A brief clinical review of pulmonary causes of chest pain

1. Pulmonary causes of
chest pain
Leul Biruk
MD 014/15

2. IntroIntro
• Common complaint in the EDCommon complaint in the ED
5% of all ED visits or 5 million visits per year5% of all ED visits or 5 million visits per year
• Wide range of etiologiesWide range of etiologies
CVS, Pulmonary, GI, MusculoskeletalCVS, Pulmonary, GI, Musculoskeletal
• Chest pain can be:Chest pain can be:
Visceral:Visceral: poorly localized and characterized (discomfort, heaviness,poorly localized and characterized (discomfort, heaviness,
dull, aching) (Heart, blood vessels, esophagus and visceral pleura)dull, aching) (Heart, blood vessels, esophagus and visceral pleura)
Parietal: as sharp and can be localized toParietal: as sharp and can be localized to
dermatome superficial to the site of stimulus.

3. Intro…Intro…
There are various causes of chest pain:There are various causes of chest pain:
GI (42%) (Esophageal rupture, GERDGI (42%) (Esophageal rupture, GERD
(hb),Esophagitis)(hb),Esophagitis)
CVS (Coronary artery disease - 31%)CVS (Coronary artery disease - 31%)
(Pericarditis (4%))(Pericarditis (4%))
Musculoskeletal (28%) (Fibromyalgia)Musculoskeletal (28%) (Fibromyalgia)
Rsp (Rsp (Pulmonary embolismPulmonary embolism(2%),Pneumonia,(2%),Pneumonia,
Lung cancer)Lung cancer)

4. Pulmonary causes…Pulmonary causes…
• Pulmonary embolismPulmonary embolism
• BronchitisBronchitis
• PneumoniaPneumonia
• Tension pneumothoraxTension pneumothorax
• Lung malignancyLung malignancy
• HemothoraxHemothorax
• TuberculosisTuberculosis
• Pleurisy- inflammationPleurisy- inflammation
of the pleuraeof the pleurae
• Tracheitis- inflammationTracheitis- inflammation
of the tracheaof the trachea

5. PleurisyPleurisy
Possible causes:Possible causes:
• Aortic dissectionsAortic dissections
• Autoimmune disordersAutoimmune disorders
Bacterial infectionsBacterial infections
(pneumonia and(pneumonia and
tuberculosis)tuberculosis)
• Chest injuries (blunt orChest injuries (blunt or
penetrating)penetrating)
• Familial MediterraneanFamilial Mediterranean
• Heart surgeryHeart surgery
• Cardiac problemsCardiac problems
(ischemia, pericarditis)(ischemia, pericarditis)
• IBDIBD
• Lung cancerLung cancer
• PneumothoraxPneumothorax
• Pulmonary embolismsPulmonary embolisms

6. TracheitisTracheitis
• Mostly bacterialMostly bacterial
• Symptoms:Symptoms:
• Chest painChest pain
• FeverFever
• Ear acheEar ache
• HeadacheHeadache
• DizzinessDizziness
• Labored breathingLabored breathing
• Increasing deep or barking croup cough (ff URTI)Increasing deep or barking croup cough (ff URTI)
• Inspiratory stridor (Crowing-inhaling)Inspiratory stridor (Crowing-inhaling)
• 'scratchy' feeling in the throat'scratchy' feeling in the throat

7. Pulmonary embolismPulmonary embolism
• Thrombosis of a pulmonary arteryThrombosis of a pulmonary artery
• >90% arise from DVT>90% arise from DVT
• Clot from a DVT travels through the venous systemClot from a DVT travels through the venous system
and lodges in the pulmonary vasculature creating aand lodges in the pulmonary vasculature creating a
ventilation/perfusion mismatchventilation/perfusion mismatch

8. Pulmonary embolism…Pulmonary embolism…
• History:History:
• Dyspnea is the most common symptom, presentDyspnea is the most common symptom, present
in 90% of patients diagnosed with PEin 90% of patients diagnosed with PE
• Sharp pleuritic chest pain, syncopeSharp pleuritic chest pain, syncope
• Prolonged immobilization, neoplasm (improb.),Prolonged immobilization, neoplasm (improb.),
hypercoagulable disorderhypercoagulable disorder

9. Pulmonary embolism…Pulmonary embolism…
• Physical exam:Physical exam:
• Tachycardia, tachypnea, diaphoresis,Tachycardia, tachypnea, diaphoresis,
hypotension, hypoxia, low grade fever, anxiety,hypotension, hypoxia, low grade fever, anxiety,
cardiovascular collapse, right ventricular heavecardiovascular collapse, right ventricular heave
• Treatment:Treatment:
• Prevention (hep)Prevention (hep)
• Unfractionated heparin vs low molecular weightUnfractionated heparin vs low molecular weight
heparin (superior-LMWH)(HIT)heparin (superior-LMWH)(HIT)
• Thrombolysis (for CVS collapse)Thrombolysis (for CVS collapse)

10. BronchitisBronchitis
• Inflammation of the bronchi (large and medium-Inflammation of the bronchi (large and medium-
sized airways) in the lungs.sized airways) in the lungs.
• Symptoms includeSymptoms include coughing upcoughing up mucus, wheezing,mucus, wheezing,
SOB,SOB, andand chest discomfort.chest discomfort.
• divided intodivided into acuteacute andand chronicchronic

11. Bronchitis…Bronchitis…
Acute (chest cold)Acute (chest cold)
• short term (few to tenshort term (few to ten
days) inflammation ofdays) inflammation of
the bronchi of the lungsthe bronchi of the lungs
• The most commonThe most common
symptom is a cough.symptom is a cough.
Other symptoms:Other symptoms:
coughing up mucus,coughing up mucus,
wheezing, shortness ofwheezing, shortness of
breath, fever, and chestbreath, fever, and chest
ChronicChronic
• productiveproductive cough thatcough that
lasts for three months orlasts for three months or
more per year for atmore per year for at
least two yearsleast two years
• Treatment:Treatment:
corticosteroids,corticosteroids,
Mucolytic,Mucolytic,

12. PneumoniaPneumonia
• inflammatory condition of the lung affectinginflammatory condition of the lung affecting
primarily the alveoli.primarily the alveoli.
• Signs and symptoms include: a varying severity andSigns and symptoms include: a varying severity and
combination of productive or dry cough, chest pain,combination of productive or dry cough, chest pain,
fever, and trouble breathing, depending on thefever, and trouble breathing, depending on the
underlying cause.underlying cause.
• Caused by infection with viruses or bacteria and lessCaused by infection with viruses or bacteria and less
commonly by other microorganisms and certaincommonly by other microorganisms and certain
medications and conditions such as autoimmunemedications and conditions such as autoimmune
diseases.diseases.

14. Tension pneumothoraxTension pneumothorax
• Collection of air in the pleural spaceCollection of air in the pleural space
causes collapse of the ipsilateral lungcauses collapse of the ipsilateral lung
and then CVS collapse as intrathoracicand then CVS collapse as intrathoracic
pressures increasepressures increase
• Risk factors: COPD; CT disease, trauma,Risk factors: COPD; CT disease, trauma,
positive pressure ventilationpositive pressure ventilation
• Absent breath sounds unilaterally,Absent breath sounds unilaterally,
hypotension, distended neck veins,hypotension, distended neck veins,
tracheal deviationtracheal deviation
• Treatment: Needle decompression,Treatment: Needle decompression,

16. Lung malignancyLung malignancy
• a malignant lung tumora malignant lung tumor
• Respiratory symptoms: coughing,Respiratory symptoms: coughing,
coughing up blood, wheezing, orcoughing up blood, wheezing, or
SOBSOB
• Systemic symptoms: weight loss,Systemic symptoms: weight loss,
weakness, fever, or clubbing of theweakness, fever, or clubbing of the
fingernailsfingernails
• Symptoms due to the cancer massSymptoms due to the cancer mass
pressing on adjacent structures:pressing on adjacent structures:

17. TuberculosisTuberculosis
• Infectious disease causedInfectious disease caused
by the bacteriumby the bacterium
MycobacteriumMycobacterium
tuberculosis.tuberculosis.
• classic symptoms ofclassic symptoms of
active TB are a chronicactive TB are a chronic
cough with blood-cough with blood-
containing sputum, fever,containing sputum, fever,
night sweats, and weightnight sweats, and weight
loss.loss.
• DIAGNOSISDIAGNOSIS: A chest X-: A chest X-

18. Essential pointsEssential points
• Pulmonary EmbolismPulmonary Embolism
• Immobilized patient with chest pain and dyspneaImmobilized patient with chest pain and dyspnea
• DVTDVT

19. ………………..Thank You for listening...Thank You for listening.
Any Questions?Any Questions?