Respiratory Induced Chest Pain By Nicole Qaqish 7192010

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

Clinical Presentations • Shortness of breath • Cough • Pleuritic chest pain

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.

Imagining • Chest –Xray – 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

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.

Pulmonary Hypertension • Increase blood pressure in lung vasculature; Mean arterial pressure <25 mm. Hg 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 S 2 and loud P 2 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

Treatment • Treat Diagnosed condition: – Pulmonary Embolism : • O 2 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 O 2 and insert chest tube to allow lung expansion • Secondary pneumothorax- chest tube drainage

Continued Treatment • Pleurisy – 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 1. 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: a. b. c. d. e. 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. 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, O 2 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: a. b. c. d. e. 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