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Summary

This protocol describes an effective therapy using auricular acupressure to relieve wheezing symptoms in stable chronic obstructive pulmonary disease.

Abstract

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Due to the restriction of expiratory airflow, it is characterized by emphysematous destruction of the lungs. Shortness of breath is one of the main clinical symptoms. Auricular acupressure is a clinical therapy characteristic of Chinese medicine that treats the disease by compressing ear points. Usually, the seeds of Vaccaria segetalis are used to stimulate ear points, which has the effect of regulating qi and alleviating wheezing. In this paper, we propose this characteristic therapy of traditional Chinese medicine (TCM) for the clinical symptoms of wheezing of lung and kidney qi deficiency type in stable COPD patients. Ear points are selected as the treatment protocol for Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i) points. The protocol describes a case study using auricular acupressure for a patient with chronic obstructive pulmonary disease to relieve wheezing symptoms.

Introduction

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable chronic respiratory disease. The disease is characterized by persistent respiratory symptoms and airflow limitation, usually associated with airway and/or alveolar abnormalities caused by significant exposure to harmful particles or gases¹. In 2016, more than 3 million people died from COPD, accounting for 6% of all deaths worldwide². Healthcare costs for COPD are an increasing burden on the world³. COPD is now a major public health problem with high rates of death, morbidity, disability, and disease burden⁴.

The main symptoms of COPD are chronic cough, sputum, dyspnea, wheezing, and chest tightness. Depending on the symptoms and lung function, it can be divided into an acute exacerbation phase and a stable phase⁵. Aggressive treatment during the stable phase can effectively reduce the number of acute exacerbations and delay the deterioration of lung function. Currently, treatment in the stable phase relies largely on pharmacological treatments such as bronchodilators, glucocorticoids, and expectorants. Non-pharmacological treatment modalities still have limitations⁶. The experiment here provides a special traditional Chinese medicine therapy, auricular acupressure, to expand the treatment modality.

For in-ear acupressure, small round granular objects are applied to the surface of the ear points. Moderate kneading, pressing, pinching, and squeezing are used to produce stimulation sensations such as soreness, numbness, swelling, and pain. As the main ingredient in auricular pressure, the seeds of Vaccaria segetalis can stimulate acupuncture points for the treatment of disease⁷. It is a non-drug external treatment method for the treatment of diseases⁸. The therapy is easy to use, inexpensive, safe, has no side effects, and is less prone to infection. It has certain advantages, like improving clinical symptoms, quality of life, and reducing acute exacerbations. It is suitable for adjuvant treatment of patients with stable COPD⁹.

As for the mechanism of auricular acupressure for wheezing, Chinese medicine believes that pressing certain acupuncture points on the auricle can communicate with qi, blood, meridians, and internal and external organs and harmonize the internal and external organs. In this way, acupuncture can play a role in regulating qi and relieving wheezing¹⁰. Modern medicine has shown that auricular acupressure stimulates blood vessels, nerves, and lymphatic vessels in the ear¹¹. It regulates the immune system and suppresses the inflammatory response by activating the cholinergic anti-inflammatory signaling pathway, which in turn relieves bronchial inflammation and alleviates wheezing symptoms. The theory of holographic biology states that the auricle is allometric to the body's information. According to the correspondence, there could be a connection between auricular acupressure and wheezing symptoms¹².

According to related studies, lung and kidney qi deficiency account for 23.20% of COPD in the stable stage¹³. The patients have frequent chronic coughs with wheezing, which means deficiency in the lungs; simultaneously, cold intolerance, weakness in the waist and knees, and self-perspiration show a deficiency in the kidney¹⁴. In this experiment, we implemented auricular acupressure for COPD patients with lung and kidney qi deficiency. In identifying wheezes of the lung and kidney qi deficiency, reference was made to the 2020 edition of the Committee on Auricular Acupuncture Diagnosis and Treatment of the Chinese Society of Acupuncture and Moxibustion⁸. The ear points formulated for this experiment were Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i).

The aim of this study is to provide a non-pharmacological treatment modality for stable COPD patients with wheezing and lung and kidney qi deficiency using auricular acupressure. Auricular acupressure was introduced after screening patients for a stable phase of COPD. The treatment protocol is clinically simple, safe, and cost-effective.

CASE PRESENTATION:
The patient is a 64-year-old male from Sichuan, China. He has been experiencing repeated cough and sputum for the past 5 years, along with worsening chest tightness over the last month. The patient has had diabetes for 5 years and has been taking metformin to manage his blood sugar levels, although he does not regularly monitor them. Additionally, he has a history of hypertension for 7 years and takes amlodipine besylate orally to control his blood pressure, which is also not regularly monitored. The patient denies any surgical history, trauma history, or blood transfusions. He smoked an average of 2 packs per day for 30 years but quit smoking 10 years ago. Furthermore, the patient denies any family genetic history.

Diagnosis, Assessment, and Plan:
After the doctor's specialized examination of the patient, he found a barrel chest and widened rib space. Chest CT showed chronic bronchitis, emphysema, and coronary artery calcification. Pulmonary function showed that the patient had moderate obstructive ventilation dysfunction, slightly obstructed airflow in the large airways, and increased total airway resistance. Combined with the patient's symptoms and signs, auxiliary examinations, and past medical history, a diagnosis of chronic obstructive pulmonary disease, hypertension, and diabetes mellitus was made. For treatment, Budesonide, Glycopyrronium Bromide, and Formoterol Fumarate Inhalation were performed twice daily in the morning and in the evening¹⁵. Additionally, hydroxypropyl theophylline intravenous drip (2 mL: 0.25 g, dilute 1 vial with 5% of 250 mL sugar water) was administered 1x day¹⁶. Auricular acupressure was given to relieve wheezing.

Protocol

The protocol is carried out in accordance with the Declaration of Helsinki. It is approved by the Approval Committee of the Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine. The number is KY2022009. Informed consent was obtained.

1. Patient candidacy screening

1. Inclusion criteria
   1. Ensure age is between 50-65 years. Ensure that the patients meet the diagnosis of stable COPD and lung and kidney qi deficiency. Ensure patients volunteer to participate in and comply with study requirements and sign informed consent forms.
   2. For the diagnosis of stable COPD, reference the Global Strategy for The Diagnosis Management and Prevention of Chronic Obstructive Pulmonary Disease 2022 Report¹⁵. Ensure that patients have a modified Medical Research Council grade (mMRC) ≤ 2; the degree of airflow limitation is mild or moderate, which means the forced expiratory volume in 1 s (FEV1) ≥ 50% of the predicted value.
   3. Ensure that the diagnosis of COPD with wheezing due to lung and kidney qi deficiency refers to the corresponding criteria in the Guidelines for the Management of Chronic Obstructive Pulmonary Disease in Chinese Medicine¹⁶. Main symptoms include 1) wheezing, shortness of breath, aggravated by exercise; 2) weakness, or spontaneous sweating, aggravated by exercise; 3) Susceptibility to cold and wind; 4) Senselessness and weakness of the waist and knees; 5) Tinnitus, dizziness, or floaters; 6) Frequent urination, nocturnal urination, or coughing and drowning; 7) Pale tongue with white coating and sunken or weak pulse. If two of 1), 2), and 3) and two of 4), 5), 6), and 7) are present, diagnose it as COPD.
2. Exclusion criteria
   1. Exclude patients with diseases that seriously affect breathing or quality of life, such as acute myocardial infarction, stroke, Alzheimer's disease, and mental illness.
   2. Exclude patients with severe cognitive and motor dysfunction and uncooperative.

2. Material preparation

1. Check equipment to be used for disinfection: cotton balls with 75% ethanol, sterile forceps, and medical blades.
2. Prepare medicinal seeds in advance. Sieve the seeds of Vaccaria segetalis with spherical shape to obtain uniform seeds 2 mm in diameter, as shown in Figure 1A.
3. Prepare the medical tape and auricular acupressure patch template. Use hypoallergenic ultra-thin paper tape with a width of 5 cm, as shown in Figure 1B. Prepare a 5 cm x 8.5 cm white auricular acupressure patch template, as shown in Figure 1B.
   NOTE: For people who are allergic to regular tape, use desensitizing tape. Be careful not to get the tape wet, or the skin may become infected.

3. Treatment preparation

1. Ensure cleanliness and hygiene in the environment to avoid pollution.
2. Ask the operator to wash hands with a disinfectant. Then, wipe fingers with cotton balls containing 75% ethanol.
3. Place the seeds of Vaccaria segetalis on the auricular acupressure patch template. Stick them down with medical tape, as shown in Figure 1C. Maintain strict disinfection to avoid infection.

3. Treatment steps

1. Body position: Ask the patient to be seated.
2. Disinfection and positioning: Ask the operator to fix the patient's auricle. Keep the patient in the sitting position. Use one hand to immobilize the patient's head. Use 75% ethanol cotton balls for one-time skin disinfection.
3. Locating the points: Follow the points in the national standard Nomenclature and location of auricular points issued by the National Committee for Standardization in 2008¹⁷. Based on the locations shown in Figure 1D and Table 1, find the positions of the ear points of Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i).
4. Patching: Remove the prepared auricular acupressure patch and stick it on the corresponding ear point. For each ear point, use a single ear patch.
5. Compression: After applying the patch, apply compression using direct pressure. Place the thumb and index finger on both sides of the ear auricle. Apply relative pressure to the medical seed patch on the ear point, ensuring that the patient feels mild pain but does not interfere with sleep.
   NOTE: Pressure intensity is determined according to different pain levels on the Visual Analog Scoring Tool (VAS)¹⁸: moderate pain on a scale of 1 to 3 is chosen as the criterion for pressure intensity.

5. Treatment course

1. Press the auricular pressure points 3x a day. Apply pressure once at 9:00 am, 3:00 pm, and 9:00 pm. Keep the intensity of the pressure between 1-3 on the VAS pain scale. Alternate compressions every 3 days, alternating on both ears, for 12 days.
2. Check the patch daily and replace it if it is wet or the ear cavity has skin lesions, frostbite, or inflammation. If none of them occur, keep the patch. The patches exert buried pressure or moderate pressure; ask the patient not to rub the patch to prevent contamination of the skin caused by infection. Ensure that the ear patches are applied to the auricular points and do not affect the patient's sleep.

6. Efficacy evaluation

NOTE: Efficacy is judged by objective and subjective indicators together. When it comes to subjective indicators such as scale filling, patients must complete the scoring independently without any suggestive reminder.

1. Instruct patient to perform tests for pulmonary function indices, including FEV1, FVC (forced vital capacity), and FEV1/FVC. The increase in the above indicators after receiving treatment suggests that the therapy is effective.
2. Use the TCM symptom rating scale to evaluate efficacy¹⁹. Changes of more than 2 points before and after treatment indicate that the treatment has clinical significance.
3. Use mMRC Grade to evaluate patient's quality of life. Patients with a score of 0-1 mean light dyspnea; between 2-4 mean heavy dyspnea. Changes of more than 1 point in patient's mMRC scores before and after treatment indicate that the treatment has clinical significance.

Representative Results

The above protocol describes a controlled trial to investigate the efficacy of auricular acupressure in improving wheezing symptoms in stable COPD patients. For this study, 1 patient who met the criteria was enrolled and completed the trial. The patient was male and 64 years old. The patient suffered from chronic obstructive pulmonary disease for 5+ years. Long-term regular treatment with inhalation preparations was administered for long-term cough and wheezing.

The patient was admitted to the hospital with cough and sputum, shortness of breath, and tightness in the chest. After admission, pulmonary function, chest CT, and other examinations were completed. The patient's lung function FEV1/FVC was <0.7, consistent with chronic obstructive pulmonary disease. Treatment included both conventional Western medicine inhalation preparation and Chinese medicine auricular pressure bean therapy. In Figure 2, the result shows that the patient's FEV1 increased from 1.51 L to 1.63 L. FVC increased from 2.48 L to 2.76 L. PEF increased from 3.95 L/s to 5.94 L/s. VC increased from 2.48 L to 2.8 L. Meanwhile, the symptom score in Table 2 is reduced from 18 to 13. The mMRC score is grade 2 before and after treatment, as shown in Table 3. Overall, this patient had a mild increase in lung function indices after treatment. The TCM score was greater than 2. The mMRC did not change. This indicates that the above treatment methods can improve wheezing symptoms in stable COPD patients. Meanwhile, previous clinical studies have shown that auricular acupressure has significant improvement effects on wheezing symptoms and lung function in COPD patients. Liao Guixiang et al. conducted a randomized controlled trial involving 60 COPD patients, and their findings confirmed that auricular acupressure resulted in significant improvement in wheezing symptoms²⁰. Furthermore, Chen et al. also demonstrated that this treatment led to improved respiratory symptoms and lung function in patients^21,22.

Figure 1: Experimental preparation. (A) The seeds of Vaccaria segetalis. Approximately 2 mm seeds of Vaccaria segetalis. (B) The medical tape and auricular acupressure patch template. A 5 cm wide medical tape and auricular acupressure patch template. (C) Preparation of auricular acupressure patch. Stick the seeds of Vaccaria segetalis with medical tape. (D) The positions of the ear points of the Lung, Spleen, Kidney, Shen Men, and Ping Chuan. Apply the auricular acupressure patch to the Lung, Spleen, Kidney, Shen Men, and Ping Chuan acupoints. Please click here to view a larger version of this figure.

Figure 2: FEV 1, FVC, PEF, VC measurements of the patient before and after treatment. The x-axis represents absolute values. Abbreviations: Pred = predicted value, Meas = measured value, FEV1 = forced expiratory volume in 1 s, FVC = forced vital capacity, PEF = peak expiratory flow, VC = vital capacity. L and L/s refer to the units of the corresponding index of lung function. L is the unit of volume, i.e., liters. L/s is the unit of velocity, i.e., liters per second. Please click here to view a larger version of this figure.

Name	Number	Auricle partition	Location
Lung	CO14	Located ear region 14	Around the heart and trachea
Spleen	CO13	Located auricular region 13	In the upper posterior part of the auricular cavity
Kidney	CO10	Located the posterior part of the auricular cavity in zone 10 of the auricular nail	Below the lower pedicle of the contralateral ear chakra
Shen Men	TF4	Located zone 4 of the triangular furrow	In the upper part of the posterior 1/3 of the triangular furrow
Ping Chuan	AT1.2.4i	At the tip of the free edge of the opposite ear screen	At the intersection of opposite ear screen sectors 1, 2 and 4

Table 1: The location of Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i).

Symptom Score
Frequency	None (1 Point)	Occasionally (Two points)	Frequently (Three points)	All Day (Four points)
Cough		A	B
Coughing Sputum			A	B
Wheezing		A	B
Shortness of Breath		A	B
Tiredness		B A
Soreness of Waist and Knees		A	B
Total	B for 18 points. A for 13 points.

Table 2: TCM symptom rating scale for the patient before and after treatment. Abbreviations: B = before auricular acupressure treatment, A = after auricular acupressure treatment. The total before-treatment score is 18. The total after-treatment score is 13.

mMRC Grade
Grade	Description of Breathlessness						Before treatment	After treatment
0	I only get breathless with strenuous exercise.
1	I get short of breath when hurrying on level ground or walking up a slight hill.
2	On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace.
3	I stop for breath after walking about 100 yards or after a few minutes on level ground.
4	I am too breathless to leave the house or I am breathless when dressing.

Table 3: Patient mMRC grade before and after auricular acupressure treatment.

Discussion

Modern medicine treats COPD patients mainly with long-acting β2 agonists (LABAs), long-acting muscarinic antagonists (LAMAs), and ICS²³. Chinese medicine classifies COPD as wheezing based on the clinical characteristics of cough, sputum, shortness of breath, and dyspnea²⁴. At the same time, Chinese medicine believes that the 12 meridians are connected to the ear. Auricular points are interconnected with meridians, tissues, and organs. It is closely related to the body's physiological functions and pathological changes. Therefore, auricular therapy can effectively prevent and treat many diseases²⁵. By observing the effects of auricular acupressure bean therapy on symptoms and pulmonary function in elderly patients with AECOPD, Cheng et al.²⁶ found that the FEV1% and FEV1/FVC% in the observation group using conventional therapy combined with auricular acupressure bean therapy were significantly higher than those in the control group using conventional therapy only. By observing the FEV1, FEV1%, FVC, and FEV1 /FVC values of patients with COPD using auricular acupressure. Liu et al.⁹ found that auricular acupressure bean therapy significantly improved clinical efficacy and lung function levels. Zhang et al.²⁷ also demonstrated through clinical trials that auricular acupoint pressure bean therapy has a better therapeutic effect on COPD, improves patients' lung function, enhances their activity endurance, and improves their quality of life.

The selection of the five acupoints in this protocol, including Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i), is determined by referring to clinical reports^28,29. Research has shown that the above five points are the core ear points for treating lung and kidney qi deficiency type COPD^28,29,30. According to the theory of traditional Chinese medicine, auricular acupuncture points of the Lung, Spleen, Kidney, Shen Men, and Ping Chuan can strengthen the spleen and tonify the kidney, lowering qi and calming wheezing⁸. Therefore, it can improve the symptoms of wheezing and lung function of COPD patients.

This treatment is used as adjuvant therapy for patients with stable COPD and lung and kidney qi deficiency. It has the advantages of low cost and easy operation³¹. Moreover, the operation is a non-invasive treatment, which is relatively safe with reduced risks of infections³². Thus, this treatment modality provides new therapies and ideas for improving COPD patients' symptoms. It can effectively reduce the incidence of acute exacerbations and improve patients' quality of life and the prognosis³³.

The following two key steps deserve attention. The first is the localization of the acupuncture points. The ear points of Lung (CO14), Spleen (CO13), Kidney (CO10), Shen Men (TF4), and Ping Chuan (AT1.2.4i) should be positioned strictly according to the Auricular Acupuncture Diagnosis and Treatment. The second key point is the intensity and frequency of the compressions. When pressing, align the treatment points, use the index finger and thumb together, and press the front and back of the auricle. The pressure should be as strong as necessary to make the auricle warm and painful but tolerable. The frequency of compression should be once daily at 9:00 am, 3:00 pm, and 9:00 pm. Each time is maintained for 3 min. Every 3 days, alternating between the ears. 12 days is a course of treatment. Adherence to the above ear acupressure program provides stable long-term results⁸.

Pulmonary function indices such as FEV1 and FVC increase after treatment. Symptom scores such as cough, sputum, and wheezing improve in patients compared to before-treatment. However, there is no change in the MRC grade, which is all grade 2. Auricular pressure beans can relieve wheezing in stable COPD patients to a certain extent²⁰. But it has no improvement effect on mMRC grade. This may be related to the incomplete reversible pathologic changes of COPD and the insufficient duration of auricular acupressure bean pressure treatment.

There are some limitations in the implementation of this protocol. The auricular patch is applied for a longer period, and the skin under the patch is prone to allergic reactions. The auricular skin shows continuous redness, rash, and itching. Therefore, operators should try to choose anti-allergic medical tape. It should not be applied for too long and should be replaced in 3 days. If there is any contamination in the middle of the process, the tape should be replaced immediately with a new one with pressed beans. Note that the operation should not be performed on people with skin lesions in the ear or diseases related to the ear cartilage. In addition, the use of this treatment is limited to patients who are stable and in remission. In case of acute exacerbation or severe disease, it should be used in combination with other therapeutic drugs.

Materials

Auricular acupressure patch template	Hengshui Runhuang Trading Co., Ltd
Cotton balls with 75% ethanol	Qingdao Hainuo Biological Engineering Co., Ltd	20172640783
Medical blades	Suzhou Kaiyuan Medical Equipment Co., Ltd	20192020831
Medical tape	Zhende Medical Supplies Co., Ltd	20170090
Sterile forceps	Yangzhou Zhixiang Medical Technology Co., Ltd	20210081
The seeds of Vaccaria segetalis	Anhui Kang Yunuo Biotechnology Co., Ltd	SC10334161107893