Objectives

1. List the major forms of alternative therapies used in lung disease.
2. Provide a brief overview of acupuncture and its application to pulmonary issues.
3. Describe manual therapies and breathing exercises used in lung disease.
4. Describe aromatherapy and distant healing techniques.
5. Identify some adverse effects of alternative therapies.

Key words

Acupuncture; asthma; breathing exercises; complementary and alternative medicine; COPD; dyspnea; herbal therapies; homeopathy

Abbreviation

CAM = complementary and alternative medicine

The term complementary and alternative medicine (CAM) is used to describe a multitude of different therapeutic techniques that are not generally used in mainstream medical practice. Examples include acupuncture, homeopathy, aromatherapy, manual therapies, breathing exercises, herbal medicines, Reiki, and therapeutic touch. These therapies are commonly used by the American public, and the rate of use has increased dramatically over the past decade.^1,2 Because many people combine CAM with conventional medicine, there is a strong impetus in the medical community to better understand what these techniques are, the reasons for which they are used, and their effectiveness and safety. This article will address these issues for the most common forms of CAM used for pulmonary complaints.

Given the importance of good-quality evidence in this field, frequent reference is made to the Cochrane Collaboration library in this text. The Cochrane Collaboration is a nonprofit international organization that prepares, maintains, and promotes accessible, regularly updated systematic reviews of the effects of health-care interventions (see http://www.cochrane.org).

Acupuncture

Acupuncture and Smoking Cessation

Acupuncture is an ancient Chinese technique, developed more than 2,000 years ago, that is based on the principle that energy in the human body flows along certain channels, called meridians. In health, this system holds that energy flows in a balanced manner along these channels. In disease, specific points along these channels on the body are stimulated, often with needles, to help rebalance the flow of energy (qi) and promote health. Support for using acupuncture for nicotine addiction stemmed from studies showing that it decreased the symptoms of opiate withdrawal in animals.³ Controlled trials on the use of acupuncture for smoking cessation, however, have had conflicting results. Of three reviews published, two concluded there was no benefit^4,5 and one concluded that, although acupuncture looked promising, there was insufficient evidence to recommend it.⁶ The largest, most recent meta-analysis of 20 controlled studies found that acupuncture was not superior to sham acupuncture or other antismoking interventions, including behavioral counseling and nicotine replacement.⁷ The authors noted, however, that strongly positive results from three of the trials suggest a possible benefit for intensive and continuous acupuncture treatment.

Acupuncture and Asthma

There have been several reviews of controlled trials published on the effect of acupuncture in asthma.^8-11 In general, the authors have noted that the studies on acupuncture and asthma have had small sample sizes and variable methodologic quality and study endpoints, and that these heterogenous studies have been marked by conflicting results.^8-10 Of the three small, single-blind trials that have been published on the effect of acupuncture in patients with acute asthma, two reported statistically significant improvements in FEV₁.⁹ The two studies on acupuncture in exercise-induced asthma had conflicting results, one positive and one negative.⁹ In terms of the effect of short-term acupuncture (1 to 12 weeks) as an adjuvant therapy for the treatment of chronic asthma, a recent review of seven randomized, controlled trials found no statistically significant difference between acupuncture and sham acupuncture.⁸ A recently published controlled, crossover study assessing the effect of short-term acupuncture on moderate persistent asthma found no beneficial effect on lung function or patient symptoms.¹²

Acupuncture and Dyspnea With or Without COPD

Two trials (one open pilot study and one randomized, controlled trial) have assessed the effect of acupuncture in patients with disabling dyspnea. The pilot study found that in 20 patients with cancer-related breathlessness, there was a statistically significant improvement in subjective symptoms of dyspnea and anxiety.¹³ In the randomized controlled trial of 26 COPD patients with disabling breathlessness, similar improvements were found in subjective symptoms of dyspnea, in addition to an improvement in mean 6-min walking distance.¹⁴

One open study of 51 patients has been published on the use of acupuncture for the treatment of COPD. The authors report that 63.8% of the patients were able to eliminate steroid use for, on average, the last 10.2 months, and that seven patients were able to eliminate all medication use for, on average, the last 9.8 months.¹⁵ In the absence of randomized, controlled trials, however, it is difficult to draw a firm conclusion on the effectiveness of acupuncture in the treatment of COPD.

Safety of Acupuncture

Acupuncture is a relatively safe therapy. The most common adverse events reported are pain at the needle site and bleeding.¹⁶ Other adverse effects include feelings of fatigue and vasovagal episodes.¹⁶ Serious complications from acupuncture are infrequent, but include transmission of infection, pneumothorax, and laceration of various organs.¹⁷ Transmission of both hepatitis B and C, secondary to improper sterilization or reuse of needles, has been documented, as well as case reports of sepsis and endocarditis. Many of these complications can be avoided with the use of disposable needles.

Homeopathy

Homeopathy is one of the most commonly used forms of CAM worldwide.¹⁸ It is based on the principle of similars, or "like cures like." According to this principle, a remedy provokes a certain constellation of symptoms in a healthy person. This same remedy is thought to cure the patient who presents with a similar constellation of symptoms in illness. It is one of the more controversial forms of CAM because the remedies used are often diluted to the point where none of the original molecules of the diluted substance are presumed to remain. Thus, much of the medical literature has focused on whether or not homeopathy's clinical effects can be attributed to the placebo effect.¹⁸ To this end, two meta-analyses published recently concluded that the clinical effects of homeopathy cannot be attributed entirely to placebo.^19,20 Because there have been insufficient numbers of independent investigations assessing any single clinical condition, however, the authors of both meta-analyses were unable to draw any condition-specific conclusions.

There has been one review of three randomized, controlled trials published regarding the use of homeopathy for asthma treatment in 154 patients. ²¹ The authors found that two of the three studies were positive, although two were thought to be of suboptimal quality. The authors therefore concluded that there was insufficient evidence to reliably assess the possible role of homeopathy in treatment for asthma. The best of the three studies reviewed, which was rated 4/5 on the Jadad scale for internal validity, found that patientsÕ assessment of symptom severity decreased significantly, while FVC slightly improved. Although the FEV₁ also improved, this was not statistically significant.²²

In one cohort study, published by a health maintenance organization in Israel, the authors found that integrating homeopathic treatment with conventional treatment for allergic disorders decreased overall use of conventional medications by 56%, resulting in a cost savings of approximately 60% in 3 months. The most significant reduction was in antihistamine use (a 70% reduction), followed by decreases in bronchodialator use (55%) and steroids (50%).²³

Homeopathy and Safety

Because most homeopathic preparations are diluted beyond AvogadroÕs number, they are not likely to contain many molecules, if any, of the original agents used. Thus, they are generally considered as safe as a placebo, and are used extensively with few reports of adverse events. The primary concern is for patients who choose homeopathy when other treatments have been shown to be more efficacious.²⁴ There has been one case series published on three patients who developed allergic reactions to homeopathic remedies.²⁵

Aromatherapy

Aromatherapy is a form of CAM that uses concentrated ÒessentialÓ oils from plants to treat disease. These oils can be applied topically or taken internally, or their fragrance (vapors) can be inhaled, to provide the therapeutic effect. One review of 12 randomized, controlled trials found that, in spite of the methodologic flaws of the studies included, aromatherapy had a mild, transient anxiolytic effect when used in massage.²⁶ There has been one randomized, controlled trial of aromatherapy in 182 patients with chronic bronchitis; with oral use of a proprietary aromatic liquid, the treatment group had fewer relapses.²⁷

Aromatherapy and Safety

Essential oils are generally safe when their fragrance is inhaled. These preparations, however, can be active pharmacologically when applied topically. One well-known example, oil of wintergreen, is obtained from the leaves of Gaultheria procumbens and is a concentrated source of methyl salicylate. Salicylate poisoning has been reported via absorption through the skin, particularly with frequent application, heat, exercise, and skin disruption.²⁸ Essential oils may also be toxic when taken internally, and this practice should in general be avoided.

Breathing Exercises and Asthma

Breathing exercises, including physiotherapy, diaphragmatic breathing, and various yogic practices, are one of the most commonly used forms of CAM for asthma. In one survey of > 3,000 asthmatics in the United Kingdom, 30% of the respondents were using breathing techniques to help decrease symptoms, and 79% reported it to be of some benefit, making it the most useful CAM treatment for asthma in the eyes of this population.²⁹ Observational studies have shown that regular yogic breathing practices decrease oxygen consumption and respiratory rate, synchronize autonomic cardiovascular rhythms, and improve vital capacity in healthy individuals.^30-32 Only a few well-designed, randomized, controlled trials have been performed to assess the effect of breathing exercises in asthmatics, however. One review of six randomized, controlled trials concluded that physiotherapeutic breathing techniques may offer some benefit in mild to moderate asthma, although the author noted that the studies reviewed were of modest quality.³³ In a review of five randomized, controlled trials that were deemed to be of good quality, positive results were found in four of the five trials, but the authors concluded that the small number of trials and paucity of data precluded pooled analysis.³⁴ Although there are few published data regarding the safety of breathing techniques, in general they are thought to be fairly safe. There is an extensive literature on pulmonary rehabilitation that, although related, will not be addressed here.

Manual Therapy and Asthma (Massage, Chiropractic, Reflexology)

Manual therapies, such as massage and chiropractic spinal manipulation, are thought to help asthmatics by increasing mobility of the thoracic cage, loosening secretions, and improving lung function.³⁵ Reflexology is a therapeutic system that posits that a specific organ of the body, such as the lungs, can be affected by stimulating a specific area on the hands or feet. In one review of five randomized, controlled trials, the authors found insufficient evidence to support the use of these therapies for asthma; three of the trials were deemed to be of poor quality.³⁶ The two best studies in this review evaluated the use of chiropractic manipulation for asthma, and found no benefit for asthmatics.^37,38 Manual therapy in general is thought to be fairly safe.

Distant Healing and Lung Disease

Distant healing is a general term used to describe therapies in which the practitioner uses intention to influence the health of a patient who is not in direct proximity to the practitioner. It includes such modalities as noncontact therapeutic touch, Reiki done from a distance, and spiritual healing modalities such as prayer.^39-41 Both Reiki and therapeutic touch are systems of bodywork in which the practitioner is thought to consciously modulate human energy. These methods can be practiced with the patient present or from a distance. Studies on distant healing have assessed only the latter practice. Spiritual healing is has been defined in a similar manner to distant healing, with the added reference to a higher power.^37,38 Many Americans use distant healing techniques to address health concerns: based on a survey done in 1998, 7% of respondents had tried some form of spiritual healing, and 35% had used prayer to augment health.²

There is a limited amount of medical literature assessing the effect of distant healing on health. A recent review of 23 trials with 2,774 patients assessed the effect of distant healing on any medical condition; 57% of the trials showed statistically significant treatment effects compared with control treatments.³⁹ Although no trials have been done specifically assessing the effect of distant healing on pulmonary disease, one double-blind, randomized, controlled trial of 393 patients in the critical care unit found that the intervention group required less antibiotics, diuretics, and ventilatory assistance than the control group.⁴²

Diet, Supplements, and Herbal Therapies

Diet, Supplements, and Herbal Therapies in Asthma

Many CAM practitioners advocate that delayed-onset food sensitivity is an important contributor to asthma symptoms, and recommend elimination diets that avoid a variety of foods, most commonly dairy, wheat, citrus, eggs, and food additives. One study of 34 patients eating a vegan diet did find that 92% had a significant decrease in medication use.⁴³ However, the dietary restrictions in this study were numerous, and nine patients dropped out within the first 2 months, indicating that the participants who remained likely represented a highly motivated population with a specific belief system.

Herbal therapies are commonly used forms of CAM in asthmatics.⁴⁴ Frequently used herbs include ephedra, caffeine-containing products such as coffee or black tea, and Chinese herbal combinations.⁴⁵ Studies have suggested that increased nonprescription medication use by asthmatics may correlate with less frequent physician contact and decreased personal insight into the severity of illness.⁴⁶ For further details on herbal therapies in lung disease, please refer to lesson 11, volume 13 of Pulmonary and Critical Care Update on-line (http://www.chestnet.org/education/online/pccu/vol13/lesson11.php).⁴⁷

Supplements commonly recommended for asthma include vitamin C and magnesium. Small studies have suggested that patients with asthma tend to have lower levels of vitamin C, and that vitamin C supplementation may inhibit bronchial constriction in healthy subjects as well as asthmatics.^48-50 In a review of six randomized, placebo-controlled trials, the authors found that three trials reported a statistically significant benefit and concluded that there was currently insufficient evidence to recommend a role for vitamin C.⁵¹ Of three other reviews on this subject, two found possible benefit, and all three emphasized the need for further studies.^52-54

Magnesium has been proposed for the treatment of asthma based on the thought that it acts as a smooth muscle relaxant at high blood levels. Most studies have focused on the use of IV magnesium for acute asthma exacerbations, and there are limited data to support its use for severe acute exacerbations.⁵⁵ One study examined oral magnesium supplementation in chronic stable asthma, but no benefit was identified.⁵⁶

Supplements and Herbal Therapies in Acute Bronchitis/Pneumonia

Supplements commonly recommended for acute bronchitis and pneumonia include vitamin C and bromelain. There is a paucity of data on vitamin C for pulmonary infection, although one study of 57 patients hospitalized for severe bronchitis or pneumonia found a significant improvement in respiratory symptoms with 200 mg of vitamin C supplementation compared with placebo.⁵⁷

The Safety of Supplements and Herbal Therapies

The Dietary Supplement and Health Education Act passed in 1994 limited regulation of supplements and herbal products by the Food and Drug Administration. Consequently, manufacturers are not obligated to demonstrate evidence of good manufacturing practices, safety, or efficacy prior to making dietary supplements available to the public.⁵⁸ Although most herbs are relatively safe, they can interact with prescription medications, and some Chinese preparations have been found to contain prescription drugs and heavy metal contaminants. Ephedra, an herb that is used for self-treatment by asthmatics, has been associated with a number of adverse effects, including hypertension, stroke, and acute myocardial infarction.⁵⁹

Conclusion

With the increasing prevalence of CAM use by the public, health-care providers are increasingly aware of the need educate themselves about CAM modalities in order to enhance open communication with patients, reduce adverse events, and promote compliance with conventional medical recommendations. Fortunately, medical education opportunities are expanding, and the National Institutes of Health has budgeted more than $200 million in the fiscal year 2002 for clinical and basic science research to further our understanding of this field.

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