A woman in New Zealand suffered bilateral pneumothoraces (collapsed lungs) after undergoing acupuncture treatments for arm and wrist pain. Needles had been placed at Jian Jing points (see Figure 1) in both shoulders followed by immediate shortness of breath.

Jian Jing points on the posterior shoulders

The acupuncturist told her to take it easy and discharged her. That night, the patient was taken to a hospital and successfully treated.

An investigation found the acupuncturist at fault for not telling the patient about the risk of pneumothorax and for not obtaining written consent. She was told to obtain further training in acupuncture needling techniques.

I tweeted about the story and Jan Hansel [@VirtueOfNothing] sent me a link to a case report of a 15-week pregnant woman with bilateral tension pneumothorax after acupuncture of the chest for nausea and vomiting. After treatment with chest tubes on both sides, she recovered and was discharged three days later.

Here is an x-ray of a patient with bilateral tension pneumothoraces (Figure 2). The white arrows show the edges of the collapsed lungs and the plural cavities filled with air.

Bilateral pneumothoraces

How common is pneumothorax after acupuncture? The true incidence is unknown. A study from Taiwan of 400,000 patients who underwent more than 5.4 million acupuncture treatments said the rate of pneumothorax was only 1.75 cases per 1 million patients receiving acupuncture in “at risk” areas of the body.

However, investigators at a single hospital in South Korea documented 17 cases (one bilateral) of pneumothorax after acupuncture over a 5-year period from 2011 to 2015.

Untreated bilateral pneumothoraces may result in life-threatening consequences not only due to difficulty breathing, but also obstruction of venous return to the heart causing decreased cardiac output and eventual death.

The diagnosis of bilateral tension pneumothorax can be difficult because some of the usual clinical features of a unilateral tension pneumothorax—decreased breath sounds and hyper-resonance to percussion on one side and deviation of the trachea toward the non-involved side—may be absent.

The following case illustrates that making the diagnosis of bilateral tension pneumothorax on a postmortem CT scan is not the way to go. A 52-year-old Chinese man arrived at an emergency department 30 hours after acupuncture treatment of neck and back pain. Although his blood pressure was 149/94 and heart rate was 86, his oxygen saturation was only 54% and he was gasping for air.

Both pleural cavities are filled with air and the lungs (L) are collapsed posteriorly

He was diagnosed with a possible foreign body airway obstruction. About half an hour later, he lost his pulse and blood pressure and resuscitation failed. After his death, a CT scan (Figure 3) showed collapse of both lungs and marked compression of the mediastinum, major vessels, and heart. One wonders if the history of having had acupuncture was obtained.

A case of bilateral tension pneumothorax after acupuncture diagnosed at autopsy also occurred in Japan.

I found two cases of bilateral pneumothoraces after acupuncture initially treated with a chest tube on the larger side only followed by expansion of the pneumothorax on the other side requiring a tube. Such patients must be watched carefully for the second pneumothorax to worsen.

 

 

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.