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Observation on promoting resuscitation in the patients with coma of acute carbon monoxide poisoning by acupuncture combined with hyperbaric oxygen
World Journal of Acupuncture – Moxibustion 29 (2019) 103–107
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Clinical Research
Observation on promoting resuscitation in the patients with coma of acute carbon monoxide poisoning by acupuncture combined with hyperbaric oxygen Mao-li LUO () a, Hui-jie LI () a, Liang-ce MA () a, Yuan JIANG () b,∗ Emergency Department, Dazhou Central Hospital, Dazhou 635000, Sichuan Povince, China (, 635000, ) Department of Rehabilitation Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Povince, China ( , 610500, ) a
b
a r t i c l e
i n f o
Article history: Available online 29 May 2019 Keywords: Acupuncture Hyperbaric oxygen Acute carbon monoxide coma Cytokines Serum brain-derived growth factor
∗
a b s t r a c t Objective: To evaluate the effect of promoting resuscitation and the effect differences between acupuncture combined with hyperbaric oxygen therapy (HBOT) and simple HBOT in the patients with coma of acute carbon monoxide poisoning (ACMP). Methods: A total of 36 patients with ACMP coma were randomized into a simple HBOT group and acupuncture combined with HBOT group, 18 cases in each one. In the simple HBOT group, HBOT was provided once a day for 2 weeks. In the acupuncture combined with HBOT group, acupuncture was provided during HBOT. The acupuncture was given before the patients were sent to the hyperbaric oxygen chamber and the needles were retained until the hyperbaric oxygen treatment was completed. The ¯ ( GV 26), Sìshéncong ¯ ¯ acupoints included Ba˘ ihuì ( GV 20), Shu˘ıgou ( EX-HN1), Fengchí ¯ ( GB20), Hégu˘ ( LI 4), Tàichong ( LR 3) and Yo˘ ngquán ( KI 1). The needles were retained through the entire process of HBOT. Such combined treatment was given once a day for 2 weeks. Before the treatment, the score of Glasgow Coma Scale (GCS) was recorded, the levels of serum interleukin-6 (IL-6), interleukin-8 (IL-8) and brain-derived growth factor (BDNF) were tested and the time from unconsciousness to resuscitation was recorded of the two groups. After treatment, the levels of serum IL-6, IL-8 and BDNF were tested again and the clinical therapeutic effects were evaluated. Results: At last, there were 16 cases in the simple HBOT group and 17 cases in acupuncture combined with HBOT group got resuscitation. The time from unconsciousness to resuscitation was (5.17 ± 1.10) h in the acupuncture combined with HBOT group, which was less than (6.83 ± 2.73) h in the simple HBOT group, indicating the significant difference in statistic (P < 0.05). After treatment, the total effective rate was 94.4% in the acupuncture combined with HBOT group, which was higher than 88.9% in the simple HBOT group, indicating the significant difference in statistic (P < 0.05). After treatment, the levels of serum IL-6 and IL-8 were (29.72 ± 3.49) and (67.17 ± 7.61) pg/mL respectively in the acupuncture combined with HBOT group, which were lower as compared with those before treatment, indicating the significant differences in statistic (both P < 0.05). The level of IL-8 in the acupuncture combined with HBOT group was lower than (72.67 ± 7.17) pg/mL in the simple HBOT group after treatment, indicating the significant difference in statistic (P < 0.05). After treatment, the level of BDNF was (14.78 ± 3.90) pg/mL in the acupuncture combined with HBOT group, higher than the level before treatment, presenting the significant difference (P < 0.05), and higher than (12.93 ± 2.59) pg/mL in the simple HBOT group after treatment, presenting the significant difference in statistic (P < 0.05). Conclusion: Acupuncture combined with HBOT achieves the superior effect of promoting resuscitation and the clinical therapeutic effects as compared with the simple HBOT. Such combined treatment reduces the levels of serum IL-6 and IL-8, increases the level of serum BDNF in ACMP patients, as well as plays the active role in the prevention from delayed encephalopathy after acute carbon monoxide poisoning. © 2019 World Journal of Acupuncture Moxibustion House. Published by Elsevier B.V. All rights reserved.
Corresponding author. E-mail address: [email protected] (Y. JIANG).
https://doi.org/10.1016/j.wjam.2019.05.005 1003-5257/© 2019 World Journal of Acupuncture Moxibustion House. Published by Elsevier B.V. All rights reserved.
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Introduction
(4) Agreement of the patient’s family member during the follow-up.
Acute carbon monoxide poisoning (ACMP) is a kind of acute poisoning with the highest morbidity and the highest number of deaths [1] and it is one of the most common emergent and severe cases in emergency department. Carbon monoxide (CO) is a colorless, odorless, nonirritating and poisonous gas [2]. CO is produced under the insufficient combustion of carbonaceous material in daily work and life. It is invisible, especially in winter with combustion heating system used. The patient is poisoned during sleep at night and loses consciousness because of hypoxia. The effective self-rescue is impossible and such emergent situation cannot be found easily. The long-term coma and hypoxia result in severe cerebral impairment very easily. The delayed rescue not only causes severe sequela, but also threatens the patient life. Hence, the in-time rectifying cerebral hypoxia and regaining the consciousness from ACMP coma are the crucial approach to the successful rescue. The early active and effective treatment reduces the case fatality rate and the disability rate of ACMP coma and lowers the occurrence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) in the patients. In our study, the patients of ACMP coma were treated by acupuncture combined with hyperbaric oxygen therapy (HBOT) and the effect of promoting resuscitation and clinical therapeutic effects were evaluated. Moreover, the levels of cytokines and brain-derived growth factor (BDNF) in serum were tested so as to explore the protective effect on DEACMP. Clinical data
Exclusion criteria (1) Failure to have HBOT because of unsatisfactory control of blood pressure, severe upper respiratory infection, otitis media, nasosinusitis, auditory tube obstruction, etc. (2) Absolute contraindication of HBOT, such as pulmonary tuberculosis cavity combined with hemoptysis, active internal hemorrhage, hemorrhagic disorder, pneumatocele, etc. (3) Voluntary dropout in the study. (4) Loss of assessment records. Treatment methods Simple HBOT group The medical hyperbaric oxygen chamber made in China was adopted. In the treatment, the pressure was 0.12–0.15 MPa, pressure was increased for 20 min, the duration of oxygen uptake with mask was 60 min under a stable pressure, at the interval of 5 min, and then, the pressure was reduced at an even speed for 20 min. The treatment was given once a day. According to the patients’ condition, the 125 mL intravenous drops with 20% mannitol injection (once a day) and edaravone injection 30 mg (once a day) were administered for the routine treatment to prevent from cerebral edema, promote cerebral cellular metabolism and corresponding treatment. Acupuncture combined with HBOT group
General data A total of 36 patients of ACMP coma were all from the Emergency Department and the Rehabilitation Department of Traditional Chinese Medicine (TCM) in Dazhou Central Hospital from October 2016 to December 2018. The random number table method was adopted to divide these patients into a simple HBOT group and acupuncture combined with HBOT group, 18 cases in each one. The differences were not significant statistically in gender, age, disease course and the score of Glasgow Coma Scale (GCS) in the patients between the two groups (all P > 0.05), indicating the comparability between the two groups. The detailed data can be seen in Table 1. This study has been approved by the Ethics Committee of Dazhou Central Hospital (Approval No. DZYEC2015027). Inclusion criteria (1) Meet the diagnostic criteria of ACMP. That is definite contact history of carbon monoxide (CO), the symptoms and physical signs of acute central nervous impairment, carbonyl hemoglobin (HbCO) 20–40%, excluding other factors. (2) Coma state when visiting hospital, GCS score 12 points. (3) Signing the informed consent by the patient’s family member.
On the base of the treatment as the simple HBOT group, acupuncture was given additionally. The acunpuncture was given before the patients were sent to the hyperbaric oxygen chamber and the needles were retained until the hyperbaric oxygen treatment was completed. The needles were withdrawn after the patients exited from the chamber. The acupoints included Ba˘ ihuì ¯ ( GV 26), Sìshéncong ¯ ( EX-HN1), ( GV 20), Shu˘ıgou ¯ ¯ ( GB20), Hégu˘ ( LI 4), Tàichong Fengchí ( LR 3) and Yo˘ ngquán ( KI 1). Acupoint areas were sterilized routinely and the sterile acupuncture needle for single use, 0.25 mm × 40 mm (Hwato brand) was selected. GV 20 was punctured transversely backward, 15 mm in depth, GV 26 was punctured obliquely toward nasal septum, 15 mm in depth, EX-HN1 was punctured obliquely toward GV 20, 15 mm in depth, GB 20 was punctured obliquely toward the nose tip, 30 mm in depth, LI 4 was punctured obliquely ¯ an ¯ ( LI 3), 15 mm in depth and KI 1 was punctured toward Sanji perpendicularly, 25 mm in depth. The even-needling technique was used by lifting, thrusting and rotating the needle. The rotating angle was in the range from 90° to 180°, with the frequency from 60 to 90 times per minute. The amplitude of lifting and thrusting was 10–15 mm with the frequency from 60 to 90 times per minute. The acupuncture was given once every day. The patients of the two groups took the above treatment for 2 weeks.
Table 1 Comparison of general data of ACMP coma patients between the two groups (Mean ± SD). Groups
Simple HBOT group Acupuncture combined with HBOT group
Cases
18 18
Gender (case)
Age (year)
Male
Female
Youngest
Oldest
Average
Shortest
Disease course (hour) Longest
Average
GCS score
12 10
6 8
14 16
56 63
38.67 ± 13.17 37.28 ± 14.92
2 3
6 7
4.17 ± 1.04 4.39 ± 1.30
8.78 ± 1.73 8.50 ± 1.42
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Table 2 Comparison of time from unconsciousness to resuscitation in the patients of ACMP coma between the two groups (Mean ± SD, h).
Therapeutic effects Outcomes (1) Glasgow Coma Scale (GCS) score According to the eye response, verbal response and motor response, the patient was scored in the range from 3 to 15 points. 15 points indicate clear consciousness, 13–14 points indicate mild coma, 9–12 points moderate coma and 3–8 points severe coma. (2) Time from unconsciousness to resuscitation The time from unconsciousness to resuscitation referred to the time (hours) till the clear consciousness regained (GCS score = 15) since the first treatment. Clinical effects In reference to the recommendations in Guideline of acute carbon monoxide poisoning [3], the rehabilitation effects were drafted as follows: (1) Cured: clear consciousness, disappearance of clinical symptoms, independent living. (2) Remarkably effective: clear consciousness, obvious improvements in clinical symptoms, independent living mostly. (3) Effective: clear consciousness, improvements in clinical symptoms, unable to handle daily life activity. (4) No effect: unconsciousness, no any improvement in clinical symptoms, or even getting aggravation. The total effective rate = (cured cases + remarkably effective cases + effective cases)/total cases × 100%. Levels of serum interleukin-6 (IL-6), interleukin-8 (IL-8) and brain-derived growth factor (BDNF) Before and after treatment, venous blood was collected, about 5 mL, which was centrifuged at 30 0 0 r/min, for 5 min, and thus, serum was collected. According the instruction of enzyme-linked immunosorbent assay (ELISA) kit (Jianglai Biology Co. Ltd., China), ELISA was adopted to test the levels of human IL-6, IL-8 and BDNF separately. Statistical methods SPSS 21.0 software was adopted in the data analysis. Measurement data were expressed as Mean ± SD. The paired-samples t-test was used for the comparison before and after treatment within the groups, and the two independent-samples t-test was for the comparison before and after treatment between the groups, chi-square test was for the comparison of enumeration data between groups. P < 0.05 indicated statistically significant difference. Results (1) Comparison of the time from unconsciousness to resuscitation of the patients of ACMP coma between the two groups The time from unconsciousness to resuscitation (the duration after the first treatment till GCS score reached 15) was recorded in the patients of ACMP coma in the two groups. In the simple
Groups
Cases
Simple HBOT group Acupuncture combined with HBOT group
16 17
a
Time from unconsciousness to resuscitation 6.83 ± 2.73 5.17 ± 1.10a
Compared with the simple HBOT group, P < 0.05.
HBOT group, 16 cases got resuscitation after treatment and 2 cases were still under the unconsciousness after the end of the treatment (GCS score < 15). In the acupuncture combined with HBOT group, 17 cases got resuscitation after treatment and the time from unconsciousness to resuscitation was less than the simple HBOT group, indicating the significant difference in statistic (P < 0.05). There was 1 case under the unconsciousness after the end of the treatment (GCS score < 15). See the details in Table 2. (2) Comparison of the clinical effects in the patients of ACMP coma between the two groups After treatment, the total effective rate (94.4%) in the acupuncture combined with HBOT group was higher than that (88.9%) in the simple HBOT group. See the details in Table 3. (3) Comparison of serum IL -6, IL -8 and BDNF of the patients of ACMP coma between the two groups After treatment, the levels of serum IL-6 and IL-8 were all lower as compared with those before the treatment in the patients of the two groups and the levels of BDNF were all higer, indicating the significant differences in statistic (all P < 0.05). After treatment, the level of IL-8 in the acupuncture combined with HBOT group was lower than the simple HBOT group and the level of BDNF was higher than the simple HBOT group, indicating the significant differences in statistic (both P < 0.05). See the details in Table 4. Discussion Acute carbon monoxide poisoning (ACMP) results from the strong binding ability of CO to hemoglobin in the body, which is 200 times higher than that of oxygen and is difficult to dissociate. Carbonyl haemoglobin (COHb) formed after binding has no ability to carry oxygen, which hinders the transportation and utilization of oxygen in the body and leads to hypoxia of the whole body [4,5]. The brain tissue is sensitive to hypoxia. In CO poisoning, the brain tissue hypoxia occurs first and brain function is damaged to the most degree. One of the crucial approaches to rescue ACMP is to inhale pure oxygen of high concentration, accelerate the dissociation of COHb, restore the formation of oxyhemoglobin and timely rectify the body hypoxia. At present, the hyperbaric oxygen therapy (HBOT) is the first emergency treatment to rescue the ACMP patients [6]. Liao et al. [7] thinks that HBOT should be carried out as soon as possible, preferably within 22.5 h after CO poisoning. Hyperbaric oxygen can rapidly increase the partial pressure of blood oxygen, promote the decomposition of COHb, eliminate CO out of the body, increase the content of tissue oxygen, reverse the state of hypoxia, effectively improve microcirculation, and relieve brain edema. Additionally, hyperbaric oxygen has the effect of promoting resuscitation in coma patients [8]. While, some scholars believe
Table 3 Comparison of the clinical effects in the patients of ACMP coma between the two groups (Case). Groups
Cases
Cured
Remarkably effective
Effective
No effect
Total effective rate (%)
Simple HBOT group Acupuncture combined with HBOT group
18 18
7 10
4 4
5 3
2 1
88.9 94.4a
a
Compared with the simple HBOT group, P < 0.05.
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Table 4 Comparison of serum IL-6, IL-8 and BDNF in the patients of ACMP coma between the two groups (Mean ± SD, pg/mL). Groups
Cases
Time points
IL-6
IL-8
BDNF
Simple HBOT group
18
Acupuncture combined with HBOT group
18
Before treatment After treatment Before treatment After treatment
33.84 ± 3.65 31.61 ± 2.91 34.22 ± 9.13 29.72 ± 3.49a
78.72 ± 6.39 72.67 ± 7.17a 77.31 ± 4.38 67.17 ± 7.61a , b
11.33 ± 2.30 12.93 ± 2.59 11.17 ± 1.98 14.78 ± 3.90a , b
a b
Compared with the same group before treatment, P < 0.05. Compared with the simple HBOT group after treatment, P < 0.05.
that repeated use of HBOT may induce the similar pathological changes as ischemia/reperfusion, which may increase the generation of oxygen free radicals and worsen brain tissue damage. Thus, it is still controversial in the prevention and treatment with HBOT for DEACM [9,10]. However, the underlying benefits of HBOT combined with other therapy may contribute to the therapeutic effects in patients. Acupuncture is a common external therapy of traditional Chinese medicine and its satisfactory effects on cerebrovascular disease and consciousness impairment have been widely recognized [11]. In acupuncture treatment, through changing thermodynamics of cerebral blood vessel, increasing blood flow and improving cerebral blood circulation, the ischemia and hypoxia of brain tissue are rectified. Acupuncture also activates brain nerve cells and improves brain cell function. Some scholars have put forward the “oxygen acupuncture therapy”, in which, an appropriate amount of oxygen is inhaled while receiving acupuncture. Such therapy increases the partial pressure of blood oxygen in the body, improves the anoxic state of brain cells [12] and it is advantageous at the collaborative effects of oxygen and acupuncture. Some studies have been proved that acupuncture could enhance the therapeutic effects of hyperbaric oxygen in the treatment of ACMP and DEACMP in combination with HBOT [13,14]. Studies have found that the needle retaining therapy in hyperbaric oxygen chamber achieves not only the better effects of prevention and treatment of DEACMP as compared with simple HBOT [15], but also the satisfactory effects on neurogenic bladder [16], ischemic vertigo [17], motor aphasia [18] and cognitive impairment after craniocerebral injury [19]. Potentially, under high pressure condition, the function of the human body is in high metabolic state, which increases the external stimulation and stress ability, and thus, the response to acupuncture is stronger as compared with that under the regular condition and the state of deqi is sustainable at acupoints [20]. It is strictly prohibited to bring fire (such as lighters, mobile phones and electronic toys), flammable, explosive and volatile substances (i.e. grease and chemical fiber materials) into the chamber [21]. In this study, acupuncture needles of Hwato brand (manufactured by Suzhou Medical Supplies Factory Co., Ltd.) were used. It is made of stainless steel [16] and has good electrical conductivity that prevents from static electricity. Such kind of needle does not belong to the strictly prohibited objects. The needles were inserted before the patients entering the chamber and withdrawn after exiting. Such operation avoids metal impact in the chamber and ensures the patient’s safety. Acupuncture was applied to GV20, GV 26, EX-HN1, GB 20, LI 4, LR 3 and KI 1. GV 20 is the meeting site of three yang meridians of foot, liver meridian and the governor vessel, acting on benefiting qi, regaining consciousness and tranquilizing the mind. GV 26 is the meeting point of the governor vessel and yangming meridians of hand and foot, acting on opening orifice, strengthening the function of the brain and tranquilizing the mind. EX-HN1 is an extra point, acting on clearing head and eyes, strengthening the function of the brain, tranquilizing the mind and regaining consciousness. LI 4 and LR 3 are the points of yangming and jueyin meridians respectively, acting on opening orifices. The bilateral LI 4 and LR 3 are named as four-gate points,
representing yin, yang, qi and blood separately and they are located in the upper part and the lower part of the body separately. LI 4 and LR 3 co-act on balancing yin and yang, regulating the functions of zangfu organs and promoting the circulation of qi and blood of the whole body. KI 1 is the jing-well point of kidney meridian of foot-shaoyin, acting effectively on opening orifice, regaining consciousness, regulating kidney function and benefiting essence. After acupuncture at the above mentioned acupoints in combination with HBOT, the time from unconsciousness to resuscitation was less than that with the simple HBOT. The combined treatment promotes the early awakening of patient. Such therapy not only effectively prevents from respiratory asphyxia, but also avoids the occurrence of serious complications and reduces the incidence of the delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) and disability rate. DEACMP is the most severe complication of ACMP. The pathogenesis of DEACMP is unknown at present. But some studies believe that a variety of cellular inflammatory factors are correlated with DEACMP [22,23]. IL-6 is a central regulatory factor of inflammatory response, with extensive biological activity, participating in the regulation of immune function, stress response and inflammation. In the patients with ACMP, the serum IL-6 level is persistently high, which plays the important role in the occurrence of DEACMP. It is valuable to judge the condition and prognosis of DEACMP in the patients by testing the level of IL-6 in clinic [24]. IL-8 is an inflammatory cytokine produced by monocytes and vascular endothelial cells. In the patients with ACMP, the serum IL-8 level is also increased obviously, which is important in the pathological process of DEACMP and is also one of the outcomes to evaluate the condition of sickness. BDNF is the most important item of the neurotrophic factor family and is extensively distributed in the brain. It promotes the survival and growth of neurons and plays an important role in the process of nerve repair. ACMP is usually accompanied by neurological symptoms, which may affect the secretion of neurotrophic factors [25] and result in the decrease of serum BDNF level [26]. Liu et al. [27] suggested that HBOT at early stage could alleviate delayed memory impairment after ACMP through increasing BDNF level. In our study, it was discovered that after the combined treatment of acupuncture and HBOT, the clinical symptoms were relieved obviously and the self-care ability in daily life was improved. The total effective rate (94.4%) was higher than that (88.9%) in the treatment with simple HBOT group. In the simple HBOT group, after HBOT treatment, the levels of serum IL-6 and IL-8 were all lower as compared with the levels before treatment and BDNF level was higher. In the acupuncture combined with HBOT group, after treatment, the levels of serum IL-6 and IL8 were all lower as compared with the levels before treatment and the level of IL-8 after treatment was lower than that in the simple HBOT group. After treatment, BDNF level was higher than that before treatment in the acupuncture combined with HBOT group, but also higher than that as compared with the simple HBOT group. Such effects may be caused by the collaborative effects of oxygen and acupuncture in such combined treatment. HBOT alleviates the inflammatory reaction after cerebral injury, relieves hypoxic state of brain tissue and promotes the repair of injured nerve cells. The
M.-l. LUO, H.-j. LI and L.-c. MA et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 103–107
effect mechanism of acupuncture is similar to HBOT. Acupuncture at GV 20, GV 26, EX-HN1, GB 20, LI 4, LR 3 and KI1 improves the excitability of cerebral cortex, promotes the recovery of brain neural function, improves cerebral microcirculation and promotes the absorption of brain cell edema. Therefore, with acupuncture combined, HBOT plays a better role in treatment and contributes to the promotion of resuscitation. In conclusion, acupuncture combined with HBOT achieves the better effect of promoting resuscitation and clinical therapeutic effects than the simple HBOT. Such combined treatment reduces the levels of serum IL-6 and IL-8, increases the level of serum BDNF, alleviates brain tissue damage and plays an active role in the prevention of DEACM of the patients with ACMP, References [1] Kohshi K. Delayed neuropsychologic sequelae of carbon monoxide poisoning. Chudoku Kenkyu 2007;20(4):381–2. [2] Xu X, Zhang H, Wang K, Tu T, Jiang Y. Protective effect of edaravone against carbon monoxide induced apoptosis in rat primary cultured astrocytes. Biochem Res Int 2017;2017:5839762. [3] Gao CJ, Ge H, Zhao LM, Wu LH, Li Z, Yang L, et al. Guideline of treatment of acute carbon monoxide poisoning: Part 3. Chin J Naut Med Hyperb Med (Chin) 2013;20(1):72–4. [4] Ghosh RE, Close R, McCann LJ, Crabbe H, Garwood K, Hansell AL, Leonardi G. Analysis of hospital admissions due to accidental non-fire-related carbon monoxide poisoning in England, between 2001 and 2010. J Public Health (Oxf) 2016;38(1):76–83. [5] Reumuth G, Alharbi Z, Houschyar KS, Kim BS, Siemers F, Fuchs PC, Grieb G. Carbon monoxide intoxication: what we know. Burns 2018;S0305-4179(18) 30613-2. [6] Weaver LK. Hyperbaric oxygen therapy for carbon monoxide poisoning. Undersea Hyperb Med 2014;41(4):339–54. [7] Liao SC, Mao YC, Yang KJ, Wang KC, Wu LY, Yang CC. Targeting optimal time for hyperbaric oxygen therapy following carbon monoxide poisoning for prevention of delayed neuropsychiatric sequelae: a retrospective study. J Neurol Sci 2019;396:187–92. [8] Jiang JY, Bo YH, Yin YH, Pan YH, Liang YM, Luo QZ. Effect of arousal methods for 175 cases of prolonged coma after severe traumatic brain injury and its related factors. Chin J Traumatol (Chin) 2004;7(6):341–3. [9] Gröger M, Radermacher P, Speit G, Muth CM. Genotoxicity of hyperbaric oxygen and its prevention: what hyperbaric physicians should know. Diving Hyperb Med 20 08;38(4):20 0–5. [10] Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev 2011(4):CD002041. [11] Wang S, Ma T, Wang L, Liu L, Liu H, Li B, et al. Effect of acupuncture on cerebrovascular reserve in patients with acute cerebral infarction: protocol for a randomized controlled pilot study. Trials 2017;18(1):292. [12] Wang YJ, Yuan J, Li M, Ding M, Su ZW, Xing J, et al. Clinical study on treatment of ischemic cerebrovascular disease by oxygen acupuncture. Liaoning J Tradit Chin Med (Chin) 2007;34(3):347–8.
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Clinical Research
Observation on promoting resuscitation in the patients with coma of acute carbon monoxide poisoning by acupuncture combined with hyperbaric oxygen Mao-li LUO () a, Hui-jie LI () a, Liang-ce MA () a, Yuan JIANG () b,∗ Emergency Department, Dazhou Central Hospital, Dazhou 635000, Sichuan Povince, China (, 635000, ) Department of Rehabilitation Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Povince, China ( , 610500, ) a
b
a r t i c l e
i n f o
Article history: Available online 29 May 2019 Keywords: Acupuncture Hyperbaric oxygen Acute carbon monoxide coma Cytokines Serum brain-derived growth factor
∗
a b s t r a c t Objective: To evaluate the effect of promoting resuscitation and the effect differences between acupuncture combined with hyperbaric oxygen therapy (HBOT) and simple HBOT in the patients with coma of acute carbon monoxide poisoning (ACMP). Methods: A total of 36 patients with ACMP coma were randomized into a simple HBOT group and acupuncture combined with HBOT group, 18 cases in each one. In the simple HBOT group, HBOT was provided once a day for 2 weeks. In the acupuncture combined with HBOT group, acupuncture was provided during HBOT. The acupuncture was given before the patients were sent to the hyperbaric oxygen chamber and the needles were retained until the hyperbaric oxygen treatment was completed. The ¯ ( GV 26), Sìshéncong ¯ ¯ acupoints included Ba˘ ihuì ( GV 20), Shu˘ıgou ( EX-HN1), Fengchí ¯ ( GB20), Hégu˘ ( LI 4), Tàichong ( LR 3) and Yo˘ ngquán ( KI 1). The needles were retained through the entire process of HBOT. Such combined treatment was given once a day for 2 weeks. Before the treatment, the score of Glasgow Coma Scale (GCS) was recorded, the levels of serum interleukin-6 (IL-6), interleukin-8 (IL-8) and brain-derived growth factor (BDNF) were tested and the time from unconsciousness to resuscitation was recorded of the two groups. After treatment, the levels of serum IL-6, IL-8 and BDNF were tested again and the clinical therapeutic effects were evaluated. Results: At last, there were 16 cases in the simple HBOT group and 17 cases in acupuncture combined with HBOT group got resuscitation. The time from unconsciousness to resuscitation was (5.17 ± 1.10) h in the acupuncture combined with HBOT group, which was less than (6.83 ± 2.73) h in the simple HBOT group, indicating the significant difference in statistic (P < 0.05). After treatment, the total effective rate was 94.4% in the acupuncture combined with HBOT group, which was higher than 88.9% in the simple HBOT group, indicating the significant difference in statistic (P < 0.05). After treatment, the levels of serum IL-6 and IL-8 were (29.72 ± 3.49) and (67.17 ± 7.61) pg/mL respectively in the acupuncture combined with HBOT group, which were lower as compared with those before treatment, indicating the significant differences in statistic (both P < 0.05). The level of IL-8 in the acupuncture combined with HBOT group was lower than (72.67 ± 7.17) pg/mL in the simple HBOT group after treatment, indicating the significant difference in statistic (P < 0.05). After treatment, the level of BDNF was (14.78 ± 3.90) pg/mL in the acupuncture combined with HBOT group, higher than the level before treatment, presenting the significant difference (P < 0.05), and higher than (12.93 ± 2.59) pg/mL in the simple HBOT group after treatment, presenting the significant difference in statistic (P < 0.05). Conclusion: Acupuncture combined with HBOT achieves the superior effect of promoting resuscitation and the clinical therapeutic effects as compared with the simple HBOT. Such combined treatment reduces the levels of serum IL-6 and IL-8, increases the level of serum BDNF in ACMP patients, as well as plays the active role in the prevention from delayed encephalopathy after acute carbon monoxide poisoning. © 2019 World Journal of Acupuncture Moxibustion House. Published by Elsevier B.V. All rights reserved.
Corresponding author. E-mail address: [email protected] (Y. JIANG).
https://doi.org/10.1016/j.wjam.2019.05.005 1003-5257/© 2019 World Journal of Acupuncture Moxibustion House. Published by Elsevier B.V. All rights reserved.
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Introduction
(4) Agreement of the patient’s family member during the follow-up.
Acute carbon monoxide poisoning (ACMP) is a kind of acute poisoning with the highest morbidity and the highest number of deaths [1] and it is one of the most common emergent and severe cases in emergency department. Carbon monoxide (CO) is a colorless, odorless, nonirritating and poisonous gas [2]. CO is produced under the insufficient combustion of carbonaceous material in daily work and life. It is invisible, especially in winter with combustion heating system used. The patient is poisoned during sleep at night and loses consciousness because of hypoxia. The effective self-rescue is impossible and such emergent situation cannot be found easily. The long-term coma and hypoxia result in severe cerebral impairment very easily. The delayed rescue not only causes severe sequela, but also threatens the patient life. Hence, the in-time rectifying cerebral hypoxia and regaining the consciousness from ACMP coma are the crucial approach to the successful rescue. The early active and effective treatment reduces the case fatality rate and the disability rate of ACMP coma and lowers the occurrence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) in the patients. In our study, the patients of ACMP coma were treated by acupuncture combined with hyperbaric oxygen therapy (HBOT) and the effect of promoting resuscitation and clinical therapeutic effects were evaluated. Moreover, the levels of cytokines and brain-derived growth factor (BDNF) in serum were tested so as to explore the protective effect on DEACMP. Clinical data
Exclusion criteria (1) Failure to have HBOT because of unsatisfactory control of blood pressure, severe upper respiratory infection, otitis media, nasosinusitis, auditory tube obstruction, etc. (2) Absolute contraindication of HBOT, such as pulmonary tuberculosis cavity combined with hemoptysis, active internal hemorrhage, hemorrhagic disorder, pneumatocele, etc. (3) Voluntary dropout in the study. (4) Loss of assessment records. Treatment methods Simple HBOT group The medical hyperbaric oxygen chamber made in China was adopted. In the treatment, the pressure was 0.12–0.15 MPa, pressure was increased for 20 min, the duration of oxygen uptake with mask was 60 min under a stable pressure, at the interval of 5 min, and then, the pressure was reduced at an even speed for 20 min. The treatment was given once a day. According to the patients’ condition, the 125 mL intravenous drops with 20% mannitol injection (once a day) and edaravone injection 30 mg (once a day) were administered for the routine treatment to prevent from cerebral edema, promote cerebral cellular metabolism and corresponding treatment. Acupuncture combined with HBOT group
General data A total of 36 patients of ACMP coma were all from the Emergency Department and the Rehabilitation Department of Traditional Chinese Medicine (TCM) in Dazhou Central Hospital from October 2016 to December 2018. The random number table method was adopted to divide these patients into a simple HBOT group and acupuncture combined with HBOT group, 18 cases in each one. The differences were not significant statistically in gender, age, disease course and the score of Glasgow Coma Scale (GCS) in the patients between the two groups (all P > 0.05), indicating the comparability between the two groups. The detailed data can be seen in Table 1. This study has been approved by the Ethics Committee of Dazhou Central Hospital (Approval No. DZYEC2015027). Inclusion criteria (1) Meet the diagnostic criteria of ACMP. That is definite contact history of carbon monoxide (CO), the symptoms and physical signs of acute central nervous impairment, carbonyl hemoglobin (HbCO) 20–40%, excluding other factors. (2) Coma state when visiting hospital, GCS score 12 points. (3) Signing the informed consent by the patient’s family member.
On the base of the treatment as the simple HBOT group, acupuncture was given additionally. The acunpuncture was given before the patients were sent to the hyperbaric oxygen chamber and the needles were retained until the hyperbaric oxygen treatment was completed. The needles were withdrawn after the patients exited from the chamber. The acupoints included Ba˘ ihuì ¯ ( GV 26), Sìshéncong ¯ ( EX-HN1), ( GV 20), Shu˘ıgou ¯ ¯ ( GB20), Hégu˘ ( LI 4), Tàichong Fengchí ( LR 3) and Yo˘ ngquán ( KI 1). Acupoint areas were sterilized routinely and the sterile acupuncture needle for single use, 0.25 mm × 40 mm (Hwato brand) was selected. GV 20 was punctured transversely backward, 15 mm in depth, GV 26 was punctured obliquely toward nasal septum, 15 mm in depth, EX-HN1 was punctured obliquely toward GV 20, 15 mm in depth, GB 20 was punctured obliquely toward the nose tip, 30 mm in depth, LI 4 was punctured obliquely ¯ an ¯ ( LI 3), 15 mm in depth and KI 1 was punctured toward Sanji perpendicularly, 25 mm in depth. The even-needling technique was used by lifting, thrusting and rotating the needle. The rotating angle was in the range from 90° to 180°, with the frequency from 60 to 90 times per minute. The amplitude of lifting and thrusting was 10–15 mm with the frequency from 60 to 90 times per minute. The acupuncture was given once every day. The patients of the two groups took the above treatment for 2 weeks.
Table 1 Comparison of general data of ACMP coma patients between the two groups (Mean ± SD). Groups
Simple HBOT group Acupuncture combined with HBOT group
Cases
18 18
Gender (case)
Age (year)
Male
Female
Youngest
Oldest
Average
Shortest
Disease course (hour) Longest
Average
GCS score
12 10
6 8
14 16
56 63
38.67 ± 13.17 37.28 ± 14.92
2 3
6 7
4.17 ± 1.04 4.39 ± 1.30
8.78 ± 1.73 8.50 ± 1.42
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Table 2 Comparison of time from unconsciousness to resuscitation in the patients of ACMP coma between the two groups (Mean ± SD, h).
Therapeutic effects Outcomes (1) Glasgow Coma Scale (GCS) score According to the eye response, verbal response and motor response, the patient was scored in the range from 3 to 15 points. 15 points indicate clear consciousness, 13–14 points indicate mild coma, 9–12 points moderate coma and 3–8 points severe coma. (2) Time from unconsciousness to resuscitation The time from unconsciousness to resuscitation referred to the time (hours) till the clear consciousness regained (GCS score = 15) since the first treatment. Clinical effects In reference to the recommendations in Guideline of acute carbon monoxide poisoning [3], the rehabilitation effects were drafted as follows: (1) Cured: clear consciousness, disappearance of clinical symptoms, independent living. (2) Remarkably effective: clear consciousness, obvious improvements in clinical symptoms, independent living mostly. (3) Effective: clear consciousness, improvements in clinical symptoms, unable to handle daily life activity. (4) No effect: unconsciousness, no any improvement in clinical symptoms, or even getting aggravation. The total effective rate = (cured cases + remarkably effective cases + effective cases)/total cases × 100%. Levels of serum interleukin-6 (IL-6), interleukin-8 (IL-8) and brain-derived growth factor (BDNF) Before and after treatment, venous blood was collected, about 5 mL, which was centrifuged at 30 0 0 r/min, for 5 min, and thus, serum was collected. According the instruction of enzyme-linked immunosorbent assay (ELISA) kit (Jianglai Biology Co. Ltd., China), ELISA was adopted to test the levels of human IL-6, IL-8 and BDNF separately. Statistical methods SPSS 21.0 software was adopted in the data analysis. Measurement data were expressed as Mean ± SD. The paired-samples t-test was used for the comparison before and after treatment within the groups, and the two independent-samples t-test was for the comparison before and after treatment between the groups, chi-square test was for the comparison of enumeration data between groups. P < 0.05 indicated statistically significant difference. Results (1) Comparison of the time from unconsciousness to resuscitation of the patients of ACMP coma between the two groups The time from unconsciousness to resuscitation (the duration after the first treatment till GCS score reached 15) was recorded in the patients of ACMP coma in the two groups. In the simple
Groups
Cases
Simple HBOT group Acupuncture combined with HBOT group
16 17
a
Time from unconsciousness to resuscitation 6.83 ± 2.73 5.17 ± 1.10a
Compared with the simple HBOT group, P < 0.05.
HBOT group, 16 cases got resuscitation after treatment and 2 cases were still under the unconsciousness after the end of the treatment (GCS score < 15). In the acupuncture combined with HBOT group, 17 cases got resuscitation after treatment and the time from unconsciousness to resuscitation was less than the simple HBOT group, indicating the significant difference in statistic (P < 0.05). There was 1 case under the unconsciousness after the end of the treatment (GCS score < 15). See the details in Table 2. (2) Comparison of the clinical effects in the patients of ACMP coma between the two groups After treatment, the total effective rate (94.4%) in the acupuncture combined with HBOT group was higher than that (88.9%) in the simple HBOT group. See the details in Table 3. (3) Comparison of serum IL -6, IL -8 and BDNF of the patients of ACMP coma between the two groups After treatment, the levels of serum IL-6 and IL-8 were all lower as compared with those before the treatment in the patients of the two groups and the levels of BDNF were all higer, indicating the significant differences in statistic (all P < 0.05). After treatment, the level of IL-8 in the acupuncture combined with HBOT group was lower than the simple HBOT group and the level of BDNF was higher than the simple HBOT group, indicating the significant differences in statistic (both P < 0.05). See the details in Table 4. Discussion Acute carbon monoxide poisoning (ACMP) results from the strong binding ability of CO to hemoglobin in the body, which is 200 times higher than that of oxygen and is difficult to dissociate. Carbonyl haemoglobin (COHb) formed after binding has no ability to carry oxygen, which hinders the transportation and utilization of oxygen in the body and leads to hypoxia of the whole body [4,5]. The brain tissue is sensitive to hypoxia. In CO poisoning, the brain tissue hypoxia occurs first and brain function is damaged to the most degree. One of the crucial approaches to rescue ACMP is to inhale pure oxygen of high concentration, accelerate the dissociation of COHb, restore the formation of oxyhemoglobin and timely rectify the body hypoxia. At present, the hyperbaric oxygen therapy (HBOT) is the first emergency treatment to rescue the ACMP patients [6]. Liao et al. [7] thinks that HBOT should be carried out as soon as possible, preferably within 22.5 h after CO poisoning. Hyperbaric oxygen can rapidly increase the partial pressure of blood oxygen, promote the decomposition of COHb, eliminate CO out of the body, increase the content of tissue oxygen, reverse the state of hypoxia, effectively improve microcirculation, and relieve brain edema. Additionally, hyperbaric oxygen has the effect of promoting resuscitation in coma patients [8]. While, some scholars believe
Table 3 Comparison of the clinical effects in the patients of ACMP coma between the two groups (Case). Groups
Cases
Cured
Remarkably effective
Effective
No effect
Total effective rate (%)
Simple HBOT group Acupuncture combined with HBOT group
18 18
7 10
4 4
5 3
2 1
88.9 94.4a
a
Compared with the simple HBOT group, P < 0.05.
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Table 4 Comparison of serum IL-6, IL-8 and BDNF in the patients of ACMP coma between the two groups (Mean ± SD, pg/mL). Groups
Cases
Time points
IL-6
IL-8
BDNF
Simple HBOT group
18
Acupuncture combined with HBOT group
18
Before treatment After treatment Before treatment After treatment
33.84 ± 3.65 31.61 ± 2.91 34.22 ± 9.13 29.72 ± 3.49a
78.72 ± 6.39 72.67 ± 7.17a 77.31 ± 4.38 67.17 ± 7.61a , b
11.33 ± 2.30 12.93 ± 2.59 11.17 ± 1.98 14.78 ± 3.90a , b
a b
Compared with the same group before treatment, P < 0.05. Compared with the simple HBOT group after treatment, P < 0.05.
that repeated use of HBOT may induce the similar pathological changes as ischemia/reperfusion, which may increase the generation of oxygen free radicals and worsen brain tissue damage. Thus, it is still controversial in the prevention and treatment with HBOT for DEACM [9,10]. However, the underlying benefits of HBOT combined with other therapy may contribute to the therapeutic effects in patients. Acupuncture is a common external therapy of traditional Chinese medicine and its satisfactory effects on cerebrovascular disease and consciousness impairment have been widely recognized [11]. In acupuncture treatment, through changing thermodynamics of cerebral blood vessel, increasing blood flow and improving cerebral blood circulation, the ischemia and hypoxia of brain tissue are rectified. Acupuncture also activates brain nerve cells and improves brain cell function. Some scholars have put forward the “oxygen acupuncture therapy”, in which, an appropriate amount of oxygen is inhaled while receiving acupuncture. Such therapy increases the partial pressure of blood oxygen in the body, improves the anoxic state of brain cells [12] and it is advantageous at the collaborative effects of oxygen and acupuncture. Some studies have been proved that acupuncture could enhance the therapeutic effects of hyperbaric oxygen in the treatment of ACMP and DEACMP in combination with HBOT [13,14]. Studies have found that the needle retaining therapy in hyperbaric oxygen chamber achieves not only the better effects of prevention and treatment of DEACMP as compared with simple HBOT [15], but also the satisfactory effects on neurogenic bladder [16], ischemic vertigo [17], motor aphasia [18] and cognitive impairment after craniocerebral injury [19]. Potentially, under high pressure condition, the function of the human body is in high metabolic state, which increases the external stimulation and stress ability, and thus, the response to acupuncture is stronger as compared with that under the regular condition and the state of deqi is sustainable at acupoints [20]. It is strictly prohibited to bring fire (such as lighters, mobile phones and electronic toys), flammable, explosive and volatile substances (i.e. grease and chemical fiber materials) into the chamber [21]. In this study, acupuncture needles of Hwato brand (manufactured by Suzhou Medical Supplies Factory Co., Ltd.) were used. It is made of stainless steel [16] and has good electrical conductivity that prevents from static electricity. Such kind of needle does not belong to the strictly prohibited objects. The needles were inserted before the patients entering the chamber and withdrawn after exiting. Such operation avoids metal impact in the chamber and ensures the patient’s safety. Acupuncture was applied to GV20, GV 26, EX-HN1, GB 20, LI 4, LR 3 and KI 1. GV 20 is the meeting site of three yang meridians of foot, liver meridian and the governor vessel, acting on benefiting qi, regaining consciousness and tranquilizing the mind. GV 26 is the meeting point of the governor vessel and yangming meridians of hand and foot, acting on opening orifice, strengthening the function of the brain and tranquilizing the mind. EX-HN1 is an extra point, acting on clearing head and eyes, strengthening the function of the brain, tranquilizing the mind and regaining consciousness. LI 4 and LR 3 are the points of yangming and jueyin meridians respectively, acting on opening orifices. The bilateral LI 4 and LR 3 are named as four-gate points,
representing yin, yang, qi and blood separately and they are located in the upper part and the lower part of the body separately. LI 4 and LR 3 co-act on balancing yin and yang, regulating the functions of zangfu organs and promoting the circulation of qi and blood of the whole body. KI 1 is the jing-well point of kidney meridian of foot-shaoyin, acting effectively on opening orifice, regaining consciousness, regulating kidney function and benefiting essence. After acupuncture at the above mentioned acupoints in combination with HBOT, the time from unconsciousness to resuscitation was less than that with the simple HBOT. The combined treatment promotes the early awakening of patient. Such therapy not only effectively prevents from respiratory asphyxia, but also avoids the occurrence of serious complications and reduces the incidence of the delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) and disability rate. DEACMP is the most severe complication of ACMP. The pathogenesis of DEACMP is unknown at present. But some studies believe that a variety of cellular inflammatory factors are correlated with DEACMP [22,23]. IL-6 is a central regulatory factor of inflammatory response, with extensive biological activity, participating in the regulation of immune function, stress response and inflammation. In the patients with ACMP, the serum IL-6 level is persistently high, which plays the important role in the occurrence of DEACMP. It is valuable to judge the condition and prognosis of DEACMP in the patients by testing the level of IL-6 in clinic [24]. IL-8 is an inflammatory cytokine produced by monocytes and vascular endothelial cells. In the patients with ACMP, the serum IL-8 level is also increased obviously, which is important in the pathological process of DEACMP and is also one of the outcomes to evaluate the condition of sickness. BDNF is the most important item of the neurotrophic factor family and is extensively distributed in the brain. It promotes the survival and growth of neurons and plays an important role in the process of nerve repair. ACMP is usually accompanied by neurological symptoms, which may affect the secretion of neurotrophic factors [25] and result in the decrease of serum BDNF level [26]. Liu et al. [27] suggested that HBOT at early stage could alleviate delayed memory impairment after ACMP through increasing BDNF level. In our study, it was discovered that after the combined treatment of acupuncture and HBOT, the clinical symptoms were relieved obviously and the self-care ability in daily life was improved. The total effective rate (94.4%) was higher than that (88.9%) in the treatment with simple HBOT group. In the simple HBOT group, after HBOT treatment, the levels of serum IL-6 and IL-8 were all lower as compared with the levels before treatment and BDNF level was higher. In the acupuncture combined with HBOT group, after treatment, the levels of serum IL-6 and IL8 were all lower as compared with the levels before treatment and the level of IL-8 after treatment was lower than that in the simple HBOT group. After treatment, BDNF level was higher than that before treatment in the acupuncture combined with HBOT group, but also higher than that as compared with the simple HBOT group. Such effects may be caused by the collaborative effects of oxygen and acupuncture in such combined treatment. HBOT alleviates the inflammatory reaction after cerebral injury, relieves hypoxic state of brain tissue and promotes the repair of injured nerve cells. The
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effect mechanism of acupuncture is similar to HBOT. Acupuncture at GV 20, GV 26, EX-HN1, GB 20, LI 4, LR 3 and KI1 improves the excitability of cerebral cortex, promotes the recovery of brain neural function, improves cerebral microcirculation and promotes the absorption of brain cell edema. Therefore, with acupuncture combined, HBOT plays a better role in treatment and contributes to the promotion of resuscitation. In conclusion, acupuncture combined with HBOT achieves the better effect of promoting resuscitation and clinical therapeutic effects than the simple HBOT. Such combined treatment reduces the levels of serum IL-6 and IL-8, increases the level of serum BDNF, alleviates brain tissue damage and plays an active role in the prevention of DEACM of the patients with ACMP, References [1] Kohshi K. Delayed neuropsychologic sequelae of carbon monoxide poisoning. Chudoku Kenkyu 2007;20(4):381–2. [2] Xu X, Zhang H, Wang K, Tu T, Jiang Y. Protective effect of edaravone against carbon monoxide induced apoptosis in rat primary cultured astrocytes. Biochem Res Int 2017;2017:5839762. [3] Gao CJ, Ge H, Zhao LM, Wu LH, Li Z, Yang L, et al. Guideline of treatment of acute carbon monoxide poisoning: Part 3. Chin J Naut Med Hyperb Med (Chin) 2013;20(1):72–4. [4] Ghosh RE, Close R, McCann LJ, Crabbe H, Garwood K, Hansell AL, Leonardi G. Analysis of hospital admissions due to accidental non-fire-related carbon monoxide poisoning in England, between 2001 and 2010. J Public Health (Oxf) 2016;38(1):76–83. [5] Reumuth G, Alharbi Z, Houschyar KS, Kim BS, Siemers F, Fuchs PC, Grieb G. Carbon monoxide intoxication: what we know. Burns 2018;S0305-4179(18) 30613-2. [6] Weaver LK. Hyperbaric oxygen therapy for carbon monoxide poisoning. Undersea Hyperb Med 2014;41(4):339–54. [7] Liao SC, Mao YC, Yang KJ, Wang KC, Wu LY, Yang CC. Targeting optimal time for hyperbaric oxygen therapy following carbon monoxide poisoning for prevention of delayed neuropsychiatric sequelae: a retrospective study. J Neurol Sci 2019;396:187–92. [8] Jiang JY, Bo YH, Yin YH, Pan YH, Liang YM, Luo QZ. Effect of arousal methods for 175 cases of prolonged coma after severe traumatic brain injury and its related factors. Chin J Traumatol (Chin) 2004;7(6):341–3. [9] Gröger M, Radermacher P, Speit G, Muth CM. Genotoxicity of hyperbaric oxygen and its prevention: what hyperbaric physicians should know. Diving Hyperb Med 20 08;38(4):20 0–5. [10] Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev 2011(4):CD002041. [11] Wang S, Ma T, Wang L, Liu L, Liu H, Li B, et al. Effect of acupuncture on cerebrovascular reserve in patients with acute cerebral infarction: protocol for a randomized controlled pilot study. Trials 2017;18(1):292. [12] Wang YJ, Yuan J, Li M, Ding M, Su ZW, Xing J, et al. Clinical study on treatment of ischemic cerebrovascular disease by oxygen acupuncture. Liaoning J Tradit Chin Med (Chin) 2007;34(3):347–8.
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