What is the recommended treatment for pleuritic pain?

Treatment of Pleuritic Pain

NSAIDs are the first-line treatment for pleuritic chest pain, with adequate pain control being essential to allow deep breathing and prevent complications such as atelectasis and secondary infection. 1

First-Line Treatment

• NSAIDs:

  • Ibuprofen or naproxen are suitable options 1
  • Continue until pain resolves
  • Helps reduce inflammation at the pleural surface
  • Enables deeper breathing and effective coughing to clear secretions

• Acetaminophen:

  • Can be used for symptomatic relief, particularly in post-MI pericarditis 2
  • Consider as an alternative when NSAIDs are contraindicated

Treatment Based on Underlying Cause

For Viral Pleurisy (Most Common Cause)

• NSAIDs as primary treatment
• Supportive care with adequate hydration
• Monitor for complications including worsening respiratory status 1

For Post-MI Pericarditis

• Early pericarditis (1-3 days post-MI): Acetaminophen for symptomatic relief 2
• Late pericarditis (Dressler's syndrome):
  • High-dose aspirin (500-1,000 mg every 6-8 hours) if symptoms persist 2
  • Consider colchicine (0.5-0.6 mg once or twice daily for 3 months) 2
  • Avoid glucocorticoids and other NSAIDs as they may increase risk of recurrent MI or impaired myocardial healing 2

For Pleural Effusion with Infection

• Small-bore chest tube drainage (14F or smaller) under ultrasound guidance 1
• Appropriate antibiotics based on suspected origin of infection 1
• For complicated parapneumonic effusions with inadequate drainage:
  • Combination tissue plasminogen activator (TPA) and DNase therapy
  • 10 mg TPA twice daily + 5 mg DNase twice daily for 3 days 1

Advanced Pain Management Options

For severe or refractory pleuritic pain:

• Thoracic paravertebral block can be effective when conventional analgesics fail 3
  • Particularly useful in patients with respiratory compromise where pain is limiting their ability to clear secretions
  • Can help avoid endotracheal intubation in severe cases

Important Considerations

• Rule out serious causes before treating as simple pleurisy:

  • Pulmonary embolism (most common potentially life-threatening cause, found in 5-20% of patients) 4
  • Pericarditis
  • Pneumonia
  • Myocardial infarction
  • Pneumothorax 4

• Monitoring requirements:

  • Follow temperature, white blood cell count, clinical symptoms
  • Assess radiographic improvement
  • Reassess if no improvement after 48-72 hours 1

Pitfalls to Avoid

1. Treating symptoms without identifying underlying cause - Always investigate for potentially serious conditions before diagnosing simple pleurisy

2. Inadequate pain control - Insufficient analgesia can lead to shallow breathing, atelectasis, and secondary infection 1

3. Using glucocorticoids or NSAIDs (other than aspirin) in post-MI pericarditis - May increase risk of recurrent MI or impaired myocardial healing 2

4. Using aminoglycosides for pleural infections - Poor penetration into pleural space and may be inactive in acidic pleural fluid 1

5. Delaying surgical consultation - Consider surgical drainage (preferably VATS) if no improvement after 5-7 days of medical management 1