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. 2023 Apr 14;102(15):e33537. doi: 10.1097/MD.0000000000033537

Efficacy of acupuncture therapy for stable chronic obstructive pulmonary disease: A systematic review and meta-analysis

Su Fan a, Zhenyu Zhang a, Qinglin Wang b,*
PMCID: PMC10101258  PMID: 37058051

Background:

Acupuncture therapy (AT) is a widely used, alternative medicine in China. AT is an effective treatment for many diseases, but its efficacy in stable chronic obstructive pulmonary disease (COPD) remains controversial. Therefore, we performed the present meta-analysis to evaluate the efficacy of AT in stable COPD patients.

Methods:

Randomized controlled trials (RCTs) for AT efficacy in stable COPD patients were searched in literature databases from the inception to December 31, 2021. Pooled effect sizes of outcome measurements with respect to lung function (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], FEV1 in predicted value [FEV1%], FEV1/FVC), quality of life (St. George respiratory questionnaire [SGRQ]), exercise capacity (6-minute walking distance [6MWD]) and effective rate were estimated by calculating weighted mean difference (WMD) or odds ratio (OR) with corresponding 95% confidence interval (95% CI), respectively, by a random-effect model.

Results:

A total of 28 RCTs with 2130 COPD patients were included. AT group had significant improvement in FVC (WMD = 0.29 L, 95% CI: 0.22–0.36, P < .001), FEV1 (WMD = 0.33 L, 95% CI: 0.23–0.43, P < .001), FEV1% (WMD = 3.30%, 95% CI: 3.30–4.64, P < .001), FEV1/FVC (WMD = 5.45%, 95% CI: 4.41–6.49, P < .001), 6MWD (WMD = 45.48 m, 95% CI: 28.21–62.16, P < .001), SGRQ (WMD = −7.79, 95% CI: −12.34 to −3.24, P < .001), and a higher effective rate (OR = 3.71, 95% CI: 2.50–5.52, P < .001) compared to the control group. Subgroup analysis stratified by comparison model (AT combined with other treatments vs other treatments, AT alone vs sham AT) and treatment duration (≥8 weeks, <8 weeks) also showed more improvement in AT arm than control arm without significant between-subgroup difference. Adverse events were reported in a few studies and only mild reactions were observed.

Conclusion:

AT is effective in improving lung function, quality of life and exercise capacity, and can be used as an adjunctive treatment in patients with stable COPD.

Keywords: acupuncture therapy, COPD, lung function, meta-analysis, quality of life

1. Introduction

Chronic obstructive pulmonary disease (COPD) is a common, progressive disease characterized by irreversible airflow limitation, airway inflammation and gradual loss of lung function.[1] COPD is a major global health issue causing more than 3 million deaths in 2015 and is estimated to be the third major cause of global mortality in 2030.[2,3] With the growing number of smokers and the elderly, COPD becomes more and more prevalent, which is estimated to cause 4.5 million COPD-related deaths in 2030 and 5.4 million deaths in 2060.[2,4] In China, national cross-sectional surveys demonstrated a significant increase of COPD prevalence in people aged 40 or above from 8.2% in 2002 to over 13% in 2015, indicating an urgent need for prevention and treatment of COPD.[5–7]

COPD patients are experiencing persistent respiratory symptoms and airway limitation, and may also suffer repeated respiratory infection, frequent acute exacerbation and hospitalization, which adds an additional burden to the society and medical system.[8] Pharmacological interventions, mainly bronchodilators and anti-inflammatory drugs, have been proven to be efficient in relieving COPD symptoms, improving quality of life and exercise capacity, and reducing risk of exacerbation and hospitalization.[9,10] However, alternative and more effective treatments are still in need to achieve a better management of COPD symptoms and prevention of COPD progression.[11]

Acupuncture therapy (AT) is a widely used, alternative medicine in China for a variety of diseases. Randomized controlled trials (RCTs) proved that AT was effective in the treatment of migraine,[12] chronic knee pain,[13] reflex sympathetic dystrophy after stroke,[14] nocturnal enuresis[15] and Alzheimer disease,[16] although the mechanism was not fully elucidated. Recent trials suggested a promising efficacy of AT in COPD patients by reducing dyspnea and improving quality of life and exercise capacity.[17–19] However, the efficacy of AT in improving lung function, quality of life and exercise capacity for stable COPD patients was still in controversy. The inconsistency may be caused by the small sample size of study arms and the difference in comparators of RCTs. Here, we performed a systematic review and meta-analysis to evaluate the efficacy of AT in patients with stable COPD by incorporating current evidence from RCTs.

2. Methods

2.1. Literature search and study selection

We performed the present meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.[20] English literature databases including PubMed, Cochrane Library, Web of Science and Clinicaltrials.gov, and Chinese databases comprising Wanfang, Chinese National Knowledge Infrastructure and Chinese Biomedical Literature Database, were searched for eligible studies from the inception to December 31, 2021. The following keywords were used for search: “acupuncture” AND (“chronic obstructive pulmonary disease” OR “COPD”). Only English and Chinese articles were considered. We identified additional studies by manually searching the reference lists of included studies. Since this was a meta-analysis synthesizing published data, ethical approval and patient consent were not necessary.

All eligible studies fulfilled the following criteria: patients were clinically diagnosed with stable COPD; studies were randomized, controlled trials; studies compared AT vs sham AT, or AT combined with other treatments (Western medicine [WM], traditional Chinese medicine [TCM], or pulmonary rehabilitation [PR]) with other treatments; studies reported at least one of the following outcomes: pulmonary function, exercise capacity, quality of life, effective rate. AT included needling acupuncture, electroacupuncture, warm acupuncture and auricular acupuncture, and noninvasive moxibustion and acupressure should be excluded. Case series, review, meta-analysis, studies without sufficient data and studies comparing AT alone with other therapies were also discarded. For duplicated studies, only the most recent one was included.

2.2. Outcome measurements

Pulmonary functions included forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), the percentage of FEV1 in predicted value (FEV1%) and in FVC (FEV1/FVC). The exercise capacity was assessed by 6-minute walking distance (6MWD) and quality of life by St. George respiratory questionnaire (SGRQ). The criteria for effective rate was based on the Criteria of Diagnosis and Therapeutic Effect of Disease and Syndromes in Traditional Chinese Medicine.[21]

2.3. Data extraction and assessment of risk of bias

We extracted the following information from each study: first author, year of publication, interventions, sample size, mean age, average disease duration, percentage of male, acupoints, treatment duration, outcome measurements, the mean change from baseline and corresponding standard deviation (SD) of each outcome in both groups. If the change value was not directly provided, then we calculated it as follows: Change MEAN = Post-treatment MEAN − Baseline MEAN. The corresponding SD was estimated as follows: Change SD = SQRT (Post-treatment SD2 + Baseline SD2 − 2R × Post-treatment SD × Baseline SD). Usually, we used 0.5 for R.

Risk of bias of each study was evaluated using the Cochrane Collaboration tool for assessing risk of bias for randomized trials.[22] This tool assessed the risk of bias of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. The risk of bias was considered as low, high, or unclear.

Two independent investigators reviewed the abstracts and full texts of all studies to obtain eligible studies, extracted the information and assessed the risk of bias of each study. A third investigator made final decisions when discrepancies occurred.

2.4. Statistical analysis

Between-study heterogeneity was assessed by I2, and I2 < 25%, 25% to 50% or more than 50% indicated small, moderate or large heterogeneity, respectively. We calculated the weighted mean difference (WMD) and the 95% confidence interval (CI) for continuous variables, or pooled odds ratio (OR) and the 95% CI for dichotomous variables. The random-effect DerSimonian-Laird model by was applied for all analyses to gain more conservative estimates than using the fixed-effect model. Subgroup analysis regarding comparison (AT + Other treatments vs Other treatments, AT vs Sham AT) and treatment duration (≥8 weeks, <8 weeks) was conducted. Sensitivity analysis was performed to assess whether a single study obviously affected the pooled estimates or not. Meta-regression analyses for publication year, percentage of male, mean age, sample size and treatment duration were also performed when there were 10 or more eligible studies. Funnel plot and Egger test were used for the assessment of publication bias. All analyses were conducted by using STATA 16.0 (StataCorp LP, TX). P value < .05 was considered statistically significant.

3. Results

3.1. Description of eligible studies included in meta-analysis

The literature search yielded a total of 517 studies (Fig. 1). We discarded 413 obviously irrelevant studies after reviewing the titles and abstracts. Among the 104 remaining studies, 6 used duplicated samples, 42 recruited patients with acute exacerbation of COPD, 25 investigated the combined effect of AT and TCM, and 3 compared AT alone with WM. Finally, 28 RCTs with 2130 stable COPD patients were eligible for our meta-analysis.[17–19,23–47] Five studies were published in English language[17–19,24,31] and the others were in Chinese language. The sample size of each study ranged between 30 and 150. Six studies compared AT to sham AT,[17,18,23,28,29,34] and the others compared AT + other treatments to other treatments. The characteristics of all eligible studies are summarized in Table 1.

Figure 1.

Figure 1.

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Flowchart of literature search.

Table 1.

Characteristics of all studies included in meta-analysis.

Author Year Intervention Sample size Mean age, yr Duration Outcome measurement
Treatment Control Treatment Control Treatment Control
Jia J 2004 AT + PR + WM PR + WM 22 22 61.0 61.0 100 d FEV1%, FEV1/FVC, effective rate
Wan WR 2009 AT + TCM TCM 75 75 62.4 61.8 36 d FVC, FEV1, FEV1/FVC, effective rate
Yang P 2009 AT + PR PR 40 40 NR NR 40 d FEV1%, FEV1/FVC, 6MWD
Deering BM 2011 AT + PR PR 16 25 65.1 67.7 8 w FEV1%, SGRQ
Gao J 2011 AT WM 30 30 64.87 65.25 8 w FEV1, FEV1%, FEV1/FVC, SGRQ
Suzuki M 2012 AT Sham AT 34 34 72.7 72.5 12 w FVC, FEV1, FEV1%, 6MWD, SGRQ
Guo YM 2013 AT Sham AT 18 15 65.28 66.6 6 w FEV1%, FEV1/FVC, 6MWD,
Tong J 2014 AT Sham AT 16 14 64 67 5 w FEV1%, FEV1/FVC, 6MWD, SGRQ
Chu EX 2015 AT + WM + TCM WM + TCM 32 32 NR NR 3 m FEV1, FEV1%, FEV1/FVC, effective rate
Liu LJ 2015 AT + WM WM 40 40 58.3 63.2 3 m FEV1%, FEV1/FVC, 6MWD, effective rate
Deng CH 2016 AT + WM WM 22 22 57.1 58.5 24 w FEV1%, FEV1/FVC, 6MWD
Feng JF 2016 AT Sham AT 36 36 67.8 67.1 8 w FVC, FEV1%, 6MWD, SGRQ
Li XY 2016 AT + WM + TCM WM + TCM 30 30 NR NR 3 w FEV1%, FEV1/FVC, effective rate
Ge Y 2017 AT Sham AT 24 20 65 65 14 sessions 6MWD, FEV1%, FEV1/FVC
Wang Z 2017 AT + WM WM 50 50 NR NR 6 m 6MWD, SGRQ
Chen NH 2018 AT + WM WM 47 47 59.83 60.29 8 m FVC, FEV1%, FEV1/FVC, SGRQ, effective rate
Shi GC 2018 AT + WM + TCM WM + TCM 40 40 56.2 58.1 24 w FVC, FEV1, FEV1/FVC
Zhong GJ 2018 AT + WM WM 30 30 50 52 7 d FEV1%, FEV1/FVC
Deng YQ 2019 AT + WM WM 43 43 64.28 64.96 4 w FEV1, FEV1/FVC, 6MWD
Lv ZJ 2019 AT + TCM TCM 40 40 64.36 64.23 8 w FEV1, FEV1/FVC, effective rate
Yu G 2019 AT + WM WM 56 56 58.46 57.23 3 m FEV1%, FEV1/FVC
Zhou Y 2019 AT + WM WM 44 44 65.84 65.38 3 m FEV1%, 6MWD
Li Y 2019 AT + WM WM 45 46 65.9 67.0 6 w FEV1, FEV1%, 6MWD
Li D 2020 AT + WM WM 40 40 60.53 61.15 5 m FVC, FEV1, 6MWD, SGRQ, effective rate
He Y 2021 AT Sham AT 30 26 65 65 4.6 w FEV1, FEV1/FVC, 6MWD
Shi ZW 2021 AT + WM WM 49 48 64.96 65.11 8 w FEV1, FEV1%, FEV1/FVC, 6MWD, effective rate
Wang TT 2021 AT + TCM TCM 58 58 58 59 2 m FVC, FEV1, FEV1/FVC, effective rate
Wang X 2021 AT + WM WM 41 41 51.89 52.21 50 d FVC, FEV1, FEV1/FVC, effective rate
Zhang P 2021 AT + WM WM 50 50 70.22 70.29 2 w FEV1, FEV1/FVC, effective rate
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6MWD = 6-minute walking distance, AT = acupuncture treatment, d = days, FEV1 = forced expiratory volume in 1 second, FVC = forced vital capacity, m = months, NR = not reported, PR = pulmonary rehabilitation, SGRQ = St. George respiratory questionnaire, TCM = traditional Chinese medicine, w = weeks, WM = western medicine.

Seventeen studies reported adequate method of randomization. Only 4 reported proper method of allocation concealment.[17,23,29,33] Blinding of participants and personnel were achieved in 5 studies which used sham acupuncture as control.[17,18,23,28,29,34] Therefore, the majority of studies had high risk of performance bias. Six studies reported blinding of outcome assessment and thus had low risk of detection bias.[17–19,23,24,29] All studies reported a small number of or no dropouts, and then low risk of attrition bias was assigned. There was no evidence of selective reporting in 3 studies[17–19] as they were in accordance with their registered protocols while the others were rated as unclear risk of bias. However, we did not have adequate information for the judgement of other bias. The assessment of risk of bias is shown in Table 2. In summary, the methodological quality of studies comparing AT versus Sham AT was high, and that of the other studies was poor.

Table 2.

Assessment of risk of bias using Cochrane collaboration tool for assessing risk of bias for randomized trials.

Study Random sequence generation Allocation concealment Blinding of participants and personnel Blinding of outcome assessment Incomplete outcome data Selective reporting Other bias
Jia J (2004) Unclear Unclear High Unclear Low Unclear Unclear
Wan WR (2009) Unclear Unclear High Unclear Low Unclear Unclear
Yang P (2009) Unclear Unclear High Unclear Low Unclear Unclear
Deering BM (2011) Low Unclear High Low Low Low Unclear
Suzuki M (2012) Low Unclear Low Low Low Low Unclear
Guo YM (2013) Low Unclear Low Unclear Low Unclear Unclear
Tong J (2014) Low Low Low Low Low Unclear Unclear
Chu EX (2015) Unclear Unclear High Unclear Low Unclear Unclear
Liu LJ (2015) Unclear Unclear High Unclear Low Unclear Unclear
Deng CH (2016) Unclear Unclear High Unclear Low Unclear Unclear
Feng JF (2016) Low Low Low Low Low Low Unclear
Li XY (2016) Low Low High Unclear Low Unclear Unclear
Ge Y (2017) Low Unclear Low Unclear Low Unclear Unclear
Wang Z (2017) Unclear Unclear High Unclear Low Unclear Unclear
Chen NH (2018) Low Unclear High Unclear Low Unclear Unclear
Shi GC (2018) Low Unclear High Unclear Low Unclear Unclear
Zhong GJ (2018) Unclear Unclear High Unclear Low Unclear Unclear
Deng YQ (2019) Low Unclear High Unclear Low Unclear Unclear
Li Y (2019) Low Unclear High Low Low Unclear Unclear
Lv ZJ (2019) Low Unclear High Unclear Low Unclear Unclear
Yu G (2019) Unclear Unclear High Unclear Low Unclear Unclear
Zhou Y (2019) Low Unclear High Unclear Low Unclear Unclear
Li D (2020) Unclear Unclear High Unclear Low Unclear Unclear
He Y (2021) Low Low Low Low Low Unclear Unclear
Shi ZW (2021) Low Unclear High Unclear Low Unclear Unclear
Wang TT (2021) Low Unclear High Unclear Low Unclear Unclear
Wang X (2021) Low Unclear High Unclear Low Unclear Unclear
Zhang P (2021) Unclear Unclear High Unclear Low Unclear Unclear
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3.2. FVC

A total of 8 studies with 742 COPD patients analyzed the efficacy of AT in improving FVC. There was large heterogeneity (I2 = 67.4%, P < .003). We observed a significantly larger FVC improvement in AT group than the control group (WMD = 0.29 L, 95% CI: 0.22–0.36, P < .001, Fig. 2). The exclusion of Li D study[43] significantly reduced heterogeneity to 10.1% (WMD = 0.26 L, 95% CI: 0.22–0.29). Subgroup analysis showed that AT combined with other treatments improved FVC more than other treatments (WMD = 0.32 L, 95% CI: 0.20–0.44, Fig. 2), and that AT alone showed more FVC improvement than sham AT (WMD = 0.26 L, 95% CI: 0.21–0.30, P < .001, Fig. 2). There was no significant difference between both subgroups (P = .340). We also found significantly FVC improvement in subgroups of treatment duration <8 weeks (WMD = 0.21 L, 95% CI: −0.01 to 0.42) and ≥8 weeks (WMD = 0.30 L, 95% CI: 0.22–0.38).

Figure 2.

Figure 2.

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Meta-analysis of AT in improving FVC of stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease, FVC = forced vital capacity.

3.3. FEV1

We included 12 eligible studies comprising 1094 participants in the meta-analysis of FEV1. Eleven out of 12 studies compared AT + other treatments to other treatments and only 1 compared AT to sham AT. We found AT group had more FEV1 improvement than control group (WMD = 0.33 L, 95% CI: 0.23–0.43, P < .001, Fig. 3). Divided by treatment duration, both short-term (WMD = 0.25 L, 95% CI: 0.18–0.33) and long-term (WMD = 0.38 L, 95% CI: 0.21–0.56) treatment could significantly improve FEV1 of COPD patients, and there was no significant between-subgroup difference (P = .179).

Figure 3.

Figure 3.

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Meta-analysis of AT in improving FEV1 of stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease, FEV1 = forced expiratory volume in 1 second.

3.4. FEV1%

The meta-analysis of FEV1% included 1256 patients from 19 eligible studies. There was small between-study heterogeneity (I2 = 11.6%, P = .313). Overall, FEV1% improved more in the AT group compared with the control group (WMD = 3.30%, 95% CI: 3.30–4.64, P < .001, Fig. 4). The subgroup of “AT + Other treatments vs Other treatments” included 13 low-quality RCTs and had moderate between-study heterogeneity (I2 = 38.1%). Compared with other treatments, AT combined with other treatments could significantly improve FEV1% (WMD = 3.83%, 95% CI: 2.88–4.77, Fig. 4). Six high-quality RCTs compared AT alone to sham AT and had no between-study heterogeneity (I2 = 0), which showed better FEV1% improvement in AT group than sham AT group (WMD = 4.38%, 95% CI: 2.99–5.77, Fig. 4). We also found no heterogeneity in long-term treatment subgroup, and both short-term (WMD = 4.29%, 95% CI: 2.38–6.20) and long-term (WMD = 4.02%, 95% CI: 3.35–4.70) treatment could improve FEV1% with no significant between-subgroup difference.

Figure 4.

Figure 4.

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Meta-analysis of AT in improving FEV1% of stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease, FEV1 = forced expiratory volume in 1 second.

3.5. FEV1/FVC

The FEV1/FVC outcome was reported in 21 studies with 1592 cases. Patients in the AT group exhibited significant FEV1/FVC improvement compared with those in the control group (WMD = 5.45%, 95% CI: 4.41–6.49, P < .001, Fig. 5). The between-study heterogeneity was obvious (I2 = 63.5%). However, if we excluded 2 outlier studies from Lv ZJ and Yu G,[41,42] there was no heterogeneity anymore (I2 = 0), and the WMD decreased slightly to 5.06% (95% CI: 4.46–5.65, P < .001). Subgroup analysis demonstrated FEV1/FVC improvement in AT combined with other treatments prior to other treatments with substantial heterogeneity (WMD = 5.47%, 95% CI: 4.33–6.61, I2 = 70.6%, Fig. 5), and in AT alone prior to sham AT with no heterogeneity (WMD = 5.52%, 95% CI: 2.46–8.58, I2 = 0, Fig. 5). Both short-term (WMD = 6.12%, 95% CI: 5.01–7.23) and long-term (WMD = 5.13%, 95% CI: 3.65–6.60) treatment resulted in significant FEV1/FVC improvement.

Figure 5.

Figure 5.

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Meta-analysis of AT in improving FEV1/FVC of stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease, FEV1 = forced expiratory volume in 1 second, FVC = forced vital capacity.

3.6. 6MWD

Exercise capacity was reported in 14 studies that included 896 COPD patients. A larger 6MWD improvement was found in AT group than the control group by meta-analysis (WMD = 45.48 m, 95% CI: 28.21–62.16, P < .001, Fig. 6). However, there was substantial heterogeneity in the overall group and any subgroup. There was no significant between-subgroup difference when divided by comparison model (Fig. 6) or treatment duration.

Figure 6.

Figure 6.

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Meta-analysis of AT in improving 6MWD of stable COPD patients. 6MWD = 6-minute walking distance, AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease.

3.7. SGRQ

Seven studies with 485 participants used SGRQ score to assess the quality of life. There was substantial between-study heterogeneity. Meta-analysis demonstrated that AT had better performance in improving quality of life than control (WMD = −7.79, 95% CI: −12.34 to −3.24, P < .001, Fig. 7).

Figure 7.

Figure 7.

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Meta-analysis of AT in improving SGRQ of stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease, SGRQ = St. George respiratory questionnaire.

3.8. Effective rate

Meta-analysis of 12 studies with 1047 participants demonstrated that the addition of AT to other treatments improved the effective rate compared with other treatments (OR = 3.71, 95% CI: 2.50–5.52, P < .001, I2 = 0, Fig. 8).

Figure 8.

Figure 8.

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Meta-analysis of effective rate of AT in treating stable COPD patients. AT = acupuncture therapy, COPD = chronic obstructive pulmonary disease.

3.9. Safety

Only 4 studies provided information of adverse events.[18,24,30,33] Suzuki et al reported minor reactions, including fatigue, subcutaneous hemorrhage, dizziness and needle site pain, in some patients who all recovered in a short time.[18] All of 4 studies reported no serious adverse events.

3.10. Sensitivity analysis, meta-regression, and publication bias

Sensitivity analysis showed that none of a single study had obvious influence on the pooled results. Meta-regression demonstrated that moderators, including publication year, percentage of male, mean age, sample size and treatment duration, did not significantly affect the FEV1, FEV1%, FEV1/FVC or 6MWD (Table 3). The funnel plots of all meta-analyses were symmetrical, and Egger test suggested no obvious evidence of publication bias (Table 4).

Table 3.

Results of meta-regression analysis.

Moderator Co-efficient Standard error t P value
FEV1
 Publication yearr 0.005 0.139 0.37 .708
 Percentage of male −0.650 0.463 −1.40 .160
 Mean age −0.011 0.009 −1.20 .229
 Sample size 0.001 0.002 0.44 .660
 Treatment duration 0.003 0.010 0.32 .752
FEV1%
 Publication year −0.052 0.137 −0.38 .705
 Percent of male 1.014 2.566 0.40 .693
 Mean age −0.112 0.065 −1.71 .087
 Sample size 0.005 0.016 0.30 .761
 Treatment duration −0.083 0.056 −1.49 .137
FEV1/FVC
 Publication year −0.003 0.132 −0.03 .980
 Percent of male 0.057 4.483 0.01 .990
 Mean age 0.115 0.120 0.96 .337
 Sample size −0.013 0.018 −0.74 .457
 Treatment duration −0.118 0.075 −1.57 .117
6MWD
 Publication year 0.469 2.779 0.17 .866
 Percent of male 59.07 46.63 1.27 .205
 Mean age 1.288 2.190 0.59 .556
 Sample size 0.206 0.396 0.52 .604
 Treatment duration 0.961 1.346 0.71 .475
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6MWD = 6-minute walking distance, FEV1 = forced expiratory volume in 1 second, FVC = forced vital capacity.

Table 4.

Egger test for publication bias.

Outcome z value P value
FVC 1.64 .102
FEV1 1.41 .159
FEV1% 0.45 .656
FEV1/FVC 0.98 .327
6MWD 0.29 .774
SGRQ 1.46 .143
Effective rate 0.43 .667
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6MWD = 6-minute walking distance, FEV1 = forced expiratory volume in 1 second, FVC = forced vital capacity, SGRQ = St. George respiratory questionnaire.

4. Discussion

In the current meta-analysis with evidence from 28 RCTs that included 2130 patients, we found that AT, a popular alternative medicine in China, alone or combined with other treatments could significantly improve lung function, quality of life and exercise capacity of COPD patients. The mean differences of FEV1, 6MWD and SGRQ were 0.33 L, 45.48 m, and −7.79, respectively, which were significantly larger than the minimal clinical important differences of 100 mL, 26 m and 4 points,[48–50] suggesting the improvements by AT were huge.

Despite better efficacy of AT than control, there was substantial heterogeneity and high risk of bias, which may weaken the interpretation of the results of meta-analysis. Most of included studies investigated the efficacy of AT as an adjunctive treatment by comparing AT added to the other treatment (PR, WM, TCM) to other treatment alone. These studies were included in the subgroup “AT + Other treatments vs Other treatments.” Meta-analysis showed that the AT arm of this subgroup had more improvements in FEV1, FEV1%, FEV1/FVC, 6WMD, SGRQ, and higher effective rate than the control arm. These results indicated that the efficacy of conventional treatments of stable COPD could be furtherly improved by adding AT. In clinical practice, AT could be used as an adjunctive treatment to conventional treatments of stable COPD. However, there was substantial between-study heterogeneity in this subgroup as indicated by I2 statistic. Moreover, the risk of bias of these studies is high according to the Cochrane Collaboration tool for assessing risk of bias for randomized trials. All these studies had high risk of performance bias, since they did not used placebo AT as control and the randomization was not blinding to participants.

On the contrary, the subgroup “AT vs Sham AT” included 6 sham-controlled RCTs that had low risk of bias according to quality assessment. Subgroup analysis showed there was no between-study heterogeneity (I2 = 0) in lung function in terms of FVC, FEV1% and FEV1/FVC, indicating that these trials were in homogeneity. Meta-analysis demonstrated that AT alone could significantly improve lung function in stable COPD compared with placebo AT, which might reflect the real efficacy of AT.

Between-subgroup comparison analysis showed no significant difference between subgroups stratified by comparison model (AT combined with other treatments vs other treatments, AT alone vs sham AT) and treatment duration (≥8 weeks, <8 weeks). A previous network meta-analysis in migraine prophylaxis demonstrated a higher proportion of responders in sham-acupuncture subgroup than oral pharmacological placebo subgroup, suggesting a nonspecific effect of acupuncture.[51] Thus, the overall effect in the subgroup of AT combined with other treatments which were not sham-controlled trials may be over-estimated.

Although AT may be effective, the mechanism remains largely unclear. It was reported that acupuncture may have modulation effects on immune system by reducing the release of inflammation factors and balancing the pro-inflammation and anti-inflammation cytokines.[52] The concentrations of inflammation markers, including IL-6, IL-8, and TNFα, were consistently higher in COPD patients than in the healthy controls.[53] In a randomized controlled study, acupuncture treatment in asthma patients was found to reduce IL-6 level significantly while the control group had no change.[54] Another study in COPD patients showed that IL-6 and TNFα levels were significantly decreased in acupuncture group than in the placebo needling group.[55] These data supported an immune-modulating effect of acupuncture and may partially explain its therapeutic mechanism. Meanwhile, another study showed that electroacupuncture may attenuate the pulmonary vascular remodeling through VEFR/PI3K/Akt pathway in COPD rat model.[56] More studies are needed to elucidate the concise mechanism of AT.

Several meta-analyses of AT treatment for COPD have been previously performed.[57–61] However, our study has some differences and advantages over them. Our study has the largest sample size (28 trials, 2130 participants), thus improving the statistical power. We performed several subgroup analyses, including AT versus Sham AT, AT + Other treatments versus Other treatments, long-term duration (≥8 weeks) and short-term duration (<8 weeks) to comprehensively show the treatment effect of AT. Our study only focused on the treatment effect of AT on stable COPD and has excluded noninvasive moxibustion and acupressure and exacerbated COPD to keep the homogeneity of included studies.

Some limitations should also be noted. Firstly, the majority of included studies had poor quality since a high risk of bias, especially in the aspect of blinding and randomization, was found. Secondly, there was high between-study heterogeneity in most of the comparisons. The heterogeneity of FVC and FEV1/FVC could be significantly reduced by excluding outliers, but the source of heterogeneity of 6MWD and SGRQ has not been determined. Thus, the interpretation of these results should be in caution. Thirdly, adverse events were only reported in a few studies and the safety needs further confirmation in the future. Fourthly, the long-term effect of AT, for example, the prevention of acute exacerbation, were seldom investigated.

5. Conclusions

Our study demonstrated that AT is effective in improving lung function, quality of life and exercise capacity, and can be effectively used as an adjunctive treatment in stable COPD. More large-scale, well-designed, long-term follow-up RCTs are needed in the future.

Author contributions

Conceptualization: Su Fan, Qinglin Wang.

Data curation: Su Fan, Zhenyu Zhang.

Formal analysis: Su Fan, Zhenyu Zhang, Qinglin Wang.

Supervision: Qinglin Wang.

Writing – original draft: Su Fan.

Writing – review & editing: Su Fan, Zhenyu Zhang, Qinglin Wang.

Abbreviations:

6MWD
6-minute walking distance
AT
acupuncture therapy
CI
confidence interval
COPD
chronic obstructive pulmonary disease
FEV1 =
forced expiratory volume in 1 second
FVC
forced vital capacity
OR
odds ratio
PR
pulmonary rehabilitation
RCTs
randomized controlled trials
SD
standard deviation
SGRQ
St. George respiratory questionnaire
TCM
traditional Chinese medicine
WM
Western medicine
WMD
weighted mean difference

This work was supported by Beijing Health Promotion Project of Traditional Chinese Medicine and a part of the Excellent Team for Standardized Training of Traditional Chinese Medicine Residents of Beijing.

The authors have no conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

How to cite this article: Fan S, Zhang Z, Wang Q. Efficacy of acupuncture therapy for stable chronic obstructive pulmonary disease: A systematic review and meta-analysis. Medicine 2023;102:15(e33537).

Contributor Information

Su Fan, Email: sue57570@163.com.

Zhenyu Zhang, Email: zzytuina@163.com.

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