Silent chest?

[mobey]

Hey all!

I am wondering if ya'll can shed some light on this. I had a 72 y/o female with CHF and COPD last night that coded about a minute after we arrived at her house. Here is the call:

Called @ 2100 72 y/o female Difficulty breathing

PMHx MI x 3 weeks ago, Hypertension, IDDM, Possible COPD (that's all I got)

Asessment, Patient answers door, slightly overweight, obvious distress. 2-3 word sentences, purse lip breathing, decrease tidal volumes, acc muscle use, you get the picture.

SpO2 68 on room air (no home O2)

BP 184/80 Pulse 112

Denies chest pain, or any other symptoms, Sudden onset approx 10 min ago.

Air entry (here is where I get confused) Inspiration clear in Apex bilateraly. Expiration completly silent and I mean SILENT. I listened in multiple spots front and back with a Littman Master Classic 2. Believe me there was nothing to ausiltate.

Suddenly tidal volumes decrease till there are none.

Setup BVM w/OPA

Check pulse.....Nope begin CPR

Apply pads....Asystole. *Frick*

Off to the hospital (BLS CREW) Drop in a King on the way.

Work her at the hospital for about 20 min and call it.

So I am stuck between Exacerbation of COPD (which she was unsure of in the first place), or some sort of CHF episode (which I have been studying harder and harder to understand).

I know "All that wheezes is not asthma" but what if there are no wheezes??

Sorry if this is confusing been a long week already, let me know any more info you may want.

[AZCEP]

Are you sure you were hearing air moving in the apices? It is not uncommon to mistake no air movement for clear sounds. Just as a thought, but the extra insulation the patient was carrying around may have made for poor sound transmission as well.

Good possibility that there was a combination of pathologies going on. Going from tachycardic to asystole that quickly does not bode particularly well either. The last effort of a globally hypoxic heart to keep this patient upright may have been just enough to end things.

[ERDoc]

This could have been any of the things you mentioned. May have also been a pappilary muscle rupture which happens after an MI. From the sounds of things, there is really not much else you could have done. This guy was done by the time he called 911.

[VentMedic]

Silent chest usually means not air movement. In Emphysema or disease processes where there is a loss of elasticity and hyperinflation, there may be silence even on a good day. When exacerbated, serious silence.

This is not a good sign for the asthmatic. If the patient is still very symptomatic with the chest still silent after a couple of high dose albuterol BAN treatments, heliox is started and may continue for many days even if the patient is intubated.

Obese patients may also have chronic hypoventilation with little air movement or poor lung inflation and can be CO2 retainers without a history of lung disease.

Along with the systemic HTN, there may be Pulmonary HTN which can also cause severe hypoxia. This can get into right heart failure also.

For older patients with extensive medical history or the odds of having severe health complications, it could be any one or many things that can exacerbate an already compromised breathing situation. What failed first? HTN and IDDM also sets her up for renal failure which pretty much affects all systems including electrolytes and acid-base.

[mobey]

Silent chest usually means not air movement. In Emphysema or disease processes where there is a loss of elasticity and hyperinflation, there may be silence even on a good day. When exacerbated, serious silence.

Thank you VentMedic I was hoping you would chime in on this one. (Thank you also to ERDoc and AZCEP).

Yes this is the sort of thing I was thinking, I thought due to bronchoconstriction, narrowed airways, increase mucus production, the patient was able to suck air through using acc muscles but unable to "Push" it back out. Therefor the air was "Trapped" in the lower airways and aveoli, hyperinflating the lungs till there was basically no gas exchange occuring at all.

Mix up some COPD with Pulmonary HTN causing right ventricle hypertrophy, and an MI 3 weeks ago, I guess it was only a matter of time.

I guess i still wonder if i had of walked in there and slapped on a salbutomol neb if this would have turned out different. but i highly doubt it.

My indications for ventolin is wheezes. That is it. There must be wheezes or I am breaking protocol. I am all for flexing protocol when nessesary, but this happened soo fast there was no time. I was assessing air entry when she quit breathing.

[smax]

hey marc

what did you think of the response to your postings? do you think that the no lung sounds was from a silent chest? i thought the responses were very interesting. did you ever ask the doctor about using ventolin for this call as there was no bronchoconstriction that we could tell.