View Abstract

A5343 - Chest Pain and Respiratory Failure: The Challenge of the Differential Diagnosis. Clinical or Surgical Management?
Author Block: L. Fernandez1, J. E. Bolaños2, M. Velasquez3, C. S. Leib4, Biomedical Research Group in Thorax; 1Interventional Pulmonology, Fundacion Valle del Lili, Universidad Icesi, Cali, Colombia, 2Medical Student, Fundacion Valle del Lili, Universidad Icesi, Cali, Colombia, 3Thoracic Surgery, Fundacion Valle del Lili, Universidad Icesi, Cali, Colombia, 4Medical Research, Fundacion Valle del Lili, Universidad Icesi, Cali, Colombia.
INTRODUCTIONChest pain can have a wide spectrum of etiologies varying from life-threatening conditions to benign diseases. The most common causes are musculoskeletal, gastrointestinal, stable angina, respiratory and coronary syndrome. The differential diagnosis is challenging, particularly in the elderly. Treatment options are can be completely opposed depending on the origin. Thoracic trauma represents 10-15% of the trauma cases, mainly derived from traffic accidents and falls. One third of these patients present rib fractures. Multiple costal fractures produce a fail chest (FC), defined as three or more consecutive rib fractures in two or more locations, creating an independent segment, moving paradoxically to the chest wall. Patients with a FC have increased respiratory effort and may present respiratory failure, requiring ventilatory support. The elderly, in particular those with osteopenia and osteoporosis, have a greater risk of suffering from a FC after a fall. We describe a case of thoracic pain, initially diagnosed as chronic obstructive pulmonary disease (COPD) associated with severe respiratory infection, progressing to respiratory failure. Here, a proper medical history and interrogation were essential to indentify a FC that required surgical management, with significant improvement of the condition. CASE REPORT An 82 year-old female patient, with a previous history of hypertension and COPD, was referred to our service with one week of chest pain, cough and shortness of breath. Chest x-ray showed a hemi-diaphragmatic elevation and infiltrates. She was diagnosed with severe pneumonia and started on a course of antibiotics, with no improvement and pain incensement, requiring vasoactive and ventilatory support. On re-interrogation an episode of a fall with no loss of consciousness or neurological deterioration the previous week was noted. She was in observation for a few hours and discharged with pain management. Physical exam revealed respiratory distress, paradoxical chest motion and painful costal palpation. Chest CT showed multiple right costal fractures, a small pleural effusion and ground-glass opacities. A FC diagnosis was made and a surgical repair was performed resulting in marked improvement of the symptoms. DISCUSSION In the elderly presenting with thoracic pain, it is important to discard the musculoskeletal causes since they account for approximately 30% of the chest pain etiologies; particularly rib fractures and chest trauma since they have a high risk of morbid-mortality. Surgical fixation significantly improves the patient´s condition and has shown good results in the literature. A proper interrogation, physical exam and thorough analysis are fundamental in achieving a correct diagnosis.