Efficacy and safety of electroacupuncture in chronic obstructive pulmonary disease: a systematic review and meta-analysis

Introduction

Chronic obstructive pulmonary disease (COPD) is a prevalent lung condition that significantly impacts human health (1). According to estimates by the World Health Organization, COPD is projected to rank as the third leading cause of death and the fifth leading cause of disability globally between 2010 and 2030. An epidemiological survey in China from 2002 to 2004 reported that 8.2% of individuals aged 40 years and older suffered from COPD (e.g., 40 million individuals), with 2.5 individuals dying from this disease every minute. Additionally, the prevalence of COPD increased to 13.7% after a decade (2).

COPD is a heterogeneous disease with persistent respiratory symptoms (e.g., dyspnea, cough, and expectoration) caused by progressive airflow restriction due to abnormalities of the airway (e.g., bronchitis or bronchiolitis) and/or alveoli (emphysema). As the disease progresses, these symptoms can significantly impact daily activities and quality of life (QoL) (3). Although COPD is not curable, it can be managed by various Western medicines such as anti-inflammatory agents, bronchodilators, and phlegm relief medicines (4). While these approaches provide quick symptom relief, they are unable to effectively delay lung function decline in COPD patients, leading to relapse after discharge (5). Acupuncture is an important external therapy of traditional Chinese medicine (TCM) and a simple, safe, and affordable treatment for numerous diseases (6,7). The purpose of acupuncture is to stimulate specific acupoints in the body in order to restore the flow of Qi to meridians, regulate visceral functions, improve internal environment, and consequently prevent and treat disease. Acupuncture is recommended as an effective non-pharmacological therapy for alleviating dyspnea and improve the QoL of COPD patients in the Guidelines for the Diagnosis and Treatment of COPD (8). Clinical studies have shown that acupuncture can improve QoL, enhance vital capacity, and alleviate clinical symptoms in COPD patients (9-12). Electroacupuncture (EA) is a form of acupuncture where a small current is passed between pairs of needles to stimulate the acupoint (13). Studies have shown that EA can regulate endodermal vasoconstriction, restore oxidant/antioxidant balance, attenuate inflammation and lung injury, and improve pulmonary functions in COPD rats via the p38 MAPK signaling pathway (14).

In a randomized controlled trial (RCT) involving 66 patients with stable COPD, Kang et al. (15) found that EA combined with pursed-lip abdominal breathing exercises significantly improved forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratios. In contrast, another RCT (16) involving 124 stable COPD patients reported that combining EA with medication and aerobic exercise failed to improve these pulmonary function parameters. Despite numerous studies investigating the efficacy and safety of EA in COPD, no definitive conclusions have been reached. Furthermore, existing meta-analysis primarily focused on the therapeutic effect of ordinary acupuncture (without electrical stimulation) in COPD, with limited sensitivity and subgroup analyses (17). Therefore, the present meta-analysis was conducted to systematically evaluate the effectiveness of EA in COPD, providing support for its application in COPD management. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1001/rc) (18).

Methods

This study has been registered on PROSPERO (CRD42024526557).

Search strategy

RCTs of EA for COPD were searched in PubMed, Embase, Cochrane, Web of Science, Wanfang, and China National Knowledge Infrastructure (CNKI) from inception to October 8, 2023 without any language restriction. Additional relevant articles were also identified by screening the references of retrieved studies. The search terms used primarily comprised of intervention (EA and other related terms), subject (COPD), and study type (RCT). The specific search terms used in Pubmed were ((“Electroacupuncture”[MeSH]) OR (electroacupuncture)) AND ((“Pulmonary Disease, Chronic Obstructive”[MeSH]) OR ((((((((((Chronic Obstructive Lung Disease) OR (Chronic Obstructive Pulmonary Diseases)) OR (COAD)) OR (COPD)) OR (Chronic Obstructive Airway Disease)) OR (Chronic Obstructive Pulmonary Disease)) OR (Airflow Obstruction, Chronic)) OR (Airflow Obstructions, Chronic)) OR (Chronic Airflow Obstructions)) OR (Chronic Airflow Obstruction))). The search strategy for other databases is shown in Table S1.

Eligibility criteria

Inclusion criteria

(I) RCTs published in Chinese and English; (II) ≥18 years old patients diagnosed with COPD according to guidelines or expert consensus with clear diagnostic criteria (COPD patients in the stable phase and acute exacerbation phase were also included); (III) intervention group: EA alone or in combination with other interventions; and (IV) control group: sham acupuncture, conventional treatment, Western medicine, TCM, breathing exercise and aerobic training.

Exclusion criteria

(I) Reviews, letters, editorial comments, case reports, animal experiments, conference abstracts, unpublished articles, and experience summary; and (II) other respiratory diseases (e.g., asthma, bronchiectasis, pulmonary fibrosis, lung cancer) or severe liver, kidney, and heart diseases.

Data extraction

Data were extracted independently by two researchers, and any discrepancy was addressed by a third researcher. The extracted data included first author, year of publication, study period, study country, study design, sample size, age, gender, course of disease, duration of intervention, respiratory rate (RR), heart rate (HR), pulmonary hypertension (PH), partial pressure of arterial oxygen (pPaO₂), partial pressure of arterial carbon dioxide (pPaCO₂), arterial oxygen saturation (pSaO₂), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, TCM syndrome score, total protein (TP), albumin (Alb), body mass index (BMI), St. George’s Respiratory Questionnaire (SGRQ) score, modified Medical Research Council (mMRC) score, COPD Assessment Test (CAT) score, clinical effective rate, 6-minute walk distance (6MWD), FEV1, FVC, FVC%, FEV1%, and FEV1/FVC%. Mean ± standard deviation (SD) was calculated for continuous variables reported in median and range or interquartile range using validated mathematical methods (15,16,19-31).

Quality assessment

The quality of the included RCTs was evaluated using the Cochrane Collaboration’s tool for assessing risk of bias across seven domains: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other potential biases (32). Each domain was scored as low, high, or unclear risk. Studies with more low-risk evaluations were considered of higher quality. Two authors independently assessed the quality, resolving disagreements through discussion.

Statistical analysis

Continuous and dichotomous variables were pooled and analyzed using weighted mean difference (WMD) and risk ratio, respectively, along with their corresponding 95% confidence intervals (CIs). Heterogeneity was evaluated using Cochran’s Q test (χ², P<0.10) and I² statistic (I²>50% indicating significant heterogeneity), with a random-effects model employed when significant heterogeneity was present. Sources of clinical heterogeneity were systematically assessed using subgroup analyses by intervention protocols and control group designs. Sensitivity analyses were conducted at three levels: methodological (excluding studies with high risk of bias), clinical (stratified by COPD severity), and statistical (trim-and-fill method), all of which supported the robustness of the conclusions. For outcomes reported in ≥3 studies, publication bias was assessed using funnel plots and Egger’s test. Subgroup analyses of changes in FEV1/FVC% and CAT scores were performed based on population characteristics, intervention measures, and treatment duration (≥8 vs. <8 weeks). The significance level was set at P<0.05.

Results

Study search and characteristics

The article search and selection processes are presented in Figure 1. We initially identified 198 studies from PubMed (n=26), Embase (n=45), Cochrane (n=9), Web of Science (n=17), Wanfang (n=58), and CNKI (n=43). After the screening of titles and abstracts, as well as a thorough review of the full texts, a final total of 15 RCTs encompassing 1,076 patients (539 in the EA group and 537 in the control group) were selected for the meta-analysis (15,16,19-31). The baseline study characteristics are summarized in Table 1.

Figure 1 A schematic diagram of the article search and selection strategy. CNKI, China National Knowledge Infrastructure.

Quality assessment

The methodological quality of the 15 RCTs was evaluated using the Cochrane Collaboration’s tool for assessing risk of bias. Three (28,30,31) of the 15 RCTs had unclear risk of bias in the randomization process due to the lack of detailed procedures on random sequence generation. In addition, these RCTs failed to conduct appropriate analysis or provide adequate information on the methodology of analysis. The risks of bias for “blinding of participants” and “blinding of outcome assessment” were low in one RCT (19) and unclear in all other RCTs. Furthermore, the risk of bias was low for “allocation concealment” in three (19,23,29) RCTs, and low for “incomplete outcome data” in all 15 RCTs. Fourteen RCTs had unclear risk of bias for “selective outcome reporting” due to the lack of trial protocols (Figure 2).

Figure 2 Methodological quality of the included RCTs. RCTs, randomized controlled trials.

Meta-analysis

Change in BMI

Regarding forest plots of meta-analyses of different outcomes between the EA group and control group (Figure 3), change in BMI was reported in four RCTs with 219 patients (109 EA vs. 110 control) (20,21,29,30) and was not significantly different between the two groups (WMD: 0.27; 95% CI: −0.47, 1.01; P=0.47). No significant heterogeneity (I²=0%; P=0.90) was detected among the studies (Figure 3A). Regarding Funnel plots of different outcomes (Figure 4), a minor publication bias was detected in the funnel plot (Figure 4A) but not by the Egger’s test (P=0.29).

Figure 3 Forest plots of meta-analyses of different outcomes between the EA group and control group. (A) Change in BMI; (B) change in FEV1; (C) change in FVC; (D) change in FEV1%; (E) change in FEV1/FVC%; (F) change in 6MWD; (G) change in mMRC score; (H) change in clinical effective rate; (I) change in CAT score. 6MWD, 6-minute walk distance; BMI, body mass index; CAT, COPD Assessment Test; CI, confidence interval; EA, electroacupuncture; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; IV, instrumental variable; mMRC, modified Medical Research Council; SD, standard deviation.

Figure 4 Funnel plots of different outcomes. (A) Change in BMI; (B) change in FEV1; (C) change in FVC; (D) change in FEV1%; (E) change in FEV1/FVC%; (F) change in 6MWD; (G) change in mMRC score; (H) change in clinical effective rate; (I) change in CAT score. 6MWD, 6-minute walk distance; BMI, body mass index; CAT, COPD Assessment Test; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; MD, mean difference; mMRC, modified Medical Research Council; SE, standard error.

Change in FEV1

Change in FEV1 was reported in three RCTs with 268 patients (134 EA vs. 134 control) (22,25,26). Pooled analysis showed significantly greater FEV1 increase in the EA group than in the control group (WMD: 0.23; 95% CI: 0.01, 0.45; P=0.04). However, heterogeneity was present among the studies (I²=58%; P=0.09) (Figure 3B). A minor publication bias was detected in the funnel plot (Figure 4B) but not by the Egger’s test (P=0.43).

Change in FVC

Change in FVC was examined in three RCTs with 268 patients (134 EA vs. 134 control) (22,25,26). Our data demonstrated that the EA group had significantly greater FVC increase than the control group (WMD: 0.28; 95% CI: 0.14, 0.43; P<0.001). No significant heterogeneity was identified (I²=0%; P=0.50) (Figure 3C), and a minor publication bias was detected in the funnel plot (Figure 4C) but not by the Egger’s test (P=0.15).

Change in FEV1%

Change in FEV1% was evaluated in four studies with 302 patients (153 EA vs. 149 control) (15,16,19,30). The increase in FEV1% was significantly greater in the EA group compared to the control group (WMD: 3.99; 95% CI: 2.30, 5.67; P<0.001), and there was no significant heterogeneity (I²=0%; P=0.76) (Figure 3D). A minor publication bias was detected in the funnel plot (Figure 4D) but not by the Egger’s test (P=0.20).

Change in FEV1/FVC%

Change in FEV1/FVC% was assessed in six studies with 508 patients (256 EA vs. 252 control) (15,16,19,22,25,26). Pooled analysis revealed significantly greater increase in FEV1/FVC% after EA treatment compared to control treatment (WMD: 3.77; 95% CI: 2.38, 5.17; P<0.001). No significant heterogeneity was observed among studies (I²=0%; P=0.93) (Figure 3E). A minor publication bias was detected in the funnel plot (Figure 4E) but not by the Egger’s test (P=0.22).

Change in 6MWD

Change in 6MWD was analyzed in four studies with 302 patients (153 EA vs. 149 control) (15,16,19,30). We found that EA treatment resulted in significantly greater increase in 6MWD than control treatment (WMD: 11.74; 95% CI: 7.48, 16.01; P<0.001). Heterogeneity was not detected across the studies (I²=0%; P=0.81) (Figure 3F). A minor publication bias was identified by the funnel plot (Figure 4F) but not by the Egger’s test (P=0.26).

Change in mMRC score

Change in mMRC score was analyzed in three studies with 178 patients (91 EA vs. 87 control) (16,19,30) and was found to be comparable between the two groups (WMD: −0.07; 95% CI: −0.27, 0.13; P=0.49). Heterogeneity was not detected across the studies (I²=0%; P=0.43) (Figure 3G). A minor publication bias was present in the funnel plot (Figure 4G) but not in the Egger’s test (P=0.74).

Clinical effective rate

Clinical effective rate was calculated in three RCTs involving 310 patients (155 EA vs. 155 control) (16,22,24). Pooled analysis showed significantly higher clinical effective rate in the EA group than in the control group (risk ratio: 1.11; 95% CI: 1.03, 1.20; P=0.006). Heterogeneity was not detected across the studies (I²=9%; P=0.33) (Figure 3H). Funnel plot (Figure 4H) but not Egger’s test (P=0.20) indicated a minor publication bias.

Change in CAT score

Change in CAT score was determined in seven studies with 491 patients (247 EA vs. 244 control) (15,16,19,25,26,29,30). Our data demonstrated that EA treatment led to markedly lower CAT score than control treatment (WMD: −2.39; 95% CI: −3.63, −1.15; P<0.001). Heterogeneity was absent across the studies (I²=0%; P=0.90) (Figure 3I), and a minor publication bias was present in the funnel plot (Figure 4I) but not in the Egger’s test (P=0.64).

TP

TP level was measured in two studies with 120 patients (60 EA vs. 60 control) (27,31) and was significantly higher after EA treatment compared with control treatment (WMD: 1.78; 95% CI: 1.58, 1.98; P<0.001). Regarding Forest plots of perioperative outcomes (Figures S1,S2), no heterogeneity was observed between the studies (I²=0%; P=0.95) (Figure S1A). Funnel plot revealed a slight publication bias (Figure S2A).

Alb

Alb level was reported in two studies with 120 patients (60 EA vs. 60 control) (27,31). Meta-analysis revealed significantly higher Alb level after EA treatment compared to control treatment (WMD: 2.22; 95% CI: 1.16, 3.28; P<0.001). Heterogeneity was not detected (I²=0%; P=0.87) (Figure S1B), but minor asymmetry was observed in the funnel plot (Figure S2B).

SGRQ score

SGRQ score was mentioned in two studies with 184 patients (92 EA vs. 92 control) (15,16) and was found to be markedly lower in the EA group compared to the control group (WMD: −5.56; 95% CI: −8.61, −2.52; P<0.001). Heterogeneity was not detected (I²=0%; P=0.98) (Figure S1C), but minor asymmetry was observed in the funnel plot (Figure S2C).

RR

RR was measured in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was comparable between the two groups (WMD: −0.16; 95% CI: −1.75, 1.44; P=0.85). Heterogeneity was not detected (I²=0%; P=0.63) (Figure S1D), but minor asymmetry was observed in the funnel plot (Figure S2D).

HR

HR was reported in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was comparable between the two groups (WMD: −0.22; 95% CI: −6.69, 6.24; P=0.95). Heterogeneity was not detected (I²=0%; P=0.39) (Figure S1E), but minor asymmetry was observed in the funnel plot (Figure S2E).

PH

PH was analyzed in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was similar between the two groups (WMD: 0.01; 95% CI: −0.02, 0.04; P=0.67). Heterogeneity was not detected (I²=0%; P=0.64) (Figure S1F), but minor asymmetry was observed in the funnel plot (Figure S2F).

pPaO₂

pPaO₂ was measured in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was found to be similar between the two groups (WMD: −3.71; 95% CI: −11.16, 3.74; P=0.33). However, the two studies had significant heterogeneity (I²=99%, P<0.001) (Figure S1G) and slight publication bias (Figure S2G).

pPaCO₂

pPaCO₂ was measured in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was similar between the two groups (WMD: −0.27; 95% CI: −5.88, 5.34; P=0.93). Heterogeneity was not detected (I²=0%; P=0.44) (Figure S1H), but minor asymmetry was observed in the funnel plot (Figure S2H).

pSaO₂

pSaO₂ was analyzed in two studies with 120 patients (60 EA vs. 60 control) (27,28) and was comparable between the two groups (WMD: −1.74; 95% CI: −4.16, 0.68; P=0.16). Heterogeneity was not detected (I²=0%; P=0.55) (Figure S1I), but minor asymmetry was observed in the funnel plot (Figure S2I).

APACHE II score

Meta-analysis of APACHE II score from two studies with 120 patients (60 EA vs. 60 control) (27,31) revealed no difference between the two groups (WMD: 0.74; 95% CI: −0.91, 1.85; P=0.50). Heterogeneity was not detected (I²=0%; P=0.45) (Figure S1J), but minor asymmetry was observed in the funnel plot (Figure S2J).

TCM syndrome score

TCM syndrome score was recorded in two studies with 97 patients (48 EA vs. 49 control) (15,29) and was comparable between the two groups (WMD: −6.26; 95% CI: −12.51, 0.01; P=0.05). However, the two studies had significant heterogeneity (I²=87%; P=0.006) (Figure S1K) and slight publication bias (Figure S2K).

Sensitivity analysis

One-way sensitivity analysis showed that removal of the Shi [2018] study (25) rendered the difference in FEV1 non-significant (P>0.05), indicating that this study was the main contributor for unstable results. Therefore, it was impossible to conclude whether EA is more effective than other treatments for improving FEV1. Furthermore, exclusion of the Qiu [2022] (26) or Wang [2021] (22) study also removed the heterogeneity in FEV1 (I²=0%, P=0.39 or I²=0%, P=0.56), suggesting that the heterogeneity was predominantly attributed to these studies (Figure 5).

Figure 5 Sensitivity analysis of FEV1. CI, confidence interval; FEV1, forced expiratory volume in 1 second.

Subgroup analysis

Subgroup analysis of different types of intervention showed that EA significantly reduced the CAT score of patients with stable COPD (P<0.001) but not those with acute exacerbation of COPD (AECOPD; P>0.05). In addition, EA combined with Western medicine and respiratory rehabilitation therapy, or EA combined with Western medicine and TCM, significantly increased FEV1/FVC% in COPD patients (P<0.05). However, while EA + Western medicine + respiratory rehabilitation markedly lowered the CAT score of COPD patients (P=0.002), EA + Western medicine or EA + Western medicine + TCM had no impact on CAT score (P>0.05). In terms of treatment cycle, ≥8 weeks of EA treatment significantly increased FEV1/FVC% (P<0.001), but any duration (<8 or ≥8 weeks) of EA therapy had no impact on CAT score (P<0.05) (Table 2).

Discussion

EA is a classical TCM external therapy that has been shown to effectively ameliorate diseases and play an important role in various cellular processes. EA combined with Baling capsule can improve immune functions, inhibit airway remodeling, downregulate PTX3, 5-HT, and NF-κB expression, and dampen inflammatory responses (22). Furthermore, EA application can effectively attenuate inflammation and improve pulmonary functions in stable COPD patients (25). EA has also been reported to stimulate the central nervous system, transmit fiber discharge through the vagus nerve, promote acetylcholine release, prevent macrophage activation, dampen inflammation, alleviate lung tissue injury, and inhibit airway remodeling (33). Clinical studies have confirmed that EA can effectively improve the single lung vital capacity and lung compliance of COPD patients (25). Likewise, animal experiments demonstrated that EA stimulation of ST36 significantly enhanced pulmonary functions and downregulated inflammatory cytokines such as IL-1β and IL-6 in COPD rats (34).

This meta-analysis has incorporated the latest findings on the clinical efficacy of EA in COPD. Our pooled analysis of 15 RCTs involving 1,076 COPD patients revealed that EA is an overall effective therapy for COPD. The 6-minute walk test (6MWT) is often used to evaluate exercise endurance and has been shown to be highly correlated with pulmonary function parameters (35). Thus, the 6MWD is an important measure for the fitness of COPD patients. Our data showed that EA significantly increased the 6MWD and improved the exercise endurance of COPD patients. mMRC score is a measure of the degree of dyspnea in COPD patients. In contrast to the finding that acupuncture during acute exacerbation of COPD can improve dyspnea (36,37), our results indicated that EA did not significantly improve mMRC score compared to other interventions. This difference may be attributed to the small sample size in our study. FEV1, FVC, and FEV1/FVC are objective clinical parameters for assessing the pulmonary functions of patients, whereas the CAT score is a subjective measure for predicting the risk of acute exacerbation and mortality in COPD patients (38). All of these parameters have been shown to effectively reflect the QoL of patients and treatment efficacy (3). Our results indicated that EA significantly increased FEV1, FVC, FEV1%, and FEV1/FVC% and decreased CAT scores.

Although we identified two studies (22,26) as the main sources of heterogeneity for FEV1, the sources of heterogeneity remain unclear for other outcomes. Therefore, our results should be interpreted with this shortcoming in mind. Respiratory training can increase chest activity, coordinate breathing, improve respiratory muscle strength, enhance pulmonary ventilation, and increase oxygen intake (39). Our subgroup analyses indicated that respiratory rehabilitation training enhances the efficacy of EA in COPD, and EA in combination with respiratory rehabilitation may be beneficial for patients. In addition, a duration of ≥8 weeks of EA therapy resulted in significantly increased FEV1/FVC%, suggesting that EA may take longer to exert its therapeutic effects in COPD patients. Therefore, the treatment cycle of EA should be appropriately extended in subsequent clinical treatment of COPD.

The most commonly investigated acupoints in the included RCTs were ST36, CV12, CV17, LU9, and BL13. Jiang et al. (34) found that ST36 exerts anti-inflammatory effects in COPD rats by downregulating TNF-α and IL-1β levels, decreasing lipid peroxidation products, and alleviating airway obstruction. Liu et al. (40) proposed that CV12 may indirectly improve diaphragmatic mobility and respiratory efficiency in COPD patients by stimulating the vagus nerve and regulating gastrointestinal motility. Hu et al. (41) demonstrated that acupuncture at CV17 improved diaphragmatic mobility, enhanced pulmonary function and oxygenation, and reduced ventilator weaning time in patients with AECOPD. Taiyuan (LU9), the Yuan-Source point of the Lung Meridian, has shown significant therapeutic potential in the management of pulmonary diseases such as bronchial asthma and COPD. Its effects may be mediated through modulation of neuroimmune pathways, including activation of the vagus nerve and cholinergic anti-inflammatory pathways (42). Yang et al. (43) reported that BL13 (Feishu) alleviated pulmonary inflammation and pathological damage in COPD by modulating neuroreflex pathways associated with spinal segments and improving local microcirculation, thereby reducing levels of pro-inflammatory cytokines such as IL-1β and IL-6. Yang et al. (17) conducted a meta-analysis to investigate the efficacy of acupuncture in AECOPD. While both our study and that of Yang et al. focused on the therapeutic effects of acupuncture in COPD, our research specifically evaluated the efficacy of EA, whereas their study did not restrict the type of acupuncture used, which may have contributed to greater heterogeneity. Moreover, unlike Yang et al., our study conducted subgroup analyses based on population, intervention, and treatment duration.

Strengths and limitations

This is the first meta-analysis to systematically evaluate the efficacy and safety of EA in the treatment of COPD, offering significant insights into its clinical implications. The study design is rigorous, adhering to PRISMA guidelines and registered with PROSPERO, ensuring methodological transparency and reproducibility. By analyzing data from 15 RCTs involving 1,076 patients, the study provides robust evidence supporting EA’s remarkable benefits in improving pulmonary function and QoL. Additionally, sensitivity and subgroup analyses were conducted to further validate the reliability of the results and to exploring the impact of treatment duration (≥8 weeks) and combination with pulmonary rehabilitation on therapeutic outcomes, informing evidence-based clinical decision-making. Despite limitations in sample size and regional diversity, this study establishes a scientific foundation for the application of EA in COPD management and highlights directions for future multicenter, large-scale research.

There are several limitations in this study. First, the participants included in this study were of Asian descent, limiting the ability to assess the effectiveness of EA in Caucasians or other ethnic populations. Second, heterogeneity in interventions and controls (e.g., EA alone vs. combination therapies) represents a critical limitation. Although subgroup analyses were conducted to address this variability, future meta-analyses would benefit from more homogeneous study designs to minimize confounding effects. Third, the relatively small sample size may introduce bias and limit the statistical power of the findings. Future cross-cultural studies are warranted to confirm the generalizability of EA across diverse ethnic groups. Additionally, mechanistic studies based on preclinical evidence should be further pursued to elucidate the underlying biological pathways and inform clinical application.

Conclusions

EA is an effective non-pharmacological intervention for COPD. However, caution is needed when interpreting our findings given the limitations in sample size and ethnic homogeneity. More high-quality studies from different regions of the world are warranted to confirm the efficacy of EA in COPD.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1001/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1001/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1001/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wang C, Xu J, Yang L, et al. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health CPH study): a national cross-sectional study. Lancet 2018;391:1706-17. [Crossref] [PubMed]
2. Fang LW, Bao HL, Wang BH, et al. Survey and analyses of rate of spirometry examination in adults aged 40 years and older in China, 2014. Zhonghua Liu Xing Bing Xue Za Zhi 2018;39:593-9. [Crossref] [PubMed]
3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for prevention, diagnosis and management of COPD: 2024 report. 2023. Available online: https://goldcopd.org/2024-gold-report/
4. Yan P, Ye LB, Chen WQ. Progress in therapeutic targets and development of drugs against chronic obstructive pulmonary disease. Journal of China Pharmaceutical University 2021;52:144-55.
5. Huang WG, Wan J. Study on the efficacy of Ma Xing Shi Gan Tang combined with Qian Jin Reed Stem Tang in the treatment of chronic obstructive pulmonary disease in old age. Inner Mongolia Journal of Traditional Chinese Medicine 2019;38:14-5.
6. Wang TJ, Pang LJ, Yu RZ. Application of TCM Characteristic Lung Rehabilitation Technology in Rehabilitation of Chronic Complex Lung Disease. Journal of Liaoning University of Traditional Chinese Medicine 2020;22:78-81.
7. Wang YD, Li FS, Li Z, et al. Systematic evaluation of acupuncture on pulmonary rehabilitation in patients with stable chronic obstructive pulmonary disease. World Science and Technology-Modernization of Traditional Chinese Medicine 2020;22:196-204.
8. Chen YH. Interpretation of global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2021 report. Chinese Journal of the Frontiers of Medical Science (Electronic Version) 2021;13:16-37.
9. Wu K, Ruan C. Acupuncture for Chronic Obstructive Pulmonary Disease: A 38-Year Bibliometric Landscape of Global Research Trends and Knowledge Evolution (1986-2024). Int J Chron Obstruct Pulmon Dis 2025;20:2393-408. [Crossref] [PubMed]
10. Li G, Liu J, Yang G, et al. Efficacy of acupuncture as adjunctive therapy for patients with acute exacerbation of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Front Med (Lausanne) 2025;12:1513888. [Crossref] [PubMed]
11. Suzuki M, Takahashi Y, Inoue D, et al. Effectiveness of a long-term acupuncture treatment in patients with COPD: a randomised controlled trial. ERJ Open Res 2025;11:00668-2024. [Crossref] [PubMed]
12. Cardoso RF, Lacerda ACR, Lima VP, et al. Efficacy of Acupuncture on Quality of Life, Functional Performance, Dyspnea, and Pulmonary Function in Patients with Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial. J Clin Med 2022;11:3048. [Crossref] [PubMed]
13. Yang J, Yue ZH, Xie T, et al. Summary of Stimulation to Acupoints Compatibility Effect. Chinese Archives of Traditional Chinese Medicine 2015; [Crossref]
14. Lu J, Xie JJ, Xiang SY, et al. Electroacupuncture Improves Pulmonary Function of Rats with Chronic Obstructive Pulmonary Disease by Down-regulating Inflammatory Reaction and Expression of Macrophage Migration Inhibitory Factor/CD 74-CD 44/p 38 MAPK Signaling in Lung Tissues. Zhen Ci Yan Jiu 2018;43:759-66. [Crossref] [PubMed]
15. Kang X, Wang B, Zhang X, et al. Effect of Electroacupuncture Combined with Lip-Abdominal Breathing Training on Pulmonary Function and Quality if Life in Patients with Qi Deficiency of Lung and Kidney in Stable Stage of Chronic Obstructive Pulmonary Disease. Liaoning Journal of Traditional Chinese Medicine 2023;50:208-12.
16. Zhang MX, Huang YC, Yang X, et al. Observation of the therapeutic effect of electroacupuncture combined with medication and aerobic exercise in the treatment of stable chronic obstructive pulmonary disease and its influence on cardiopulmonary exercise function. Shanghai Journal of Acupuncture and Moxibustion 2023;42:221-6.
17. Yang C, Tian H, Xu G, et al. Efficacy of Acupuncture in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis 2024;19:707-20. [Crossref] [PubMed]
18. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535. [Crossref] [PubMed]
19. He Y, Li GY, Zheng ZG, et al. Effect of electroacupuncture on small airway function in patients with stable chronic obstructive pulmonary disease. Zhongguo Zhen Jiu 2021;41:861-5. [Crossref] [PubMed]
20. Peng XQ, Li LF, Liu J, et al. The effect of electroacupuncture meridian points on airway resistance and oxygenation function during one-lung ventilation in patients with chronic obstructive pulmonary disease. New Chinese Medicine 2014;46:180-2.
21. Du YY, Peng XQ, Yang Y, et al. Effect of electroacupuncture meridian points on erythrocyte immunity during one-lung ventilation in patients with chronic obstructive pulmonary disease. Modern Diagnosis and Treatment 2015;26:2656-8.
22. Wang TT, Zhou LZ, Ren T, et al. Efficacy Observation of Electroacupuncture Combined with Corbrin Capsules for Remission-stage Chronic Obstructive Pulmonary Disease and Its Effects on Serum PTX3, 5-HT and NF-κB. Shanghai Journal of Acupuncture and Moxibustion 2021;40:820-5.
23. Hu XY, Li YH, Li H, et al. Electroacupuncture for acute exacerbation of chronic obstructive pulmonary disease complicated with gastrointestinal dysfunction: a randomized controlled trial. Zhongguo Zhen Jiu 2023;43:499-503. [Crossref] [PubMed]
24. Zhao X, Qiu WY, Fang YX, et al. Observation on the effect of the treatment of abdominal distension caused by non-invasive ventilation by applying the umbilical cord with eliminating flatulence powder combined with electro-acupuncture and its effect on blood oxygen indexes. Chinese Journal of Traditional Medical Science and Technology 2021;28:785-7.
25. Shi GC, Wang KS, Zou Y, et al. Effect of electroacupuncture combined with astragalus injection on patients with stable chronic obstructive pulmonary disease. Chongqing Medical Journal 2018;47:2992-4, 3004.
26. Qiu L, Gong D, Zhao JL, et al. Clinical study of extracorporeal diaphragmatic pacing combined with electroacupuncture in the treatment of chronic obstructive pulmonary disease. Clinical Journal of Traditional Chinese Medicine 2022;34:531-4.
27. Han Y, Zhang Y, Xie DP. Effect of Chinese medicine intestine adjusting therapy on patients with respiratory failure caused by acute exacerbation of chronic obstructive pulmonary disease and undergoing noninvasive ventilation. Zhongguo Zhong Xi Yi Jie He Za Zhi 2010;30:814-8.
28. Han Y, Lin YZ, Lin L, et al. Influence of Spleen-Supplementing and Lung-Strengthening Therapy on Patients with Chronic Obstructive Pulmonary Disease Treated by Mechanical Ventilation and Enteral-parenteral Nutritional Support. Journal of Guangzhou University of Traditional Chinese Medicine 2008;25:18-22.
29. Yan Y. Therapeutic efficacy of electroacupuncture in treating COPD patients with skeletal muscle atrophy by benefiting qi and tonifying the lung, activating blood and resolving phlegm. Guiyang: Guizhou University of Traditional Chinese Medicine; 2019.
30. Gao Y, Mao Y, Sun LR, et al. A study on the efficacy and evaluation of acupuncture treatment in acute exacerbation of chronic obstructive pulmonary disease. Chinese Journal for Clinicians 2014;42-4.
31. Weng YN, Han Y, Zhang ZD, et al. Effects of the Pei Tu Sheng Jin method on respiratory pump function in mechanically ventilated patients with COPD expiratory failure. In: Chinese Society of Chinese Medicine Internal Medicine Pulmonary Diseases Professional Committee, World Federation of Chinese Medicine Societies Respiratory Disease Branch Academic Seminar. 2008:63-6.
32. Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev 2019;10:ED000142. [Crossref] [PubMed]
33. Chen JF, Luo WX, Zhou HF. Effects of Different Acupuncture Frequency on Respiratory Function and Immune Status in Patients with Stable Chronic Obstructive Pulmonary Disease. World Chinese Medicine 2018;13:2839-42.
34. Jiang LH, Li PJ, Wang YQ, et al. Anti-inflammatory effects of acupuncture in the treatment of chronic obstructive pulmonary disease. J Integr Med 2023;21:518-27. [Crossref] [PubMed]
35. Zeng GS, Chen LC, Fan HZ, et al. The relationship between steps of 6MWT and COPD severity: a cross-sectional study. Int J Chron Obstruct Pulmon Dis 2019;14:141-8. [Crossref] [PubMed]
36. Zheng ZT, Xu W, Chen N, et al. Therapeutic effect of electroacupuncture combined with pulmonary rehabilitation training in patients with stable chronic obstructive pulmonary disease. Chinese Journal of Physical Medicine and Rehabilitation 2024;46:940-3.
37. Levy I, Elimeleh Y, Gavrieli S, et al. Treatment of acute exacerbations of chronic obstructive pulmonary disease with acupuncture during hospitalization: a three-arm double-blinded randomized sham-controlled trial. Acupunct Med 2022;40:505-15. [Crossref] [PubMed]
38. Qiao LM, Zhang ZM, Wang J, et al. Relationship of FEV 1%pred with SGRQ, mMRC and CAT in chronic obstructive pulmonary disease patients. International Journal of Respiration 2021;41:1493-9.
39. Dong YR. The Improvement of Lung Function and the Effect on Quality of Life in Elderly Patients with Stable COPD by Resistance Breathing Training Apparatus Combined with Labial Abdominal Breathing Training. Medical Innovation of China 2020;17:97-100.
40. Liu Q, Duan H, Lian A, et al. Rehabilitation Effects of Acupuncture on the Diaphragm Dysfunction in Chronic Obstructive Pulmonary Disease: A Systematic Review. Int J Chron Obstruct Pulmon Dis 2021;16:2023-37. [Crossref] [PubMed]
41. Hu L, Cao ZQ, Chen C. Clinical Study on Acupuncture with Thick Needle at Danzhong Point to Assist in Improving Difficulty in Weaning from Ventilator During Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Journal of New Chinese Medicine 2023;55:156-9.
42. Xu YQ. Intervention effect of "Taiyuan" (LU9) acupoint on pulmonary function and inflammatory factors in rat models with acute lung injury. Beijing: China Academy of Chinese Medical Sciences; 2022.
43. Yang HM, Chang J, Wu JR, et al. Blood perfusion at Feishu (BL13): A potential early warning biomarker for chronic obstructive pulmonary disease. J Integr Med 2025; Epub ahead of print. [Crossref]