Use of acupuncture to reduce gagging during the insertion of an oral airway

Abstract

Inability to obtund the gag reflex during awake fibreoptic intubation (AFOI) can occur. This increases patient anxiety, discomfort and reduces tolerance of the procedure. Acupuncture successfully suppresses the gag reflex in patients undergoing dental procedures and transoesophageal echocardiography [1, 2]. Efficacy of CV-24 acupuncture in dental patients with severe gag reflexes has been shown to moderate the reflex in the majority of these patients [1]. We investigated the potential benefits of acupuncture at the CV4 point to suppress the gag reflex during the insertion of a Berman airway device. This was a blinded randomised controlled trial. After receiving Local Research Ethics Committee approval, 45 healthy volunteers were recruited and consented. All subjects were asked to insert an appropriately sized Berman airway and retain it for as long as they could tolerate, up to 20 s. Gagging was assessed using a modified Gag Severity Index Score, and time the airway was tolerated recorded. Subjects were also asked to score the acceptability of the procedure and their urge to gag. They were then randomised to receive real acupuncture, sham acupuncture, or no acupuncture (control). Real acupuncture needles were inserted to a depth of 3 mm into the Chengjiang point CV-24 (midline between lower lip and chin). Sham Streitberger style needles [3] were positioned 1 cm below the CV 24 point. A ‘Minimalist’ approach was used with the needle being manipulated for 30 s and then removed. A sticking plaster was placed over the volunteer’s chin in order to blind the observer. Volunteers then reinserted the airway. All observations were reassessed. Sixteen patients received real acupuncture, 16 received sham acupuncture and 13 were randomised to the control group. There was no difference in the patient demographics between each group. A Wilcoxon rank sum analysis showed no statistical difference in the gag reflex, duration, desire to gag or level of acceptance in the control group. Both the sham and real acupuncture groups showed statistical significance in the gag reflex (p > 0.005), duration (p > 0.025 and p > 0.005), desire to gag (p > 0.005), and level of acceptance (p > 0.01, p > 0.005). Most volunteers found the procedure more acceptable on the second attempt, and greater than 50% of volunteers had less desire to gag. Acupuncture may well suppress the gag reflex significantly when inserting a Berman airway after receiving acupuncture to the CV 24 point, and thus may be a useful adjunct in an AFOI. We have demonstrated a clear placebo effect from the sham acupuncture group which may in itself be beneficial. The benefit of acupuncture may be particularly significant in those patients with severe gag reflexes and requires a larger scale study in this group of people.