Pleuritic Chest Pain

Pleuritic chest pain is chest pain that is sharp or stabbing and is provoked or worsened by breathing in, coughing, sneezing or movement of the chest wall. It is a symptom with many causes, from a self-limiting viral illness to pulmonary embolism, and it needs a structured assessment to find those that are life threatening.

• The pain arises from the parietal pleura and chest wall, the diaphragm (referred to the shoulder tip through the phrenic nerve), and the pericardium.
• Common causes:
  • Pleural and lung disease: viral pleurisy, pneumonia, pulmonary embolism with infarction, pneumothorax, pleural effusion, tuberculosis, lung cancer and mesothelioma, and connective tissue disease.
  • Cardiac: pericarditis and myopericarditis, and, less often, acute coronary syndrome (usually not pleuritic) and aortic dissection.
  • Chest wall: costochondritis, rib fracture, intercostal muscle strain, herpes zoster before the rash, and precordial catch syndrome (brief stabbing pain in young people).
  • Abdominal: pancreatitis, cholecystitis, subphrenic abscess, and splenic infarction.
  • Systemic: sickle cell crisis, familial Mediterranean fever, and autoimmune disease.
• In primary care, musculoskeletal pain and viral pleurisy are most frequent, but pulmonary embolism is found in about 1 to 5% of patients with pleuritic pain, and it is the diagnosis not to miss.
• Risk factors for serious causes: recent surgery or immobility, malignancy, previous venous thromboembolism, oestrogen use or pregnancy, long travel, smoking, tall thin young men (pneumothorax), age above 60, and immunosuppression.

• A sharp, localised pain that increases with inspiration and coughing, and eases with shallow breathing or holding the breath. A patient lies still, breathes shallowly and splints the affected side.
• Features that suggest the cause:
  • Pulmonary embolism: sudden breathlessness, haemoptysis, leg swelling or pain, tachycardia, low grade fever, and a risk factor.
  • Pneumonia: fever, productive cough, rigors, and focal crackles.
  • Pneumothorax: sudden onset, breathlessness, reduced breath sounds, and hyperresonance, in tall young smokers or those with lung disease.
  • Pericarditis: pain relieved by sitting forwards and worse lying flat, with a pericardial friction rub and a recent viral illness.
  • Viral pleurisy or pleurodynia: a preceding viral illness, myalgia, and a rub.
  • Costochondritis and chest wall pain: reproducible tenderness on palpation of the costochondral junctions or ribs, and pain on movement or twisting.
  • Herpes zoster: burning pain in a dermatomal distribution, followed by vesicles after 2 to 4 days.
  • Rib fracture: a history of trauma or severe coughing, and localised bony tenderness.
  • Aortic dissection: abrupt tearing pain radiating to the back, with blood pressure differences between arms.
  • Subdiaphragmatic cause: upper abdominal tenderness, shoulder tip pain, fever, and jaundice.
• Differential diagnosis: pulmonary embolism, pneumonia, pneumothorax, pericarditis, viral pleurisy, costochondritis, herpes zoster, rib fracture, aortic dissection, subdiaphragmatic disease, oesophageal disorders (reflux, spasm, rupture), anxiety or hyperventilation, and referred pain from the cervical or thoracic spine.
• Red flags: breathlessness at rest, oxygen saturation below 94%, respiratory rate above 24 per minute, heart rate above 110 per minute, systolic blood pressure below 90 mmHg, haemoptysis, syncope, unilateral leg swelling, a history of cancer, recent surgery or long travel, cardiac risk factors with exertional pain, tearing pain, tracheal deviation, new neurological features, and fever with rigors in an immunosuppressed patient.
• Complications depend on the cause: respiratory failure, haemodynamic collapse, tension pneumothorax, effusion, empyema, and post-herpetic neuralgia.

• Clinical assessment and risk stratification, with immediate stabilisation of unstable patients (oxygen, intravenous access, monitoring).
• Examine: vital signs, oxygen saturation on room air, chest (rub, crackles, dullness, hyperresonance), heart (rub, murmurs), legs (calf swelling), chest wall tenderness, skin (rash) and abdomen.
• First line tests:
  • Chest X-ray (erect, posteroanterior): pneumothorax, pneumonia, effusion, mass, rib fracture, widened mediastinum.
  • Electrocardiogram: pericarditis, ischaemia, right heart strain (S1Q3T3 pattern, sinus tachycardia), arrhythmia.
  • Troponin for suspected cardiac causes, full blood count, C-reactive protein, urea and electrolytes, and liver tests.
• Pulmonary embolism assessment:
  • Estimate pretest probability using a validated clinical score based on signs of deep vein thrombosis, heart rate above 100, immobilisation or recent surgery, previous venous thromboembolism, haemoptysis, malignancy, and an alternative diagnosis being less likely than embolism.
  • In low risk patients meeting all rule out criteria (age below 50, heart rate below 100, oxygen saturation 95% or more on room air, no haemoptysis, no oestrogen use, no previous venous thromboembolism, no unilateral leg swelling, and no recent surgery or trauma), no further testing is needed.
  • Otherwise, a negative D-dimer (below 500 micrograms/L, or an age adjusted threshold of age times 10 micrograms/L for patients over 50 years) excludes embolism in low and intermediate probability, and CT pulmonary angiography is indicated for high probability or a positive D-dimer. Use ventilation perfusion scanning in pregnancy, renal impairment or contrast allergy.
• Other tests, by suspicion:
  • Bedside or formal ultrasound for effusion, pneumothorax and deep vein thrombosis (compression ultrasound).
  • CT of the chest or aorta for suspected dissection, mass or persistent pain.
  • Echocardiography for pericardial effusion, right heart strain and ventricular function.
  • Pleural fluid analysis if effusion is present, and sputum or blood cultures for pneumonia.
  • Autoantibody tests when connective tissue disease is suspected.

• Immediate care for unstable patients: oxygen to maintain saturation 94 to 98% (88 to 92% in chronic hypercapnic lung disease), intravenous access, monitoring, and emergency transfer for suspected pulmonary embolism with instability, tension pneumothorax, aortic dissection or acute coronary syndrome.
• Analgesia for pleuritic pain (when serious causes are excluded or being treated):
  • Ibuprofen 400 to 600 mg orally 8 hourly with food for 5 to 14 days, or naproxen 500 mg orally 12 hourly with food, with omeprazole 20 mg once daily if at risk of gastrointestinal bleeding.
  • Paracetamol 1 g orally 6 hourly (maximum 4 g per day, 3 g if weight below 50 kg, and 2 g with liver disease).
  • Codeine 30 mg orally 6 hourly or tramadol 50 mg orally 6 to 8 hourly for severe pain, for 3 to 5 days, with a laxative.
  • Topical diclofenac 1% gel 2 to 4 g to the chest wall 3 to 4 times daily for musculoskeletal pain, and lidocaine 5% patches for rib fracture or post-herpetic pain.
  • Splint the chest with a pillow during coughing and encourage deep breathing exercises to prevent atelectasis.
• Treat the cause:
  • Viral pleurisy and pleurodynia: NSAIDs, rest and reassurance, with resolution in 3 to 14 days.
  • Pneumonia: amoxicillin 500 mg to 1 g orally 8 hourly for 5 days, with clarithromycin 500 mg 12 hourly added for atypical cover, or doxycycline 200 mg on day 1, then 100 mg once daily for 4 days. Admit for severe features.
  • Pulmonary embolism: anticoagulation at once with apixaban 10 mg orally 12 hourly for 7 days, then 5 mg 12 hourly, or rivaroxaban 15 mg 12 hourly for 21 days, then 20 mg once daily with food, or enoxaparin 1.5 mg/kg subcutaneously once daily. Treat for a minimum of 3 months. Provoked embolism needs 3 months, and unprovoked embolism needs an extended review at 3 to 6 months.
  • Pneumothorax: small primary pneumothorax (rim below 2 cm) with minimal symptoms can be observed with a review in 24 to 48 hours. Larger or symptomatic pneumothorax needs needle aspiration (second intercostal space midclavicular line, or 4th to 5th intercostal space in the anterior axillary line), or a small bore chest drain (10 to 14 French). Tension pneumothorax is an emergency needing immediate decompression.
  • Pericarditis: ibuprofen 600 mg orally 8 hourly for 1 to 2 weeks (or aspirin 750 to 1000 mg 8 hourly), with colchicine 500 micrograms orally once daily (weight below 70 kg) or 12 hourly (weight 70 kg or more) for 3 months, omeprazole 20 mg daily, and restriction of strenuous exercise until symptoms resolve and markers normalise.
  • Costochondritis and muscle strain: NSAIDs, topical analgesia, heat, and gentle mobilisation, with resolution in 1 to 6 weeks.
  • Rib fracture: analgesia (paracetamol, an NSAID, and short term opioid), deep breathing and incentive spirometry. Admit older patients, and those with 3 or more fractures, a flail segment, haemothorax or poor respiratory function.
  • Herpes zoster: valaciclovir 1 g orally 8 hourly for 7 days (or aciclovir 800 mg 5 times daily for 7 days, or famciclovir 500 mg 8 hourly for 7 days), started within 72 hours of the rash.
  • Tuberculosis, autoimmune and malignant disease: start disease specific treatment under specialist care.
• Special groups:
  • Pregnancy: use paracetamol. Avoid NSAIDs from 20 weeks. Investigate suspected embolism with ventilation perfusion scanning or CT pulmonary angiography and treat with enoxaparin 1 mg/kg subcutaneously 12 hourly. Avoid direct oral anticoagulants and warfarin.
  • Children: chest pain is mostly musculoskeletal or related to infection. Treat with paracetamol 15 mg/kg every 4 to 6 hours or ibuprofen 5 to 10 mg/kg every 6 to 8 hours, and arrange a chest X-ray for fever, cough or breathlessness.
  • Elderly: broader differential, lower threshold for investigation, caution with NSAIDs and opioids.
  • Renal impairment: avoid NSAIDs and adjust anticoagulant and antibiotic doses.
  • Sickle cell disease: consider acute chest syndrome, and give oxygen, analgesia and antibiotics, and admission.
  • Anticoagulated patients: assess for bleeding and haemothorax after trauma.
• Follow up: review within 48 hours if the cause remains uncertain. Advise return for breathlessness, haemoptysis, fever, leg swelling or worsening pain. Refer to respiratory, cardiology or surgery according to the cause, and for any unexplained pleural effusion.