Introduction• Pain : an unpleasant sensory and emotional experience

associated with actual tissue damage

• Complex experience, influences by subject’s culture, emotional and cognitive contributors, previous experience

• Chest pain do not neglect !

• It announce the presence of severe, occasionally the occurrence of life-threatening disease

• Many types of chest pain are visceral origin

My chest hurts,Can you help me?

How it is described?

• Stabbing• Tearing• Burning• Twisting• Squeezing• Terrifying• Sickening• Nauseating

Pain Syndromes

• Many of them arise from chest wall and intrathoracic structures

• Various proximity organs overlap

• Medical history is important!

• Most common symptom that brings people to seek medical attention

Goals

1. Rapid recognition of management of true ACS2. Recognition of other life-threatening causes of

chest pain• Aortic dissection• Pulmonary embolism• Tension pneumothorax

3. Minimize cost and hospitalization in patients with chest pain of benign etiology.

Sources, types and most common causes of chest pain

• Pleuropulmonary disorders– Pleuritic pain: infection, pumonary embolism, spontaneous

pneumothorax– Pain of pulmonary hypertension: pulmonary embolism, primary

pulmonary hypertension– Tracheobronchial pain: infection, irritants inhalation,

malignancy

• Musculoskeletal disorders– Chostochodral pain, neuritis-radiculitis: herpes-zoster, spine

disorders– Upper extrimities pain: pancoast syndrome– Chest wall pain: rib fracture, myalgia, infection, malignancy

• Cardioascular disorders– Myocardial ischemia: angina pectoris, MCI, aortic

valve disease, cardiomyopathy– Pericardial pain: infection, post surgery, idiopathic– Substernal and back pain: aortic dissection

• Gastrointestinal disorders– Esophageal pain: reflux esophagitis– Epigastric-substernal pain: cholecystitis, peptic ulcer,

acute pancreatitis

……Sources, types and most common causes of chest pain

• Psychiatric disorders– Atypical anginal pain: neurocirculatory asthenia,

hyperventilation syndrome, panic disorders

• Others– Substernal pain: mediastinal emphysema

……Sources, types and most common causes of chest pain

Chest pain assessment

• Medical history• Physical examination• Chest X ray• ECG• Laboratory: hematology, cardiac enzymes and

other related test, according to other findings• Others

• Complete medical interview– The quality, location, duration, provoking events,

relieving measures guidance to focus on subsequent examinations

• Physical examination

…………Chest pain assessment

What are risk factors you would ask about for cardiac etiologies for chest pain?

• Smoking• Family history

• Hyperlipidemia • Left ventricular hypertrophy

• Hypertension• Cocaine

• Age• Past History

What characteristics of the chest pain might make you more concerned for cardiac chest

pain?

• Location• Associated Symptoms• Quality• Chronology• Onset

• Duration• Intensity• Exacerbating• Relieving• Situation

Any exam findings that might help distinguish cardiac from non cardiac chest

pain?

• General Appearance – may suggest seriousness

of symptoms.

• Vital signs – marked difference in blood

pressure between arms suggests aortic dissection

• Palpate the chest wall – Hyperesthesia may be due

to herpes zoster

• Complete cardiac examination– pericardial rub– signs of acute AI or AS – Ischemia may result in MI

murmur, S4 or S3

• Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

Differential diagnosis of chest pain

• Angina pectoris– Pain: substernal– Characteristic: transient– ECG changes: normal– CXR: normal or vascular congestion/cardiomegaly– Relief: NTG

• MCI– Pain: substernal, crushing– Characteristic: persistent, severe– ECG changes: STEMI or NSTEMI– CXR: normal or vascular congestion/cardiomegaly

……Differential diagnosis of chest pain

• Pulmonary embolism– Pain: Pleuritic– Characteristic: sudden onset with dyspnea– ECG changes: non spesific, RV strain– CXR: normal or infiltrate or small pleural effusion– Risk factor of DVT

• Pneumonia– Pain: pleuritic– Characteristic: onset minutes to hours– ECG changes: maybe normal– CXR: consolidation– Associated features: fever, productive coughm dyspnea

……Differential diagnosis of chest pain

• Pneumothorax– Pain: sharp, unilateral– Characteristic: sudden onset with dyspnea– ECG changes: normal– CXR: collapsed lung– Risk factor of pneumothorax

• Aortic dissection– Pain: severe, substernal– Characteristic: radiation, back– ECG changes: LVH, IMI– CXR: widened mediastinum– Associated features: loss of pulse, AI

……Differential diagnosis of chest pain

• Esophageal reflux– Pain: substernal– Characteristic: burning– ECG changes: normal– CXR: normal– Relief: antacids

• Herpes zoster– Pain: sharp, unilateral– Characteristic: dysesthesia– ECG changes: normal– CXR: normal– Associated features: vesicular rash

……Differential diagnosis of chest pain

• Pericarditis– Pain: pleuritic– Characteristic: gradual onset– ECG changes: general ST elevation– CXR: enlarged cardiac silhouette– Friction rub

• Chostochondritis– Pain: dully, achy– Characteristic: increased by cough/deep breath– ECG changes: normal– CXR: normal– Associated features: localized tenderness

Chest pain & respiratory emergency

• Tension pneumothorax• Pulmonary embolism

• Massive pleural effusion

Diagnostic tools

• Chest imaging :– X rays : PA, lateral, lateral decubitus– Thoracic ultrasound– CT scanning

Pneumothorax

• The presence of free air between the visceral pleura and the parietal pleura .

• Any air that leaks into this space (pleural space) will cause the lung tissue to collapse in proportion to the amount of air that enters the pleural cavity.

Diagram representing 3 mechanisms of formation of pneumothorax

(A) rupture of an apical pleural bleb in primary spontaneous pneumothorax

(B) visceral pleural tear responsible for the escape of air into the pleural space in secondary spontaneous pneumothorax

(C) one mechanism of traumatic pneumothorax by dissection of air along tracheobronchial tree with proximal rupture.

Pathophysiology of pleural effusion

• The normal pleural space contains approximately 1 mL of fluid, representing the balance of hydrostatic and oncotic forces in the visceral and parietal pleural vessels and lymphatic drainage. Pleural effusions result from disruption of this balance

Diagram representing pressures involved in formation and absorption of pleural fluid.

Modified from Fraser RG et al: Diagnosis of diseases of the chest, ed 3, Philadelphia, 1988, WB Saunders.

Etiology• Transudate :

– congestive heart failure, cirrhosis with ascites, nephrotic syndrome, hypoalbuminemia, myxedema, peritoneal dialysis, glomerulonephritis, superior vena cava obstruction, pulmonary embolism

• Exudates :– Infections : pneumonia, tuberculosis, lung abscess, viral illness– Malignancy : lung cancer, mesothelioma, pulmonary/pleural metastases,

lymphoma– Connective tissue disaese : rhematoid arthritis, SLE– Abdominal disorders : pacreatitis, esophageal rupture, subphrenic abscess– Others: pulmonary embolism, uremia, postpartum, drug reaction,

chylothorax•

Concluding remarks

• Chest pain is symptoms which can associated with serious illness

• Prompt diagnosis and management important

• Reduced morbidity and mortality

• Avoid uneccessary examination and hospital stays for benign etiology

aniwidyaningsih@gmail.com

WAHJU ANIWIDYANINGSIH, MD

Academic Qualification :• 1999 MD, Faculty of Medicine

University of Indonesia • 2004 Pulmonologist, Faculty of

Medicine University of Indonesia

Academic / Clinical Appointments :• Department of Pulmonology and

Respiratory Medicine Faculty of Medicine University of Indonesia, Persahabatan Hospital

Chest Pain in Respiratory Disease

Wahju Aniwidyaningsih

Division of Interventional Pulmonology & Respiratory Critical CareDepartment of Pulmonology & Respiratory Medicine, Faculty of Medicine

University of Indonesia – Persahabatan Hospital