A recent case report published in Acupuncture in Medicine by Tagami et al (2012) reminds us to be vigilant in our practice when it comes to the potential risk of pneumothorax.
It describes the case of a 69 year old large bodied man who was diagnosed with a rare case of bilateral pneumothorax at a Tokyo hospital's emergency department. He presented with chest pressure, cold sweats and shortness of breath. Immediately after the pneumothorax was confirmed on X Ray, his cardiopulmonary status deteriorated and bilateral tension pneumothorax was diagnosed - an emergency. He was treated successfully with the insertion of drainage chest tubes and he made a full recovery.
It was only after treatment that is was discovered he had received acupuncture 8 hours previously and with no risk factors for spontaneous pneumothorax it was determined that the acupuncture must have been the cause (Remember that pneumothorax can develop up to 48 hours post treatment).
This case should serve to remind us that If performing acupuncture about the chest wall, we must inform the patient of the risk of damage to the lungs so that should symptoms such as those described above develop, early and accurate diagnosis can be made.
However we should also explain that with proper needling techniques applied by a trained practitioner the risk of such a major adverse reaction is extremely low, around 0.05 per 10,000 treatments (White et al, 2004).
It's a fine line between alarming a patient which could negate the potential benefits of acupuncture and well balanced informed consent. We all need to decide how we are going to approach this issue of consent, ideally it should be written and documented which is often a requirement depending on the clinical setting. For a useful informed consent document go to http://www.medical-acupuncture.co.uk/Portals/0/Public%20Docs/clinic-consent.pdf
Of course prevention is better than cure as they say. So when needling about the chest wall we can reduce the risk of penetrating the pleura and potentially needling a bolus, by needling at a tangent to a rib, over or onto a rib, or needling superficially. I always listen to that little voice in my head which tells me I may be heading into dangerous territory and back off immediately and reassess where the tip of my needle is located.
Overall, medical acupuncture is generally a very safe technique to use in the right hands with the incidence of adverse reactions both minor and major generally low. However we should always be aware that there is an element of risk and every effort to negate this risk should be taken in clinical practice.
