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External Chest Compressions in Severe Asthma

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
Acute severe asthmaPhysician experience over three yearsNoneIncrease FEV by 30%Does not discuss cases or how the results were determined
Severe reftractoy bronchospasm while intubatedPhysician experience over eight yearsNoneUsed successfully during expiration for up to 2 hoursDoes not discuss cases
Fisher et al
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%) agreeNot a controlled study, bias from questionnaire, response could have been from beta agonist and epinephrine given en route, no major outcomes
Eason et al
Eight children and adults intubated with asthma and difficult to ventilate Case seriesBenefit - improved ventilation, decreased peak inflation pressuresReported in 4/8 (50%) of patientsNot a controlled study, does not discuss the benefit in detail
Burton et al
United States
Intubated with severe asthmaCase reportNoneRestored cardiac output and decreased risk of barotraumaDoes not discuss case
Van der Touw et al
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<0.001Canine model, not true asthma (hyperinflation)
Reduction in end-expiratory lung volumes (L)MERC 0.45 vs MEAC 0.40, P>0.75
Acute severe asthmaEditorial of Van der Touw studyChange in peak airway pressureUsually associated with 5-10 cmH2O decreaseEditorial, authors opinion without any data to support claim
Van der Touw et al
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 856All 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
2 year-old intubated in status asthmaticus and difficult to ventilate Case reportChange in pCO2Normalized over 3 hoursNo objective data to support claim of normalization
Change in pHNormalized over 3 hours
Niramatsu et al
7 year-old patient intubated with status asthmaticus and difficult to ventilate Case reportNoneExternal chest compressions improved ventilation, but was thought to have caused a cardiac arrest and hypotensionSingle case report, no objective data
Fisher et al
27 year-old patient intubated with status asthmaticus Case report and review of the literature NoneMechanical external chest compressions should be a supportive strategy used in acute near-fatal asthmaDoes not fully discuss case, no objective data
Margareta etl al
25 year-old patient intubated with status asthmaticus and difficult to ventilate Case reportNonePatient survived and was discharged in 2 daysSingle case without details of the event
United Kingdom
Three cases of sudden severe life-threatening asphyxic asthma Case seriesImprovement with manual external chest compressions3/3 (100%) patients were successfully resuscitatedDoes 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.


  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