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Postgrad Med J 2000;76:413–414 413

Chest pain and non-respiratory symptoms in Postgrad Med J: first published as 10.1136/pmj.76.897.413 on 1 July 2000. Downloaded from acute

W M Edmondstone

Abstract textbooks. Occasionally the combination of The frequency and characteristics of chest dyspnoea and results in diagnostic pain and non-respiratory symptoms were confusion. This study was prompted by the investigated in patients admitted with observation that a number of patients admitted acute asthma. One hundred patients with with asthmatic chest pain had been suspected a mean admission peak flow rate of 38% of having cardiac ischaemia, , pericardi- normal or predicted were interviewed tis, or . It had also been using a questionnaire. Chest pain oc- observed that many patients admitted with curred in 76% and was characteristically a asthma complained of a range of non- dull ache or sharp, stabbing pain in the respiratory symptoms, something which has sternal/parasternal or subcostal areas, been noted previously in children1 and in adult worsened by coughing, deep inspiration, asthmatics in outpatients.2 The aim of this or movement and improved by sitting study was to examine the frequency and char- upright. It was rated at or greater than acteristics of chest pain and other symptoms in 5/10 in severity by 67% of the patients. A patients admitted with acute asthma. wide variety of upper respiratory and sys- temic symptoms were described both Patients and methods before and during the attack. One hundred patients (66 females, mean (SD) Non-respiratory symptoms occur com- age 45.0 (19.7) years) admitted with acute monly in the prodrome before asthma asthma were studied. Patients were included if attacks and become more frequent after a compatible history was supported by an onset of the attack. Chest pain is usual admission peak expiratory flow (PEF) of less during asthma attacks. Although it is than 50% predicted or previous best. Patients benign and self limiting it may cause diag- readmitted were not studied a second time. nostic confusion and patient distress. The patients were interviewed within two days (Postgrad Med J 2000;76:413–414) of admission using a questionnaire that asked about symptoms including the presence and Keywords: asthma; chest pain; non-respiratory symp- features of chest pain, and new non-respiratory toms

symptoms during the attack and the 24 hours http://pmj.bmj.com/ The Royal Hospital, preceding its onset. Patients reporting chest Haslar, Gosport, Hants pain were interviewed again before discharge PO12 2AA, UK Characteristic symptoms of asthma are breath- lessness, chest tightness, wheeze, and . or by telephone soon after. Correspondence to: Although physicians may be familiar with the Dr Edmondstone chest pain described by some asthmatics Results The mean (SD) PEF on admission expressed Submitted 26 October 1999 during attacks the phenomenon has not been Accepted 20 December 1999 studied, nor does it merit a mention in most as % predicted or previous best was 37.9 (12.1)% and on discharge was 87.0 (13.7)%. on September 24, 2021 by guest. Protected copyright. Table 1 Chest symptoms described by 100 patients Seventy six patients reported chest pain during the attack of asthma. Details of the pain are in Breathlessness = 100% Wheezing = 94% table 1. Five patients had two diVerent pains Chest tightness = 91% such as retrosternal soreness due to tracheitis Cough = 88% and a second pain elsewhere in the chest or Chest pain = 76% Features of the chest pain (% patients aVected) back. Location: Quality: Typically the pain developed gradually over Sternal/parasternal 30 Dull ache 30 the first few hours of the attack, was located in Subcostal 26 Sharp and stabbing 28 Chest and back 26 Dull ache + sharp and stabbing 17 the sternal/parasternal area, and was dull and Sternal and subcostal 9 Others (burning, raw, abrasive, tight) 25 aching or sharp and stabbing in nature. In Back only 6 Others 3 some patients it was a dull ache that became Time started: Severity: (scale 1–10) sharp and stabbing on coughing, deep inspira- With onset of attack 37 9 5 tion, or change in position. These activities also Within 60 min of onset 25 8 17 1–6 hours 16 7 19 worsened the pain in 84%, 47%, and 43% of 6–24 hours 4 6 12 patients respectively. The pain was often >24 hours 18 <6 47 relieved by sitting upright. Of those who had Worsened by: Improved by: Coughing 84 Sitting upright 66 chest pain its severity was rated at or above Deep inspiration 47 Shallow 22 7/10 in 41%, and although only 22% received Movement 43 Keeping still 18 analgesics, many more would have liked them. Lying supine 36 Holding chest 12 Lying on side 12 Lying on side 9 All the patients reported that their pain eased PF manoeuvre 8 Lying supine 8 as the asthma attack settled, and 69 (91%) Sitting up without support 3 Stretching 7 patients were pain free when they were NB: Most patients reported several factors. discharged. Of the others, in five the pain was 414 Edmondstone

Table 2 Non-respiratory symptoms associated with the Postgrad Med J: first published as 10.1136/pmj.76.897.413 on 1 July 2000. Downloaded from asthma attack (% patients) Learning points

Before the During the x Most patients with acute asthma have Symptoms attack attack chest pain that may cause diagnostic Nose and throat symptoms 50 54 confusion and be severe enough to Tiredness/sleepiness 48 52 require analgesia, but which settles as the Dry mouth 43 66 asthma improves. Thirst 42 59 Sweating 32 61 x Many asthmatics develop prodromal Headache 32 43 symptoms before attacks and may be Depression 28 28 Skin flush 21 37 able to recognise impending attacks. Increased urinary frequency 21 30 Irritability 21 29 Palpitations 19 41 Skin itch 17 20 Limb pains 15 16 thoracic geometry may also result in painful Nausea 11 30 Dizziness 9 36 distortion of the costochondral joints. Faintness 9 23 Surprisingly, asthmatic chest pain has been Limb tingling 9 19 neglected in adults, although paediatricians are Abdominal colic 7 14 Weight change 7 — aware of its importance in the diVerential diag- nosis of exertional chest pain.3 Its significance should not be underestimated. Firstly, it can thought to be due to rib fracture or intercostal lead to diagnostic uncertainty, evidenced in muscle tear. In only one case did an area of this study by unnecessary radioisotope consolidation on the chest radiograph corres- scans in some patients. Secondly, many pa- pond to the site of the pain, and in no other tients are apprehensive about the pain and may case did the radiograph help to explain the need reassurance that it is a predictable and self pain. There were no diVerences in the severity limiting feature of acute asthma, and finally of the asthma attack between those who did, they may need analgesia. and those who did not have chest pain. Four of This study has also shown that non- the patients with chest pain had radioisotope respiratory symptoms frequently occur both lung scans. All were normal. Electrocardio- before and during attacks of asthma. Many of grams were done in 36% of those with chest the prodromal symptoms are explained by pain and were normal apart from showing coryzal upper respiratory inflammation, and sinus tachycardia. many of the symptoms during the attack are The commonest non-respiratory symptoms probably due to anxiety, lack of sleep, repeated during the 24 hours before the asthma attack coughing, side eVects of bronchodilators, and were irritation of the nose and throat, fre- due to nasal obstruction. quently coryzal in nature, but other common may account for the limb tin- symptoms including excessive tiredness or gling, dizziness, and faintness. None the less, sleepiness, dry mouth, thirst, sweating, and http://pmj.bmj.com/ some patients reported prodromal symptoms headache also occurred (table 2). After the without having an upper respiratory infection, start of the attack the frequency of non- while others said that their asthma attacks were respiratory symptoms increased with the ex- predictably preceded by harbinger symptoms ception of depression. such as tingling, itching, or scratchy discomfort in the nose, mouth, and throat. Mood change, Discussion including inappropriate depression or irritabil- This study has demonstrated that chest pain is

ity, itching of the skin around the nose or on September 24, 2021 by guest. Protected copyright. common in . In some mouth, and urinary frequency were commonly patients tracheitis may precede or accompany reported, and some patients noted muscular the attack, while in others repeated violent aches and pains in the absence of other features coughing may provoke tears where the inter- of influenza. Whether these symptoms, in some costal muscles insert into the periosteum of the respects similar to the prodromal symptoms of rib, or even rib fracture. Occasionally the pain migraine, are due to release of inflammatory may be pleuritic due to . In most mediators in advance of the asthma attack is cases in this study, however, features of the pain not known. Patients whose prodromal symp- suggest that it is musculoskeletal in origin: its toms follow a stereotypic pattern may be able temporal relationship to the asthma attack, its to avert acute attacks by increasing the dose of localisation around the costochondral joints their preventer medication when they recognise and lower ribs, and its relationship to position the characteristic features. and movement of the . The chest hyper- inflates during severe asthma and ventilation occurs at lung volumes approaching total lung 1 Beer S, Laver J, Karpuch J, et al. Prodromal features of asthma. Arch Dis Child 1987;62:345–8. capacity. This increases the work of breathing 2 Shneerson J. Non-respiratory symptoms of acute asthma. as the respiratory muscles are required to oper- Thorax 1986;41:701–2. 3 Wiens L, Sabath R, Ewing L, et al. Chest pain in otherwise ate at a mechanical disadvantage, resulting in healthy children and adolescents is frequently caused by muscle fatigue and consequent pain. Altered exercise-induced asthma. Pediatrics 1992;90:350–3.