Stimulated by Lin et al 2019.
Not more adverse event reports I hear you cry! No, this paper is very different, and again unexpected, despite actually being rather similar to the previous one I highlighted (sorry to be cryptic). It was just last week that I was musing at the end of the blog about the potential questions we could pose to the large national databases in the East (where acupuncture is such a common treatment). I did not consider they could be used to examine the incidence of adverse effects, as has been done in this paper.
This is the sort of information we have been seeking ever since we started performing prospective safety surveys. In the early 90’s I got involved with the first one, along with many other BMAS and AACP members – this was the SAFA study. We recorded over 30 000 treatments and perhaps not surprisingly there were no pneumothoraces. From this we could say that serious adverse events were not more common than 1:10 000. Then in 2004 Adrian White summarised all the subsequent prospective surveys and we got the 1:200 000 figure for serious adverse events (4 pneumothoraces and 2 broken needles in 1.1 million treatments).
Some years later and we had the huge survey from Germany. 2.2 million treatments in some 220 000 patients, and long list of all the possible adverse events, including 2 pneumothoraces. But rather frustratingly we did not know how many of the 2.2 million treatments involved needling over the thorax, so I was never comfortable quoting an incidence of 1:1 000 000, since for some of these patients there was no chance of lung damage, which means that it would have been an underestimate.
Now we have this Taiwanese data, which gives us way more than we dreamed of! The team randomly identified 1 million people from their national database. The database contains details of 23 million patients covered by the national health insurance scheme, which is more than 99% of the population. From this cohort patients were excluded if they had a history of pneumothorax (14 340) or they had not had acupuncture treatment (573 926). This left them with 411 734 patients who had had a total of 5 407 378 acupuncture treatments. They then divided this group based on whether or not acupuncture was performed in an ‘at risk’ area for pneumothorax or not. looked to see how many of them were admitted within 7 days of acupuncture for treatment of pneumothorax. 191 745 patients had 2 684 774 acupuncture treatments in at risk areas, and there were 47 cases of pneumothorax related to acupuncture.
The incidence of pneumothorax following acupuncture over the thorax or neck (in Taiwan between 1997 and 2012) was 1.75 per million treatments. The risk was considerably higher if the patient was male or had one of a variety of lung diseases or thoracic surgery:
Condition – Adjusted OR
- Male – 3.41
- Chronic bronchitis – 2.61
- Emphysema – 4.87
- Tuberculosis – 3.65
- Lung cancer – 3.85
- Pneumonia – 2.09
- Thoracic surgery – 7.85
Age, urbanisation, affluence, asthma and the number of treatments did not appear to influence risk significantly.
There are other interesting figures in the paper, in particular the decreasing trend in incidence. The authors attribute this to national education campaigns to train acupuncturists particularly concerning safety. Of course we highly approve of this in the BMAS.
1 Lin S-K, Liu J, Hsu R, et al. Incidence of iatrogenic pneumothorax following acupuncture treatments in Taiwan. Acupunct Med Published Online First: 21 August 2019. doi:10.1136/acupmed-2018-011697
2 White A, Hayhoe S, Hart A, et al. Survey of Adverse Events following Acupuncture (Safa): A Prospective Study of 32,000 Consultations. Acupunct Med 2001;19:84–92. doi:10.1136/aim.19.2.84
3 White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122
4 Witt CM, Pach D, Brinkhaus B, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed 2009;16:91–7. doi:10.1159/000209315