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| TCM CLINICAL RESEARCH |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 45-58 |
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Acupoint herbal patching with or without conventional treatment for stable chronic obstructive pulmonary disease: a systematic review of randomized controlled trials
Fen Zhou1, Ya-Wei Shan2, George Lewith3, Jian-Ping Liu2
1 Centre for Evidence-Based Chinese Medicine; Nursing School, Beijing University of Chinese Medicine, Beijing, China
2 Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
3 University of Southampton, UK
| Date of Web Publication | 11-Sep-2020 |
Correspondence Address:
Jian-Ping Liu
Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing
China
 Source of Support: None, Conflict of Interest: None  | 3 |
DOI: 10.15806/j.issn.2311-8571.2014.0013
Background: Acupoint herbal patching (AHP) alone or as an adjuvant therapy with conventional treatment (CT) has been widely used for prevention and treatment of chronic obstructive pulmonary disease (COPD). However, current clinical evidence from a systematic review of RCTs is lacking.
Objective: To evaluate the effectiveness and safety of AHP with or without CT for people with COPD at stable stage.
Methods: We searched randomized controlled trials comparing AHP (with or without CT) with no intervention, placebo, or CT from six databases. Two authors selected studies, extracted data and evaluated risk of bias of included trials. RevMan 5.2 software was used to analysis data.
Results: Twenty one RCTs (2327 participants) were included. AHP of non sanfu applied on no fixed dates with CT significantly decreased the mean frequency of acute exacerbation of COPD (times per year) (MD: -1.24; 95% CI: -2.02 to -0.46; 2 trials), and improved lung function parameters and quality of life. The AHP with CT showed no better effect in 6-minute walking distance (6MWD) that CT alone. AHP applied at sanfu (specific dates based on lunar calendar) with CT had significant effect for 6MWD (MD: 11.20; 95% CI: 0.83 to 21.56; I2 = 0%; 3 trials). One trial reported skin irritation from AHP. Another trial reported two patients had eye discomfort, which was inferred as the adverse effects of seretide.
Conclusion: AHP used as an adjunct to CT, appears to be more effective than CT alone in patients with stable COPD. However, further large, rigorously designed trials are warranted to confirm these potential effects.
Keywords: Traditional chinese medicine, Acupoint herbal patching, Chronic obstructive pulmonary disease, Treatment, Systematic review, Randomized controlled trials
How to cite this article:
Zhou F, Shan YW, Lewith G, Liu JP. Acupoint herbal patching with or without conventional treatment for stable chronic obstructive pulmonary disease: a systematic review of randomized controlled trials. World J Tradit Chin Med 2015;1:45-58 |
How to cite this URL:
Zhou F, Shan YW, Lewith G, Liu JP. Acupoint herbal patching with or without conventional treatment for stable chronic obstructive pulmonary disease: a systematic review of randomized controlled trials. World J Tradit Chin Med [serial online] 2015 [cited 2023 Dec 1];1:45-58. Available from: https://www.wjtcm.net/text.asp?2015/1/1/45/294847 |
| Background | |  |
Chronic obstructive pulmonary disease (COPD) is a progressive disease which presents with dyspnea, cough, sputum production, wheezing and chest tightness[1]. It is one of the leading causes of morbidity, disability, and mortality globally. According to the World Health Organization, it was the fifth most common cause of death in 2002 and will be up to the third most common cause of death in 2030[2]. If an acute exacerbation of COPD occurs there is usually an acceleration of the rate of lung function decline, substantial socioeconomic costs, and a significant first of mortality and diminished quality of life[3],[4],[5].
The 2011’s Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines summarized the major pharmacologic treatments for stable COPD and preventative interventions to avoid acute exacerbations of COPD; this includes administering bronchodilators and corticosteroids alone or in combination, mainly in the form of inhalers. These pharmacologic treatments do not halt the deterioration of lung function and are associated with adverse effects[1]. Forty to 60% of patients with COPD do not adhere to their prescribed medications and between 4% and 94% of patients fail to use their inhalers correctly[6] mainly because of the variety of medicines[7] and complication of the inhaler devices[8].
In China, acupoint herbal patching (AHP, sticking herbal medicine patches on acupuncture points) is first described in the Wu Shi Er Bing Fang[9] to help wheezing and cough[10]. It is one of the external therapies used to prevent or treat conditions through combined transcutaneous absorption of herbal extracts and stimulation of acupuncture points[11]. AHP for COPD can be given in 2 ways: applied only on sanfu days or on non-sanfu days. Sanfu (literally hibernating days) usually last from around the Lesser Heat, the 11th Solar Term and through the Autumn, the 13th Solar Term. The duration of the 13th Solar Term varies from 30 days to 40 days depending on the lunar calendar for each year. This period of time is of special significance in TCM in treating certain diseases and is characterized by high temperatures and muggy weather when yang is strongest in human body. If AHP is applied on non-sanfu days it is with the aim of both of prevention and treatment.
There have been five systematic reviews published for COPD using Chinese herbal medicines administered by oral or intravenous route[12],[13],[14],[15],[16]. Most suggest a promising benefit for herbal medicine. Another systematic review[17] covers a similar area to this one but the search retrieval is limited to Chinese databases. It evaluated a composite outcome (clinical efficacy) and ignored other patient centered outcomes such as quality of life and it did not classified the AHP as sanfu or non-sanfu. Our review adopted a more comprehensive search strategy and focused on clinical end-point outcomes incorporating of Traditional Chinese Medicine (TCM) theory by comparing sanfu and non-sanfu AHP application.
| Materials and Methods | | |
Standard protocol registrations
This systematic review protocol was registered in an international prospective register of systematic reviews, PROS-PERO. The registration No is CRD42014008999[18].
Inclusion and exclusion criteria
Randomized controlled trials (RCTs) were included for data analysis in participants with stable COPD using AHP with or without conventional treatment (CT, which means therapy referred by GOLD[1]) compared with no intervention, placebo, and conventional therapy. Combination of AHP and conventional therapy compared with the same conventional therapy was also included.
Participants with stable COPD regardless of gender, age, etiology, ethnic group, severity, diagnosed with specific criteria (i.e. mention any one of criteria for diagnosis of COPD) are eligible for inclusion. Participants of COPD complicated with asthma were excluded.
Primary outcome measure was acute exacerbation of COPD. Secondary outcome measures included clinical symptom improvement, quality of life, lung function parameters, 6-minute walking distance and adverse events.
Data Source and Searches
Two authors (YWS and FZ) searched the following electronic databases from their inception to April 2014: PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP Database, Sino-med and Wanfang Database.
In order to acquire comprehensive search, FZ also searched for ongoing trials from mainstream registries including Current Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov trials registry, The Australian New Zealand Clinical Trials Registry, and CentreWatch.
Unpublished postgraduate theses in China Doctoral Dissertations Full-text Database (CDFD), China Master’s Theses Full-text Database (CMFD) and China Master’s Theses Full-text Database supplement-2013 (CMFD supplement-2013) were also searched.
Search terms used for Pubmed were as follows: (COPD OR chronic obstructive pulmonary disease OR emphysema, pulmonary disease) for COPD search, (acupoint OR acupoint application OR local application OR acupuncture point OR acupoint sticking OR acupoint herbal patching OR sanfutie OR sanjiutie) for acupoint herbal patching search were combined. For other databases, these terms were slightly modified. No language limitation was applied. Searches were limited to randomized controlled trials and a filter applied to limit by humans.
Reference lists of all full text papers were hand-searched in order to find additional relevant reports.
Details of the search strategy are available from the author (FZ) on request.
Study Selection
YWS and FZ identified studies for eligibility and checked against the inclusion criteria.
Methodological quality
Risk of bias for included studies was assessed by two authors (YWS and FZ) according to the Cochrane Handbook (Version 5.2) for Systematic Reviews of Interventional[19]. Six items were evaluated: (1) selection bias (random sequence generation and allocation concealment); (2) performance bias (blinding of participants and personnel); (3) detection bias (blinding of outcome assessment); (4) attrition bias (incomplete outcome data); (5) reporting bias (selective reporting); (6) other bias (namely as baseline comparability and sample-size calculation). All these bias were categorized as low (met all items), high (met none of the item) and unclear risk (without sufficient information to judge). If there are any disagreements happened between the aforementioned two authors, a third author (JPL) was involved.
Data collection and Synthesis
YWS and FZ independently extracted data on patient characteristics, details of the intervention and control, outcome measures, main results, and consensus was reached by discussion with a third party (JPL) in case of discrepancy.
Statistical analyses were performed using RevMan 5.2 software (The Cochrane Collaboration). Dichotomous data were presented as risk ratio (RR) with 95% confidence interval (CI); while the continuous data were presented as mean difference (MD) with 95% CI. If different measurement scales were used, standardized mean difference (SMD) was performed to analyze continuous data. Heterogeneity was assessed using the I-square statistic, and we considered an I-square value greater than 50% indicating substantial heterogeneity. For I2 ≤ 50%, a random-effect model was applied.
| Results | | |
Study Characteristics
[Figure 1] shows the flow chart for search process and study selection. We included twenty one RCTs[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40] in this review. All of them were conducted in China and published in Chinese. Among the included studies, six trials were reported as dissertations[20],[21],[24],[25],[33],[34]. One trial was a conference paper[32]. The remaining fourteen trials[22],[23],[26],[27],[28],[29],[30],[31],[35],[36],[37],[38],[39],[40] were published in scientific journals.
The total number of participants with stable COPD in twenty one trials was 2327, aged between 55 to 85 years old, and the duration of disease varied from 3 to 56 years. All the participants came from hospitals. Eight trials reported from outpatients and inpatients[22],[24],[25],[30],[33],[34],[36],[40]; seven trials were from outpatients alone[20],[21],[26],[28],[32],[35],[39]; one trial was from inpatients[37]; the other five trials were unclear[23],[27],[29],[31],[38]. Although there were several different diagnostic criteria applied in the included trials, they had similar criteria showing the presence of a post-bronchodilator FEV1/FVC<0.70. Other detailed characteristics of included trials are listed in [Table 1].
There were no trials using AHP as a single intervention on stable COPD. All the four comparisons were in combination with CT: Four trials were sanfu AHP plus CT versus placebo plus CT[20],[21],[22]; Eleven trials were sanfu AHP plus CT versus CT[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33]; Two trials were non-sanfu AHP plus CT versus placebo plus CT[34],[35]; Five trials were non-sanfu AHP plus CT versus CT[36],[37],[38],[39],[40]. The treatment sessions varied from 9 times to 60 times per one treatment duration. The detailed characteristics of interventions of included trials are listed in [Table 2]. | Table 2: Characteristics of interventions and outcomes measures of included trials
Click here to view |
Five trials[23],[27],[33],[35],[38] mentioned the sources of financial support. Among them, three trials were sponsored by different government funds[27],[33],[35], the other two trials were sponsored by industry[23],[38].
Methodological Quality
According to the predefined quality assessment criteria, all included trials had a high risk of bias [Figure 2]. The general methodological quality of the majority of trials was poor. | Figure 2: Risk of bias summary. Presentation of the risk of bias summary of the review author&s judgments about each risk of bias item for each included trials.
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 | Figure 3: Risk of bias graph. Presentation of the risk of bias graph of the review author's judgments about each risk of bias item presented as percentages across all included trials.
Click here to view |
1. Random Sequence Generation
Four of the twenty one trials[23],[26],[37],[38] used a random number table, while only one trial[21] used central randomization, and 16 trials did not provide the specific random sequence generation method and only reported as “randomization used”.
2. Allocation Concealment
Two trials[21],[34] used an opaque sealed envelope while the rest nineteen trials did not provide any information.
3. Blinding
Two trials[21],[34] applied double-blinding (for participants and personnel), three trials[20],[22],[35] didn&t provide information about blinding, but they used placebo, so we considered them as single-blinding method (only for participants).
4. Incomplete Outcome Data
Five trials[20],[21],[25],[34],[39] provided the number of withdrawals, but no information about the reasons for withdrawal. Only one trial[34] did an intention-to-treat analysis.
5.Selective Outcome Reporting
Since no trials gave clinical trial registration information, we could not compare the trial reported with the corresponding protocol, so could not identify whether there was selective outcome reporting.
For other bias, all the trials reported that there was a comparable baseline between two groups and none of them reported sample-size calculations in their methodology.
Effects of interventions
For the two comparisons, we divided the included trials into different subgroups according to the treatment time, treatment sessions and follow up period (only for quality of life). Although some of the ingredients of AHP are different among the included trials, the formulae of the herbal patches had the same purpose to warm yang for dispelling cold, benefit qi for relieving wheezing, making expectoration easier and freeing the flow of Qi in the meridians. Due to variations in study quality, intervention types and limited information about the participants’ age or disease severity, most outcome data could not be pooled quantitatively.
The overall effect estimates of AHP were shown in the [Table 3], and all the units used for the continuous data are also listed in [Table 3]. | Table 3: Estimate effect of AHP combine with CT for improving clinical outcomes of patients with COPD
Click here to view |
1. Acute exacerbation of COPD
Eight trials reported outcomes for acute exacerbations of stable COPD (AECOPD).
Sanfu AHP plus CT versus placebo plus CT
Two trials[21],[22] reported the mean frequency of AECOPD, each of them had three years’ data. But no differences were seen at three sessions respectively (1.first year: MD: 0.19; 95% CI: -0.03 to 0.40; I2 = 4%; 2.second year: MD: -1.34; 95%CI: -3.18 to 0.50; random effects model; I2 = 92%; 3.third year: MD: -1.68; 95%CI: -4.17 to 0.80; random effects model; I2 = 97%; 2 trials). We attributed the significant heterogeneity to low methodological quality.
Sanfu AHP plus CT versus CT alone
Four trials compared sanfu AHP plus CT with CT alone, which showed a significant difference (MD: -0.92; 95%CI: -1.58 to -0.27; random effects model; I2 = 87%; 4 trials). When we excluded two trials[29],[33] with outliers the data showed sanfu AHP plus CT had a better effect on reducing frequency of AECOPD (MD: -0.50; 95%CI: -0.66 to -0.33; I2 = 0%; 2 trials).
Non sanfu AHP plus CT with CT alone
Two trials[38],[39] belonged to this comparison type and found a significant difference between non sanfu AHP plus CT and CT alone in reducing the frequency of AECOPD (MD: –1.24; 95%CI: –2.02 to –.46; random effects model; I2 = 84%; 2 trials). The heterogeneity in this meta-analysis may due to disease severity differences after comparing the baseline of the included two trials.
2. Symptom improvement
Seventeen trials[20],[22],[25],[26],[27],[29],[30],[31],[32],[33],[35],[36],[37],[38],[39],[40] reported the symptom improvement. Among them, fifteen trials[22],[25],[26],[27],[29],[30],[31],[32],[33],[35],[36],[37],[38],[39],[40] used an unvalidtated composite outcome index which combined symptoms, signs and laboratory tests together. There were three to four levels of improvement: cure, markedly effective, effective (only for some trials), and ineffective. The classification for each level were unclear and some of them overlapped so we did not extract these data. The two trials[20],[24] used modified medical research council questionnaires for assessing the severity of breath-lessness (mMRC) so we only extracted the data from them.
Sanfu AHP plus CT versus CT alone
Gong’s trial[24] reported the data’s difference of pre and post treatment, which showed that the sanfu AHP plus CT improved patients’ breathless symptom (MD: 0.90; 95% CI: 0.63 to 1.17).
Sanfu AHP plus CT versus placebo plus CT
Tian’s[20] trials reported the severity of breathlessness at three different follow up times, and no differences were found (MD: 0.00; 95%CI: –0.44 to 0.44 at three months; MD: 0.03; 95%CI: –0.41 to 0.47 at six months; MD: 0.18; 95% CI: –0.63 to 0.27 at 12 months).
3. Lung function parameters
Eleven trials evaluated the lung function parameters. FEV1 was reported in five trials[20],[21],[36],[37],[40]. Wu’s trial[21] reported three years’ data. Eight trials reported the FEV1/PR%[21],[24],[31],[33],[34],[36],[37],[39]. Nine trials[21],[23],[31],[33],[34],[36],[37],[39],[40] reported the FEV1/FVC.
Sanfu AHP plus CT versus placebo plus CT
Only Wu’s trial[21] belonged to this category which did not find significant difference in all the three spirometric parameters in any of the three years respectively.
Sanfu AHP plus CT versus CT alone
Marginal but significant differences were found in absolute FEV1 in this comparison in Tan’s trial[28] (MD: 0.38; 95% CI: 0.00 to 0.76; 1 trial). Such changes were not observed in FEV1% predicted (MD: 1.13; 95% CI: –0.58 to 2.84; I2 = 32%; 2 trials), and in FEV1/FVC (MD: 1.18; 95% CI: 0.26 to 2.10; I2 = 33%; 3 trials). Besides, Gong’s trial[24] reported the data’ s difference of pre and post treatment, which demonstrated no significant difference in this comparison (MD: 1.47; 95% CI: –3.86 to 6.81; 1 trial).
Non sanfu AHP plus CT with placebo plus CT
Trial by Ayoufu et al[34] reported no significant increases in FEV1/PR% (MD: –5.90; 95% CI: –18.34 to 6.54; 1 trial) and FEV1/FVC (MD: –2.88; 95% CI: –13.28 to 7.52; 1 trial) as well.
Non- sanfu AHP plus CT with CT alone
There were significant differences between non- sanfu AHP plus CT and CT alone on FEV1 (MD: 0.52; 95% CI: 0.42 to 0.62;3 trials), on FEV1/PR% (MD: 5.92; 95% CI: 4.02 to 7.82; 3 trials), and on FEV1/FVC (MD: 7.76; 95% CI: 2.88 to 12.63; random effects model; I2 = 87%; 4 trials) as well.
4. Quality of life (QoL)
Seven trials[20],[21],[24],[28],[23],[31],[40] evaluated quality of life. Among them, most trials were measured by SGRQ (St. George’s Respiratory Questionnaire), only Yang’s trial[31] used the self-modified questionnaire by Cai et al.
Sanfu AHP plus CT versus placebo plus CT
Tian’s[20] trial reported three follow up periods for quality of life’ s data and all of these data showed positive QoL improvement (third month: MD: –8.36; 95% CI: –14.10 to –2.62; sixth month: MD: –14.02; 95% CI: –21.04 to –7.00; 12 month: MD: –10.61; 95% CI: –16.87, –4.35; 1 trial). Wu’s trial[21] found no significant difference after two sessions (first session: MD: –5.70; 95% CI: –15.40 to 4.00; second session: MD: –0.19; 95% CI: –6.89 to 6.51; 1 trial), but improvement was observed after the third session (MD: –6.84; 95% CI: –13.29 to –0.39; 1 trial).
Sanfu AHP plus CT versus CT alone
Yang’s[31] trial used Cai et al’s questionnaire to evaluate QoL, which demonstrated significant difference in this comparison (MD: –0.27; 95%CI: –0.46 to –0.08; 1 trial). Such changes were not observed in Guan’s and Tan’s pooled data in the score of QoL based on SGRQ (SGRQ) (MD: –2.58; 95% CI: –8.54 to 3.38; I2 = 42%; 2 trials).
Furthermore, Gong’s trial[24] reported pre and a post treatment data, which showed significant differences (MD: 6.75; 95% CI: 3.24 to 10.26; 1 trial).
Non-sanfu AHP plus CT with CT alone
Xu’s[40] trial reported quality of life in this comparison and reported significant difference (MD: –16.23; 95% CI: –18.93 to –13.53; 1 trial).
5. 6 minutes walking distance (6-MWD)
Five trials[21],[25],[28],[33],[34] assessed the effects of AHP plus CT on 6-MWD. Wu’s trial[21] reported three years’ data. Zhu, Kan and Tan’s trials[25],[28],[33] compared sanfu AHP plus CT with CT alone after one year, two years and three years respectively. Ayoufu’s trial compared non sanfu AHP plus CT with CT alone.
Sanfu AHP plus CT versus placebo plus CT
Wu’s[21] trial showed significant increase the 6-MWD after first session(MD: 6.06; 95% CI: 0.88 to 11.24; 1 trial) and third session (MD: 28.14; 95% CI: 23.90 to 32.38; 1 trial), and no significance after the second session (MD: 2.51; 95% CI: –2.03 to 7.05; 1 trial).
Sanfu AHP plus CT versus CT alone
Significant difference was found in this comparison in pooled data (MD: 11.20; 95% CI: 0.83 to 21.56; I2 = 0%; 3 trials).
Non-sanfu AHP plus CT with placebo plus CT
Ayoufu’s[34] trial showed no significant difference in this index (MD: 24.94; 95% CI: –26.98 to 76.92;1 trial).
Adverse events
Wu’s[21] trial stated that the number of skin irritation according to different severity level. And there were no significant difference between two groups in three sessions. Kan’s trial[25] reported that two patients had eyes discomfort, but which was inferred as the adverse effects of seretide by the original author. The remaining trials did not report adverse events.
| Discussion | | |
Statement of Main Findings
Twenty one RCTs conducted in China were included in this systematic review, which used AHP plus CT in at least one arm. Non-sanfu AHP used in combination with CT appears to be more effective than CT alone in managing patients’ with stable COPD. Non-sanfu AHP was given more frequently and at closer intervals than sanfu AHP suggesting this might be a dose effect. Sanfu AHP plus CT compared CT alone showed improvement in reducing frequency of AECOPD, increasing quality of life and 6-MWD compared with placebo plus CT, the efficacy of sanfu AHP or non-sanfu AHP plus CT seemed to be unclear for most outcomes (except for QoL and 6-MWD) but there were only two trials (sanfu AHP plus CT vs CT) and one trial (non-sanfu AHP plus CT vs CT) in the comparisons. Only one trial reported the skin irritation which happened in both groups, indicating that AHP therapy might be well tolerated.
Limitations of this systematic review
The methodological quality of the included trials is poor indicating a high risk of bias consequently our findings need to be interpreted cautiously. The inadequacy of randomization, prior sample size calculations, allocation concealment and a near absence of blinding were found in the majority of the 22 included trials. None of the included trials reported protocol registration information. The trials included in the meta-analyses showed a relatively high degree of heterogeneity. The reasons for this heterogeneity may partly be related to the differences of the severity of participants’ condition, the acupoints selected, the AHP formula selected, and the different conventional treatments used.
We did not contact the authors to clarify information. Fifteen trials didn’t report the severity of participants’ condition[2],[24],[27],[29],[30],[31],[32],[34],[6],[37],[39],[40]; while for most trials’ the follow up periods were unclear.
Differences with the similar reviews’ findings
In 2012, Li et al published a systematic review which was similar with our review[17]. Li’s review only searched Chinese databases and included RCTs as long as they contained any AHP intervention. Li’ s review concuded that AHP plus western medicine showed significant improvement for FEV1 and predicted FEV1% predict compared with western medicine. Unlike Li’ s review, our review focused on AHP alone or combination with CT (whose effect were confirmed) compared with same CT in the control group. Although none of the included trials were published outside of China, nine new trials were included in our current review[20],[21],[25],[26],[29],[34],[36],[37],[38]. The beneficial results on the pulmonary function parameters of non- sanfu AHP plus CT were congruent with Li’s reports. But the result of comparing of sanfu AHP plus CT with CT alone did not show any significant. The reason may be the increased frequency of non-sanfu AHP application.
Implications for Future Research
Our suggestions for future research are:
- Trials Registration. Completing registration before the first patient is entered and including this in the publication should reduce selective reporting and encourage prior sample size calculations.
- Improving Methodology. Secure randomization and strict allocation concealment are needed. Although using double (both health professionals and participants) or single blinding (only for participants) is still a challenge for AHP, blinding for outcome can be applied to most trials. An intention-to-treat analyses, especially for evaluating long term AHP intervention, is essential.
- Standardized Reporting. Using a CONSORT to report the trail outcome is essential[41].
- Selecting Patients’ Centered Outcomes. Most trials did not report symptom improvement such as dyspnea, cough, and sputum production. We suggest that the future trials should focus the COPD patient centered outcomes.
| Conclusions | | |
AHP used in combination with conventional medication, especially when it is applied over a long time and more frequently may be more effective than conventional medication alone in managing patients’ with stable COPD. However, further large, rigorously designed trials are warranted to confirm these effects.
| Acknowledgements | | |
F Zhou and JP Liu were supported by the Program for Innovative Research Team (2011-CXTD-09) of Beijing University of Chinese Medicine. The work was partially supported by the Program for the Model of Building Clinical Research Capacity for Chinese Medicine (grant number 201207007) from the State Administration of Traditional Chinese Medicine of China, the program for Young Faculty Fellow Plan of Beijing University of Chinese Medicine (2012- QNJSZX012), and young elite talent plan of Beijing Municipal Commission of Education (YETP0796). JP Liu was also supported by Ba Gui Scholarship from Guangxi Zhuang Autonomous Region.
Thank Yue Qiu from the respiratory department of the third hospital affiliated to Beijing University of Chinese Medicine and Bing Zhang from the respiratory department of the Wangjing hospital affiliated to China Academy of Chinese Medical Sciences, for expert knowledge of Chinese medicine.
| Author Contributions | | |
Designers: FZ and JPL; Trials searchers: FZ and YWS; Trials appraisers: FZ, YWS and JPL; Data extractors: FZ and YWS; Analyzer: FZ and JPL; Writers: FZ and JPL.
| Disclosure Statement | | |
No competing financial interests to claim.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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