saga AS. Treatment of chronic pain with acupuncture. JAMA. 1975;232:1133.
- Carron H, Epstein BS, Grand B. Complications of acupuncture. JAMA. 1974;228:1552.
- Rosted P. Literature survey of reported adverse effects associated with acupuncture treatment. Am J Acupunct. 1996;24:27-34.
- Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national clinic in Japan. J Altern Complement Med. 1999;5:229-236.
- Wright RS, Kupperman JL, Libhaber MI. Bilateral tension pneumothorax after acupuncture. West J Med. 1991;154:102-103.
- Bodner G, Topiskky M, Greif J. Pneumothorax as a complication of acupuncture in treatment of bronchial asthma. Ann Allergy. 1983;51: 401-402.
- Gray R, Maharajh GS, Hyland R. Pneumothorax resulting from acupuncture. Can Assoc Radiol J. 1991;42:139-140.
- Valenta LJ, Henhesh JW. Pneumothorax caused by acupuncture. Lancet. 1980;II:332.
- Peuker E, Gronemeyer D. Rare but serious complications of acupuncture: traumatic lesions. Acupunct Med. 2001;19(2):103-108.
- Rotchford JK. Overview: adverse events of acupuncture. Medical Acupuncture. 2000;11(2):1-8.
Dr Thye K. Leow is in private practice in Penrose, Auckland, New Zealand. Dr Leow is a Fellow of the New Zealand College of General Practitioners (FRNZCGP), and a member of the New Zealand Institute of Acupuncture. He has been practicing Medical Acupuncture over 20 years, especially in the field of musculoskeletal medicine.
Thye K, Leow, MD, MBBS(Qld), FRNZCGP*
766 Great North Rd
*Correspondence and reprint requests