Respiratory Induced Chest Pain By Nicole Qaqish 7/19/2010

Clinical Presentations Shortness of breath Cough Pleuritic chest pain Non specific

Initial Approach to Chest Pain Ensure adequate A,B,C’s, asses vital signs, Detailed history on the chest pain Rule out Life threatening Lung/ Cardiac conditions. Categorize the chest pain Pleuritic ( Pain upon inspiration) Visceral ( Dull, Tightness, that is poorly localized) Chest wall pain

Approach to Chest Pain Many Respiratory induced chest pain have similar symptoms. Evaluate any risk factors the patient might have. Pulmonary embolism ( Hypercougable states, H/O DVT’s, recent immobilization) Pneumothorax ( trauma, recent ventilation) Pnuemonia ( age >65, Immune deficient, Hospitalization causing noscomial pneumonia

The Physical Exam Inspection – rate and pattern of breathing Palpation – Focal tenderness, rib fractures Percussion – Determine Resonance within the lung tissue Hyperresonance (pneumothorax) vs dull percussion (pneumonia) Auscultation – the quality and intensity of breath sounds. Adventitious sounds such as rales, rhonchi, friction rubs can also be heard and be diagnostic for specific lung conditions. I-increased work of breathing. Asymmetric expansion of the chest is usually due to an asymmetric process affecting the lungs, such as endobronchial obstruction of a large airway, unilateral parenchymal or pleural disease, or unilateral phrenic nerve paralysis. Visible abnormalities of the thoracic cage include kyphoscoliosis and ankylosing spondylitis, either of which can alter compliance of the thorax, increase the work of breathing, and cause dyspnea. A- ronchophony andwhispered pectoriloquy, respectively, are present. The sound of a spoken E becomes more like an A, although with a nasal or bleating quality, a finding that is termed egophony. Crackles are the discontinuous, typically inspiratory sound created when alveoli and small airways open and close with respiration. They are often associated with interstitial lung disease, microatelectasis, or filling of alveoli by liquid. Wheezes, which are generally more prominent during expiration than inspiration, reflect the oscillation of airway walls that occurs when there is airflow limitation, as may be produced by bronchospasm, airway edema or collapse, or intraluminal obstruction by neoplasm or secretions. Rhonchi is the term applied to the sounds created when there is free liquid or mucus in the airway lumen; the viscous interaction between the free liquid and the moving air creates a low-pitched vibratory sound. Other adventitious sounds include pleural friction rubs and stridor. The gritty sound of a pleural friction rubindicates inflamed pleural surfaces rubbing against each other, often during both inspiratory and expiratory phases of the respiratory cycl

Imagining Chest –Xray Further diagnostic imaging initial diagnostic imaging performed Can show consolidation, air/ fluid, opacification Further diagnostic imaging CT scan V/Q scan- to observe the perfusion and ventilation throughout the pulmonary vasculature.

Most Common Causes of Respiratory induced chest pain Pulmonary Embolism Pneumothorax Pleurisy Pneumonia Pulmonary Hypertension

Pulmonary Embolism Thrombosis from the venous system that embolizes in the pulmonary vasculature Clinical Manifestations Dyspnea (73%) Pleuritic chest pain (66%) Cough (37%) Hemptopysis (13%) Acute Cor Pulmonale Physical Exam Tachypnea Tachycardia Rales Cyanosis Pleura friction rub

Pulmonary Embolism Imaging: CXR- normal V/Q scan- Diagnostic imaging in PE distribution of blood flow (perfusion scan) and the distribution of alveolar ventilation (ventilation scan) are obtained following the inhalation of a radioactive gas and the IV injection of labeled albumin.

Pneumothorax Presence of air between the two layers of pleura, resulting in partial or complete collapse of the lung. Clinical Manifestations: Sudden onset of shortness of breath Unilateral sharp chest pain Physical Exam: Tachycardia Unilateral Hyperresonance Decreased breath sounds

Pneumothorax Chest X-Ray- Diagnostic Air Filled in the Lung space

Pleuritis Pleura membrane inflammation. Clinical Manifestations: Sharp chest pain with inhalation Shortness of breath Fever/ Chills Physical Exam: Pluritic friction rub upon auscultation

Diagnosis CXR-It may show air or fluid in the pleural space. It also may show what's causing the pleurisy –for example, pneumonia, a or a lung tumor. CT- may show pockets of fluid, lung abscess or pneumonia Blood tests can show bacterial or viral infectious process Thoracocentesis and biopsy can be used to determine the specific cause

Pneumonia Inflammation of the parenchyma of the lung due to an infectious process. Clinical Manifestation: Fever/ Chills Shortness of Breath Pleuritic chest pain Dry cough Physical Exam: Pulse- temperature dissociation ( normal pulse with high fever) Dull Percussion Rales/Rhonchi and decreased breath sounds upon auscultation

Pneumonia Chest X-ray can be Diagnostic. RUL consolidation Blood and mucus tests. You may have a blood test to measure your white cell count and look for the presence of viruses, bacteria or other organisms. Your doctor also may examine a sample of your mucus or your blood to help identify the particular microorganism that's causing your illness.

Pulmonary Hypertension Increase blood pressure in lung vasculature; Mean arterial pressure <25mmHg at rest or <30 mmhg during exercise. Clinical Manifestations: Shortness of Breath Fatigue Non productive cough Angina Cyanosis Peripheral edema Syncope Physical Exam: JVD Parasternal lift due to RV dilation Wide Split S2 and loud P2 in pulmonic area upon Auscultation

Pulmonary Hypertension ECG- right axis deviation (RVH) CXR- Dilated pulmonary vessels with right ventricle enlargement. Echocardiogram- Dilated pulmonary Artery, Dilation of RA/RV, right heart catherization reveals increased pulmonary artery pressure

Chest x ray of PAH Pulmonary artery dilation plus rvh

Treatment Treat Diagnosed condition: Pulmonary Embolism : O2 to correct hypoxia Anticouglation therapy heparin to prevent another PE and oral warfarin for long term treatment Thrombolytics Surgical removal if large enough IVC filter if long h/o if DVTs/ PE Pneumothorax: Primary Pneumothorax – small , observe should resolve by 10 days; Large administer O2 and insert chest tube to allow lung expansion Secondary pneumothorax- chest tube drainage

Continued Treatment Pleurisy Pneumonia Treat underlying cause NSAIDS for symptomatic pain Pneumonia Antimicrobial Therapy Pulmonary hypertension Pulmonary vasodilators ( IV prostacylines) and CCB Anticougulation due to venous stasis

Musculoskelatal Induced Chest Pain Costochondritis- Inflammation of cartilage that conncets rib to sternum localized sharp or dull pain Tenderness on palpation Herpes Zoster- Viral infection that causes painful rash Intense unilateral pain along dermatome Anxiety- Causes a chest tightness, sweating, hyperventilation

Questions A 24 year old smoking male presents to you with a 2 hour history of right sided chest pain. He claims that he was walking and suddenly felt chest pain. He denied any diaphoresis or radiation of pain. He has no other medical problems. His father died at the age of 67 from MI. On examination the individual is a tall male with a thin chest wall. The best method to make your diagnosis is: Cardiac enzymes every 8 hours CT scan of the chest ECG Chest X-ray Ultrasound of the chest

Answer D. Spontaneous pneumothorax has no provoking factors. It usually occurs in tall males who smoke. The diagnosis can easily be made by a chest x-ray.

2. A 65 year old female underwent hip replacement surgery 2 days ago 2. A 65 year old female underwent hip replacement surgery 2 days ago. On the third postoperative day, she suddenly became anxious, dyspneic and tachycardic. She has a history of anxiety and takes lorazepam for it. Her vital signs are BP-100/50, Pulse- 120/min RR- 36/min, O2 sat is 86% on 6 LNC and afebrile. Lung examination is unremarkable.Chest Xray did not show any abnormalities. The next step of management is: Obtain a ABG Intubate Venogram V/Q scan Give IV Lorazapam

Answer D. When PE is suspected Chest X-ray is usually normal. The initial symptoms are a sudden onset of hypoxia, tachycardia and tachypnea. The patient is at high risk for PE due to bed rest and surgery. The Ventilation Perfusion scan is the next step in evaluation the patient. If chest x-ray is negative that rules out pneumonia, atelectasis, and pulmonary edema. The next step is to rule out PE

References David A. Lipson, Steven E. Weinberger “Harrisons” Chapter 245. Approach to the Patient with Disease of the Respiratory System Steven S. Agabegi, Elizabeth D. Agabegi. “Step up to Medicine” Marc S. Sabetine. “ Pocket Medicine Third Edition” Mayo Clinic.com