---
title: "Needling over the chest"
url: "https://acuiq.com/wiki/safety/needling-over-the-chest"
updated: 2026-10-09
last_verified: 2026-10-09
license: CC-BY-4.0
license_url: "https://creativecommons.org/licenses/by/4.0/"
section: "safety"
basis: "Modern research"
audience: "Anyone"
published: "2026-10-09"
reading_minutes: 10
sources: 18
---

# Needling over the chest

_Where the case series place pneumothorax and cardiac tamponade after acupuncture, how deep imaging studies found the pleura at the points involved, and what the reports say about build and timing._

A needle that passes through the chest wall can reach two organs: the lung, whose outer lining is the pleura, and the heart, inside the pericardial sac. Puncturing the pleura lets air into the space around the lung, a pneumothorax; puncturing the heart can fill the pericardial sac with blood, a cardiac tamponade. Reviews of case reports place nearly all of these injuries in a few regions, and imaging studies have measured how far below the skin the pleura lies at the points involved. Most of this page reports those measurements, which vary with the person, the posture and the method. How often serious events occur over all acupuncture, and the symptoms of a collapsed lung, are on [After a treatment](/wiki/safety/after-a-treatment).

## How often it is reported

A [2010 systematic review](https://pmc.ncbi.nlm.nih.gov/articles/PMC2995190/) by Zhang and colleagues, Edzard Ernst among them, read 115 Chinese-language articles, 98 case reports and 17 case series, which together described 479 adverse events after acupuncture. Pneumothorax was the event reported most often, at 201 cases, and 4 of those patients died. A [2013 review of Korean records](https://pmc.ncbi.nlm.nih.gov/articles/PMC3738306/) from 1999 to 2010 found 1,104 adverse events linked to acupuncture or moxibustion, mostly infections, pneumothorax and burns. In England, a [review of 325 acupuncture incidents](https://pubmed.ncbi.nlm.nih.gov/22936058/) reported to the National Patient Safety Agency between 2009 and 2011 found pneumothorax in 1%.

These counts record injuries, not the number of people needled over the chest. A hospital department in Odense, Denmark, that [admitted two cases in three months](https://doi.org/10.3978/j.issn.2072-1439.2013.08.18) made the point in 2013, writing that without that number it could not comment on the incidence. A [2019 cohort study](https://pubmed.ncbi.nlm.nih.gov/31433202/) by Lin and colleagues supplies one from Taiwan’s national health insurance records: among 411,734 patients who had 5,407,378 acupuncture treatments between 1997 and 2012, pneumothorax needing admission to hospital within 7 days occurred 0.87 times per million treatments overall, and 1.75 times per million treatments in the anatomical areas it classed as at risk. An emergency department in Singapore found [4 acupuncture-related cases among 474 pneumothoraces](https://doi.org/10.1186/s12245-022-00455-z) of every cause that it treated from 2017 to 2021.

## Which regions

The WHO’s 1999 [Guidelines on basic training and safety in acupuncture](https://iris.who.int/handle/10665/66007) name the points on the chest, the back and the supraclavicular fossa, the hollow above the collarbone, as the ones where too deep an insertion can cause a pneumothorax, and advise needling the chest, back and abdomen obliquely or horizontally. The Zhang review located its cases more narrowly: 64% followed needling at the shoulder and scapula and 24% needling on the chest. Four points accounted for most of them.

| Point | Region | Share of cases |
| --- | --- | --- |
| [`GB21`](/points/GB21) (Jianjing) | Top of the shoulder, over the upper trapezius | 30% |
| [`BL13`](/points/BL13) (Feishu) | Upper back, the back-shu point of the lung | 15% |
| [`ST12`](/points/ST12) (Quepen) | Supraclavicular fossa | 10% |
| [`CV22`](/points/CV22) (Tiantu) | Above the sternum, at the base of the throat | 10% |

The same review lists [`BL18`](/points/BL18), [`BL23`](/points/BL23), [`LI17`](/points/LI17), [`CV15`](/points/CV15), [`CV14`](/points/CV14), [`SI09`](/points/SI09) and [`SI13`](/points/SI13) among the other points used in its cases. BL13 and BL18 belong to the back-shu points, a row of points beside the spine that [Back-shu and front-mu points](/wiki/nomenclature/back-shu-and-front-mu-points) describes.

Individual case reports fill in the same regions. In the Singapore series the three patients who consented to be reported had been needled between the ribs on both sides of the chest, over the back and chest, and over both trapezius and shoulder regions. In an [Australian series of three cases](https://doi.org/10.5811/cpcem.2016.11.32757) from 2014 to 2016, two by dry needling and one by acupuncture, the needles went into the posterior shoulder, the neck and the shoulder. One of the Danish patients had a single needle placed just inside the lower tip of the shoulder blade. A [2014 case report](https://pmc.ncbi.nlm.nih.gov/articles/PMC4142775/) traced its pneumothorax to [`SI11`](/points/SI11) (Tianzong), which belongs on the shoulder blade but had been placed medial to it, over the rhomboid muscle; its authors add that [`BL13`](/points/BL13) to [`BL15`](/points/BL15) enter the thorax if needled straight in rather than angled towards the spine.

## How deep the pleura sits

Researchers have measured the distance from the skin to the pleura with ultrasound and computed tomography (CT), on volunteers and on patients who had a chest scan for other reasons. A [2011 review of 33 such studies](https://pubmed.ncbi.nlm.nih.gov/21417806/) by Chou and colleagues at China Medical University, Taichung, found great inconsistency between them, by subject group and by measuring method, and called for trials to establish the depth at each point.

| Study | People | Method and point | Depth |
| --- | --- | --- | --- |
| [Chu and colleagues, Korea, 2018](https://pmc.ncbi.nlm.nih.gov/articles/PMC5817322/) | 52 volunteers aged 19 to 32 | Ultrasound, GB21, sitting and lying face down | Sitting: 42.3 men, 34.5 women. Face down: 40.4 to 42.1 overall |
| [Chen and colleagues, Taiwan, 2018](https://doi.org/10.1016/j.jams.2018.06.004) | 101 adults, median age 29 | Ultrasound, vertical depth to the pleura at the apex of the lung under GB21 | 17.4 men, 14.6 women |
| [Ma and colleagues, Taiwan, 2015](https://pmc.ncbi.nlm.nih.gov/articles/PMC4592721/) | 319 children aged 4 to 18 | CT, 28 points on the front of the chest | 1.23 to 1.75 times deeper in the obese group than the underweight group |

The two GB21 studies used the same instrument at the same point, and the Korean means are more than twice the Taiwanese ones. The Korean study also found the pleura deeper lying face down than sitting, and found that breathing in or out changed the depth by less than 1 mm in most volunteers but by about 5 mm in one, whose body mass index (BMI, weight in kilograms divided by the square of height in metres) was 17.5. The 2014 case report estimates that the lung lies about 20 mm below the inner edge of the shoulder blade.

AcuiQ’s catalogue prints no depth for any point, for the reason [Reading a point warning](/wiki/safety/reading-a-point-warning) gives: depth depends on the patient’s build and the practitioner’s training, and a number printed without either is worse than none.

## Body build and lung disease

The Taiwanese GB21 study found the depth rose with weight, height and BMI. The Korean study found it tended to be greater in overweight volunteers, but not consistently, and its authors conclude that applying a needling depth by sex or BMI is dangerous because the differences within each group were larger than those between groups.

The case reports point the same way. The three Australian patients were women aged 21 to 24 with a BMI of 18 to 22, and the authors put forward the hypothesis that people with a low BMI may be at particular risk. The 2014 case report’s patient was an athletic woman of 43 with little fat under the skin, and its authors list low BMI, thin subcutaneous fat, lung disease and smoking as risk factors. One of the Danish patients was 82 and had chronic obstructive pulmonary disease. The Singapore authors cite smoking, being a tall man, emphysema, steroid use and active cancer as recognised risk factors, and note that none of their three patients had any of them. In the Taiwanese cohort, a history of thoracic surgery, emphysema, lung cancer, tuberculosis, chronic bronchitis or pneumonia each raised the odds of a pneumothorax, by between about 2 and 8 times, and men had about 3.4 times the odds of women; the number of treatments a person had was not associated with the risk.

## When symptoms start

The WHO guidelines say the symptoms of a needle pneumothorax can begin abruptly while the needle is being manipulated, or develop gradually over several hours. The case reports cover that range: pain at the moment of insertion, symptoms 30 minutes or 90 minutes later, and pain and breathlessness the night after treatment. In Singapore all three patients told their acupuncturist and were advised to rest, and they reached the emergency department on the first, second and third day. Two of the three needed only oxygen and observation, and one needed a chest drain.

The WHO’s 2020 [benchmarks for the practice of acupuncture](https://iris.who.int/handle/10665/340838) set out the practitioner’s steps when a pneumothorax is suspected: stop needling, withdraw all needles, have the patient rest, and assess and refer to other health professionals as appropriate. The Australian authors recommend that patients be told about the risk before treatment; the Singapore patients said they had not been.

## The heart and the sternal foramen

A [2011 review](https://doi.org/10.1016/j.ijcard.2010.10.016) by Ernst and Zhang found 26 reported cases of cardiac tamponade after acupuncture, without limits of date or language; 14 of the patients died. In the Chinese literature two of the deaths in the Zhang review followed puncture of the right ventricle, and a puncture of a coronary artery at [`LU01`](/points/LU01) (Zhongfu) caused a tamponade the patient survived.

One mechanism is anatomical. A sternal foramen is a hole through the breastbone, thought to arise from incomplete union of the two bars of tissue from which the sternum develops. A [2023 meta-analysis](https://doi.org/10.1007/s00276-023-03116-9) of 35 studies covering 16,666 people found one in the body of the sternum in 6.5% of them, with a mean size of about 5 mm across and 6 mm high, most often at the level of the fifth intercostal space (63% of foramina) and next at the fourth (22%). [`CV17`](/points/CV17) (Danzhong) sits on the midline of the sternum level with the fourth intercostal space in the [WHO standard point locations](https://iris.who.int/handle/10665/353407). In 1995 Halvorsen and colleagues reported a [fatal cardiac tamponade after acupuncture through a congenital sternal foramen](https://doi.org/10.1016/s0140-6736(95)91004-2); the meta-analysis describes the patient as a Norwegian woman whose right ventricle the needle punctured. The meta-analysis also summarises a study by Babinski and colleagues of 16 cadavers in which a needle passed through a sternal foramen damaged the right ventricle every time, and the entry point coincided with CV17 in 62.5% of them.

## What the sources cannot tell you

The regional figures come from published case reports, which record the injuries that someone chose to write up; the Singapore authors state that the true incidence of acupuncture pneumothorax is unknown. The Australian authors argue that rates from large safety studies, which count treatment at every site, the knee included, understate the risk of chest wall treatment. The depth studies are small, mostly of young adults in one country each, and the Taiwanese cohort counts only the cases that led to a hospital admission. The Chen study calls for controlled studies of whether measuring the depth with ultrasound before needling helps prevent a pneumothorax. AcuiQ’s point pages print a pneumothorax caution wherever a source gave one; they hold no record of how deep any study needled, and [What AcuiQ does not do](/wiki/method/what-acuiq-does-not-do) sets out that limit.

### Sources

1. Zhang J, Shang H, Gao X, Ernst E, Acupuncture-related adverse events: a systematic review of the Chinese literature, Bulletin of the World Health Organization 2010 — https://pmc.ncbi.nlm.nih.gov/articles/PMC2995190/
2. Shin HK, Jeong SJ, Lee MS, Ernst E, Adverse events attributed to traditional Korean medical practices: 1999–2010, Bulletin of the World Health Organization 2013 — https://pmc.ncbi.nlm.nih.gov/articles/PMC3738306/
3. Wheway J, Agbabiaka TB, Ernst E, Patient safety incidents from acupuncture treatments: a review of reports to the National Patient Safety Agency, International Journal of Risk and Safety in Medicine 2012 — https://pubmed.ncbi.nlm.nih.gov/22936058/
4. Stenger M, Bauer NE, Licht PB, Is pneumothorax after acupuncture so uncommon?, Journal of Thoracic Disease 2013 — https://doi.org/10.3978/j.issn.2072-1439.2013.08.18
5. Lin SK, Liu JM, Hsu RJ, Chuang HC, Wang YX, Lin PH, Incidence of iatrogenic pneumothorax following acupuncture treatments in Taiwan, Acupuncture in Medicine 2019 — https://pubmed.ncbi.nlm.nih.gov/31433202/
6. Th'ng F, Rao KA, Huang PY, Case series: acupuncture-related pneumothorax, International Journal of Emergency Medicine 2022 — https://doi.org/10.1186/s12245-022-00455-z
7. Grusche F, Egerton-Warburton D, Traumatic pneumothorax following acupuncture: a case series, Clinical Practice and Cases in Emergency Medicine 2017 — https://doi.org/10.5811/cpcem.2016.11.32757
8. Hampton DA, Kaneko RT, Simeon E, Moren A, Rowell S, Watters JM, Acupuncture-related pneumothorax, Medical Acupuncture 2014 — https://pmc.ncbi.nlm.nih.gov/articles/PMC4142775/
9. World Health Organization, Guidelines on basic training and safety in acupuncture, 1999 — https://iris.who.int/handle/10665/66007
10. World Health Organization, WHO benchmarks for the practice of acupuncture, 2020 — https://iris.who.int/handle/10665/340838
11. World Health Organization Regional Office for the Western Pacific, WHO standard acupuncture point locations in the Western Pacific Region, 2008 — https://iris.who.int/handle/10665/353407
12. Chou PC, Chu HY, Lin JG, Safe needling depth of acupuncture points, Journal of Alternative and Complementary Medicine 2011 — https://pubmed.ncbi.nlm.nih.gov/21417806/
13. Chu H, Kim J, Ha W, et al., Change of safe needling depth at acupoint GB21 according to posture and breathing, Evidence-Based Complementary and Alternative Medicine 2018 — https://pmc.ncbi.nlm.nih.gov/articles/PMC5817322/
14. Chen HN, Chang CY, Chen LZ, Chang YJ, Lin JG, Using ultrasonography measurements to determine the depth of the GB 21 acupoint to prevent pneumothorax, Journal of Acupuncture and Meridian Studies 2018 — https://doi.org/10.1016/j.jams.2018.06.004
15. Ma YC, Peng CT, Huang YC, Lin HY, Lin JG, The depths from skin to the major organs at chest acupoints of pediatric patients, Evidence-Based Complementary and Alternative Medicine 2015 — https://pmc.ncbi.nlm.nih.gov/articles/PMC4592721/
16. Ernst E, Zhang J, Cardiac tamponade caused by acupuncture: a review of the literature, International Journal of Cardiology 2011 — https://doi.org/10.1016/j.ijcard.2010.10.016
17. Pasieka P, Pasieka PM, Komosa A, et al., Prevalence and morphometry of sternal and xiphoid foramen: a meta-analysis on 16,666 subjects, Surgical and Radiologic Anatomy 2023 — https://doi.org/10.1007/s00276-023-03116-9
18. Halvorsen TB, Anda SS, Naess AB, Levang OW, Fatal cardiac tamponade after acupuncture through congenital sternal foramen, Lancet 1995 — https://doi.org/10.1016/s0140-6736(95)91004-2