《针灸临床实践指南：肿瘤治疗相关副作用 呼吸困难》推荐意见 第三轮德尔菲调查问卷

尊敬的专家： 
您好！感谢您抽出宝贵时间参与本次临床问题征询。
《针灸临床实践指南：肿瘤治疗相关副作用 呼吸困难》是一部由世界针灸学会联合会（WFAS）立项的国际学会组织标准，针对经治疗后出现呼吸困难的肿瘤患者，围绕针灸治疗，基于系统评价形成的证据，结合专家意见，经全面利弊平衡后，形成可在国际范围内推广的针灸治疗肿瘤呼吸困难的具体方案。由天津中医药大学中医药标准化研究所牵头制定。
我们将对您的信息保密，请您如实填写并认真阅读调研问卷，结合您的专业经验进行选择和填写。您在填写中有任何问题，请随时联系我们。联系人：任海燕，rhyxiaotong@163.com。
最后，期待和您共同推动针灸在肿瘤呼吸困难领域的应用，再次感谢您的指导和支持！
天津中医药大学中医药标准化研究所/针灸标准化研究所
《针灸临床实践指南：肿瘤治疗相关副作用 呼吸困难》指南制定工作组
Dear Esteemed Expert,
Greetings! Thank you for taking the time to participate in this clinical consultation.
"Clinical Guide on Acupuncture and Moxibustion: Cancer treatment-related side effects Dyspnea" is an international organizational standard initiated by the World Federation of Acupuncture-Moxibustion Societies (WFAS). This guideline focuses on cancer patients experiencing dyspnea following treatment, proposing acupuncture-based interventions grounded in systematically reviewed evidence, expert consensus, and comprehensive risk-benefit assessments. Its goal is to establish globally applicable protocols for managing cancer-related dyspnea with acupuncture. This project is led by the Institute of Traditional Chinese Medicine Standardization and Acupuncture-Moxibustion Standardization at Tianjin University of Traditional Chinese Medicine.
All responses will remain confidential. Please complete the questionnaire thoroughly and honestly, drawing on your professional expertise. For any inquiries, kindly contact Ren haiyanat  rhyxiaotong@163.com.
We sincerely appreciate your valuable insights and collaboration in advancing the global application of acupuncture for cancer-related dyspnea. Thank you for your guidance and support!
Tianjin University of traditional Chinese Medicine Standardization Institute of traditional Chinese Medicine / Acupuncture Standardization Institute
Working Group on guidelines for "Clinical Guide on Acupuncture and Moxibustion: Cancer treatment-related side effects Dyspnea" effects Dyspnea"
第一部分：基本信息
本调研将对您的信息保密，请您如实填写以下基本信息。
Part Ⅰ: Basic Information
All information provided will remain strictly confidential. Please answer the following questions truthfully.
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姓名 Name
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性别 Gender
男 male
女 female
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国家及地区 Countries and regions：
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您所在工作单位全称 The full name of your work unit
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您的从业时间 Years of Professional Experience
五年以下（含五年）Less than 5 years (including 5 years)
6～10年（含10年）6～10 years (including 10 years)
11～20年（含20年）11～20 years (including 10 years)
20年以上 over 20 years
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您参与本次调研的身份 Your Role in This Survey
西医肿瘤医师 Western Medicine Oncology Practitioner
针灸医师 Acupuncture Practitioner
针灸医师+肿瘤医师 Acupuncture Practitioner + Oncology Practitioner
方法学专家 Methodology Expert
其他，请注明 Other (please specify): _________________
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您的职称等级划分 Your professional title is graded
高级职称 senior title
副高级职称 deputy senior title
中级职称 intermediate title
初级职称 junior title
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您所处医院等级 The level of your hospital
三级 level 3
二级 level 2
一级 level 1
其他 other
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最高学历 Highest Academic Degree
专科及以下 Associate degree or below
本科 Bachelor’s degree
硕士研究生 Master’s degree
博士研究生 Doctoral degree
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您是否有参与指南制定的工作经验?
Have you previously participated in clinical guideline development? 
是Yes
否No
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请输入您的邮箱 Please enter your mailbox：
第二部分：临床问题

Part Ⅱ: Clinical Question

本指南起草组经前期工作已明确以下8个临床问题：

临床问题1：相比于不干预，针灸疗法是否可以使肿瘤伴随呼吸困难患者有更多获益？
临床问题2：相比于药物（中药、西药、或中西药联合）治疗，针灸治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
临床问题3：相比于药物治疗（中药、西药、或中西药联合），针灸联合药物治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
临床问题4：相比于其他非药物疗法，针灸疗法是否可以使肿瘤伴随呼吸困难患者获益更多?
临床问题5：在使用联合治疗（包含吸氧、西药、中药、康复锻炼、其他非药物疗法、胸水引流等疗法两种及以上）的基础上，加用针灸治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
临床问题6：针灸治疗肿瘤伴随呼吸困难的较好时期是？
临床问题7：针灸治疗肿瘤伴随呼吸困难是否需要辨证分型？
临床问题8：针灸治疗肿瘤伴随呼吸困难的安全性如何？ 

The drafting group of this guideline has identified the following 8 clinical questions through preliminary work:
Clinical Question 1: Compared to non-intervention, can acupuncture therapy provide greater benefits for patients with cancers accompanied by dyspnea?
Clinical Question 2: Compared to pharmacological treatments (traditional Chinese medicine, Western medicine, or combination of both), can acupuncture therapy provide greater benefits for patients with cancers accompanied by dyspnea?
Clinical Question 3: Compared to pharmacotherapy (traditional Chinese medicine, Western medicine, or combination of both), can acupuncture combined with pharmacotherapy provide greater benefits for patients with cancers accompanied by dyspnea?
Clinical Question 4: Compared with other non-pharmacological therapies, can acupuncture therapy provide greater benefits for patients with cancers accompanied by dyspnea?
Clinical Question 5: Can the addition of acupuncture therapy provide greater benefits for patients with cancers accompanied by dyspnea on the basis of combined therapy (including oxygen therapy, Western medicine, traditional Chinese medicine, rehabilitation exercises, other non-pharmacological therapies, pleural drainage, and two or more other therapies)?
Clinical Question 6: What is the optimal period for acupuncture treatment in patients with cancers accompanied by dyspnea?
Clinical Question 7: Is syndrome differentiation required for acupuncture treatment of cancers with dyspnea?

Clinical Question 8: What is the safety profile of acupuncture in the treatment of cancers with dyspnea?
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您对以上临床问题是否有补充意见或建议？

Do you have any additional comments or suggestions on the above clinical questions?

第三部分：推荐意见
背景介绍：

呼吸困难，也称为气促或空气饥饿感，是一种主观的呼吸不适体验，由性质不同、强度各异的感觉组成。

Part Ⅲ: Recommendations
Background Introduction:
Dyspnea, also known as shortness of breath or air hunger, is a subjective experience of respiratory discomfort composed of sensations of varying natures and intensities.

请您基于对EtD框架的12个维度（即问题的优先性、有利效果、不利效果、证据可信度、结局指标的重要性、利弊平衡、资源花费、资源花费的证据质量、成本效益、健康公平性、干预措施的可接受度、干预措施的可行性，具体见下表）充分考虑，给出每个临床问题的“推荐方向和强度”，并对“初拟推荐意见”给出修改建议。

Please provide the "recommendation direction and strength" for each clinical question after carefully considering the 12 dimensions of the EtD framework (i.e., priority of the problem, desirable effects, undesirable effects, certainty of evidence, importance of outcomes, balance of benefits and harms, resource use, certainty of evidence on resource use, cost-effectiveness, health equity, acceptability, and feasibility—see the table below for details). Additionally, offer revision suggestions for the "draft recommendation statements."


《针灸临床实践指南：肿瘤治疗相关副作用 呼吸困难》
"Clinical Guide on Acupuncture and Moxibustion: Cancer treatment-related side effects Dyspnea" 

临床问题1：相比于不干预，针灸疗法是否可以使肿瘤伴随呼吸困难患者有更多获益？

证据来源：本临床问题共纳入11项RCT研究和1项meta分析 [10-21] ，涉及5项结局指标。3篇RCT[7, 8, 12]（n=267）提示对于治疗肿瘤相关呼吸困难，艾灸与不治疗相比具有显著效果（MD = -0.33；95% CI：-0.42~-0.25；P ＞ 0.05）（低质量证据）。2篇RCT[9, 11]（n=173）提示对于治疗肿瘤相关呼吸困难，艾灸与不治疗相比具有显著效果（MD = 3.11；95% CI：-8.45~-14.66；P ＜ 0.05）；1篇Meta分析[18]（n=480）提示对于改善呼吸困难严重程度，针灸组呼吸困难严重程度显著改善（SMD=-1.77；95% CI -3.05 ~ - 0.49，P=0.007）。其余6项无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[10]（n=66）研究报告了对于降低肺癌患者EORTC QLQ-C30 量表呼吸困难积分，岐黄针疗法优于不干预 (P＜0.05)（低级质量证据）；1篇RCT[13]（n=96）研究报告了对于降低晚期癌症患者MDASI呼吸困难评分，穴位按摩优于不干预(P＜0.05)（低级质量证据）；1篇RCT[14]（n=73）研究报告了对于降低胃癌患者气短乏力中医证候积分，药物铺灸疗法优于不干预。 (P＜0.05)（低级质量证据）；1篇RCT[15]（n=84）研究报告了对于降低胃癌术后患者ESAS呼吸困难评分，电针优于不干预 (P＜0.05)（低级质量证据）；1篇RCT[16]（n=30）研究报告了对于降低癌症患者EORTC QLQ-C30 量表呼吸困难积分，针刺治疗优于不干预(P＜0.05)（低级质量证据）；1篇RCT[17]（n=60）研究报告了对于改善肺癌患者EORTC QLQ-C30 量表呼吸困难积分，针刺联合艾灸治疗优于不干预(P＜0.05)（低级质量证据）。

Clinical Question 1: Compared with no intervention, can acupuncture therapy provide more benefits to patients with cancer-related dyspnea?

Evidence Sources:This clinical issue included 11 RCTs and 1 meta-analysis [10-21], involving 5 outcome measures. Three RCTs [7, 8, 12] (n=267) suggested that moxibustion has a significant effect compared with no treatment for tumor-related dyspnea (MD = -0.33; 95% CI: -0.42 to -0.25; P > 0.05) (low-quality evidence). Two RCTs [9, 11] (n=173) suggested that moxibustion has a significant effect compared with no treatment for tumor-related dyspnea (MD = 3.11; 95% CI: -8.45 to -14.66; P < 0.05); one meta-analysis [18] (n=480) indicated that acupuncture significantly improved the severity of dyspnea (SMD = -1.77; 95% CI -3.05 to -0.49, P = 0.007). The remaining six studies could not be included in the meta-analysis, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [10] (n=66) reported that Qihuang acupuncture therapy was superior to no intervention in reducing dyspnea scores on the EORTC QLQ-C30 scale in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [13] (n=96) reported that acupoint massage was superior to no intervention in reducing MDASI dyspnea scores in advanced cancer patients (P < 0.05) (low-quality evidence); one RCT [14] (n=73) reported that herbal cake-partitioned moxibustion was superior to no intervention in reducing TCM syndrome scores for shortness of breath and fatigue in gastric cancer patients (P < 0.05) (low-quality evidence); one RCT [15] (n=84) reported that electroacupuncture was superior to no intervention in reducing ESAS dyspnea scores in postoperative gastric cancer patients (P < 0.05) (low-quality evidence); one RCT [16] (n=30) reported that acupuncture was superior to no intervention in reducing dyspnea scores on the EORTC QLQ-C30 scale in cancer patients (P < 0.05) (low-quality evidence); one RCT [17] (n=60) reported that acupuncture combined with moxibustion was superior to no intervention in reducing dyspnea scores on the EORTC QLQ-C30 scale in lung cancer patients (P < 0.05) (low-quality evidence).
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推荐意见：对于伴随呼吸困难的肿瘤患者，针灸疗法较不干预可以使患者获益更多。
 Recommendation: Acupuncture is recommended for cancer patients with dyspnea.
同意Agree
不同意Disagree
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推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题2：相比于药物（中药、西药、或中西药联合）治疗，针灸治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
证据来源：本临床问题共纳入2项RCT研究 [34, 35] ，涉及3项结局指标。均为单篇RCT，无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[20]（n=60）研究报告了对于改善肺癌患者突发气喘次数的发生，提高患者的生存质量，穴位注射联合西药优于假注射联合西药(P＜0.05)（低质量证据）；1篇RCT[19]（n=145）研究报告了对于改善肺癌患者30分钟Borg 呼吸困难评分，针刺或针刺联合西药治疗优于西药治疗(P＜0.05)（低质量证据）。
Clinical Question 2: Compared with medication (Chinese medicine, Western medicine, or a combination of Chinese and Western medicine), can acupuncture provide more benefits to patients with cancer-related dyspnea?
Evidence Sources: This clinical issue included 2 RCTs [34, 35], involving 3 outcome measures. Both were single RCTs and could not be subjected to meta-analysis, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [20] (n=60) reported that acupoint injection combined with Western medicine was superior to sham injection combined with Western medicine in reducing the frequency of sudden dyspnea episodes and improving the quality of life in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [19] (n=145) reported that acupuncture alone or acupuncture combined with Western medicine was superior to Western medicine alone in improving the 30-minute Borg dyspnea score in lung cancer patients (P < 0.05) (low-quality evidence).
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推荐意见：对于伴随呼吸困难的肿瘤患者，针灸治疗较药物治疗可以使患者获益更多。
Recommendation: For cancer patients with dyspnea, acupuncture therapy is more beneficial than no intervention.
同意Agree
不同意Disagree
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推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题3：相比于药物治疗（中药、西药、或中西药联合），针灸联合药物治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
证据来源：本临床问题共纳入7项RCT研究[21-27]，涉及3项结局指标。均为单篇RCT，无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[21-27]（n=120）研究报告了对于改善肺癌患者肺功能FEV1 及 FVC 用力肺活量、PEF 呼气峰流速，穴位敷贴联合药物治疗优于药物治疗(P＜0.05)（低质量证据）；1篇RCT[22]（n=60）研究报告了对于降低肺癌患者气短的中医证候积分，雷火灸联合中药治疗优于中药治疗(P＜0.05)（低质量证据）；1篇RCT[23]（n=60）研究报告了对于降低肺癌患者气短的中医证候积分，穴位敷贴联合药物治疗优于药物治疗（P<0.05）（低质量证据）；1篇RCT[24]（n=97）研究报告了对于改善肺功能FEV1 、FVC、PEF，降低气短乏力的中医证候积分，揿针、穴位敷贴联合西药优于西药治疗 (P＜0.05)（低质量证据）；1篇RCT[25]（n=60）研究报告了对于降低肺癌患者气促、喘息中医证候积分，穴位敷贴联合西药治疗优于西药治疗(P＜0.05)（低质量证据）；1篇RCT[26]（n=56）研究报告了对于改善肺癌患者气急的症状，穴位埋线联合西药治疗优于西药治疗(P＜0.05)（低级质量证据）；1篇RCT[27]（n=84）研究报告了对于降低肺癌患者气急的中医证候积分，穴位埋线联合西药治疗优于西药治疗(P＜0.05)（低质量证据）。
Clinical Question 3: Compared with medication (Chinese medicine, Western medicine, or a combination of Chinese and Western medicine), can acupuncture combined with medication provide more benefits to patients with cancer-related dyspnea?
Evidence Sources: This clinical issue included 7 RCTs [21-27], involving 3 outcome measures. All were single RCTs and could not be subjected to meta-analysis, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [21-27] (n=120) reported that acupoint application combined with medication was superior to medication alone in improving lung function parameters including FEV1, FVC, and PEF in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [22] (n=60) reported that thunder-fire moxibustion combined with Chinese herbal medicine was superior to Chinese herbal medicine alone in reducing TCM syndrome scores for shortness of breath in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [23] (n=60) reported that acupoint application combined with medication was superior to medication alone in reducing TCM syndrome scores for shortness of breath in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [24] (n=97) reported that press needle and acupoint application combined with Western medicine were superior to Western medicine alone in improving lung function (FEV1, FVC, PEF) and reducing TCM syndrome scores for shortness of breath and fatigue (P < 0.05) (low-quality evidence); one RCT [25] (n=60) reported that acupoint application combined with Western medicine was superior to Western medicine alone in reducing TCM syndrome scores for dyspnea and wheezing in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [26] (n=56) reported that acupoint catgut embedding combined with Western medicine was superior to Western medicine alone in improving symptoms of breathlessness in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [27] (n=84) reported that acupoint catgut embedding combined with Western medicine was superior to Western medicine alone in reducing TCM syndrome scores for breathlessness in lung cancer patients (P < 0.05) (low-quality evidence).
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推荐意见：对于伴呼吸困难的肿瘤患者，针灸联合药物治疗较药物治疗可以使患者获益更多。
Recommendation: For tumour patients with concurrent dyspnoea, acupuncture combined with medication can provide more benefits than medication alone.
同意Agree
不同意Disagree
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推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题4：相比于其他非药物疗法，针灸疗法是否可以使肿瘤伴随呼吸困难患者获益更多?
证据来源：本临床问题共纳入3项RCT研究[28-30]，涉及3项结局指标。均为单篇RCT，无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[28]（n=86）研究报告了对于降低肺癌患者气短、气急症状分级、发生率，艾灸联合穴位敷贴优于穴位敷贴(P＜0.05)（低质量证据）；1篇RCT[29]（n=86）研究报告了对于改善肺癌患者肺通气功能指标（FEV1、FEV1/FVC%、FVC、MVV%）、肺换气功能指标（PaO2、SaO2、RR），穴位按摩联合呼吸功能锻炼优于呼吸功能锻炼(P＜0.05)（低质量证据）；1篇RCT[30]（n=30）研究报告了对于降低肺癌患者mMRC评分，针刺联合穴位敷贴优于穴位敷贴（P<0.05）（低质量证据）。
Clinical Question 4: Compared with other non-pharmacological therapies, can acupuncture provide more benefits to patients with cancer-related dyspnea?
Evidence Sources: This clinical issue included 3 RCTs [28-30], involving 3 outcome measures. All were single RCTs and could not be subjected to meta-analysis, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [28] (n=86) reported that moxibustion combined with acupoint application was superior to acupoint application alone in reducing the severity grading and incidence of shortness of breath and breathlessness in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [29] (n=86) reported that acupoint massage combined with respiratory function exercises was superior to respiratory function exercises alone in improving pulmonary ventilation function indicators (FEV1, FEV1/FVC%, FVC, MVV%) and pulmonary gas exchange function indicators (PaO2, SaO2, RR) in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [30] (n=30) reported that acupuncture combined with acupoint application was superior to acupoint application alone in reducing the mMRC score in lung cancer patients (P < 0.05) (low-quality evidence).
*
推荐意见：对于伴呼吸困难的肿瘤患者，针灸疗法较其他非药物疗法可以使患者获益更多。
Recommendation: For tumour patients with accompanying shortness of breath, acupuncture therapy can provide more benefits than other non-drug therapies.
同意Agree
不同意Disagree
*

推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题5：在使用联合治疗（包含吸氧、西药、中药、康复锻炼、其他非药物疗法、胸水引流等疗法两种及以上）的基础上，加用针灸治疗是否可以使肿瘤伴随呼吸困难患者获益更多？
证据来源：本临床问题共纳入7项RCT研究[31-37]，涉及5项结局指标。均为单篇RCT，无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[32]（n=100）研究报告了对于改善肺癌患者肺功能FEV1 及 MVV 用力肺活量，联合治疗加入电针疗法优于联合疗法(P＜0.05)（低级质量证据）；1篇RCT[33]（n=110）研究报告了对于降低肺癌患者呼吸困难VAS评分，联合治疗加入耳穴、穴位敷贴疗法优于联合治疗(P＜0.05)（低级质量证据）；1篇RCT[34]（n=86）研究报告了对于降低肺癌患者mMRC评分，联合治疗加入耳穴、穴位敷贴疗法优于联合治疗（P<0.05）（低级质量证据）；1篇RCT[35]（n=64）研究报告了对于降低肺癌患者喘息、气短中医证候积分，联合治疗加入延胡索穴位敷贴优于联合治疗加入白芥子穴位敷贴(P＜0.05)（低级质量证据）；1篇RCT[36]（n=92）研究报告了对于降低肺癌患者气短懒言中医证候积分，联合治疗加入麦粒灸优于联合治疗(P＜0.05)（低级质量证据）；1篇RCT[37]（n=68）研究报告了对于改善肺癌患者肺功能FEV1 、FVC、FEV1 /FVC 和PEF，降低气喘、气短中医证候积分，联合治疗加入针刺优于联合治疗(P＜0.05)（低级质量证据）；1篇RCT[31]（n=115）研究报告了对于降低肿瘤患者呼吸困难改良博格量表评分，联合治疗加入穴位按压优于联合治疗 (P＜0.05)（低级质量证据）。
Clinical Question 5: On the basis of combined therapy (including two or more of the following: oxygen inhalation, Western medicine, Chinese medicine, rehabilitation exercise, other non-pharmacological therapies, pleural effusion drainage, etc.), can additional acupuncture provide more benefits to patients with cancer-related dyspnea? 
Evidence Sources: This clinical issue included 7 RCTs [31-37], involving 5 outcome measures. All were single RCTs and could not be subjected to meta-analysis, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [32] (n=100) reported that adding electroacupuncture to combination therapy was superior to combination therapy alone in improving lung function parameters FEV1 and MVV in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [33] (n=110) reported that adding auricular acupoint therapy and acupoint application to combination therapy was superior to combination therapy alone in reducing VAS scores for dyspnea in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [34] (n=86) reported that adding auricular acupoint therapy and acupoint application to combination therapy was superior to combination therapy alone in reducing mMRC scores in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [35] (n=64) reported that adding Corydalis yanhusuo acupoint application to combination therapy was superior to adding white mustard seed acupoint application to combination therapy in reducing TCM syndrome scores for wheezing and shortness of breath in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [36] (n=92) reported that adding grain-sized moxibustion to combination therapy was superior to combination therapy alone in reducing TCM syndrome scores for shortness of breath and lethargy in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [37] (n=68) reported that adding acupuncture to combination therapy was superior to combination therapy alone in improving lung function parameters FEV1, FVC, FEV1/FVC, and PEF, and in reducing TCM syndrome scores for wheezing and shortness of breath in lung cancer patients (P < 0.05) (low-quality evidence); one RCT [31] (n=115) reported that adding acupressure to combination therapy was superior to combination therapy alone in reducing modified Borg scale scores for dyspnea in cancer patients (P < 0.05) (low-quality evidence).
*
推荐意见：对于伴呼吸困难的肿瘤患者，在使用联合治疗的基础上，加用针灸治疗可以使患者获益更多。
Recommendation: For tumour patients with accompanying shortness of breath, adding acupuncture treatment on the basis of combination therapy can provide greater benefits to the patient.
同意Agree
不同意Disagree
*

推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题6：针灸治疗肿瘤伴随呼吸困难的较好时期是？
证据来源：本临床问题推荐意见的形成基于专家访谈证据，及GDG专家组内核心针灸临床专家的个人经验，并经本指南GDG专家组投票达成共识。

基于此，GDG专家一致认为：针灸治疗更适用于轻、中度呼吸困难的肿瘤患者。

Clinical Question 6: What is the best period for acupuncture treatment for tumours accompanied by difficulty breathing?
Source of evidence: The formation of the recommendation for this clinical issue was based on expert interview evidence and the personal experience of core acupuncture clinical experts within the GDG, and was reached through voting by the GDG panel of this guideline.
Based on this, the GDG experts unanimously agreed that acupuncture is more suitable for cancer patients with mild to moderate dyspnea.
严重程度分级：

（1）肺功能指标

通过肺功能检查量化通气功能障碍程度，是呼吸系统疾病呼吸困难分级的核心客观依据：

第1秒用力呼气容积（FEV₁）占预计值百分比：轻度：FEV₁%pred≥80%（日常活动无明显受限，仅在剧烈运动时出现呼吸困难）；中度：50%≤FEV₁%pred<80%（平地快走或爬坡时出现呼吸困难）；重度：FEV₁%pred<50%（轻微活动如穿衣、洗漱即感呼吸困难，或静息时气促）。

FEV₁/FVC（用力肺活量）比值：<70%提示气流受限（如COPD），比值越低，呼吸困难越重。

最大通气量（MVV）：反映呼吸肌储备能力，MVV%pred<50%提示重度通气功能障碍，常伴静息呼吸困难。

（2）运动耐量测试

通过定量运动试验（如6分钟步行试验、心肺运动试验CPET）评估活动时呼吸困难的客观阈值：

6分钟步行距离（6MWD）：轻度：6MWD>450米（日常活动基本不受限，仅长距离行走时气促）；中度：300米≤6MWD≤450米（平地步行100-200米或爬1-2层楼即需休息）；重度：6MWD<300米（轻微活动如室内走动即感呼吸困难，或静息时需吸氧）。

（3）生命体征与临床症状（辅助指标）

呼吸频率（RR）：静息状态下，轻度：RR20-24次/分；中度：25-30次/分；重度：>30次/分（伴三凹征、大汗）。

血氧饱和度（SpO₂）：静息时，轻度：SpO₂90%-95%；中度：85%-89%；重度：<85%（需吸氧维持）。

Severity Classification:(1) Pulmonary Function Indicators
The degree of ventilatory dysfunction is quantified by pulmonary function tests, which serve as the core objective basis for grading dyspnea in respiratory diseases.
Percentage of forced expiratory volume in one second (FEV₁) predicted: Mild: FEV₁%pred ≥ 80% (no obvious limitation in daily activities, dyspnea only during strenuous exercise); Moderate: 50% ≤ FEV₁%pred < 80% (dyspnea during fast walking on flat ground or climbing slopes); Severe: FEV₁%pred < 50% (dyspnea during mild activities such as dressing and washing, or dyspnea at rest).
FEV₁/FVC (forced vital capacity) ratio: <70% indicates airflow limitation (e.g., COPD), and the lower the ratio, the more severe the dyspnea.
Maximal voluntary ventilation (MVV): reflects respiratory muscle reserve capacity. MVV%pred < 50% indicates severe ventilatory dysfunction, often accompanied by dyspnea at rest.
(2) Exercise Tolerance Test
The objective threshold of exertional dyspnea is assessed by quantitative exercise tests (e.g., 6-minute walking test, cardiopulmonary exercise test CPET).
6-minute walking distance (6MWD): Mild: 6MWD > 450 meters (basically unrestricted daily activities, dyspnea only during long-distance walking); Moderate: 300 meters ≤ 6MWD ≤ 450 meters (rest needed after walking 100-200 meters on flat ground or climbing 1-2 floors); Severe: 6MWD < 300 meters (dyspnea during mild activities such as indoor walking, or oxygen required at rest).
(3) Vital Signs and Clinical Symptoms (Auxiliary Indicators)
Respiratory rate (RR): at rest, Mild: RR 20-24 beats/min; Moderate: 25-30 beats/min; Severe: >30 beats/min (accompanied by three-depression sign and profuse sweating).

Pulse oxygen saturation (SpO₂): at rest, Mild: SpO₂ 90%-95%; Moderate: 85%-89%; Severe: <85% (oxygen supplementation required for maintenance).
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推荐意见：针灸治疗更适用于轻、中度呼吸困难的肿瘤患者。
Recommendation: Acupuncture is more suitable for tumour patients with mild to moderate breathing difficulties. (Conditional recommendation, expert consensus based on experience).
同意Agree
不同意Disagree
*

推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题7：针灸治疗肿瘤治疗相关副作用呼吸困难是否需要辨证分型？对哪些证型针灸干预有效？
证据来源：纳入的所有RCT研究中，共7项RCT[14, 20-22, 25, 35, 38]研究涉及了中医辨证分型。其中，1篇RCT涉及肺气虚证；1篇RCT涉及气阴两虚证；2篇RCT涉及脾虚痰湿证；3篇RCT涉及脾肾阳虚证；结果显示，针灸对以上证型均有效。无法进行Meta分析，故仅对结果进行描述性综合分析。分别为：1篇RCT[21]（n=120）研究报告了对于改善肺气虚证肺功能FEV1 及 FVC 用力肺活量、PEF 呼气峰流速，穴位敷贴联合中药、西药治疗优于西药治疗(P＜0.05)（低级质量证据）；1篇RCT[20]（n=60）研究报告了对于减少肾阳虚型晚期肺癌患者突发气喘次数的发生，提高患者的生存质量，穴位注射联合西药优于假注射联合西药(P＜0.05)（低质量证据）；1篇RCT[35]（n=64）研究报告了对于改善脾虚痰湿型肺癌患者咳嗽（日）症状积分，延胡索穴位敷贴治疗优于白芥子穴位敷贴治疗（P<0.05）（低质量证据）；1篇RCT[22]（n=60）研究报告了对于降低肺脾气虚型肺癌患者气短中医证候积分，雷火灸联合中药治疗效果优于单纯中药(P＜0.05)（低质量证据）；1篇RCT[38]（n=52）研究报告了对于降低气阴两虚型癌性肠梗阻患者心悸气短中医证候积分，穴位敷贴联合中药治疗优于不干预(P＜0.05)（低质量证据）；1篇RCT[25]（n=60）研究报告了对于降低痰湿瘀阻型肺癌患者喘息、气促中医证候积分，穴位敷贴联合西药治疗优于西药治疗(P＜0.05)（低质量证据）；1篇RCT[14]（n=73）研究报告了对于降低脾胃虚寒型胃癌患者气短乏力中医证候积分，药物铺灸疗法优于不干预(P＜0.05)（低质量证据）。
Clinical Question 7: Is syndrome differentiation required for acupuncture in the treatment of dyspnea as a side effect related to cancer therapy? For which syndromes is acupuncture intervention effective? Evidence Sources: Among all included RCTs, a total of 7 RCTs [14, 20-22, 25, 35, 38] involved TCM pattern differentiation. Among these, one RCT involved lung qi deficiency pattern; one RCT involved qi and yin deficiency pattern; two RCTs involved spleen deficiency and phlegm-dampness pattern; three RCTs involved spleen-kidney yang deficiency pattern. The results indicated that acupuncture was effective for all of the above patterns. Meta-analysis could not be performed, so only a descriptive comprehensive analysis of the results was conducted. These were: one RCT [21] (n=120) reported that acupoint application combined with Chinese and Western medicine was superior to Western medicine alone in improving lung function parameters FEV1, FVC, and PEF in patients with lung qi deficiency pattern (P &lt; 0.05) (low-quality evidence); one RCT [20] (n=60) reported that acupoint injection combined with Western medicine was superior to sham injection combined with Western medicine in reducing the frequency of sudden dyspnea episodes and improving quality of life in patients with advanced lung cancer of kidney yang deficiency pattern (P &lt; 0.05) (low-quality evidence); one RCT [35] (n=64) reported that Corydalis yanhusuo acupoint application was superior to white mustard seed acupoint application in improving daytime cough symptom scores in lung cancer patients with spleen deficiency and phlegm-dampness pattern (P &lt; 0.05) (low-quality evidence); one RCT [22] (n=60) reported that thunder-fire moxibustion combined with Chinese herbal medicine was superior to Chinese herbal medicine alone in reducing TCM syndrome scores for shortness of breath in lung cancer patients with lung-spleen qi deficiency pattern (P &lt; 0.05) (low-quality evidence); one RCT [38] (n=52) reported that acupoint application combined with Chinese herbal medicine was superior to no intervention in reducing TCM syndrome scores for palpitations and shortness of breath in patients with malignant bowel obstruction of qi and yin deficiency pattern (P &lt; 0.05) (low-quality evidence); one RCT [25] (n=60) reported that acupoint application combined with Western medicine was superior to Western medicine alone in reducing TCM syndrome scores for wheezing and dyspnea in lung cancer patients with phlegm-dampness and stasis obstruction pattern (P &lt; 0.05) (low-quality evidence); one RCT [14] (n=73) reported that herbal cake-partitioned moxibustion was superior to no intervention in reducing TCM syndrome scores for shortness of breath and fatigue in gastric cancer patients with spleen-stomach deficiency cold pattern (P &lt; 0.05) (low-quality evidence).
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推荐意见：在针灸治疗肿瘤相关呼吸困难过程中需要中医辨证分型治疗，对气阴两虚、肺脾气虚、脾虚痰湿、脾肾阳虚等证型针灸干预有效。
Recommendation: Traditional Chinese Medicine (TCM) syndrome differentiation is required in the application of acupuncture for cancer-related dyspnea. Acupuncture intervention is effective for syndromes including qi-yin deficiency, lung-spleen qi deficiency, spleen deficiency with phlegm-dampness, and spleen-kidney yang deficiency.
同意Agree
不同意Disagree
*

推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention
临床问题8：针灸治疗肿瘤治疗相关副作用呼吸困难的安全性如何？
证据来源：纳入的30篇RCT中，28篇文献未明确提及针灸伴随不良事件；2篇文献报告了不良事件，具体包括：针刺部位敷料导致的皮肤刺激，穴位敷贴引起的皮肤过敏反应（为白芥子的皮肤刺激性所致）等反应。且专家访谈过程中提及灸烟或加重患者呼吸困难。
 不良反应处理措施[39]：胶布过敏者可采用选用低过敏胶布或用绷带固定贴敷药物；出现范围较大、程度较重的皮肤红斑、水泡、瘙痒，应立即停药，进行对症处理，出现全身性皮肤过敏症状者，应及时到医院就诊。
Clinical Question 8: What is the safety profile of acupuncture in the treatment of cancers with dyspnea?
 Evidence Sources: Among the 30 included RCTs, 28 studies did not explicitly mention acupuncture-related adverse events; 2 studies reported adverse events, which specifically included: skin irritation caused by dressings at the acupuncture sites, and skin allergic reactions (due to the skin irritant nature of white mustard seed) caused by acupoint application. Additionally, expert interviews noted that moxa smoke may exacerbate dyspnea in patients.
Measures for managing adverse reactions [39]: For patients allergic to adhesive tape, hypoallergenic tape or bandages may be used to secure the application material; if extensive or severe skin erythema, blisters, or itching occur, treatment should be discontinued immediately and symptomatic management should be provided; patients experiencing systemic skin allergic symptoms should seek medical attention promptly.
*
推荐意见：对于伴随呼吸困难的肿瘤患者，针灸疗法具有较好的安全性。
Recommendation: For cancer patients with dyspnea, acupuncture therapy has good safety.
同意Agree
不同意Disagree
*

推荐方向与强度  The recommendation direction and strength：

强烈推荐此干预 Strong recommendation for the intervention
有条件地推荐此干预 Weak recommendation for the intervention
有条件地推荐干预或对照 Weak recommendation for either the intervention or control
有条件地反对此干预 Weak recommendation against the intervention
强烈反对此干预 Strong recommendation against the intervention

第四部分：治疗方案

指南起草组根据临床RCT研究结合部分专家临床经验，将治疗方案做了以下梳理：

Ø 方案一：【艾灸】

选穴：关元、气海、神阙、肾俞（双）、脾俞（双）、三阴交（双）及足三里（双）。

操作要点：

艾盒灸：将20 mm×40 mm艾条点燃后放入艾灸盒，整体放入艾灸包后置于患者选穴处。

隔姜灸：患者选择合适体位暴露施术部位。在施术部位各平放 1块准备好的姜片，在患者未灸部位用双层白棉布覆盖。点燃9个艾炷（从上点燃）放在姜片上施灸。当患者感觉到灸痛时开始点燃第2组9个艾炷以准备第2轮施灸。医者一手持镊子一手端装有水的烧杯（或茶缸）在病人感到灸痛时夹起燃烧的艾炷放入瓶子中淹灭，姜片不动即刻放上第2个刚点燃的艾炷。每个穴位连续4壮以被灸腧穴处出现4～6cm直径大的红晕、但不起泡为佳。每穴4壮灸完后用白棉布将被灸部位盖上再盖上被子，医者隔着被子轻轻按摩被灸部位直到患者不感姜片温热时即结束治疗。

热敏灸：患者取仰卧位，根据《热敏灸技术操作规范》，采用热敏灸艾条（22 mm×120 mm）依次行回旋灸、雀啄灸、温和灸手法，于选穴部位进行探查，当施灸中出现1种或1种以上热敏灸感，则该探查部位为热敏化腧穴。然后在探查到的热敏化腧穴进行温和灸，距离皮肤约 5 cm，施灸时间以热敏灸感消失为度（45~60 min）。

治疗频率：麦粒灸每穴7~9壮；其余灸法10~30min；建议1次/日，或2天一次。

疗程：建议2~4周为1个疗程。

Ø 方案二：【针刺】

主穴：太渊、尺泽、膻中、足三里、肺腧、内关、列缺、中府、膏肓；配穴：根据四个证型及患者症状辨证加减，气虚加气海，痰湿加丰隆。

操作要点：

选用直径0.25mm~0.30mm、长度25mm~40mm一次性毫针。常规消毒。

常规进针后，行提插捻转手法，捻转角度 0°~180°之间，频率60次/min~90次/min，提插幅度0.3cm~0.5cm，频率60次/min~90次/min，得气为度，留针30 min，其间每隔10 min行针1次。

加用电针时，取双侧“膈俞穴”或“足三里穴”接上电针机，采用直流电，疏密波，频率为2／15Hz，强度以患者能耐受为度。

加用温针灸时，采用规格为25g/支清艾条，截取长度为2cm，直径1cm的艾柱，一端插于针柄尾部行温针灸，每壮艾柱燃尽时间约为10min，共2壮艾柱，使艾柱距离皮肤2-3cm，灸力以患者感觉温热程度能接受为度，不吹艾火，待其徐燃自灭，火力微而温和。

治疗频率：针刺留针30min；温针灸留针20min。建议1次/日，或2天一次。

疗程：建议2~4周为1个疗程。

Ø 方案三：【中药敷贴】

主穴：肺俞、定喘、膏肓、天突及阿是穴。

操作要点：敷贴药物：延胡索100g，丹参50g，白芥子、细辛、甘遂各30g，冰片20g，按以上配比打细粉备用。取适量上述药粉以蜂蜜、黄酒、热水搅拌成糊状，采用输液敷将药物敷贴于上述腧穴。

治疗频率：持续4h，每天 2次，隔日治疗1次。

疗程：建议2~4周为1个疗程。

Ø 方案四：【穴位按摩】

取穴：内关穴、合谷穴、足三里穴。

操作方法：选取穴位后用指腹以顺时针方向轻轻按压并旋转，力度以患者感到酸、麻、胀、疼、热感且能忍受为宜。

治疗频率：每日按压4~6次，每次3~5min。

疗程：建议持续1个月。

Ø 方案五：【穴位埋线】

取穴：肺俞、风门、定喘、足三里；肾虚者，加肾俞

操作方法：选取穴位，将3-0号1 cm医用羊肠线装入经消毒的9号腰穿针（针芯尖端已磨平）前端内，腹部的穴位在其局部下方向上平刺，背部的穴位向脊柱斜刺，每穴进针约1寸，施行捻转得气后，边推针芯边退针管，使羊肠线埋入穴位皮下，线头不得外露。消毒针孔后，外敷无菌敷料，胶布固定24h。

治疗频率：每10天1次

疗程：建议3次为1个疗程，连续2个疗程。

其他注意事项：诊疗环境应安静、保持空气流通、光线不宜过亮。

Ø 方案六：【耳穴压豆】

主穴：肺、皮质下、神门、交感、枕和止痛点。

操作要点：护理人员采用棉棒在耳部进行探查，确定上述耳穴的敏感点，标记并以75%酒精消毒，以医用胶布固定王不留行籽于上述耳穴，并适当进行按压，以患者有酸、麻、胀、痛或发热等得气现象为宜。

治疗频率：每个穴位每日按压５次，每次按压２min，力度以患者能耐受，感觉胀痛、酸麻为宜，每２ｄ更换１次，两耳交替轮换。

疗程：建议2~4周为1个疗程。

Part Ⅳ: Treatment Protocol

Ø Protocol 1: 【Moxibustion】

Acupoints selected:Guanyuan (CV4), Qihai (CV6), Shenque (CV8), Shenshu (BL23, bilateral), Pishu (BL20, bilateral), Sanyinjiao (SP6, bilateral), and Zusanli (ST36, bilateral).
Operation procedures:
Moxa box moxibustion:Ignite a moxa stick (20 mm × 40 mm) and place it into a moxa box, then put the box into a moxibustion bag and apply it to the selected acupoints.
Ginger-partitioned moxibustion:The patient assumes a comfortable position to expose the treatment area.One prepared ginger slice is placed on each treatment area, and non‑treatment areas are covered with double-layer white cotton cloth.Nine moxa cones are ignited (from the top) and placed on the ginger slices for moxibustion.When the patient feels burning pain, a second set of nine moxa cones is ignited for the next session.The practitioner holds tweezers in one hand and a beaker (or cup) filled with water in the other; when the patient feels pain, the burning moxa cone is removed and extinguished in water.The ginger slice remains in place, and a newly ignited moxa cone is placed immediately.Four consecutive cones are used per acupoint, until a local erythema of 4–6 cm in diameter appears without blistering.After completing four cones per point, the treated area is covered with white cotton cloth and a blanket.The practitioner gently massages the area through the blanket until the patient no longer feels warmth from the ginger slice, ending the session.
Heat-sensitive moxibustion:The patient lies in a supine position.According to the Technical Specifications for Heat-Sensitive Moxibustion, a heat-sensitive moxa stick (22 mm × 120 mm) is used to perform circulating moxibustion, sparrow-pecking moxibustion, and mild moxibustion sequentially to explore heat-sensitive reactions at the selected points.If one or more heat‑sensitive sensations occur, the point is identified as a heat‑sensitive acupoint.Mild moxibustion is then applied at that point, approximately 5 cm above the skin, until the heat‑sensitive sensation disappears (45–60 minutes).
Treatment frequency:Millet‑shaped moxibustion: 7–9 cones per acupoint;Other moxibustion methods: 10–30 minutes per session;Recommended: once daily or once every 2 days.
Course of treatment:2–4 weeks as one course.

Ø Protocol 2: 【Acupuncture】

Main acupoints:Taiyuan (LU9), Chize (LU5), Tanzhong (CV17), Zusanli (ST36), Feishu (BL13), Neiguan (PC6), Lieque (LU7), Zhongfu (LU1), Gaohuangshu (BL43).
Supplementary acupoints:Selected and modified according to the four syndromes and patient symptoms:
  • Qi deficiency: add Qihai (CV6)
  • Phlegm‑dampness: add Fenglong (ST40)
Operation procedures:Disposable sterile filiform needles with a diameter of 0.25 mm–0.30 mm and length of 25 mm–40 mm are used.Routine skin disinfection is performed.
After standard needle insertion, lifting‑thrusting and twirling techniques are applied:
  • Twirling angle: 0°–180°, frequency: 60–90 times per minute
  • Lifting‑thrusting amplitude: 0.3 cm–0.5 cm, frequency: 60–90 times per minuteuntil de qi is achieved.The needles are retained for 30 minutes, with manual stimulation repeated every 10 minutes.
Electroacupuncture (if added):Attach electrodes to bilateral Geshu (BL17) or Zusanli (ST36).Use continuous wave, dense‑disperse wave, frequency 2/15 Hz, with intensity adjusted to patient tolerance.
Warm needle acupuncture (if added):Use a pure moxa stick (25 g per stick).A moxa cylinder (2 cm long, 1 cm diameter) is fixed onto the needle handle.Each cylinder burns for approximately 10 minutes; two cylinders are used per session.The moxa cylinder is kept 2–3 cm above the skin, with warmth tolerable to the patient.The moxa fire is not fanned but allowed to burn out gently.
Treatment frequency:Acupuncture: needle retention for 30 minutes;Warm needle acupuncture: needle retention for 20 minutes.Recommended: once daily or once every 2 days.
Course of treatment:2–4 weeks as one course.

Ø Protocol 3: 【Herbal Acupoint Application】

Main acupoints:Feishu (BL13), Dingchuan (EX‑BN1), Gaohuangshu (BL43), Tiantu (CV22), and Ashi points.
Operation procedures:Herbal formula:Corydalis yanhusuo 100 g, Salvia miltiorrhiza 50 g,Semen brassicae 30 g, Asarum sieboldii 30 g,Euphorbia kansui 30 g, Borneolum syntheticum 20 g.The herbs are ground into fine powder and stored for use.An appropriate amount of powder is mixed with honey, rice wine, and warm water to form a paste.The paste is applied to the above acupoints using an infusion patch.
Treatment frequency:Continuous application for 4 hours, twice daily, treatment administered every other day.
Course of treatment:2–4 weeks as one course.

Ø Protocol 4: 【Acupoint Massage】

Acupoints selected:Neiguan (PC6), Hegu (LI4), Zusanli (ST36).
Operation procedures:Using the finger pulp, gently press and rotate clockwise on each acupoint.The pressure is adjusted to produce a tolerable sensation of soreness, numbness, fullness, pain, or warmth.
Treatment frequency:4–6 times daily, 3–5 minutes per time.
Course of treatment:Continuous application for 1 month.

Ø Protocol 5: 【Acupoint Catgut Embedding】

Acupoints selected:Feishu (BL13), Fengmen (BL12), Dingchuan (EX‑BN1), Zusanli (ST36).For kidney deficiency: add Shenshu (BL23).
Operation procedures:A 1‑cm length of 3‑0 medical catgut is loaded into the front end of a sterilized No.9 lumbar puncture needle (with the tip of the needle core ground flat).Abdominal acupoints are inserted horizontally upward beneath the skin;Back acupoints are inserted obliquely toward the spine, approximately 1 cun deep per point.After twirling to obtain de qi, the needle core is pushed while the needle tube is withdrawn, leaving the catgut embedded subcutaneously with no exposed end.The puncture site is disinfected and covered with a sterile dressing, fixed with adhesive tape for 24 hours.
Treatment frequency:Once every 10 days.
Course of treatment:3 sessions as one course, for 2 consecutive courses.
Other notes:The treatment environment should be quiet, well‑ventilated, and not overly bright.

Ø Protocol 6: 【Auricular Point Pressing with Seeds】

Main auricular points:Lung, Subcortex, Shenmen, Sympathetic, Occiput, and Analgesic Point.
Operation procedures:The caregiver uses a cotton swab to explore and mark sensitive points on the auricle.The area is disinfected with 75% alcohol.Vaccaria seeds are fixed on the selected points with medical tape and pressed appropriately to elicit a tolerable sensation of soreness, numbness, fullness, pain, or warmth (de qi).
Treatment frequency:Each point is pressed 5 times daily, 2 minutes per pressing, with tolerable intensity.The seeds are replaced every 2 days, alternating between both ears.

Course of treatment:2–4 weeks as one course.
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