Rédacteurs : Johan Nguyen, Henri Truong

Chronic Obstructive Pulmonary Disease

Broncho-Pneumopathie Chronique Obstructive : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Chan 2021

Chan KH, Tsoi YYS, McCall M. The Effectiveness of Traditional Chinese Medicine (TCM) as an Adjunct Treatment on Stable COPD Patients: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2021. [219480]. doi

Background Traditional Chinese medicine (TCM), including Chinese herbal medicine (CHM) and acupuncture, exhibits beneficial effects on stable chronic obstructive pulmonary disease (COPD) such as improving lung function and reducing exacerbation. Previous research studies have examined either CHM or acupuncture alone, which are not the usual practice in TCM clinic setting. We conduct a systematic review for evaluating the clinical effectiveness and safety of TCM by combining CHM and acupuncture.
Methods Databases are searched from inception to November 2019. Randomized controlled trials examining either acupuncture or CHM on stable COPD are included. Primary outcomes include lung functions, exacerbations, and COPD assessment test. Secondary outcomes include quality of life, TCM syndrome score and effective rate, and 6-minute walk distance. Two independent reviewers extract data and assess the quality of evidence and generate meta-analysis and risk of bias by STATA. This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines.
Results 100 randomized controlled trials (8291 participants) were included to compare add-on Chinese medicine treatment with conventional treatment (CT). Combining CHM with CT improves FEV1 (MD: 0.18, 95% CI: 0.08, 0.28), exacerbation rate (MD: −0.29, 95% CI: −0.61, 0.03), COPD assessment test (MD: −2.16, 95% CI: −3.44, -0.88), TCM syndrome score (MD: −3.96, 95% CI: −5.41, −2.51) and effective rate (RR: 0.89, 95% CI: 0.80, 0.93), and 6-minute walk test (MD: 37.81, 95% CI: 20.90, 54.73). No serious adverse events were reported. Risk of bias: low to unclear.
ConclusionsThis review identifies sufficient moderate-to-low-quality evidence to suggest TCM as an adjunct treatment for stable COPD patients. Though heterogeneity was low among studies, the results were limited and the quality of evidence was low or very low based on small sample sizes and risk of bias. Future studies with larger sample sizes are warranted. The trial is registered with CRD42019161324.
Acupuncture Pas d’analyse en sous-groupe spécifique à l’acupuncture

1.1.2. Tsai 2021

Tsai CL, Lan CC, Wu CW, Wu YC, Kuo CY, Tzeng IS, Hsu PS, Lee CT, Hsieh PC. Acupuncture Point Stimulation Treatments Combined With Conventional Treatment in Chronic Obstructive Pulmonary Disease: A Systematic Review and Network Meta-Analysis. Front Med (Lausanne). 2021. [219490]. doi

BackgroundChronic obstructive pulmonary disease (COPD), which is a disease characterized by dyspnea, cough, and respiratory symptoms, leading to impaired health-related quality of life (HRQL) and exercise capacity, is highly prevalent worldwide. Some studies demonstrated that acupuncture point stimulation treatments (APSTs) are effective and safe in treating patients with COPD. The aim of this systematic review and network meta-analysis is to analyze the effects on HRQL and FEV1% predicted of diverse APSTs in treating patients with COPD.
Materials and Methods We searched seven electronic databases. Randomized controlled trials (RCTs) with stable COPD patients comparing APSTs and conventional treatment (Tx) were included. The primary outcome was HRQL measured by COPD Assessment Test or St. George's Respiratory Questionnaire. The secondary outcome was FEV1% predicted. We performed random effect network meta-analysis using a consistency model.
Results This network meta-analysis analyzed 21 RCTs with 1,577 stable COPD participants. In comparison with Tx, acupressure massage (AM) + Tx [-5.11; 95% confidence interval (CI), -6.65 to -3.57] was the most effective intervention in improving HRQL, followed by moxibustion (Mx) + Tx (-2.86; 95% CI, -3.86 to -1.86). Moreover, in comparison with Tx, Mx + Tx (7.79; 95% CI, 2.16 to 13.42) was the most effective intervention in improving FEV1% predicted, followed by acupuncture (A) + Tx (5.79; 95% CI, 2.90 to 8.68).
ConclusionsCombined interventions (APSTs + Tx) are more effective than single intervention in improving both HRQL and FEV1% predicted. AM, Mx, and A can be considered effective non-pharmacological complementary interventions in treating patients with COPD under Tx.

1.1.3. Fernández-Jané 2020

Fernández-Jané C, Vilaró J, Fei Y, Wang C, Liu J, Huang N, Xia R, Tian X, Hu R, Wen L, Yu M, Gómara-Toldrà N, Solà-Madurell M, Sitjà-Rabert M. Acupuncture techniques for COPD: a systematic review. BMC Complement Med Ther. 2020;20(1):138. [208916]. doi

BackgroundThis is the second part of a large spectrum systematic review which aims to identify and assess the evidence for the efficacy of non-pharmacological acupuncture techniques in the treatment of chronic obstructive pulmonary disease (COPD). The results of all techniques except for filiform needle are described in this publication.
MethodsEleven different databases were screened for randomised controlled trials up to June 2019. Authors in pairs extracted the data and assessed the risk of bias independently. RevMan 5.3 software was used for the meta-analysis.
ResultsThirty-three trials met the inclusion criteria, which involved the follow techniques: AcuTENS (7 trials), moxibustion (11 trials), acupressure (7 trials), ear acupuncture (6 trials), acupressure and ear acupuncture combined (1 trial) and cupping (1 trial). Due to the great heterogeneity, only 7 meta-analysis could be performed (AcuTENS vs sham on quality of life and exercise capacity, acupressure vs no acupressure on quality of life and anxiety and ear acupuncture vs sham on FEV1 and FEV1/FVC) with only acupressure showing statistical differences for quality of life (SMD: -0.63 95%CI: - 0.88, - 0.39 I2 = 0%) and anxiety (HAM-A scale MD:-4.83 95%CI: - 5.71, - 3.94 I2 = 0%).
ConclusionsOverall, strong evidence in favour of any technique was not found. Acupressure could be beneficial for dyspnoea, quality of life and anxiety, but this is based on low quality trials. Further large well-designed randomised control trials are needed to elucidate the possible role of acupuncture techniques in the treatment of COPD.

1.1.4. Wang 2020

Wang Yide. [Systematic Evaluation of Acupuncture and Moxibustion on Pulmonary Rehabilitation in Patients with Stable Chronic Obstructive Pulmonary Disease ]. Modernization of TCM and Materia Medica-World Science and Technology. 2020. [212944].

ObjectiveTo systematically analyze the efficacy of acupuncture and moxibustion as an important means of pulmonary rehabilitation in patients with stable chronic obstructive pulmonary disease.
Methods Wanfang, PubMed, Chinese biomedical literature database online database, Chinese full text database, the Cochrane, China science and technology periodical database were used to retrieve clinical randomized controlled study on efficacy of acupuncture used in chronic obstructive pulmonary disease plateau pulmonary rehabilitation from database establishment to present, and then performed risk assessment and quality evaluation. Then RevMan5. 3 software was used for meta-analysis research indicators.
Results The results of the meta-analysis showed that a total of 9 papers of RCTs on the effects of acupuncture and moxibustion on pulmonary rehabilitation in patients with stable chronic obstructive pulmonary disease were included in 681 patients. In terms of lung function, acupuncture combined with conventional treatment is significantly better than western medicine combined with conventional treatment or western medicine combined with placebo acupuncture: improved lung function FVC% [MD = 5. 90, 95%CI (3. 07, 8. 73), P < 0. 0001], improved FEV1 index [MD = 0. 32, 95%CI (0. 08, 0. 55), P = 0. 008]; improved FEV1/FVC [MD = 10. 16, 95%CI (4. 34, 15. 99), P =0. 0006]. Lung function indicators FEV1% were also significantly improved [MD = 5. 93, 95%CI (5. 73, 6. 14), P <0. 0001]. The above indicators of lung function were statistically significant. In addition, the observation group with 6-minute walk distance and blood gas analysis were better than the control group. No adverse reactions or other safety reports were found.
Conclusion Acupuncture can significantly improve the pulmonary ventilation function, blood gas analysis, 6-minute walk distance and other indexes in pulmonary rehabilitation of patients with stable COPD, and its safety is better.

1.1.5. Fernández-Jané 2019

Fernández-Jané C, Vilaró J, Fei Y, Wang C, Liu J, Huang N, Xia R, Tian X, Hu R, Yu M, Gómara-Toldrà N, Solà-Madurell M, Sitjà-Rabert M. Filiform needle acupuncture for copd: A systematic review and meta-analysis. Complement Ther Med. 2019. [203283].

BackgroundThis is the first part of a larger spectrum systematic review which aims to identify and evaluates the effectiveness of all different non-pharmacological acupuncture techniques used for COPD. In this first publication, we describe the results of filiform needle acupuncture
MethodsRandomised controlled trials up to May 2019 were searched in 11 databases. Data extraction and risk of bias assessment was conducted in pairs independently. RevMan 5.3 was used for the meta-analysis.
Results28 trials using filiform needle alone or in combination of other techniques were included. Compared with no acupuncture, no difference was seen for dyspnoea, but statistical benefits were found on quality of life (Std. MD: -0.62, 95%CI: -0.90, -0.34), exercise capacity (stable subgroup) (6MWT MD: 33.05 m, 95%CI: 19.11, 46.99) and lung function (FEV1% MD: 1.58, 95%CI: 0.51, 2.66). Compared with sham, statistical benefits were found on dyspnoea (Std. MD: -1.07, 95%CI: -1.58, -0.56), quality of life (Std. MD: -0.81, 95%CI: -1.12, -0.49), exercise capacity (6MWT MD: 76.68 m, 95% CI: 39.93, 113.43) and lung function (FEV1% MD: 5.40, 95%CI: 2.90, 7.91; FEV1/FVC MD: 6.64, 95%CI: 3.44, 9.83).
ConclusionsResults show that filiform needle acupuncture might be beneficial for COPD, but due to the low quality of the studies this should be confirmed by future well-designed trials.

1.1.6. Hsieh 2019 ☆☆

Hsieh PC, Yang MC , Wu YK , Chen HY , Tzeng IS , Hsu PS , Lee CT , Chen CL , Lan CC. Acupuncture therapy improves health-related quality of life in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Complement Ther Clin Pract. 2019;35:208-218. [197162].

BackgroundChronic obstructive pulmonary disease (COPD) is highly prevalent around the world and has a large impact on its patients, leading to a poor health-related quality of life (HRQL) and exercise capacity. Even under optimal medications, there are still many patients with poor HRQL. Body acupuncture therapy (BAT) is a non-invasive and a popular therapy. Therefore, we aimed to comprehensively analyze the effects of BAT in COPD.
Materials and methods Eight electronic databases were searched. We included randomized controlled trials (RCTs) that evaluated the effect of BAT, medication (M), and pulmonary rehabilitation (PR). The primary outcome was HRQL evaluated by St. George's respiratory questionnaire (SGRQ) or COPD assessment test (CAT).
ResultsOf the 922 articles, 12 studies were included with attesting a total of 798 participants. The result obtained indicated a significant improvement that favored the BAT + M group over the M group in CAT scores (MD: -4.77; 95% CI: -6.53 to -3.01; p < 0.00001).
ConclusionsBAT is an effective adjunctive non-pharmacological treatment to improve HRQL in patients under medical treatment for COPD. We suggested that BAT should be considered as one of the methods of management in patients with COPD.

1.1.7. Wang 2018 ☆

Wang J, Yu X, Xie Y. Acupuncture Therapy for Functional Effects and Quality of Life in COPD Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2018. [168638].

ObjectiveThis study aimed to evaluate the efficacy and safety of acupuncture therapy (AT) for improving functional effects and quality of life in COPD patients.
Methods PubMed, Embase, Cochrane Library, Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), and Wanfang Data were searched. The randomized controlled trials (RCTs) evaluating the effect of AT on COPD patients were included. Primary outcome measures included six-minute walk distance (6MWD) and St. George's Respiratory Questionnaire (SGRQ). Study selection, data extraction, and risk of bias assessment were independently conducted, respectively. Statistical analysis was conducted by RevMan software (version 5.3) and Stata software (version 12.0).
ResultsNineteen studies (1298 participants) were included. 6MWD improved more (MD: 47.84; 95% CI: 23.33 to 72.35; Z = 3.83, P = 0.0001) and effective rate was higher (OR: 2.26; 95% CI: 1.43 to 3.58; Z = 3.48, P = 0.0005) in the experimental group compared to the control group. Symptom domain scores (MD: -24.86; 95% CI: -32.17 to -17.55; Z = 6.66, P < 0.00001), activity domain scores (MD: -16.52; 95% CI: -22.57 to -10.47; Z = 5.36, P < 0.00001) and impact domain scores (MD: -13.07; 95% CI: -17.23 to -8.9seto mty2; Z = 6.16, P < 0.00001) of SGRQ in the experimental group improved more compared to the control group. There was no significant improvement in SGRQ total scores between two groups. The improvement of FEV1 was not significant between two groups, yet subgroup analysis showed that patients treated with AT adjunctive to other treatments improved more in FEV1 (MD: 0.41; 95% CI: 0.28 to 0.54; Z = 6.01, P < 0.00001) compared to those treated with other treatments alone.
ConclusionAT may be effective in improving functional effects and quality of life in COPD patients. Besides, AT may also improve pulmonary function of patients with COPD. However, further high-quality RCTs are needed to confirm the efficacy and safety of AT for COPD patients.

1.1.8. Xue 2016 ☆

Xue Changli C, Lu Chuanjian. Chronic Obstructive Pulmonary Disease: Clinical Evidence for Acupuncture and Related Therapies, in Chronic Obstructive Pulmonary Disease. Evidence-based Clinical Chinese Medicine. Singapore: World Scientific. 2016:119-154. [199983].

ObjectiveSince the beginning of Chinese civilisation, acupuncture therapies have been used to treat respiratory diseases, including COPD. Many clinical studies have been conducted in China and abroad. This chapter provides an assessment of the current evidence from clinical trials.
MethodsExtensive searches of nine electronic databases identified almost 1,900 citations of acupuncture therapies for COPD. These were reviewed against rigorous inclusion criteria, resulting in the exclusion of over 1,500 citations. A total of 79 clinical studies of acupuncture therapies for stable COPD or acute exacerbation of COPD were selected for further analysis and are presented in this chapter. Controlled trials were subject to systematic review and a series of meta-analyses of results to evaluate the efficacy and safety of acupuncture therapies for COPD.
ResultsThere is insufficient evidence for some acupuncture therapies such as acupressure, moxibustion and electroacupuncture. However, point application therapy and acupuncture point injection therapy when combined with pharmacotherapy improved certain measures of lung function and health-related quality of life.

1.1.9. Coyle 2014 ☆☆

Coyle ME, Shergis JL, Huang ET, Guo X, Di YM, Zhang A, Xue CC. Acupuncture therapies for chronic obstructive pulmonary disease: a systematic review of randomized, controlled trials. Altern Ther Health Med. 2014. 20(6):10-23. [178352].

Context Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and is projected to be the third leading cause of death by 2030. Acupuncture, a traditional Chinese therapy, has been used for more than 2000 years to treat respiratory conditions and may treat COPD effectively. In previous literature reviews, researchers have noted significant heterogeneity among the included studies, and none of the reviewers found convincing evidence to recommend routine use of acupuncture therapies for COPD.
ObjectiveThis literature review examined the efficacy and safety of acupuncture therapies for patients with COPD in improving lung function, increasing exercise capacity, creating positive subjective changes in symptoms, and enhancing health-related quality of life (QoL).
DesignThe research team searched the following electronic databases from inception to April 2013: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), Embase (Elsevier), the China National Knowledge Infrastructure (CNKI), Chongqing VIP Information Company (CQVIP), the Chinese Biomedical Literature Database (CBM), and Wanfang Data. The review included randomized, controlled trials (RCTs) that examined the benefits of acupuncture or other related therapies for treatment of COPD. Data were extracted into a predefined form; risk of bias was assessed according to the Cochrane Risk of Bias tool; and statistical analyses were made.
Results In total, 16 studies were included in the review. The research team found that the acupuncture therapies used in these studies improved health-related QoL. The team's conclusions, comparing results from the interventions with placebo, were based on data from 3 questionnaires that the studies used: (1) the St George's Respiratory Questionnaire (SGRQ), with a mean difference (MD) of -8.33 units (95% CI, -13.13 to -3.53); (2) dyspnea on the Medical Research Council's (MRC's) dyspnea scale, with an MD of -0.34 units (95% CI, -0.38 to -0.30); and (3) the Dyspnea Visual Analogue Scale (DVAS), with an MD of -8.85 mm (95% CI, -11.81 to -5.89). Compared with placebo, acupuncture therapies also increased the distance walked in 6 min (6MWT), with an MD of -28.14 (95% CI, 23.92 to 32.36) compared with placebo. No benefit was seen on measures of lung function when acupuncture therapies were compared with either placebo or drug therapy.
ConclusionAcupuncture therapies may result in clinically important improvements in QoL and dyspnea. Future high-quality RCTs should be undertaken to provide conclusive evidence concerning the benefits of acupuncture therapies in the treatment of COPD.

1.2. Specific outcome

1.2.1. Diaphragm Dysfunction

1.2.1.1. Liu 2021

Liu Q, Duan H, Lian A, Zhuang M, Zhao X, Liu X. Rehabilitation Effects of Acupuncture on the Diaphragm Dysfunction in Chronic Obstructive Pulmonary Disease: A Systematic Review. Int J Chron Obstruct Pulmon Dis. 2021:2023-2037. [220113]. doi

IntroductionDiaphragm dysfunction is a significant extrapulmonary effect in chronic obstructive pulmonary disease (COPD), which is manifested by changes in diaphragm structure and reduced diaphragm strength. Acupuncture is a traditional rehabilitation technique in China, which has been used in rehabilitation for COPD. But whether acupuncture can improve the diaphragm function of COPD patients remains to be verified.
ObjectiveThe objective of this study was to evaluate the rehabilitation effects of acupuncture on diaphragm dysfunction in patients with COPD.
MethodsThe authors retrieved in CNKI, VIP, SinoMed, PubMed, Ebsco, Web of Science, from inception to November 2020, for relevant randomized control trials. Two researchers independently screened the articles and extracted the data. The quality of the included studies was evaluated by Physiotherapy Evidence Database scale. The primary outcome measures were maximal inspiratory pressure and the scale for accessory respiratory muscle mobilization, the secondary outcome measures were pulmonary function-related indicators and arterial blood gas indicators.
Results Nine articles were finally obtained. Seven studies added acupuncture to standard treatment for patients with diaphragm dysfunction in COPD and found statistically significant changes in the maximum inspiratory pressure and the scale for accessory respiratory muscle mobilization. Two studies have proved that use acupuncture combined with other Traditional Chinese Medicine methods in the rehabilitation for COPD can effectively improve the diaphragm strength and diaphragmatic motor performance. Seven studies showed that acupuncture has obvious improvement in pulmonary ventilation function. Seven studies reported significant differences in arterial blood gas pre- to post-intervention.
Conclusion This systematic review found that acupuncture can effectively enhance the diaphragm strength, relieve respiratory muscle fatigue, it can also play a promoting role in improving lung function, hypoxia, and carbon dioxide retention, as well as preventing and alleviating respiratory failure. The generalizability of these results is limited by the design of the included studies.

1.3. T lymphocyte subsets

1.3.1. Wu 2020

Wu JJ, Zhang YX, Xu HR, Li YX, Jiang LD, Wang CX, Han M. Effect of acupoint application on T lymphocyte subsets in patients with chronic obstructive pulmonary disease: A meta-analysis. Medicine (Baltimore). 2020;99(16). [209218]. doi

BackgroundThe development of chronic obstructive pulmonary disease (COPD) is related to the T lymphocyte mediated inflammatory immune response and immune imbalance. The purpose of this systematic review was to evaluate the clinical efficacy and safety of acupoint application on T lymphocyte subsets in patients with COPD.
Methods We searched CNKI, Wan fang, Chongqing VIP, China Biology Medicine disc, PubMed, the Cochrane Library, and EMBASE for studies published as of Oct. 31, 2019. All randomized controlled trials of acupoint application on COPD patients that met the inclusion criteria were included. The Cochrane bias risk assessment tool was used for literature evaluation. RevMan5.3 software was used for meta-analysis.
Results Eight studies (combined n = 524) qualified based on the inclusion criteria. Compared with routine treatment alone, acupoint application combined with routine treatment can significantly increase the T lymphocyte CD4/CD8 ratio (MD 0.12, 95% CI 0.03-0.21, P < .01, I = 49%), reduce CD8 T-cells (MD-0.99, 95% CI-1.70-0.28, P < .001, I = 37%), reduce the times of acute exacerbations (MD-0.28, 95% CI-0.35-0.21, P < .001, I = 0), and improve the clinical efficacy (MD 1.30, 95% CI 1.14-1.48, P < .001, I = 39%).
ConclusionAcupoint application can improve the CD4/CD8 ratio and CD8 T-cells in patients with COPD and has an auxiliary effect in reducing the times of acute exacerbations and improving clinical efficacy.

1.4. Special Acupuncture Techniques

1.4.1. Acupoint herbal patching

1.4.1.1. Zhou 2015☆

Zhou F, Shana YW, Lewith G, Liu JP. Acupoint Herbal Patching with or without Conventional Treatment for Stable Chronic Obstructive Pulmonary Disease: a Systematic Review of Randomized Controlled Trials World J Trad Chin Med. 2015;1(1):45-48. [70497].

BackgroundAcupoint herbal patching (AHP) alone or as an adjuvant therapy with conventional treatment (CT) has been widely used for prevention and treatment of chronic obstructive pulmonary disease (COPD). However, current clinical evidence from a systematic review of RCTs is lacking. Objective: To evaluate the effectiveness and safety of AHP with or without CT for people with COPD at stable stage.
MethodsWe searched randomized controlled trials comparing AHP (with or without CT) with no intervention, placebo, or CT from six databases. Two authors selected studies, extracted data and evaluated risk of bias of included trials. RevMan 5.2 software was used to analysis data.
ResultsTwenty one RCTs (2327 participants) were included. AHP of non sanfu applied on no fixed dates with CT significantly decreased the mean frequency of acute exacerbation of COPD (times per year) (MD: −1.24; 95% CI: −2.02 to −0.46; 2 trials), and improved lung function parameters and quality of life. The AHP with CT showed no better effect in 6-minute walking distance (6MWD) that CT alone. AHP applied at sanfu (specific dates based on lunar calendar) with CT had significant effect for 6MWD (MD: 11.20; 95% CI: 0.83 to 21.56; I2 = 0%; 3 trials). One trial reported skin irritation from AHP. Another trial reported two patients had eye discomfort, which was inferred as the adverse effects of seretide.
ConclusionAHP used as an adjunct to CT, appears to be more effective than CT alone in patients with stable COPD. However, further large, rigorously designed trials are warranted to confirm these potential effects.
1.4.1.2. Li 2012 ☆☆

Li F, Gao Z, Jing J, Xu D, Upur H. Effect of point application on chronic obstructive pulmonary disease in stationary phase and effects on pulmonary function: a systematic evaluation of randomized controlled trials. J Tradit Chin Med. 2012; 32(4):502-4. [159302].

ObjectiveTo evaluate clinical efficacy of point application or adjuvant therapy on chronic obstructive pulmonary disease in stationary phase and effects on pulmonary functions.
MethodsComputer retrieved CNKI, VIP, CBM and other databanks and manual operations retrieved correlative literatures to find randomized controlled trials (RCTs) about comparison between point application or adjuvant therapy and no-point-applications for treatment of chronic obstructive pulmonary disease in stationary phase in China. RevMan 5.0 software was used for Meta-analysis.
ResultsAmong 3481 cases in the inclusive 32 RCTS, 1780 cases were in the test group and 1701 cases in the control group. Meta-analysis indicated: 1) clinical efficacy: the groups containing point application therapy all were better than the groups of no-point-application; 2) force vital capacity (FVC): There was no statistically significant difference between the group of point application plus Western Medicine and the Western Medicine group; 3) force expiratory volume 1 (FEV1): The groups containing point application therapy were better than the no-point-application; 4) FEV1%: the groups of point application plus Western Medicine were better than the Western Medicine groups; 5) FEV1/FVC: there was a significant difference between the group of point application plus Chinese drugs and the group of Chinese drug.
Conclusion Point application can increase clinical efficacy of chronic obstructive pulmonary disease in stationary phase in varying degrees, and different combinations of point application with Chinese drugs or Western Medicines have incomplete same actions in improvement of pulmonary function and therapeutic effect.

1.4.2. Pharmaco-acupuncture

1.4.2.1. Coyle 2015

Coyle ME, Liu Shaonan, Zhang AL et al. Acupuncture point injection therapy plus pharmacotherapy for chronic obstructive pulmonary disease: A systematic review of randomised controlled trials. European Journal of Integrative Medicine. 2015;7(6):567-576. [207112]. doi

Introduction Acupuncture point injection therapy has been used for respiratory conditions, including chronic obstructive pulmonary disease (COPD), and may be an effective adjunct to pharmacotherapy. This review evaluated the efficacy and safety of acupuncture point injection therapy plus pharmacotherapy for COPD.
Methods Five English and four Chinese databases were searched from inceptions to May 2015. Studies of acupuncture point injection therapy reporting on clinical outcomes (including lung function, symptom severity, quality of life and exercise capacity) were included. Methodological quality was assessed using the Cochrane Collaboration’s risk of bias tool, and data analysed using RevMan 5.2.
Results Twelve studies (841 participants) were included. Results from meta-analyses showed the combination of acupuncture point injection therapy plus pharmacotherapy produced better outcomes for lung function during acute exacerbation (FEV1 L: MD 0.16 L [0.04, 0.28], I2 = 0%; FVC L: MD 0.29 L [0.14, 0.44], I2 = 0%) and effective rate for stable COPD and acute exacerbations (RR 1.45 [1.17, 1.79], I2 = 0% and RR 1.16 [1.07, 1.26], I2 = 0%, respectively) than pharmacotherapy alone. Higher arterial oxygenation (PaO2) was seen in participants with acute exacerbations who received acupuncture point injection therapy plus pharmacotherapy (MD 7.43 mmHg [3.49, 11.39], I2 = 93%), although considerable statistical heterogeneity was detected.
Conclusions Based on the included studies, there is insufficient information on the safety of acupuncture point injection therapy for COPD. There is some evidence that acupuncture point injection therapy may improve lung function and effective rate in people with COPD, however the conclusions are limited by the small number of included studies and methodological differences.

1.4.3. Acupoint autohemotherapy

1.4.3.1. Huang 2021

Huang C, Chen C, Zhou R, Liang Y, Zhang J, Hong H, Liu J. A systematic review and meta-analysis of acupoint autohemotherapy and western medicine therapy in treating chronic obstructive pulmonary disease. Complement Ther Clin Pract. 2021;29. [218681]. https://doi.org/10.1016/j.ctcp.2021.101336

Objective To evaluate the safety and efficacy of acupoint autohemotherapy(AA).
Methods We collected Controlled Trials that are random of AA plus medicine of the west therapy vs western medicine therapy alone in treating COPD from PubMed, the Cochrane library, EMBASE, CNKI, CBM SinoMed, China Science, and Wanfang Data from database inception to July 1, 2019. Meta-analysis was performed using the RevMan 5.3.
Results This meta-analysis identified that the combined treatment could enhance the total effective clinical rate, the forced expiratory volume in 1 s(FEV1)and forced vital capacity(FVC),increase the 6-min walking distance, and improve the self-assessment of chronic obstructive pulmonary disease score(CAT).
Conclusion The clinical effects of AA plus medicine of the west therapy are better than that of western medicine alone in treating COPD. However, due to the small number and poor quality of the included RCTs,this conclusion needs to be verified with larger samples and higher quality RCTs.

1.4.4. Moxibustion

1.4.4.1. Lou 2021

Lou JL, Sun HJ, Li XY, Hu HT, Zhang YJ, Jiang YL, Fang JQ. [Clinical efficacy and safety of moxibustion as adjuvant therapy for COPD in stable phase: a Meta-analysis]. Chinese Acupuncture and Moxibustion. 2021;41(4):451-7. [219072]. doi

Objective To systematically evaluate the efficacy and safety of conventional therapy combined with moxibustion in the treatment of chronic obstructive pulmonary disease (COPD) in stable phase based on Meta-analysis medicine.
Methods The randomized controlled trials (RCTs) of moxibustion as adjuvant therapy for COPD were retrieved from the databases of CNKI, Wanfang, SinoMed, PubMed, Web of Science, Cochrane Library and Ebsco. RevMan5.3 software was used for Meta analysis, and the quality of evidence was evaluated according to GRADE standards.
Results A total of 16 RCTs were included, involving 1425 patients. The results of Meta-analysis showed that: compared with the conventional treatment, ①the adjuvant therapy with moxibustion had advantages in reducing the number of acute exacerbations [MD=-0.31, 95%CI:-0.49–0.13, P=0.0006]; ②the adjuvant therapy with moxibustion improved lung function significantly [FEV1% (MD=4.00, 95%CI:2.63-5.37, P<0.000 01) and FEV1/FVC (MD=3.56, 95%CI:1.69-5.43, P=0.000 2)]; ③the adjuvant therapy with moxibustion could extend the 6 min walking distance (6WMD) (MD=35.00, 95%CI:18.02-51.99, P<0.000 1); ④the adjuvant therapy with moxibustion could improve the modified British Medical Research Council breathing questionnaire (mMRC) classification significantly (MD=-0.62, 95%CI:-1.18–0.05, P=0.03); ⑤no adverse reaction was reported in the included literature.
Conclusion The efficacy of moxibustion as adjuvant therapy for COPD in stable phase is better than that of simple conventional therapy. Due to insufficient clinical evidence and the limitations of this study, clinical safety is unclear and further evidence is needed to support the results.

2. Overview of Systematic Reviews

2.1. Chun 2021

Chun L, Li X, Feng Z, Xie Y, Li J. Role of Acupuncture in the Treatment of COPD: An Overview of Systematic Reviews. Int J Gen Med. 2021. [218233]. doi

BackgroundSince consistent evidence on the effectiveness of acupuncture in the treatment of chronic obstructive pulmonary disease (COPD) is not available, this overview aims to summarize and critically evaluate the methodological and evidence quality of systematic reviews (SRs) on this topic.
Methods Eight electronic databases were searched to identify relevant SRs of the use of acupuncture in the treatment of COPD from inception to January 2021. Two researchers independently screened the literature, extracted the data, and cross-checked the data. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) list was used to assess the methodological quality of SRs. The Grades of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of evidence for the outcomes of interest.
ResultsNine SRs that conducted quantitative syntheses were included in this overview. The methodological quality of the SRs and the quality of evidence for the main outcome measures were generally unsatisfactory. Only 2 SRs were rated as low methodological quality by AMSTAR 2, and the remaining SRs were rated as critically low quality. The key limitations of the SRs were lack of a protocol and registration or a list of excluded studies. We did not find high-quality evidence to confirm the effectiveness of acupuncture for COPD, and the main reason was that the qualitative data synthesis relied on trials with small sample sizes and critically low quality.
ConclusionAcupuncture appears to be an effective therapeutic method for COPD, but the credibility of the results is limited owing to the generally low methodological quality and evidence quality of the included SRs. Further rigorous and comprehensive studies are required to provide robust evidence and draw definitive conclusions.

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

Acupuncture. U.S. Navy Bureau of Medicine and Surgery. 2013.17p. [180539].

Category B (limited evidence): Authorized but not recommended for routine use (consider as adjunct). Chronic Obstructive Pulmonary Disease

3.2. Canadian Thoracic Society (CTS, Canada) 2011 Ø

Marciniuk D, Goodridge D, Hernandez P, Rocker G, Balter M, Bailey P, Ford G, Bourbeau J, O'donnell De, Maltais F, Mularski Ra, Cave Aj, Mayers I, Kennedy V, Oliver Tk, Brown C. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011;18(2):69-78. [156306].

Recommendation # 3C . There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counselling programs or psychotherapy.