โPleuriticโ pain is that which hurts with deep breaths or coughing. The word refers to the Pleura, the folded-over membrane attaching lungs to chest (which has nerve receptors to cause pain). This topic primarily addresses acute chest pain, that began recently.
Causes of Pleuritic Chest Pain
| xxMay Be Imminently Life-Threatening | xxxxNot Imminently Life-Threatening |
|---|---|
| ** Pneumonia ** Pneumothorax ** Pleural Effusion ** Pulmonary Embolism ** Pericarditis | ** Pleurisy / Pleuritis ** Lung Cancer ** Rib Fracture (without trauma) ** Chest Wall Pain (e.g. muscle strain) ** Anxiety |
The pain with imminently life-threatening conditions may or may not be severe. Conversely, the benign conditions can also present with โreal bad painโ. A key distinguishing characteristic in terms of seriousness isnโt how bad the pain feels; itโs shortness of breath. The worse this is, the more immediate the danger. We evaluate this by:
- Respiratory Rate — 24 breaths/min. is concerning, 28 is serious
- โRetractionsโ — we see skin being sucked in with each breath, between the ribs, where the neck meets the breastbone, or the hollows above the collarbone
- Cyanosis — if the lips / fingers / even the entire face are blue, they need immediate intubation & mechanical respiration
- Oxygen Saturation (โO2 Satโ) — a sensor placed on the finger or ear lobe can estimate blood oxygen levels: ย โฅ95% is fine, โค90% is bad, 91% – 94% equivocal.
FYIย —ย Clinicians always abbreviate โshortness of breathโ as โSOB.โย We will too.ย Itโs one reason some providers may not want patients to read their charts, at least if unsupervised.
Of course, people in the midst of a panic attack certainly feel theyโre suffocating, & often breathe very rapidly. But they wonโt have retractions, & their O2 Sats are normal. Usually, their symptoms are worse at rest, & improve with exertion; they certainly feel like they can’t breathe, but itโs not true, dangerous SOB. A sense of needing to take a deep breath on & off, like a sigh, isnโt true SOB either. [See our topic Shortness of Breath for a detailed discussion].
First, a few definitions of diseases (see links for more description):
- Pneumonia: lung infection (bacteria are usually the most dangerous germs)
- Pneumothorax: punctured lung (with / without trauma)
- Pleural Effusion: fluid build-up in between the pleural membranes lining the lungs
- Pulmonary Embolism: blood clot in the lung
- Pleurisy / Pleuritis: irritation / inflammation of the pleural membranes
- Pericarditis: inflammation of pericardium (membrane over the heart)
- โChest Wallโ: ribs, muscles, tendons, ligaments in chest
Note that Pleural Effusions and Pericarditis can be caused by a lot of different diseases. Once so identified, we use that as the starting point to find the cause (another thought process).
So a patient has Pleuritic Chest Pain. We seek CLINICAL CLUES:
History (Other Symptoms / Factors)
** Cough —
- Could be Pneumonia.
- But maybe a simple Muscle Strain, caused by coughing thatโs due to a minor cold, etc.
- Coughing up Bloody Phlegm is concerning for Pneumonia, Pulmonary Embolism, or Lung Cancer
** Fever —
- Quite possibly Pneumonia (though maybe the fever from virus, & the chest pain is muscle strain as above).
- Pulmonary Embolism can cause a low-grade fever
- Diseases causing Pleuritis, Pleural Effusion, and Pericarditis might also give a fever
** Shortness of Breath (SOB) — worrisome (see also topic Shortness of Breath)
- True SOB, thatโs worse with exertion, means heart or lung disease
- Pneumonia, Pneumothorax, Pleural Effusion, Pulmonary Embolism, and severe Pericarditis all commonly cause SOB
- SOB that occurs at night while lying in bed, but not with exertion, is due to Anxiety.
- SOB with tingling of hands and/or lips is Hyperventilation from Anxiety.
** Elderly / Immunocompromised — new symptoms are always concerning
- These patients are at special risk for Pneumonia; other conditions too
- Debilitated persons may not breathe deeply enough for a good lung exam
- Debilitated & alcoholics may get Rib Fractures
** Leaning Forward feels better — Think Pericarditis
** Pain with Twisting / Reaching — something in the Chest Wall (outside the lungs & heart)
- Likely benign: muscle Strain or ligament Sprain
- Maybe spontaneous Rib Fracture (from undiagnosed metastatic cancer) ???
Physical Examination
The stethoscope exam of the lungs disease is very useful. We might hear:
- Crackles (called “rales”) where a Pneumonia is located
- Loss of Breath Sounds on the side with Pneumothorax or Pleural Effusion
- A funny Grating Rub in the lung over a Pleural Effusion or Pleuritis
- A different Rub while listening to the heart in Pericarditis
If only one part of the chest hurts, especially with twisting or reaching, we might palpate it. If that’s tender, weโre either dealing a minor muscle strain, or rarely a non-traumatic spontaneous fracture (ominous). To distinguish, we pound on a different part of the same rib (if pain is in the front, we pound on the back). If that hurts, we worry about a fracture (vibrations travel along bone, not muscle).
Tests
Chest X-Rays (CXR) can easily identify Pneumonia, Pneumothorax, Pleural Effusion, and Lung Cancer (if the tumor is big enough to cause chest pain).
But we probably wonโt order a CXR if we have no reason to suspect any of the above serious but uncommon conditions (if there’s no fever, a normal lung exam, in an otherwise healthy person). We certainly donโt order an X-Ray if the pain seems to be a muscle strain, or if itโs not daily & continuous. We might in a heavy smoker, at risk for Lung Cancer, although cancer only rarely causes chest pain (it usually causes a chronic cough, maybe bloody phlegm & weight loss). โHeavy smokerโ means โฅ30 pack-years (1 pack-a-day for 30 yrs., 3 packs for 10 yrs., etc.).
If our exam makes us concerned about a Rib Fracture, we have to order a Rib X-ray, which is taken differently from a CXR.
If we consider Pericarditis because we hear a rub over the heart, or the patient feels lots better when leaning forward, we get an EKG.
EVERYTHINGโS NORMAL
Whatโs our diagnosis for acute pleuritic chest pain when we donโt find anything:
- no shortness of breath on exertion
- no clinical clues
- normal exam, and
- normal CXR (if obtained)
Probably Pleurisy, an ill-defined lung irritation, presumably caused by a virus. It goes away on its own; treatment is simple pain medicines. It may be impossible to distinguish from a Muscle Strain, but both are treated the same & follow the same benign course.
The only other things to consider:
Pleuritis: Inflammation due to other diseases, especially Systemic Lupus Erythematosus (SLE, or โLupusโ). So we inquire about prior history of other SLE symptoms: joint pains, cheekbone rash, other unusual rashes, fingers turn actual colors (red, white, blue) especially in cold, spotty hair loss, mouth ulcers. If revealing, we order an ANA blood test.
Pulmonary Embolism (PE): Blood clot in the lung: a very tricky diagnosis, since physical exam & CXR are usually completely normal. SOB is the main symptom, but Chest Pain is possible. We discuss PEs in depth in our topic Shortness of Breath. One study found that among patients with pleuritic chest pain, a respiratory rate less than 20/min., and no SOB, only 4% had a PE. Itโs not 0%, but still reassuring. We’d mostly be concerned in persons with hard risks for a PE.
CHRONIC PLEURITIC CHEST PAIN — Surely due to a Muscle Strain, or Anxiety. None of the other diseases last for weeks.
See also Pleuritic Chest Pain for the clinicianโs condensed thought-process when face-to-face with a patient.