What is the treatment for pleuritic chest pain?

Treatment for Pleuritic Chest Pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for pleuritic chest pain, with additional therapy directed at the underlying cause. 1

Initial Assessment and Diagnosis

Before initiating treatment, it's essential to rule out life-threatening causes of pleuritic chest pain:

• Pulmonary embolism: Most common serious cause (5-21% of emergency department visits for pleuritic pain) 2
• Myocardial infarction: May present with pleuritic features
• Pneumothorax: Requires immediate intervention
• Pericarditis: Often confused with pleurisy
• Pneumonia: Common infectious cause

Diagnostic workup should include:

• Chest radiography (all patients)
• Electrocardiography (especially with suspicion of MI, PE, or pericarditis)
• Additional tests based on clinical suspicion (D-dimer, CT angiography, etc.)

Treatment Algorithm

1. Pain Management

• First-line: NSAIDs 3, 1

  • Ibuprofen: 400-800mg every 6-8 hours
  • Naproxen: 500mg initially, then 250mg every 6-8 hours
  • Continue until pain resolves

• For pleuritic pain associated with pericarditis:

  • Aspirin is recommended (first-line) 3
  • Acetaminophen, colchicine, or narcotic analgesics may be considered if aspirin is ineffective 3
  • AVOID glucocorticoids and NSAIDs in post-MI pericarditis as they are potentially harmful 3

2. Treatment Based on Underlying Cause

Infectious Causes

• Bacterial pneumonia with parapneumonic effusion:

  • Appropriate antibiotics based on likely pathogens 1
  • Community-acquired: Cefuroxime + metronidazole OR amoxicillin-clavulanate
  • Hospital-acquired: Piperacillin-tazobactam, ceftazidime, or meropenem
  • Continue for at least 14 days

• Viral pleurisy (common cause):

  • Supportive care with NSAIDs for pain relief 4, 2
  • Rest and adequate hydration

Pleural Effusion/Empyema

• Drainage indicated for:

  • Frank pus
  • pH <7.2
  • Glucose <3.3 mmol/L
  • Large, symptomatic effusions
  • Loculated collections 1

• Technique:

  • Small-bore chest tubes (14F or smaller) under ultrasound guidance
  • Connect to underwater seal drainage system 1

• For loculated effusions:

  • Consider intrapleural fibrinolytics (TPA + DNase)
  • Recommended regimen: 10mg TPA + 5mg DNase twice daily for 3 days 1

Pericarditis

• Acute idiopathic pericarditis:

  • High-dose NSAIDs until pain resolves and CRP normalizes 5
  • Add colchicine for 3 months to reduce recurrence risk 5

• Post-MI pericarditis (Dressler syndrome):

  • Aspirin is first-line therapy 3
  • Avoid NSAIDs and glucocorticoids as they may impair myocardial healing 3

3. Supportive Measures

• Analgesia: Keep patient comfortable to allow deep breathing and coughing 3
• Avoid chest physiotherapy: Not beneficial in pleural infections 3
• Early mobilization and exercise: Recommended to prevent complications 3

Special Considerations

• Intrapleural bupivacaine: Can be used if fibrinolytic agents are causing discomfort (0.25%, 0.5-1.0 ml/kg) 3

• Surgical referral: Consider if no improvement after 5-7 days of appropriate medical therapy 1

  • VATS preferred over thoracotomy due to reduced morbidity

• Follow-up:

  • Monitor temperature, WBC count, oxygenation, and clinical symptoms
  • In patients >50 years, smokers, or those with persistent symptoms, repeat chest radiography after 6 weeks 2

Common Pitfalls to Avoid

1. Failing to rule out life-threatening causes before diagnosing viral or idiopathic pleurisy
2. Using glucocorticoids for post-MI pericarditis
3. Delaying drainage of complicated parapneumonic effusions
4. Removing chest tubes prematurely
5. Failing to adjust antibiotics based on culture results

By following this approach, most cases of pleuritic chest pain can be effectively managed with good outcomes, while ensuring that serious underlying conditions are appropriately identified and treated.