External Chest Compressions in Severe Asthma

Date First Published:
March 21, 2011
Last Updated:
March 23, 2011
Report by:
Dr Kris Chiles, Emergency Medicine Resident (Alameda County Medical Center)
Three-Part Question:
In [adults with acute severe asthma] do [external chest compressions] improve [ventilation and oxygenation]?
Clinical Scenario:
A 20 year-old female is brought into the emergency department in respiratory failure from severe asthma. Her symptoms do not respond to beta agonist, steroids, magnesium and she requires intubation. Despite intubation, paralysis and sedation she becomes increasingly hypercapnic, difficult to bag with elevated peak inspiratory pressures and poor air-exchange. You have heard of external chest compressions to improve ventilation and wonder if this will help the patient.
Search Strategy:
Medline 1966 to the third week of March 2011 using the PubMed interface.
Search Details:
Search criteria (external chest compression) OR (chest compression) AND (asthma).
Outcome:
Fifty-five papers were found in Medline using this search strategy. Of these, ten were relevant. An additional three papers were found by scanning the references of relevant papers.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Thoracic Compression for Asthma J.I.M. Watts 1984 Australia Acute severe asthma Physician experience over three years Increase FEV by 30% Does not discuss cases or how the results were determined
Emergency Treatment of Severe Bronchospasm Malcolm Fisher 1985 Australia Severe reftractoy bronchospasm while intubated Physician experience over eight years Used successfully during expiration for up to 2 hours Does not discuss cases
External chest compression in acute asthma: a preliminary study Malcolm Fisher 1989 Australia Fifty patients with severe asthma who were transported to the hospital and received external chest compressions
 Retrospective review of paramedic questionnaire
 Percent of paramedics who thought external chest compressions were 41/46 (90%) agree Not a controlled study, bias from questionnaire, response could have been from beta agonist and epinephrine given en route, no major outcomes
Complications
Manual chest compression for total bronchospasm John Eason 1991 England Eight children and adults intubated with asthma and difficult to ventilate
 Case series Benefit - improved ventilation, decreased peak inflation pressures Reported in 4/8 (50%) of patients Not a controlled study, does not discuss the benefit in detail
External chest compression in acute severe asthma Alan Burton 1991 United States Intubated with severe asthma Case report Restored cardiac output and decreased risk of barotrauma Does not discuss case
Cardiorespiratory consequences of expiratory chest wall compression during mechanical ventilation and severe hyperinflation Thomas Van der Touw 1993 Australia Seven cross-bred anesthesized dogs ventilated with iatrogenic severe pulmonary hyperinflation
 Prospective randomized cross over comparing manual expiratory rib cage compression (MERC) vs manual expiratory abdominal compression (MEAC)
 Cardiac output (L/min) MERC 1.1 vs MEAC 2.1, p<0.001 Canine model, not true asthma (hyperinflation)
Reduction in end-expiratory lung volumes (L) MERC 0.45 vs MEAC 0.40, P>0.75
Compression-assisted expiration in asthma Malcolm Fisher 1993 Australia Acute severe asthma Editorial of Van der Touw study Change in peak airway pressure Usually associated with 5-10 cmH2O decrease Editorial, authors opinion without any data to support claim
Cardiorespiratory effects of manually compressing the rib cage during tidial expiration in mechanically ventilated patients recovering from acute severe asthma Thomas Van der Touw 1998 Australia Four intubated, mechanically ventilated adult patients recovering from acute severe asthma
 Prospective convenience sampling
 Maximal tidal expiratory air flow (ml/sec) Precompression 861, Compression 861, Postcompression 856 All patients were recovering from asthma, compressions only applied for 2-3 minutes
Peak inspiratory airway pressure (cmH2O) Precompression 32.6, Compression 31.9, Postcompression 32.1
End-expiratory lung volume (ml) 1/4 (25%) decreased
External chest compression for the treatment of a mechanically ventilated child with status asthmaticus Yuichi Adachi 2001 Japan 2 year-old intubated in status asthmaticus and difficult to ventilate
 Case report Change in pCO2 Normalized over 3 hours No objective data to support claim of normalization
Change in pH Normalized over 3 hours
Serious circulatory deficiency during external chest compression for asthma attack Eichi Narimatsu 2001 Japan 7 year-old patient intubated with status asthmaticus and difficult to ventilate
 Case report External chest compressions improved ventilation, but was thought to have caused a cardiac arrest and hypotension Single case report, no objective data
External chest compression in the management of acute severe asthma--a technique in search of evidence Malcolm Fisher 2001 Australia 27 year-old patient intubated with status asthmaticus
 Case report and review of the literature
 Mechanical external chest compressions should be a supportive strategy used in acute near-fatal asthma Does not fully discuss case, no objective data
External chest compression in acute asthma--a potentially life-saving intervention? Rosenfeld Margareta 2006 Sweden 25 year-old patient intubated with status asthmaticus and difficult to ventilate
 Case report Patient survived and was discharged in 2 days Single case without details of the event
Chest compression first aid for respiratory arrest due to acute asphyxic asthma Rex Harrison 2010 United Kingdom Three cases of sudden severe life-threatening asphyxic asthma
 Case series Improvement with manual external chest compressions 3/3 (100%) patients were successfully resuscitated Does not fully discuss cases, does not discuss providers rationale to use chest compressions
Bottom Line:
In severe life-threatening asthma unresponsive to usual therapies external chest compressions should be attempted despite lack of high-quality evidence. If hypotension occurs maneuvers should be immediately discontinued.
References:
  1. J.I.M. Watts. Thoracic Compression for Asthma
  2. Malcolm Fisher. Emergency Treatment of Severe Bronchospasm
  3. Malcolm Fisher. External chest compression in acute asthma: a preliminary study
  4. John Eason. Manual chest compression for total bronchospasm
  5. Alan Burton. External chest compression in acute severe asthma
  6. Thomas Van der Touw. Cardiorespiratory consequences of expiratory chest wall compression during mechanical ventilation and severe hyperinflation
  7. Malcolm Fisher. Compression-assisted expiration in asthma
  8. Thomas Van der Touw. Cardiorespiratory effects of manually compressing the rib cage during tidial expiration in mechanically ventilated patients recovering from acute severe asthma
  9. Yuichi Adachi. External chest compression for the treatment of a mechanically ventilated child with status asthmaticus
  10. Eichi Narimatsu. Serious circulatory deficiency during external chest compression for asthma attack
  11. Malcolm Fisher. External chest compression in the management of acute severe asthma--a technique in search of evidence
  12. Rosenfeld Margareta. External chest compression in acute asthma--a potentially life-saving intervention?
  13. Rex Harrison. Chest compression first aid for respiratory arrest due to acute asphyxic asthma