Bilateral pneumothorax after acupuncture treatment

Abstract

A 31-year-old female physician was diagnosed with bilateral pneumothorax a day after her acupuncture treatment. Her body mass index was 16.9 and she did not have a prior history of respiratory disease or smoking. Acupuncture needles may easily reach the pleura around the end of the suprascapular angle of the levator scapulae muscle where the subcutaneous tissue is anatomically thin. In our patient, the thickness between the epidermis and the visceral pleura in this area was only 22 mm as confirmed by an ultrasound scan. Although she felt chest discomfort 30 min after the procedure, she assumed the symptom to be a reaction to the acupuncture. In light of our case, we advise practitioners to select appropriate acupuncture needles for patients based on the site of insertion and counsel them regarding the appearance of symptoms such as chest pain and dyspnoea immediately after the procedure.

Background

Acupuncture is one of the most widely employed treatments in traditional Chinese medicine. The literature documents iatrogenic pneumothorax as a known complication of acupuncture although the incidence is rare. A large prospective observational study in Germany and a review of safety data from the National Health Service in the UK that evaluated the safety of acupuncture reported an incidence of pneumothorax of less than 1 case per 1 million procedure.^{1 2} The presences of respiratory disease, smoking and women with low body mass index (BMI) (18–22) are the risk factors that contribute to this complication.^3–5 Treatment with acupuncture of the posterior shoulder and insufficient knowledge of anatomy are also documented risk factors.^{4 6 7}

Case presentation

A 31-year-old female chest physician visited an acupuncture clinic due to stiff shoulders, and received acupuncture for her neck, back and chest for 90 min (figure 1). Her BMI was 16.9 (height 158.1 cm, weight 42.3 kg). She had no history of respiratory disease or smoking. Half an hour after the procedure, she felt fatigue and discomfort in her chest and shoulders, which she assumed were due to the acupuncture procedure. She heard a ‘crackling’ sound coming from both sides of her chest which got louder in the supine position. The sound persisted the next day and she experienced chest pain during sneezing and discomfort during the inhalational phase. She reported to the emergency room suspecting a pneumothorax. Her vital signs were as follows: body temperature 36.5°C, pulse rate of 70 beats/min, respiratory rate 12 cycles/min and SpO2 of 98% in ambient air. A chest radiograph revealed a collapse of the right lung up to the third intercostal space and a slight collapse of the left lung apex returning a diagnosis of iatrogenic bilateral pneumothorax (figure 2). The patient recovered uneventfully after 11 days without intercostal drain insertion (figure 3).

Figure 1.

Areas treated with acupuncture. A: multifidus thoracis, B: middle part of the trapezius, C: superior angle; entry of the scapular levator muscle, D: scapular levator muscle, E: upper part of the trapezius, F: infraspinous muscle, teres minor muscle, teres major muscle, G: external oblique muscle, lumbar quadrate muscle, H: outer rim of the iliocostalis, I: entry of the iliocostal muscle, J: entry of the greatest gluteal muscle, K: middle gluteal muscle, least gluteal muscle, L: entry of the splenius muscle of head, M: semispinalis capitis muscle, N: entry of the trapezius muscle and semispinalis capitis muscle, O: entry of the minor pectoral muscle.

Figure 2.

Chest radiograph at emergency room. Pleural line of the right lung was observed at third intercostal space (arrow). Small left-sided pneumothorax was also observed (wedge).

Figure 3.

Chest radiograph on the 11th day after the onset of pneumothorax.

Outcome and follow-up

Eleven days after diagnosis, the iatrogenic bilateral pneumothorax resolved without any intervention.

Discussion

At the facility where the session of acupuncture was performed, appropriate lengths of acupuncture needles are prepared corresponding to the anatomical depth of the target muscle (figure 4). Each needle has a diameter that corresponds to the length of the needle to maintain directionality and operability during insertion. The presenting complaint, in this case, was severe muscle stiffness in the neck and superior shoulder region which was subsequently confirmed by palpation. The practitioner, in an attempt to quickly relieve the muscle stiffness, selected needles with a longer length (60 mm) and large diameter (0.3 mm) for the neck, upper shoulder and back. These needles are conventionally reserved for the lumbar or buttock area. The following precautions were taken to ensure safety:

Figure 4.

Acupuncture needles used at the facility. In this case, the needle far right (*) was used.

1. The target muscles and the bones to which they are attached were identified as landmarks, taking into account relevant body surface anatomy and palpation techniques.

2. The direction and depth of needles during insertion was controlled so that the acupuncture point does not deviate deeper than the landmark.

The area around the end of the suprascapular angle (figure 1, site C) is anatomically close to the pleura. The depth of insertion around this area was 20–30 mm. Figure 5 shows the details of the procedure at each site. The distance between the patient’s epidermis and visceral pleura at the attachment of the suprascapular angle of the levator scapulae muscle was 22 mm as confirmed by ultrasound (figure 6). The length of the needles used in this case was 60 mm, which may not be suitable for routine treatment of the neck and shoulder region. Since the maximum depth of insertions was approximately 30 mm even with angled insertion, the acupuncture needles could penetrate the pleura bilaterally. The mean distance from the surface to pleura at the attachment of the suprascapular angle of the levator scapulae muscle is reported to be 32 mm in Korean women with a BMI below 18.5.⁸ This, however, does not imply that inserting a 30-mm needle is safe. The acupuncturist should judiciously select the appropriate needles taking into account the patient’s physique and muscle stiffness. In this case, since the acupuncturist was not a novice and had 11 years of experience, the bilateral pneumothorax probably resulted due to impudence. Pain and discomfort in the treated area the following day may appear to be an immediate effect of the acupuncture treatment and mask the onset of the pneumothorax. The patient herself suspected a pneumothorax due to the ‘crackling’ sound in her chest particularly in the ‘supine’ position and reported to the emergency room.

Figure 5.

Treatment carried out at the superior angle; entry of the scapular levator muscle (ie, figure 1 site C). (A) Follow the inner margin of the scapula upward to identify the suprascapular angle at the lower level of the trapezius muscle. (B) Press the mother and the index finger into the trapezius muscle to eliminate the trapezius muscle as much as possible, and then stand upright. The practitioner’s fingers press the superior angle. (C) After insertion, move the acupuncture needle toward the direction of the superior angle and inner margin while pulling up and inserting. Insertion depth is around 20–30 mm.

Figure 6.

Ultrasound findings at the patient’s suprascapular angle of the levator scapulae muscle (figure 1 site C). The distance between her epidermis and visceral pleura at the attachment was 22 mm.

The incidence of iatrogenic pneumothorax may be more frequent than reported in literature since patients may not notice the symptoms and recover uneventfully without intervention in cases of mild lung collapse.^{5 9 10} To the best of our knowledge, there are no reports in the literature that compare a course of iatrogenic pneumothorax due to acupuncture with pneumothorax due to other aetiologies. We, however, believe that from our anecdote an iatrogenic pneumothorax due to acupuncture needles may run a relatively benign course and resolve spontaneously.

Patient’s perspective.

Thirty minutes after the acupuncture treatment, I experienced pain and paraesthesia in the treated area. However, I assumed these symptoms were a ‘positive reaction’ to the treatment because I was undergoing acupuncture for the first time and I did not know what is expected at the site after treatment. I was not aware of the possibility of the treatment causing a potential pneumothorax. Despite being a chest physician, I did not suspect the onset of a pneumothorax till the next day.

Learning points.

• Acupuncture practitioners should select acupuncture needles based on the individual patient’s anatomy.

• Pain and transient deprivation of sensation due to acupuncture make the early recognition of the symptoms of pneumothorax difficult for patients and practitioners.

• Patients should be counselled regarding the symptoms of pneumothorax to recognise the early symptoms of its onset not only immediately after acupuncture but also the following day.