Adjunct Acupuncture Improved Respiratory Status and Weaning from Mechanical Ventilation After Severe COVID-19 Pneumonia

Abstract

Background:

A patient with severe COVID-19 pneumonia had adjunctive acupuncture to improve respiration and facilitate weaning off prolonged mechanical ventilation (MV).

Case:

A man in his 40s with COVID-19 was in an advanced critical-care center on symptom day 5 for respiratory failure due to pneumonia requiring MV therapy. He received high-dose corticosteroid pulse therapy, antiviral agents, and multiple antibiotics for complicated bacterial pneumonia and bacteremia. Repeated MV weaning attempts failed, although his pneumonia gradually improved. Then, acupuncture 4 times per week was started to improve his respiration and facilitate MV weaning from day 49 of his symptoms' onset.

Results:

His weaning-related indices improved, including reductions in respiratory rate and Rapid Shallow Breath Index. His O₂ saturation increased immediately after each acupuncture treatment. The day after the first acupuncture treatment, his MV support was reduced by changing ventilation mode from synchronized intermittent mandatory ventilation mode to continuous positive airway pressure (CPAP) mode during the day without exacerbation of respiratory status. After 3 days of acupuncture, this patient was on CPAP support alone. MV therapy was discontinued completely after 8 days of acupuncture (6th acupuncture treatment).

Conclusions:

Acupuncture improved respiration and facilitated MV weaning in a patient with respiratory failure secondary to COVID-19. Adjunctive acupuncture may benefit such patients and others after severe pneumonia. Large cohort studies are needed.

INTRODUCTION

Developing effective treatment strategies for patients with severe coronavirus disease–2019 (COVID-19) and post-COVID-19 conditions remains a global health challenge. As of May 2023, more than 6.9 million patients with COVID-19 have died globally.¹ In May 2023, the World Health Organization (WHO) declared that COVID-19 was no longer a public-health emergency of international concern, emphasizing that this did not mean that the disease was no longer a global threat.² Some populations still have risk factors or comorbidities associated with COVID-19.^3–5

Among patients with COVID-19 admitted to intensive care units (ICUs), 88% required mechanical ventilation (MV) support.⁶ Furthermore, patients with COVID-19 take an average of 33 days to wean from MV.⁷ Prolonged MV (> 17 days) was necessary for 24% of patients requiring MV secondary to COVID-19.⁸ Early weaning from MV is very important given that prolonged MV dependence is associated with an increased risk of ventilator-associated events, such as deconditioning and ventilator-associated pneumonia. Such factors can increase morbidity and mortality, prolong ICU and hospital stays, and increase medical costs, even for patients without COVID-19.^9–11

Previously, some of the current authors reported that acupuncture treatment improved respiratory function in patients requiring prolonged MV therapy in an intensive-care setting.¹² Acupuncture-like stimulation—such as acupressure on certain acupoints—has also reportedly improved respiratory status and weaning indices in patients receiving MV therapy.^13,14 In a case report of a patient with COVID-19, acupuncture improved breathing, increased percutaneous oxygen saturation (SpO₂), and decreased heart rate (HR).¹⁵ According to another previous report, adjunct acupuncture appeared to alleviate dyspnea in a patient with post-COVID syndrome.¹⁶ According to a randomized controlled trial in 2022, acupuncture combined with standard therapy was reported to be more effective for improving respiratory conditions than standard therapy alone in patients with moderate-to-severe COVID-19.¹⁷

This current report concerns a patient with severe COVID-19 pneumonia who was treated successfully with adjunct acupuncture to improve respiratory status and facilitate weaning from prolonged MV therapy.

CASE

Disease History

A Japanese man in his 40s was admitted to an advanced critical care center (ACCC; i.e., intensive care unit [ICU]) in August 2021 with a 5-day history of fever and respiratory failure caused by COVID-19–related pneumonia; he required MV support. His clinical course, including medications, is shown in Figure 1.

FIG. 1.

Treatment timeline. *CPAP mode was discontinued within 1 hour because of dyspnea and tachypnea (respiratory rate >40 breaths/minute). CT, computed tomography; SIMV, synchronized intermittent mandatory ventilation; APRV, airway pressure release ventilation; CPAP, continuous positive airway pressure; SBT/ABPC, sulbactam/ampicillin; CFPM, cefepime dihydrochloride hydrate; MEPM, meropenem hydrate; LVFX, levofloxacin.

He received dexamethasone between symptom days 5 and 15 and methylprednisolone between symptom days 13 and 36 (after receiving steroid pulse therapy on days 1–3). He also completed a 10-day course of intravenous remdesivir and oral baricitinib. In addition, multiple antibiotics, including sulbactam/ampicillin, cefepime dihydrochloride hydrate (CFPM), levofloxacin (LVFX), and meropenem hydrate (MEPM), were administered to treat complicated bacterial pneumonia and bacteremia due to Klebsiella spp. on days 7–67. He developed bilateral pneumothorax and mediastinal emphysema and underwent bilateral thoracic drain placement for 2 weeks beginning on day 14. Physiotherapy was administered 5 times per week starting on day 7. A tracheostomy was performed on day 27, after which his pneumonia improved gradually.

However, despite the care team's best efforts, he could not wean from MV. An attempt was made to change the MV mode from synchronized intermittent mandatory ventilation (SIMV) to continuous positive airway pressure (CPAP) to reduce ventilation support after decreasing positive end-expiratory pressure (PEEP) and pressure support (PS) on days 46 and 48, respectively. However, this patient's dyspnea and tachypnea (40 breaths/minute) worsened, resulting in cessation of MV weaning attempts within 1 hour. He was moved from a strict infection-control room in the ACCC to a regular ACCC room because his COVID restrictions had been lifted on day 47. Acupuncture treatment as adjunctive therapy was started to improve his respiration and promote MV weaning on day 49.

The patient's demographic data are included in Table 1. His past medical history was significant for hypertension, dyslipidemia, and a 7.5 pack-year smoking history; he had stopped smoking 10 years ago. He weighed 66.7 kg, and his body mass index was 23.1 kg/m². No mental-status issues were noted. The ventilator (Dräger Evita^® Infinity,^® v500, Dräger Medical AG & Co. Lubeck, Germany) settings were pressure-controlled SIMV mode with a fraction of inspiratory oxygen (F_IO₂) of 0.35, PEEP of 5 mm Hg, PS 4 of mm Hg, and a respiratory rate (RR) of 18 breaths/minute.

Table 1.

Baseline Data at the Start of Acupuncture Treatment

Variable	Data	Normal range
Laboratory data (day 48 or later)
C-reactive protein, mg/dL	4.32	≤ 0.14
Procalcitonin, ng/mL (day 50)	1.07	< 0.05
White blood cell, 103/μL	13.4	3.3–8.6
Neutrophils, %	75.6	38.0–74.0
Lymphocytes, %	12.2	16.5–49.5
Red blood cell, 106/μL	3.04	4.35–5.55
Hemoglobin, g/dL	8.8	13.7–16.8
Platelet, 103/μL	492	158–348
KL-6, U/mL (day 48)	1270	< 500
SP-A, ng/mL (day 53)	227	< 43.8
SP-D, ng/mL (day 53)	175	< 110
Arterial blood gas (day46)
pH	7.432	7.35–7.45
PaO2, mm Hg	81	83–108
PaCO2, mm Hg	42.6	32–48
PaO2/FIO2	231	—
Ventilator setting
Mode	SIMV—PC	—
FIO2	0.35	—
PEEP, mm Hg	5	—
PS, mm Hg	4	—
RR, breaths/min	18	—
Physiologic data
SpO2, %	96	—
HR, beats/min	118	—
RR, breaths/min	30	—
Blood temperature, °C	38.5	—
sBP/dBP, mm Hg	132/70	—

KL-6, Krebs von den Lungen-6; SP-A serum level of pulmonary surfactant protein A; SP-D, serum level of pulmonary surfactant protein D; PaO₂, partial pressure of oxygen; PaCO₂, partial pressure of carbon dioxide; F_IO₂, fraction of inspiratory oxygen; SIMV: synchronized intermittent mandatory ventilation; PC, pressure controlled; PEEP, positive end expiratory pressure; PS, pressure support; RR, respiratory rate; min, minute; SpO₂, percutaneous oxygen saturation; HR, heart rate; sBP, systolic blood pressure; dBP, diastolic blood pressure.

Although his SpO₂ was 96%, within normal limits, he felt dyspneic and had tachypnea and tachycardia (RR: 30 breaths/minute; HR, 118 beats/minute). Beginning on day 26, he sustained a fever of 38°C, with a peak body temperature at the start of acupuncture was 38.5°C.

Figure 2 A–C shows chest computed tomography (CT) images on symptom days 39, 49 and 63, respectively. The CT images at the start of acupuncture (day 49; Fig. 2B) showed bilateral infiltrative shadows over the whole lung field; however, his lungs appeared to be better aerated, compared to comparison scans obtained 10 days earlier (Fig 2A).

FIG. 2.

Chest computed tomography (CT) images on symptom days: (A) 39, (B) 49 (acupuncture start), and (C) 63. The CT images reveal, respectively: (A) extensive infiltrative shadows over the entire lung field and (B) infiltrative shadows over the bilateral lungs. However, aeration appeared to be improved, compared to (A). (C) Trend of attenuation of the infiltrative shadows.

His C-reactive protein (CRP) levels, procalcitonin, and white blood cell counts (WBC) (4.32 mg/dL, 1.07 mg/mL, and 13,450/μL, respectively) were elevated, although his CRP and WBC had decreasing trends from the peak values (CRP, 24.2 mg/dL on day 39; WBC, 18,400/μL on day 22). His serum Krebs von den Lungen-6 (KL-6) level on day 48 was 1270 U/mL, higher than normal, although it was reduced from the peak level of 3166 U/mL on day 8. On day 53, his serum levels of pulmonary surfactant proteins A and D (SP-A, 227 ng/mL; SP-D, 175 ng/mL) were increased, although they were also reduced from peak levels of 393 ng/mL (SP-A) and 325 ng/mL (SP-D) on day 41. His red blood cell (RBC) counts and hemoglobin (Hb) levels were reduced. Arterial blood-gas test results under 0.35 of FiO₂ on day 49 revealed: pH, 7.43; partial pressure of oxygen (PaO₂), 81.0 mmHg; and PaCO₂, 42.6 mmHg. The PaO₂/FiO₂ ratio was 231.

In addition to dyspnea, the patient had a productive cough. He had muscle atrophy in his extremities and could not stand unaided; this was suggestive of ICU-acquired weakness.

He was administered risperidone (4 mg/day), diazepam (15 mg/day), and clonidine hydrochloride (75 μg/day) as sedative agents. Tulobuterol tape (2 mg/day) was administered as a bronchodilator. Antitussive and expectorant drugs were administered, including carbocysteine (1500 mg/day), ambroxol hydrochloride (45 mg/day), dimemorfan phosphate (60 mg/day), codeine phosphate (60 mg/day), and dextromethorphan hydrobromide (80 mg/day). He was also administered heparin as an anticoagulant on days 6–50 and rivaroxaban (15 mg/day) starting on day 51. Bisoprolol fumarate (2.5 mg/day), olmesartan (20 mg/day), and amlodipine (5 mg/day) were administered to treat dysrhythmia and hypertension. Acetaminophen via intravenous or diclofenac sodium suppository were administered as needed for fever.

Acupuncture Treatment

The LI-4, ST-36, KI-3, LU-1, CV-12, CV-4, and ST-40 acupuncture points were used. CV-23, ST-34, and SP-10 were added on day 12 (at acupuncture session 7) after acupuncture started. The locations of the acupuncture points were determined according to the WHO standard textbook¹⁸ and were selected based on previous reports^12–14 and Traditional Chinese Medicine (TCM) theory. LI-4, ST-36, KI-3, LU-1, CV-12, and CV-4 are believed to improve respiration in MV-dependent patients.¹² LU-1, CV-4, CV-12, KI-3, and ST-36 were selected because they may correspond to improvements in dyspnea, respiratory muscle strength, nutrition, and inflammation biomarkers in patients with respiratory disease.¹⁹ LI-4 and ST-36 reportedly had anti-inflammatory effects in experimental animal studies of acute respiratory distress syndrome or sepsis.^20,21 CV-13 was used to reduce saliva aspiration. ST-34 and SP-10 were used to stimulate the quadriceps muscle and alleviate fatigue caused by orthostatic training. LI-4, LU-1, CV-12, LI-4, and ST-36 were used to increase Qi energy in the lungs. KI-3 and CV-4 were used to promote inspiratory Qi energy, and ST-40 was used to reduce Phlegm based on TCM theory.

A Japanese-style gentle needle technique was used. Disposable sterilized stainless-steel acupuncture needles (diameter 0.16, length 40 mm; SEIRIN,^® Shizuoka, Japan) were inserted gently to a depth of 4–10 mm at each acupoint, depending on the skin and subcutaneous fatty-tissue thickness. The needles at bilateral ST-36 were rotated for 1 minute to enhance the anti-inflammatory effects²² and left there for 15 minutes. The other needles were left in for 15 minutes without manipulation based on the previous report.¹² At LU-1, the acupuncture needle was inserted 2–5 mm—almost horizontally—to minimize the risk of pneumothorax. Acupuncture was performed 4 times per week by a licensed acupuncturist with a Master's degree in acupuncture and 20 years of clinical experience.

RESULTS

This patient's MV and oxygen-therapy values, including tidal volume (TV), RR, and SpO₂, before and immediately after each acupuncture treatment are shown in Figure 3. The patient had 11 acupuncture sessions over 19 days between symptom days 49 and 67. The first 3 acupuncture sessions were performed while the patient was on MV therapy; the subsequent 8 sessions were performed without MV therapy. His antibiotic was switched from MEPM to CFPM (6 g/day) based on susceptibility testing completed on day 53; CFPM was continued until day 67 (Fig. 1).

FIG. 3.

Clinical course and postacupuncture changes. MV, mechanical ventilation; SIMV, synchronized intermittent mandatory ventilation; CPAP, continuous positive airway pressure; F_IO₂: fraction of inspiratory oxygen; HFOT, high-flow oxygen therapy; min, minute; SpO₂, percutaneous oxygen saturation.

Reducing trends for tachypnea and rapid shallow breathing index (RSBI), calculated as RR/TV, were observed immediately after each acupuncture treatment (Figs. 3 and 4). Meanwhile, increased TV, dynamic lung compliance, and SpO₂ were observed after each acupuncture treatment (Figs. 3 and 4). Interestingly, the patient reported relief from dyspnea after the first acupuncture treatment. During the 3 days prior to start of acupuncture, 2 attempts were made to switch ventilation mode from SIMV to CPAP mode, but the CPAP mode could not be maintained and was discontinued within 1 hour due to his tachypnea. However, on the day after starting acupuncture treatment, he was able to tolerate intermittent daytime use of the CPAP mode (9 hours on day 50 and 16 hours on day 51) instead of the SIMV mode without tachypnea or desaturation. After 3 days of starting acupuncture, CPAP mode was maintained over an entire day.

FIG. 4.

Changes in RSBI (calculated as respiratory rate/tidal volume), dynamic lung compliance, and heart rate immediately after each acupuncture treatment. RSBI, rapid shallow breath index; min, minute; bpm, beats per minute.

After 4 days of starting acupuncture (third acupuncture treatment on day 53), MV was discontinued in favor of high-flow oxygen therapy (HFOT) through a tracheostomy during the daytime. As time for HFOT (40 L/minute with an F_IO₂ of 0.35) was gradually increased, MV was gradually reduced and completely discontinued from the eighth day after starting acupuncture (sixth treatment on day 57). On the 11th day after initiating acupuncture (seventh treatment on day 60), HFOT was discontinued and the patient was started on oxygen (6 L/min) with 0.35 F_IO₂. an oxygen inhaler with a nebulizer (Inspiron^®, Japan Medicalnext, Osaka, Japan) was used from days 11–15 after acupuncture started. Sixteen days after starting acupuncture, he tolerated oxygen therapy of 3 L/minute administered via a tracheostomy mask without any respiratory worsening.

The patient's peak body temperature dropped below 38°C on the second day after starting acupuncture and dropped below 37.5°C on the third day after starting acupuncture and before changing the antibiotic regimen. On day 63 (3 days after discontinuation of HFOT), chest CTs revealed reduced pneumonia, compared to day 49 (Fig. 2B); however, infiltrative shadows remained (Fig. 2C). WBC and CRP decreased gradually and approached normal limits on the 15th day after starting acupuncture (10th acupuncture treatment on symptom day 64). Neutrophils, lymphocytes, and platelets on symptom day 64 were also within normal limits. Procalcitonin level also reached normal limits on symptom day 60 (0.04 ng/mL). Serum levels of KL-6 (1223 U/mL), SP-A (206 ng/mL), and SP-D (188 ng/mL) were still above normal limits on symptom day 68. RBC count (3.16 million/μL) and Hb level (9.2 g/dL) were still below normal limits on symptom day 68.

There were no adverse or unanticipated events related to the acupuncture treatment. Since being removed from MV therapy, MV has not been reintroduced; this patient was transferred to another hospital for further rehabilitation 21 days after starting acupuncture (symptom day 69).

Statement of Ethics

Ethical approval was not required for this case report in accordance with national guidelines. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

DISCUSSION

This is the first case report on acupuncture treatment for improving respiration and facilitating MV weaning in patients with severe pneumonia related to COVID-19. The immediate effects of acupuncture were observed on SpO₂, TV, tachypnea, RSBI, and HR after each acupuncture treatment. These trends were consistent with previous reports that described the respiratory effects of acupuncture or acupressure in patients dependent on MV.^12–14 Lower TV and higher RSBI, dynamic lung compliance, oxygenation, and respiratory-muscle strength may predict MV weaning success or failure.^23,24 Improvements in these variables facilitated successful weaning from MV. The previous report with a small sample size had suggested that the trends in improvement of weaning indices after acupuncture were related to weaning success.¹² Moreover, changing from the SIMV mode to the CPAP mode to reduce MV support was discontinued within 1 hour in this patient because of the exacerbation of his respiratory conditions, including dyspnea and tachypnea, before the start of acupuncture.

Meanwhile, after acupuncture initiation, the patient tolerated support in the CPAP mode instead of SIMV for a longer duration without exacerbation of his respiratory conditions. In this case, the long-term effects leading to MV discontinuation might have been induced by not only acupuncture but also by improvement in the patient's general condition because of continuous intensive care, including antibiotic therapy and rehabilitation. However, considering the observed short-term effects of acupuncture on MV weaning-related indices and early decrease in MV support, acupuncture might have stabilized this patient's respiratory status and facilitated MV weaning.

Respiratory muscle weakness and fatigue contribute to MV weaning failure, and respiratory-muscle training may facilitate MV weaning.²⁵ Importantly, acupuncture has been reported to increase respiratory-muscle strength in patients with respiratory disease.¹⁹ Acupoint stimulation may reduce dyspnea and improve functional capacity via bronchodilation and beta-endorphin elevation.^26,27 Given these findings, acupuncture might improve respiration and aid MV weaning by increasing muscle strength and ß-endorphin levels. However, this idea is speculation, because the patient's respiratory-muscle strength or endorphin levels were not measured directly. The reduction of body temperature, which had remained high for a long time, might have had a positive effect on MV weaning through stabilization of physical distress, such as general malaise. The alleviation of his high fever may be attributable to the anti-inflammatory effect of acupuncture, as this occurred after acupuncture was started and before the change in antibiotics. However, it is difficult to reach a clear conclusion from this single case report.

The single-case design of the current report does not allow conclusions to be drawn about acupuncture's effectiveness. However, weaning-related indices were more likely to improve after each acupuncture treatment, and an early reduction of MV support after the start of acupuncture was observed. Given these findings, the current authors believe that acupuncture could be a useful adjunctive treatment for improving respiration and facilitating MV weaning in patients with severe pneumonia, including severe COVID-19–related pneumonia. Further large cohort studies are warranted.

CONCLUSIONS

This case highlights the use of acupuncture as an adjunctive therapy in an adult patient with severe COVID-19-related pneumonia. The acupuncture treatment improved the patient's respiratory status and facilitated his MV weaning. Further large-scale cohort studies examining the effectiveness of acupuncture for improving respiratory status and promoting MV weaning following severe pneumonia should be conducted.

AUTHOR DISCLOSURE STATEMENT

No financial conflicts of interest exist.

FUNDING INFORMATION

No funding was received for work on the present report.