Acupuncture for COPD
In this article, I will discuss the use of Acupuncture for COPD (Chronic Obstructive Pulmonary Disease). To begin, I will give a clinical overview of COPD followed by acupuncture treatment strategies and acupoints to use in a treatment.
This article provides a practical approach to treating COPD with acupuncture with reference to two scientific studies. I also include my own personal experience of treating COPD in hospice care.
I have not discussed COPD in relation to Traditional Oriental Medicine theory, such as along the lines of Qi, Channel pathways or TCM pathology. So I would advise the reader to seek out other sources for this perspective.
COPD (Chronic Obstructive Pulmonary Disease)
Chronic obstructive pulmonary disease is a general term for a collection of lung diseases including emphysema (affecting the alveoli) and chronic bronchitis (affecting the bronchi). The main symptom of COPD is breathing difficulties caused by obstruction and narrowing of the airways.
COPD mostly affects middle-aged or elderly men. Smoking is a risk factor. Over time, the symptoms gradually get worse.
COPD is a chronic disease which is usually managed with pulmonary rehabilitation (e.g. exercise) programmes, inhalers or some medications.
Sometimes, the symptoms of COPD can be exacerbated, particularly due to stress. During flare-ups, patients may be treated with steroids and antibiotics to quickly reduce inflammation or risk of infection.
COPD Summary: Oxygen Machines
Oxygen machines may be used in some cases. Patients may use an oxygen machine at home for around 15 hours. Portable oxygen machines can also be carried, particularly if the patient gets easily tired upon mild exertion. With one of these machines, the oxygen is breathed in through a face mask or a small tube inserted into the nose (a nasal cannula). Patients can still eat, drink and talk whilst wearing a nasal cannula.
In severe cases, an oxygen machines (non-invasive ventilation (NIV)) machine is used. A mask is put over the face and air is pushed into your lungs so the patient doesn’t have to breathe themselves. Surgery is sometimes used but does not have good outcome measures.
The main symptoms of COPD are:
Shortness of breath on exertion – (even on minor exertion)
Chronic cough with phlegm,
Frequent chest infections
How COPD is diagnosed:
If a person has breathing difficulties, they may be sent for a Spirometry test. The patient is asked to breathe into a spirometer machine, which measures the volume of air you breathe out. The readings are compared to a chart based on your age-group, which can indicate if your airways are obstructed.
X-Rays and Blood tests
Patients can also be sent for X-rays and blood tests. X-Rays may reveal abnormalities or damaged areas of the lungs. Doctors will be looking for signs of anemia or high concentration of red blood cells in your blood.
Standard treatments include:
Bronchodilaters – to relax and widen the airways. Or steroid inhalers to reduce inflammation in the airways.
- Theophylline tablets – which relax and open the airways. Side effects can cause palpitations, headaches, nausea and insomnia.
- Mucolytic Mecixations – to reduce mucous in the throat
- Steroids (a short course) – to reduce inflammation
- Antibiotics to reduce risk of infections or if there are signs of one.
3. Pulmonary rehabilitation –
Patients will be advised to join exercise and educational programmes to help improve breathing and deal with the effects of COPD in their daily life. These programmes usually encompass exercise guidance, diet advice as well as psychological and emotional support.
In my hospice work, this was primarily carried out by Occupational therapists (OT’s) who would run specific breathing programmes for COPD sufferers.
Acupressure for COPD
If you see a COPD patient, it may be of some benefit to teach your own self-acupressure points as an extra resource to help them deal with the effects of their symptoms. For example, teaching them how to apply acupressure on Lung or Large Intestine channel points (e.g. Lung 6, LI4) to help calm and body and support the Lung Qi.
4. Surgery is another option.
Surgery may be carried out to remove a part of the diseased lung. Or an operation can be carried out to remove a portion of air from the lungs (bullectomy), which is supposed to improve breathing.
5. Recommendations to stop smoking.
This was a curious thing. In my experience in hospice care, I noticed that a few of the patients that suffered from COPD, also smoked. You would often see them in the smoking room, sometimes with an oxygen tank by their side. I am sure that they must have been told many times by doctors to quit smoking, but this is clearly something they were not prepared to do. I imagine there are psychological reasons for not quitting and it may be that smoking helped them deal with their disease and with life.
Respecting their choices
If a patient comes in smelling of smoke after having a cigarette, I wouldn’t criticise them or advise them to quit. They will already be aware of the implications of smoking on their disease and will likely have heard it many times from most medical professionals they have come across.
In the UK, there is an anti-smoking bias going on, where smoking is being listed as a possible cause for many diseases, even those with an unknown cause (at least by Western Science standards). I am tired of being asked whether I smoke at every doctors or dentist appointment I attend and I don’t even smoke (currently).
I don’t see any value in being one of the anti-smoking brigade. It is their choice. They may open up to you more if you accept their decision without judgement. Or it may be that you are in a better position to help them explore their smoking habit on a deeper level.
References: NHS website
Acupuncture and COPD
There is research on the benefits of acupuncture for COPD. For example – ‘Pilot study to assess the credibility of acupuncture in acute exacerbations of chronic obstructive pulmonary disease‘ and ‘Combined standard medication and acupuncture for COPD: a case series’. In this article I will discuss both of these studies and their treatment protocols, but before I do, I will share my approach to treating COPD with acupuncture.
I have treated a few patients with advanced cases of COPD and found that some short-term relief can be achieved with acupuncture, especially in advanced cases. Following, are certain considerations when treating people with COPD, included some recommended acupuncture points.
Treating COPD with Acupuncture
Firstly, patient comfort is important with special consideration given to their ease of breathing. Ask them what position they prefer to lie in and focus on accommodating their favoured position. They should be given the choice to sit or lie in a position that is easier for their breathing.
Occasionally some patients are all too eager to please and may offer to lie in a position to facilitate your treatment, even though is may not be the best for them, such on lying face down. This may be the case when patients especially want their backs treated – particularly for muscular pain. If you feel they are pleasing you in spite of themselves, guide them into finding the best position for them that you also can work with.
Generally, carrying out the patient lying down on the back or seated upright is usually more comfortable. Some treatment tables can be altered to sit upright. Sometimes a patient may be quite mobile and able to move around, lie on their side or sit upright on the side of the couch or a chair allowing you access to the back. In these cases you may be able to treat the back as well.
Exertion can be tiring
Patients with advanced cases of COPD, may find even minor exertion exhausting. Standing up, waking and undressing can bring on bouts of breathlessness. All the patient opportunity to rest and get their breath back, especially after the treatment has ended.
Allow the patient to take as long as they need to get ready. Be prepared to offer assistance if they are ok with it. Some patients still want to be responsible for doing things themselves and so you must respect that, but in other cases, they may appreciate it if you can help with removing socks and shoes or sometimes a pullover in more advanced cases.
It is best to avoid getting the client to move to much or to travel long distances as exertion can cause shortness of breath and may be tiring. If you walk with them to and from the treatment room, make sure to match your pace to theirs. If you don’t, you may find they try to match their pace to yours and end up tiring themselves out.
Acupoints: Acupuncture for COPD
Here are some useful distal acupuncture points for treating COPD. Some of these points are the same as for my article on Acupuncture and Lung Cancer. Due to the similarity of the symptoms of these diseases, I feel a similar strategy can be followed:
The source point of the lung channel – Lung 9 can help tonify the Lung Qi, which will be deficient. Needling this point requires some special consideration due to the radial artery underneath.
Needle superficially and obliquely. The Lung Qi flows very close to the surface and even a simple Japanese technique of non-insertive contact-needling (with intention) on this point for several breaths can activate the point. If you use insertive needling, locate the radial artery using your finger, and needle to the side of it very shallowly – a few millimetres.
Alternatively, use Lung 5. In Traditional Acupuncture – Lung 5 is the He-Sea point and used for conditions of “counterflow qi” of which breathlessness comes under. Again, special care should be taken to avoid the artery by first identifying its location by feeling for its pulsation and needling away from it. Slightly deeper insertion can be used.
The Lung 6, Xi Cleft point, can be considered even though Xi-cleft points are typically used for acute conditions or pain. Palpate this point and if it is tight or there is a little nodule at the point, it would be worth needling to open up the channel.
This point can sometimes be tight or painful (i.e. active) during lung diseases and can be safer to needle than Lung 9.
If the patient is ok with a little moxa being burned, then Japanese rice grain moxa on this point (3-5 times), especially if the point is really hard, may help to clear the channel and improve Qi flow. But his depends on whether the smoke may aggravate the patient’s breathing.
Patients with lung disease will tend to have a shallow and rapid breathing pattern. It is not unusual for there to be tightness on the inner chest and pectoral muscles as well as on the back and shoulder muscles.
Basically, there is too much yang/excess in the upper part of the body. Releasing the tension in the upper body will help the patient relax and may also improve the breathing.
Points on the upper back and shoulders can also help release muscle tension (stagnant Qi) in the upper body. Some useful points to palpate for excess and use are:
- GB 21, GV 20
- Bl 11, Bl 12, Bl 13
- SI 15, SI 14,
- SJ 15
Local Points: Acupuncture for COPD
The musculature around the lung area, upper chest and shoulders can become tight with the rapid breathing pattern. It is a case of excess Qi above, not enough below. It can help to release some of this tension in these areas. Needling does not have to be deep or have strong manipulation as the intention is to gently release any surface stagnation. Also special precaution must be taken in these areas as the Lungs are below.
Lu 1 & Lu 2
Lung 1 is the front mu point of the Lung and a meeting point for the Spleen and Lung Channels. With deficient Lung Qi, one of these points may manifest in an excess manner. It may be tight or painful upon palpation. These points are clinically indicated for lung diseases, although there are specific risks with these points so needling must be considered.
Lu1 and Lu2 – Risk of Pneumoforax
The risk of pneumoforax can be limited by following special precautions when needling. Avoid deep or perpendicular needling. Avoid heavy stimulation or needle manipulation (obtaining deqi). Use shallow needling inserted at an oblique angle.
Lu1 and Lu 2 Needle length and needling
I prefer a half cun needle. My focus is on releasing the surface tension around the upper chest area and so there is no need to go in deep. Also the lung channel Ki flows closer to the surface than the other channels. Use needles with a brightly coloured handle, like the Serin brand, in case needles fall out and you have to find them.
Some patients with lung disease may have a thin build and smaller muscles in the chest area. In these cases, make sure to keep needling shallow or superficial and at an oblique angle.
Lu 1 and Lu 2 Insertion
Insert at a transversely-oblique/transverse angle. Try to avoid using a guide-tube as it does tend to requires a more perpendicular-oblique angle to get in. Pinching the flesh up and inserting obliquely/transversely can usually be done painlessly.
If the patient fidgets or has a very rapid breathing pattern, I may leave out these points as too much movement means the needles can work their way out of the body and fall out. Also if the patient fidgets too much, I don’t really want to be concerned with the patient accidentally pushing it further in either.
If needles fall down tops, it may be useful to have an extendable magnet stick to recover them.
This can be a useful point to open up the chest. Pinch up the skin and needle obliquely in a downward direction. The needles can be retained for 10-15 minutes. No stimulation is necessary. I may omit this point is the breathing is particularly rapid or laboured. I have had patients tell me they feel the whole chest area open up when using this point.
I sometimes apply a Toyohari ‘naso-muno’-style treatment to this points on either side of the neck. The muscles around the neck and sternum can be tight in a patent with COPD and they be manifesting as active points – hard and painful (excess). Due to risk of pnuemothorax, I don’t needle these points with a standard TCM or standard needle insertion technique and would choose to omit.
Japanese Meridian Therapy utilises a shallow needling technique. Using a fine Seirin needle, tap into the hardness and insert slowly and mindfully for just a few millimetres or until you can feel that tension release. Hold the needle for a few minutes and then withdraw, focusing on the point within. If done correctly, the patient will feel the neck area open up and a release in this area, which can help with breathing.
There is a risk of pneumothorax if you needle deeply with this point, so if you do decide to utilise a standard (TCM) style needling technique, be sure to needle superficially, along the clavicle a few millimetres. I would still suggest to withdraw the needle after a few breaths with no needle retention.
It is difficult to know if patients will be ok with moxa fumes or if it will hinder breathing. Some patients are ok with the smokeless variety and can find it relaxing. But others may not. If you decide to try out moxa, make sure the area is well ventilated and keep windows open if possible.
Limit the use of moxa and keep smoke away from patient faces. If you want to try out using loose moxa, use the higher-grade Japanese moxa instead of the lower grade Chinese variations, and limit it to rice-grain moxa techniques rather than large moxa cones, which produce more smoke. Moxa on ST 36 can be helpful for enhancing the overall immune system of the body and the point is further away form the face os there is less risk of smoke reaching there airways. If the moxa does upset the breathing or cause coughing, then discontinue immediately. It may be safer to use smokeless moxa variations.
Acupuncture’s calming effects on COPD
As with my article on Lung cancer, the shortness of breath and rapid breathing pattern can over-stimulate the sympathetic nervous system, exacerbating conditions like anxiety, stress and insomnia. Acupuncture can be very effective in calming the body down and activating the parasynpathetic nervous system.
Yintang is a useful versatile point to calm the body and is easy to needle. However, any general acupuncture treatment will help put the body in a state of relaxation.
Treating COPD patients
A semi-upright position is usually best with extra pillow support behind the head. This helps with the breathing. generally, you may want to avoid laying on the front as it can hinder breathing, however, In some cases you can treat the back, with the patient laying flat down, but this depends on the patient’s condition, and usually, it is best to avoid laying face down for back treatments. A patient lying on the side or possibly sitting on a chair and leaning over a bed for support may be a better approach.
Some treatment coaches or hospital beds can be adjusted to allow a patient to sit up. Offer extra pillows to further bolster a patient upright. Make sure they are comfortable before commencing treatment as once treatment has begun, it will be harder to move the body once needles are in.
A patient could also be treated sitting upright either in a chair or wheelchair or on an adjustable couch with cushions behind for support. Avoid using a normal office chair if possible to reduce the risk of needle shock or faint, but ultimately a practitioner may have to make do with whatever resources they’ve got.
Acupuncture and massage could be applied to the upper back, shoulders and neck as well as some needling to some upper back points to help release some of the tension that can often be found in these areas.
Scientific Studies: Acupuncture for COPD
This was a study carried out at the Meiji University of Integrative Medicine in Kyoto, Japan. 26 patients with dyspnoea on exertion due to COPD received acupuncture once a week for 10 weeks.
Points used were Zhongfu (Lu1), Taiyuan (Lu9), Futu (LI 18), Guanyaun (CV4) and Zhongwan (CV12), Zusanli (St36), Taixi (Kid3), Wangu (GB12), Feishu (BL 13), Pishi (BL20) and Shenshu (BL23). All points were used on all patients.
Japanese Seirin Stainless steel needles were used with a length of 40mm and diameter of 0.16-0.20mm. They were needled at a depth ranging from 4 to 20mm depending on the thickness of thin and fatty tissue. Needles were rotated clockwise and counterclockwise for 3-4 minutes.
Needling of the LU1, BL13 and BL20 points were limited in their needling depth to less than 5mm due to risk of pneumothrorax. The treatments lasted for 50 minutes. Patients were needled supinely and then turned prone to needle the back treatments. Only those people with severe dyspnoea were not treated in a prone position and instead were treated in the lateral position (lying on the right side).
No electrical stimulation was used and patients were asked to record any de-qi sensation they felt.
One of the downsides to this research was that the patients were told “that the acupuncture treatment improves dyspnoea”. This statement along with the lack of a control group means that the placebo effect cannot be ruled out. The authors did conclude that a longer, randomised, controlled clinical trial was necessary.
Overall, the authors concluded that acupuncture for COPD had a beneficial effect on patients and that “all 26 patients showed significant improvement in the Borg dyspnoea scale after 10 weeks of acupuncture treatment”. There were also improvements in the “BODE index, 6MWT and oxygen saturation during exercise”, which indicated an improvement in the symptoms of COPD.
The authors concluded that the results suggested that acupuncture treatment has “clinically useful effects, at least in the short-term, in reducing dyspnoea on exercise in patients with COPD, particularly in those more severely affected”. Here are some quotes from the article:
“The results suggest that exercise capacity and the oxygenation of patients with COPD were improved after intervention with acupuncture treatment”
“suggests that intervention with acupuncture may have a beneficial influence on the prognosis of patients with COPD”
The authors postulated that one of the mechanics of acupuncture being helpful for COPD is that:
“Acupuncture may result in a release of tension in the respiratory accessory muscles groups and consequently the diaphragm breathing was facilitated.”
“Needling on the acupuncture points which exist on the respiratory muscles causes relaxation of the muscles, which may support recovery of the function in the respiratory muscles and lead to improvement in tolerability to exercise.”
This supports the approach I suggest – of lightly needling points in the chest and shoulder areas to release the tension caused by the breathlessness and rapid breathing patterns.
Summary of this treatment Protocol
I thought it may be useful to summarise the practical treatment points of this scientific study of acupuncture for COPD, for readers of this article wanting a straightforward protocol to use:
Acupuncture for COPD – Points:
- Zhongfu (Lu1)
- Taiyuan (Lu9)
- Guanyaun (CV4)
- Zhongwan (CV12)
- Zusanli (St36)
- Taixi (Kid3)
- Futu (LI 18)
- Wangu (GB 12)
- Feishu (BL 13)
- Pishi (BL20)
- Shenshu (BL23)
- Japanese Seirin Stainless steel needles
- 40mm – length
- 0.16-0.20mm – size
- needle depth ranging from 4 to 20mm depending on the point and body structure.
- Needles were rotated clockwise and counterclockwise for 3-4 minutes.
- Needling of the LU1, BL13 and BL20 needed to depth less than 5mm (prevent risk of pneumothrorax).
- Treatment Length – 50 minutes.
- Patient needled supinely, then turned over and needled prone or in lateral position if dyspnoea was severe.
My notes on this protocol
I would suggest that it may not be necessary to treat both front and back in one treatment. Instead allow the patient more time to relax (or nap) during the treatment and then consider treating the back on a different occasion. I would also favor the lateral (side) position rather than lying on the front even if the condition is not so severe. 25 or 30mm length needles could be used for some of these points also instead of 40mm especially Lung 9.
Pilot study to assess the credibility of acupuncture in acute exacerbations of chronic obstructive pulmonary disease
This was a short pilot study carried out as part of University Hospitals Coventry and the Warwickshire NHS Trust, UK. Its aim was to “assess the feasability of conducting a study of acupuncture during an acute exacerbation of COPD”. A sham control was also used.
11 patients with COPD were chosen with 9 completing the trial. 5 men and 4 women with a mean age of 68 (range 53-78). Four received real acupuncture and five had sham acupuncture. Acupuncture was well tolerated and no adverse effects were reported.
“Real acupuncture was administered to LI4 bilaterally to a depth of 15-20mm and to two upper sternal points, 2 cm apart in the midline, advanced to the periosteum without manual or electrical stimulation, and with no attempt to elicit de-qi.
Sham treatment was administered over the kneecaps bilaterally and ST25 bilaterally. Needles were left in place of 20 minutes without stimulation.
Duration and number of treatments
It is unclear how many treatments in total were given. As this was a pilot study, it was likely to be over a short period. Although it is apparent that the frequency of treatments during the trial may have been relatively high:
“Treatment was repeated 24 and 48 hours later, with real or sham acupuncture delivered at the same sites on each day.”
Acupuncture improved COPD, but there was little difference between the sham acupuncture or the real acupuncture
The authors noted that:
“Acupuncture was well tolerated and credibility scores were similar before and after real and sham acupuncture. Symptoms improved after treatments, with no significant difference between groups”.
“Mean dyspnoea and anxiety scores improved after both real and sham treatment, but there was no statistical difference between the groups.”
Acupuncture intervention was of benefit and was well received by the COPD patients. However, there was an implication that there was little difference between either the sham or the real acupuncture.
I will discuss this conclusion in the next paragraph, as it is a topic worth addressing. Nonetheless, even to a layperson, this study does suggest that any kind of acupuncture intervention (whether sham or real) will have a positive effect on COPD.
Refuting this finding of no difference between ‘sham’ or ‘real’ acupuncture
The acupuncture was carried out by a Medical professional trained in the ‘Medical Acupuncture’ – a system of acupuncture which focuses more on symptomatic treatment
“All treatment was administered by CAW (a palliative medicine specialist, trained in acupuncture with the British Medical Acupuncture Society with three year experience using acupuncture for symptom control in advanced disease).
I think this factor this, along with the particular treatment protocol they used – LI4 and the “two upper sternal points, 2 cm apart” may be a significant reason why the results of the sham acupuncture and the true acupuncture were indistinguishable.
Choice of Points
For example, the two sternum points is a protocol which came from another ‘Medical Acupuncture’ research article on the treatment of breathlessness from lung cancer. In that study, as well as this one, the exact location of the sternum points is not clear. I am unable to ascertain if these “sternal points correspond to actual acupuncture points. Or if in fact, they may actually be ‘sham points’, which would be kind of ironic.
The choice of LI4 is a valid point that may affect the Lung and breathing due to its interior-exterior relation to the Lung channel. However, by itself – would this be enough?
Curiously enough, two of the sham points that were used as a control, actually corresponds to an acupuncture point – St 25, which directly impact the hara. Though the St25 point is not usually indicated for lung or breathing problems, these points will have some effect on the body overall and especially the digestive function.
Real or Sham, Sham or Real?
My argument is that their choice of ‘true’ points and ‘sham’ points is questionable and actually could potentially distort the results. I wonder whether some of their ‘real’ points were actually sham points and some of their ‘sham’ points were actually real points.
As I mentioned at the beginning of this section, the acupuncture was carried out (and likely designed by an acupuncturist trained in the Medical Acupuncture System) and would not be able to predict the weaknesses in their acupuncture point choices compared to a Classical or Traditional acupuncturist, who could consider the inter-related Channel pathways.
I also wonder what they results of this study may have been like, if they had chosen points more closely related to the Lung channel – for example, Lu 9 or Lu 1 as their ‘real’ acupuncture points.
Ultimately the purpose of this trial was to see if Acupuncture for COPD could be accepted and well tolerated in the treatment of COPD. The small sample size was a weakness and the authors did acknowledge that a larger trial was necessary to “determine whether it (acupuncture) reduces symptoms
However, this trial does show that acupuncture can be applied with minimal adverse effects to patients with severe COPD and “can be applied during an acute exacerbation of COPD and offers a potential adjunct to current treatment.”
Treatment Protocol summary
- LI4 bilaterally
- 2 Sternal points – 2 cm apart in the midline, advanced to the periosteum (No manual or electrical stimulation), No attempt to elicit de-qi.
It is difficult to exactly clarify the exact location of these sternum points. It appears that this sternum point protocol came from this study, which does show pictures and by examining this article, it may be that the sternum points in this study correspond to the points – Ren 22, Ren 21 or Ren 20. Here are the pictures of the sternum points from that article on ‘Acupuncture for the Relief of Cancer Related Breathlessness’:
Also in this other study, press-tack needles were used on the sternum points instead of standard needles. That may be sigificant as the stimulation of press-tacks can go on longer as they are held in the body.
Objectives & Conclusion
COPD is a long-term and complex condition to treat. Be realistic in your outcome objectives. It may be useful to use an assessment tool to check improvements to breathing, although in some cases it may not provide useful information.
COPD can be a debilitating condition. Primary treatment should be focused on improving the quality of life with an aim to irmpove breathing patterns, relaxation and sleep. This will help to increase the body’s Qi. A secondary outcome mesaure could be to increase energy and activity levels, which can occur of the promary outcome measure are obtained.
I hope you have found this article – ‘Acupuncture for COPD’ to be useful. If you have any suggestions about it, feel free to email me. You may have your own viewpoint or experiences. Feel free to share it with me, and I may update this article.
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NHS Website: www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/ Accessed 6th June 2018
The Telegraph. co.uk. NHS warned of acupuncture needles piercing lungs. 19 November 2011. Rebecca Smith. https://www.telegraph.co.uk/news/health/news/8896616/NHS-warned-of-acupuncture-needles-piercing-lungs.html. Accessed 6thJune 2018. (PDF)
Combined Standard Medication and Acupuncture for COPD: A Case Series. Masao Suzuki, Kenji Namura, Yasushi Ohno, Masato Egawa, Takako Sugimoto, Naoto Ishizaki, Hisayoshi Fujiwara. downloaded from http://aim.bmj.com/ on June 9, 2015. Published by group.bmj.com. PDF here
Pilot Study to assess the credibility of acupuncture in acute exacerbations of chronic obstructive pulmonary disease. Claudia A Whale, Sarah J A MacLaran, Christopher I Whale, Mandy Barnett. Acupunct Med 2009;27:13-15. doi10.1136/aim.2008.000232. PDF here.
Filshie et al. Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine 1996; 10: 145-150 (PDF)
Woman Breathing:Olexsandr Pidvalnyi, via Pexels.com.
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