Can pleurisy cause residual shortness of breath (SOB)?

Can Pleurisy Cause Residual Shortness of Breath?

Yes, pleurisy can cause residual shortness of breath (SOB) that persists after the acute inflammatory phase has resolved. This is particularly common in cases where pleural thickening or scarring develops as a consequence of the inflammatory process 1.

Pathophysiological Mechanisms of Residual SOB After Pleurisy

• Pleural thickening and fibrosis can develop following pleurisy, creating a "fibrinous peel" that may restrict lung expansion despite resolution of the acute inflammation 1
• This pleural peel may persist for weeks to months and can lead to impaired respiratory mechanics 1
• Residual pleural scarring, thickening of extrapleural tissues, and even calcification can remain long after the initial pleuritic episode has been treated 1
• Postoperative or post-inflammatory pleural effusions can transition from early exudative effusions to late effusions with different biochemical characteristics, potentially causing ongoing symptoms 1

Clinical Presentation of Residual SOB After Pleurisy

• Patients may experience persistent dyspnea even after appropriate treatment of the underlying cause of pleurisy 2
• The shortness of breath may be exertional or present at rest, depending on the severity of residual pleural changes 3
• Patients may report an inability to take a full breath or air hunger with exertion, prompting interruption of ambulation on flat ground and/or basic activities of daily living 1
• Pleuritic chest pain may or may not accompany the residual shortness of breath 4

Specific Causes of Pleurisy That May Lead to Residual SOB

Infectious Causes

• Parapneumonic effusions and empyema can lead to significant pleural thickening and fibrosis that persists after resolution of the infection 1
• Tuberculous pleurisy may result in extensive pleural thickening and fibrosis, leading to long-term restrictive ventilatory defects 1

Malignant Pleural Disease

• Malignant pleural effusions can cause persistent dyspnea through several mechanisms, including trapped lung due to extensive pleural tumor infiltration 1
• The degree of dyspnea is dependent on both the volume of any residual effusion and the underlying condition of the lungs and pleura 1

Post-Inflammatory and Post-Surgical Causes

• Late postoperative pleural effusions (occurring beyond 30 days after surgery) often have lymphocytic predominance and may cause ongoing symptoms 1
• These late effusions suggest an immune-mediated response rather than direct surgical trauma 1

Diagnostic Approach for Residual SOB After Pleurisy

• Chest radiography should be performed to assess for residual pleural effusion or thickening 1
• Contrast-enhanced CT scanning is the most useful imaging modality to provide anatomical detail of residual pleural abnormalities 1
• Ultrasound can help identify residual loculated fluid collections that may contribute to ongoing symptoms 1
• Pulmonary function testing may reveal a restrictive pattern consistent with pleural disease 5

Management of Residual SOB After Pleurisy

• Treatment should target the underlying cause of the pleurisy while also addressing symptomatic relief 2
• For residual pleural effusions causing symptoms, therapeutic thoracentesis may provide relief 1
• In cases of significant pleural thickening causing symptoms, surgical interventions such as decortication may be considered in selected cases 1
• Pain management with nonsteroidal anti-inflammatory drugs may help improve respiratory mechanics by allowing deeper breathing 4
• Pulmonary rehabilitation may benefit patients with persistent symptoms by improving respiratory muscle function and exercise capacity 5

Prognosis

• Many patients with simple pleurisy will have complete resolution of symptoms with appropriate treatment 1
• Pleural peel may resolve over several weeks in patients who avoid surgical intervention 1
• However, some degree of residual calcification, thickening of extrapleural tissues, and pleural scarring may persist long after treatment 1
• The impact on quality of life depends on the extent of residual pleural changes and underlying lung function 5

Important Considerations and Pitfalls

• Persistent or worsening shortness of breath after apparent resolution of pleurisy should prompt investigation for alternative or additional diagnoses, such as pulmonary embolism or recurrent pleural effusion 1
• Unexplained dyspnea in the absence of obvious cardiopulmonary abnormalities may represent post-viral syndromes, particularly relevant in the post-COVID era 1
• Improvement in ventilatory capacity following pleural drainage often correlates poorly with the volume of fluid drained, suggesting complex mechanisms underlying dyspnea in pleural disease 5