Needle decompression in crashing status asthmaticus

[akroeze]

Ok so for some reason my brain went to status asthmaticus today and the treatment of it. Let's play doom and gloom and go for the worst case scenario, a patient who is to the point that you have absolutely silent chest. How would you determine if this patient needed a decompression for tension pneumo? Their vitals are already going to be out of whack and I don't want to be waiting for tracheal deviation to show up. Could an argument be made for performing bilat decompression on this patient to rule out bilat pneumo?

[Arctickat]

MO might play a factor in my decision. oops, cookies are done baking, more later.

[Arizonaffcep]

Ok so for some reason my brain went to status asthmaticus today and the treatment of it. Let's play doom and gloom and go for the worst case scenario, a patient who is to the point that you have absolutely silent chest. How would you determine if this patient needed a decompression for tension pneumo? Their vitals are already going to be out of whack and I don't want to be waiting for tracheal deviation to show up. Could an argument be made for performing bilat decompression on this patient to rule out bilat pneumo?

Hard to tell. I'd be very hesitant to decompress an asthma pt. If they didn't need it, now they WILL need a chest tube. Decreased lung sounds is MORE LIKELY shut down airways...epi, albuterol, atrovent, solumedrol (possibly racemic epi, but the RT's here would know better about that one). Intubate in needed, and of course...lots and lots of O2. I would follow the standard treatment first, before moving on to decompression. Remember...LS can be basically absent-not from a pneumo, but because they've just shut down that far. If, after treatment, they are still working, but now hear lung sounds (doesn't matter if good sounds or bad-just you hear something) that means the patient is getting better-keep it going.

[akroeze]

Hard to tell. I'd be very hesitant to decompress an asthma pt. If they didn't need it, now they WILL need a chest tube

That is a common fallacy that actually isn't true. Just because a patient has been decompressed does not mean they get a chest tube.

My thinking is that if they have a tension pneumo I'd rather treat assuming it than assume not and they get worse.

[p3medic]

Look at their vital signs too, if they have a good blood pressure they most likely don't have tension. Asthmatics like this, especially ones who are intubated and overzealously bagged can and do develop ptx. It may become necessary, but correcting the underlying bronchospasm is you primary concern. Allow for a prolonged expiratory time, ventilation rates will need to be decreased as well as volume. I'm sure vent will come along and post a link or offer her $.99

[VentMedic]

Look at their vital signs too, if they have a good blood pressure they most likely don't have tension. Asthmatics like this, especially ones who are intubated and overzealously bagged can and do develop ptx. It may become necessary, but correcting the underlying bronchospasm is you primary concern. Allow for a prolonged expiratory time, ventilation rates will need to be decreased as well as volume.

Exactly.

Pneumothorax is not that common in asthma unless it is "man-made" by over zealous bagging or lack of knowledge with a CPAP machine. Those with certain presentations of bronchial asthma may be more prone to a pneumothorax than others.

Pneumomediastinum can occur more often, particularly in young adults, but is generally self limiting.

A silent chest or bronchospasms may persist for hours and even days with interventions required such as heliox to assist with delivering the medications. It may not matter what meds you throw at them if some air movement can not be obtained. A special ventilator may also be required with advanced ventilation modes to prevent further damage.

There is some research ongoing for manually (or machanically) decompressing the chest externally but nothing conclusive at this time.

[Arizonaffcep]

There is some research ongoing for manually (or machanically) decompressing the chest externally but nothing conclusive at this time.

This is interesting...what is the mechanism for this?

[VentMedic]

This is interesting...what is the mechanism for this?

This is one link which was also being researched by the AHA about 4 years. UCSF/SFGH in CA were discussing a research project for some form of a mechanical device to assist ventilations externally. It may even be a device that was used many, many years ago that is being revived for a new purpose. The RTs just had their national conference last weekend so there may have been new research abstracts presented on this topic.

http://pdm.medicine.wisc.edu/Fischer.pdf

[akroeze]

Well in Australia is it not common practice to essentially squeeze the chest to aid in getting air out?

[logos]

My thoughts... If you know they are having an asthmatic episode and that is a reasonable explanation for the breath sounds (and your other observations), then it seems one would have a higher threshold to do needle decompression. Decompress without convincing evidence of tension pneumothorax, like hemodynamic deterioration, and it seems you'd be more likely to worsen the situation than improve it.