Chest pain

Pryor

Chest pain
Chest pain in respiratory
patients usually origi- nates
from musculoskeletal, pleural or
tracheal inflammation, as the
lung parenchyma and small
airways contain no pain fibres.
Pleuritic chest pain is caused
by inflammation of the parietal
pleura, and is usually described
as.a severe, shajcp, stabbing
pain which is worse
oninspirajtion. It is not
reproduced by palpation.
Tracheitis generally causes a
constant burning pain in the
centre of the chest aggravated
by breathing.
Musculoskeletal (chest wall)
pain may originate from the
muscles, bones, joints or
nerves of ihe thoracic cage. It is
usually well localized and
exacerbated by chest and/or
arm movement. Palpation will
usually reproduce the pain.
Angina pectoris is a major
symptom of cardiac disease.
Myocardial ischaemia
characteristically causes a dull
central retrosternal gripping or
band-like sensation which may
radiate to either arm, neck or
jaw

Pericarditis may cause pain

similar to angina or pleurisy.
A differential diagnosis of chest
pain is given in Table 1.3.

Donna

CHEST PAIN
Taking an accurate history is
crucial to the proper evaluation
of chest pain (Snider, j 994).
Although the definitive cause of
chest pain cannot be fully estab
lished without diagnostic
medical tests, it is usually
possible to determine whether
the pain originates in the
pleura, chest wall, or thoracic
organs by means of careful
history taking.

Chest pain can be divided into

two basic types: chest wall pain
and visceral pain (George,
1990). The first arises from
involved thoracic cage
structures and tends to be
superficial and well-localized.
The latter arises from the heart,
pericardium, aorta, medi
astinum, bronchi, or
esophagus. It is described as
deep and difficult to localize.
Pleuritic
Pleuritic chest pain originates
from the parietal pleura or
endothoracic fascia, but not the
visceral pleura, which has no
pain receptors. The patient can
usually identify it as being close
to the thoracic cage (Szidan,
Fishman, 1988). Pleuritic chest
pain worsens sharply with
inspiration as the inflamed
parietal pleura is stretched with
chest wall motion. Deep
breathing, coughing, or
laughing are extremely painful,
requir ing the patient to apply
pressure over the involved area
to control the pain.
Pleuritic chest pain is ordinarily
found in patients that have
other signs of respiratory
illness, such as cough, fever,
chills, malaise. Inflammation of
the di aphragmatic pleura
produces ipsilateral shoulder
pain by way of the phrenic
nerve (Miller, 1980).
The onset of pleuritic chest
pain varies according to its
cause (Snider, 1994). Sudden
severe pleuritic chest pain
suggest a spontaneous
pneumothorax, pul monary
embolism, or infarct. Pulmonary
embolism is usually
accompanied by sudden
dyspnea, hemoptysis,
tachycardia, cyanosis,
hypotension, anxiety, and agi
tation (Marriott, 1993).
Cardiac
There are three cardinal
features that are characteris tic
of cardiac chest pain. The
patient should be asked the
following questions (Marriott,
1993):
I. Does the pain have maximal
intensity from the onset or does
it build up for several sec onds?
Ischemic cardiac pain or angina
is caused by the myocardium
contracting in the absence of
an adequate oxygen supply.
The same type of pain can be
produced by placing a blood
pressure cuff around the upper
arm and inflating it until the
brachial pulse is no longer
palpated at the wrist. If a
patient opens and closes a fist,
pain will gradually appear and
es calate in the forearm. The
causal mechanism of this pain
is the same as that of
myocardial pain: continuing
muscular contraction in the
absence of an adequate oxygen
supply. This type of pain
requires several contractions of
the my ocardium to reach its
maximal intensity. In other
words, there is a characteristic
buildup or escalation of angina
pain.
2. Can you point to the area of
pain with one finger? Anginal
pain is characteristically
demonstrated by patients using
their entire hand or closed fist
against the anterior chest wall.
It is described as a sign of
angina, because it is so typical
(Marriott, 1993). By contrast,
any pain that can be localized
by pointing with a fingertip is
unlikely to be angina.
3. Is the pain deep inside your
chest or does it seem as
though it is close to the
surface? Anginal pain is visceral
pain that may be re ferred
superficially but always has a
deep inter nal component to it.
Myocardial ischemia may be
completely painless (silent
ischemia). Angina may in fact
not be painful but rather
described as discomfort,
pressure, squeez ing, a tight
band, heaviness, burning,
indigestion. It usually is located
substernally and radiates into
one or both arms, neck, jaw, or
back.
Angina is not limited only to
patients with CAD (Marriott,
1993). Individuals that have
normal coro nary arteries but
an insufficient oxygen supply
for a given cardiac workload
can also experience angina.
These include individuals with
anemia, hypertension,
tachycardia, and thyrotoxicosis.
Hypertrophic and di lated
cardiomyopathy can produce
typical angina pain, although
the latter tends to be
intermittent, usu ally occurring
with episodes of CHF. Aortic
valve disease can cause angina
as a result of impairment of
adequate coronary artery blood
tlow.
Angina is usually precipitated
by exertion such as walking
uphill, against the wind, or in
cold weather (Marriott, 1993). It
also is more likely to be brought
on after a meal or by emotional
stress. The rapid resolution of
chest pain by rest or sublingual
nitro glycerin strongly suggests
a cardiac origin. The pain
produced by MI is longer,
persisting more than 20
minutes; occurs at rest; and is
accompanied by nau sea,
diaphoresis, hypotension, and
dyspnea.
Pulmonary Hypertension
Chest pain related to
pulmonary hypertension may
mimic angina pectoris. It is
usually found in patients with
mitral stenosis or
Eisenmenger's syndrome (pul
monary hypertension related to
an interventricular septal
defect, patent ductus
arteriosus, or atrial septal
defect). This type of chest pain
is usually absent at rest, occurs
during exertion, and is
invariably associ ated with
dyspnea (Hurst, et ai, 1990). It
is believed to be because of
dilation of the pulmonary artery
or right ventricular ischemia.
The pain is not relieved by
nitrates. Primary pulmonary
hypertension may be ac
companied by syncope and
Raynaud's phenomenon (Sharf,
1989).
Pericardial
Pericardial chest pain is also
midline, but because of its
anatomical relationship with the
mediastinal pleura, it has
features that suggest pleural
involvement (Snider, 1994).
Deep breathing, coughing,
swallowing, move ment and
lying down may make it worse.
If the central tendon of the
diaphragm is involved, the pain
may be referred to the left
shoulder or scapular area
(Marriott, 1993). The patient
may report that each hemibeat
af fects the pain. Sitting up and
leaning forward, or lying on the
right side often relieves the
pain.
Esophageal
Diffuse esophageal spasm or
esophageal colic is a common
cause of chest pain. It is often
confused with cardiac pain
because it is located
substernally, has a squeezing
or aching quality, and may
radiate into one or both arms
(George, 1990). Furthermore,
diffuse esophageal spasm may
be relieved by sublingual ni
troglycerin as a result of its
generalized function as a
smooth muscle relaxant.
Pain that radiates through the
chest to the back, pain that
decreases by a change in
position from supine to upright,
or relief by ingesting antacids,
all
suggest an esophageal origin
(Snider, 1994). Also, diffuse
esophageal spasm is often
associated with pain on
swallowing (odynophagia),
dysphagia, and regurgitation of
stomach contents. Swallowing
hot or cold liquids, or emotional
stress tend to precipitate this
type of chest pain.
Chest Wall
Chest wall pain is the most
common type of chest pain.
Clues in the patient's history to
this type of pain include
intermittent occurrence,
variable intensity, and local
tenderness (Miller, 1980).
Because it is often located on
the anterior chest wall, many pa
tients believe it is heart pain.
However, an important
differentiation from cardiac pain
is that it does not occur during
but rather following exertion. It
may worsen with inspiration,
but its association with trunk
motions (flexion, extension,
rotation) distinguish it from
pleuritic chest pain.
Localized anterior chest pain as
a result of costo chondritis of
the second to fourth
costosternal articu lations
(Tietze's syndrome) is
described as tender to touch
(George, 1990). A complaint of
rib tenderness, together with a
history of trauma, fall, long-
term steroid use, coughing, or
upper extremity exertion,
suggests rib fracture.
Degenerative disk disease and
arthritis of the cervi cal or
thoracic spine, thoracic outlet
syndrome, spondylitis,
fibromyalgia, kyphoscoliosis, a
n d herpes zoster can all
produce chest wall pain
(Epstein, Ger ber, and Borer,
1979; Miller, 1980; Pellegrino,
1990; Snider, 1994; Wise,
Semble, and Dalton, 1992). Pri
mary lung cancer that invades
the adjoining chest wall, ribs, or
spine produces severe
persistent local ized pain
(Snider, 1994). Pancoast's
syndrome (supe rior sulcus
tumor), in which a primary lung
tumor lo cated in the extreme
apex of the lung invades the
brachial plexus and produces
pain in the shoulder, scapular
region, or medial aspect of the
arm and hand.
Chest wall pain may rarely be
caused by thrombo sis of a
superficial vein on the chest
wall (Mondor's disease). It is a
self-limiting condition of
unknown origin and can last
several weeks (Snider, 1994).
The only physical finding is a
subcutaneous cord that can be
palpated along the lateral chest
wall.

Cash

Pain: The type and position of

any pain should be noted. Are
there
any irritating factors? How can
it be relieved? It may be
necessary to
arrange analgesia prior to
treatment. Alternatively, there
may be
occasions when regular
analgesia will be sufficient to
remove the
need for prophylactic treatment
after minor surgery, or in some
cases of pleurisy or pneumonia

Mathews
Davidson

Chest pain
Chest pain is a frequent
manifestation of both cardiac
and respiratory disease, and is
considered in detail on page
535. Pleural or chest wall
involvement by lung dis- ease
gives rise to sharp, peripheral
pain which is exacer- bated by
deep breathing or coughing
(Box 19.9). Central
chest pain suggests heart
disease but also occurs with
tumours affecting the
mediastinum, oesophageal
disease (pp. 863–870) or
disease of the thoracic aorta (p.
602). Massive pulmonary
embolus may cause ischaemic
car- diac pain as well as severe
breathlessness. Tracheitis pro-
duces raw upper retrosternal
pain, exacerbated by the
accompanying cough.
Musculoskeletal chest wall pain
is usually exacerbated by
movement and associated with
local tenderness.