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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 criteria (external chest compression) OR (chest compression) AND (asthma).

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Watts 1984 Australia	Acute severe asthma	Physician experience over three years	None	Increase FEV by 30%	Does not discuss cases or how the results were determined
Fisher 1985 Australia	Severe reftractoy bronchospasm while intubated	Physician experience over eight years	None	Used successfully during expiration for up to 2 hours	Does not discuss cases
Fisher et al 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	None
Eason et al 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
Burton et al 1991 United States	Intubated with severe asthma	Case report	None	Restored cardiac output and decreased risk of barotrauma	Does not discuss case
Van der Touw et al 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
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
Van der Touw et al 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
Adachi et al 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
Niramatsu et al 2001 Japan	7 year-old patient intubated with status asthmaticus and difficult to ventilate	Case report	None	External chest compressions improved ventilation, but was thought to have caused a cardiac arrest and hypotension	Single case report, no objective data
Fisher et al 2001 Australia	27 year-old patient intubated with status asthmaticus	Case report and review of the literature	None	Mechanical external chest compressions should be a supportive strategy used in acute near-fatal asthma	Does not fully discuss case, no objective data
Margareta etl al 2006 Sweden	25 year-old patient intubated with status asthmaticus and difficult to ventilate	Case report	None	Patient survived and was discharged in 2 days	Single case without details of the event
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

Clinical 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 Chest 1984;86;505b-505
2. Malcolm Fisher Emergency Treatment of Severe Bronchospasm Critical Care Medicine 1986: 13:997
3. Malcolm Fisher External chest compression in acute asthma: a preliminary study Critical Care Medicine 1989:17(7):686-7
4. John Eason Manual chest compression for total bronchospasm Lancet 1991;336(8737):337
5. Alan Burton External chest compression in acute severe asthma Anaesthesia and Intensive Care 1991;19(3):470
6. Thomas Van der Touw Cardiorespiratory consequences of expiratory chest wall compression during mechanical ventilation and severe hyperinflation Critical Care Medicine 1993;21(12):1908-14
7. Malcolm Fisher Compression-assisted expiration in asthma Critical Care Medicine 1993;21(12):1824
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 Critical Care Medicine 1998;26(8):1361-7
9. Yuichi Adachi External chest compression for the treatment of a mechanically ventilated child with status asthmaticus Acta Paediatr 2001;90(7):826-7
10. Eichi Narimatsu Serious circulatory deficiency during external chest compression for asthma attack American Journal Emergency Medicine 2001;19(2):169-71
11. Malcolm Fisher External chest compression in the management of acute severe asthma--a technique in search of evidence Prehospital Disaster Medicine 2001;16(3):124-7
12. Rosenfeld Margareta External chest compression in acute asthma--a potentially life-saving intervention? Journal Resuscitation 2006;6:315-6
13. Rex Harrison Chest compression first aid for respiratory arrest due to acute asphyxic asthma Emergency Medicine Journal 2010;27:59-61