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Case Report

Case report of tension pneumothorax related to

acupuncture
Elmar Peuker

Elmar T Peuker
senior lecturer
Department of Anatomy
University of Muenster
Germany
Correspondence:
Elmar Peuker
e-peuker@muenster.de

Summary
Although recent prospective studies came to the conclusion that the incidence of adverse events
following acupuncture can be classified as minimal, many cases of acupuncture-related pneumothorax
have been published over the years, among them some cases of tension pneumothorax. In this case, a
slender woman received acupuncture from a fully trained medical acupuncturist including needling of the
points LU1 in the subacromial region and BL13, which is a paravertebral point at the level of the spinous
process of the third thoracic vertebra. During the final treatment, she experienced difficulties in breathing
and pain in the left chest. On x ray examination a tension pneumothorax was diagnosed. Even though
pneumothorax is the most frequently reported serious complication related to acupuncture, it is not an
inevitable complication of acupuncture, and in most cases involves negligence from inadequate
consideration of basic anatomy.
Keywords
Complication, acupuncture, pneumothorax, negligence.

Introduction
The following report describes a case of tension
pneumothorax associated with acupuncture. The
author was asked by court to give an advisory
opinion concerning the question of whether the
pneumothorax was caused by acupuncture and
whether a patient should be informed about the
risk of pneumothorax due to acupuncture before
treatment. The author is a fully trained (more than
350 hours with a diploma of the medical council)
and qualified acupuncturist from Germany. He
works as a lecturer for several acupuncture
societies both nationally and internationally.
Case report
A slender 38 year old woman (BMI: 19 kg/m2)
sought the help of a medical acupuncturist for
breathing problems. She had been examined by
a lung specialist a few weeks previously
(including spirometry and chest x-ray film), and
there were no pathological findings. Her medical
history was unremarkable. She suffered from
psychological stress as a result of caring for her
two young children alone whilst her husband was
on an extended work-related absence from home.

40

The medical acupuncturist she attended was fully

trained (more than 350 hours with a diploma of
the medical council), and worked as a lecturer for
one of the larger German acupuncture societies
(not the author of this paper).
The Chinese diagnosis made was obstruction
of lung qi, and she was treated with acupuncture
at the points LU1, LU7, ST36, HT7, BL13, KI6,
PC6, GB20 and GB34. The treatment consisted of
five sessions within five weeks. During the last
session the patient experienced a sharp pain in
the left side of her chest and increasing difficulty
breathing. The medical acupuncturist assumed
that the problems occurred due to tension in the
meridians, and advised the patient to relax.
As the complaints got worse over the following
30 minutes, he decided to auscultate the lung and
expressed the suspicion that there might be
a bubble in the lung.
He handed the patient a paper with the address
of a radiologist and called a taxi, which drove
the patient to the radiologist without further
medical attendance. The chest x ray film showed
an almost complete pneumothorax of the left lung
with an early beginning shift of the mediastinal

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Case Report

Figure 1 Chest x ray film taken approximately one hour after acupuncture. An almost complete
pneumothorax of the left lung (arrow heads) is shown. There is also some initial shifting of the
mediastinal organs to the right side.
organs to the right side (Figure 1). The diagnosis
was tension pneumothorax. The patient was
immediately transferred to a hospital and treated
with intensive care (including chest-drain) for
one week. An x ray film of the lung at the
date of discharge from the hospital showed
almost complete re-expansion of the left lung
(Figure 2).
The patient sued the acupuncturist for
negligence to at least reimburse the costs of
domestic aid and care of her children during
her hospital treatment. This was denied by the
acupuncturist who argued that the woman
experienced a spontaneous pneumothorax that
was merely coincidental with his acupuncture
treatment.

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Discussion
Many case reports and reviews deal with the
topic of pneumothorax from, or associated with,
acupuncture. Among them are several reports on
bilateral pneumothorax with or without tension
pneumothorax.1-10
Unfortunately, most of the case reports on
adverse events related to acupuncture lack
important information that would enable the
reader to learn from the case.11 There are several
papers that review pneumothoraces and other
traumatic complications related to acupuncture,
for example, those by this author.11;12
However, some of the more recent prospective
studies on adverse events related to acupuncture
came to the conclusion that pneumothorax occurs

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Case Report

Figure 2 Chest x ray film taken one week after the pneumothorax, and following appropriate treatment
with a chest drain.
extremely infrequently in association with
acupuncture.14;15 On the other hand, none of the
respective studies differentiates the acupuncture
treatments according to topographical data. It is
rather unlikely that acupuncture at points in the
leg would cause a pneumothorax. Equally, ear
acupuncture, even if the lung point is used,
cannot result in a pneumothorax as a direct
consequence of the acupuncture. Therefore, an
assessment of the frequency of adverse effects of
acupuncture (at least if traumatic complications
are concerned) requires a differentiation between
the points and regions treated.
A spontaneous pneumothorax occurs with a
frequency of 1.2 6/100,000 per year in women
younger than 35 years of age.16 Smokers suffer
significantly more frequently from spontaneous

42

pneumothorax than non-smokers. Most have a

previously undetected bulla or bleb-formation.
A bulla is defined as a sharply bordered region
within an emphysematous lung with a diameter of
at least 1cm and a wall-thickness of less than
1mm. Bullae are usually multiple.17;18 A bleb
refers to an air-filled cavity of the pulmonary
pleura,17 or within the variably thickened border
between the pulmonary pleura and the lung.19
These changes are usually located in the apical
region of the lung.
In this specific case the author came to the
conclusion that the tension pneumothorax resulted
from the acupuncture treatment, and was not a
spontaneous pneumothorax that occurred
coincidentally during the acupuncture session.
This assessment is supported by the lack of

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Case Report
findings on medical examination of the lung
specialist before acupuncture treatment. Moreover,
the x ray films before and after the treatment
showed none of the pathological features that
predispose to spontaneous pneumothorax (eg
emphysema, bulla, bleb-formation).
Two of the acupuncture points which were
treated have a topographical correlation to the lung
(LU1 and BL13). Treatment at LU1 might cause a
pneumothorax if needling is performed in a
medial rather than the suggested lateral direction.
BL13 should be needled obliquely in a medial
direction. Perpendicular needling might injure the
lung at a depth of about 2-3cm. Unfortunately, the
documentation of the acupuncturists contained no
information about the needling depth and
direction. During the treatment, the patient was
lying on her back. It may be possible that, whilst
lying, the needles at BL13 were inadvertently
pushed deeper by external pressure.
In the authors opinion, the actions of the
therapist were inappropriate. The patient suffered
from severe pain in the chest and increasing
difficulty breathing. She should have been
transferred directly to a hospital with medical
attendance.
Another question from the court referred to the
necessity for giving information on risks before
acupuncture treatment. In the authors opinion,
communicating risk information is important
before acupuncture treatment. Two proposals have
been published in this journal.20;21 On the other
hand, the author suggests that pneumothorax (like
most severe traumatic complications related to
acupuncture) is not a specific risk of acupuncture
but caused by negligent application. Therefore it
would be better to use the wording pneumothorax
related to acupuncture rather than pneumothorax
caused by acupuncture.

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Case report of tension pneumothorax related

to acupuncture
Elmar Peuker
Acupunct Med 2004 22: 40-43

doi: 10.1136/aim.22.1.40
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