I had a colleague who asked me to post about the "Silent Chest"
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#KYJ Beware the silent chest.
In the world of chronic disease, there exists, a classification or grading system that generally numbers Stage 1 through to stage 4 or 'End Stage'.
These grading or staging systems carry with them a set of typical symptoms that define the patients severity of disease.
Typically this staging system follows a predictable model of percentages of each stage.
35% with stage 1 illness generally have no obvious red flag symptoms, are often undiagnosed and live life ignorant of the fact they actually have chronic disease.
Stage two illness often recognise symptoms, and may flag these to their GP who diagnose disorders based on symptoms. These patients make up another 35%.
Stage 3 patients will be well into recognition of their disease, will often be medicated, and perhaps experience frequent acute exacerbations of their chronic disease, which results in infrequent hospitalisations. These stage 3 people make up 20-25% of patients with the respective chronic condition.
Then there is the real sickies, stage 4 or End Stage patients, who make up 5-10%.
These patients are often in hospital or ED with acute exacerbation. They have lives that are limited in activity/ or ability to function too far from their specialist/GP or healthcare support network.
Unique to the end stage chronic disease patient is a unique symptom set, that by their very features, sets them apart from the other 90-95% of sufferers of their disease.
For the Chronic renal patient it may be the need for dialysis.
For the chronic Heart failure patient it might be frequent episodes of severe Pulmonary oedema.
For the COPD patient, it might be the development of CO2 retention and permanent home oxygen.
For Asthma, it is the frequent presentation of Asthma flare-ups, which often have a silent chest on auscultation.
Now a non wheezing asthmatic patient may be a red herring.
It might be nothing, but it might be significant.
The real danger, it can be misleading or distract an unsavvy clinician; but make no mistake, you want to assess your patient with a silent chest well. Get this wrong, and your patient is making it to ICU if you (and they) are lucky.
Let's review wheeze. Wheeze is the sound of air being squeezed through narrowed bronchi and bronchioles. Say it aloud...slowly "squeeeeeezed"
Right in that word is "wheeeeze".
Frequently a symptom of mild to moderate asthma, a wheeze is audible when enough air is forced through bronchospastic airways. In end stage, preterminal exacerbation, the severe asthma flare may not be physically moving enough or any air through their low airways, meaning that no vibration or sound is audible.
This is badness!
Lack of air movement is gas trapping and not only represents a massive risk of desaturation, but also a risk of pneumothorax .
Frequently, the silent chest is a symptom of the severest form of asthma flare... the Status Asthmaticus.
This pre-arrest condition often progresses to acute respiratory failure (PaO2<60mmHg), and imminent respiratory arrest.
With limited air reaching alveoli, the wheeze disappears, oxygenation decreases, CO2 is retained, and level of consciousness rapidly declines. In adults, we have physiological reserves to keep struggling to breathe. We fight for our breaths using our developed chest and shoulder muscles (laboured breathing); but in children, especially those under 8, these kids die from shear exhaustion.
Until proven to be an irrelevant symptom, the silent chest must be regarded as a medical emergency.
So when is the silent chest, not a problem?
In a mild asthma presentation, the work of breathing is not markedly increased. The patient may be coughing, but is not distressed, cerebrally irritated, or desaturated.
In the "I can hear you wheezing from across the room" type presentations, place your stethoscope over the patients throats before auscultation grandson their chest. If the wheeze is heard in the throat, and not in the lung fields, then the presentation is likely to be anxiety induced vocal cord dysfunction, and not asthma.
The true asthmatic silent chest is as sick as an asthmatic can be. Believe them! Look at sats, their work of breathing, and history of ICU admissions, to guide your index of suspicion that this patient is sicker than they sound.
It echoes, the sound, of silence.
Interested in more?
You could attend our Respiratory seminar. http://www.ect4health.com.au/respiratory-failure-nursing-seminar/
good post, also refer Wheezing Expert In Jaipur.
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