From the Guidelines
Pleuritic pain is a common symptom of Pulmonary Embolism (PE), occurring in approximately 50-85% of patients, and is typically characterized by sharp, localized pain that worsens with breathing, coughing, or movement 1. The pain is caused by the inflammatory response to the clot, which irritates nerve endings in the pleura, and may be accompanied by shortness of breath, cough, or hemoptysis. Key characteristics of pleuritic pain in PE include:
- Sharp, localized pain
- Worsening with breathing, coughing, or movement
- Accompanied by shortness of breath, cough, or hemoptysis Not all PE patients experience pleuritic pain; those with central emboli may present with different symptoms like unexplained dyspnea or syncope. When evaluating a patient with suspected PE, it is essential to consider the clinical presentation, including pleuritic pain, in conjunction with other symptoms and risk factors, such as immobility, recent surgery, or hormonal therapy, to prompt diagnosis and treatment 1. The primary focus of treatment for pleuritic pain from PE is addressing the underlying PE with anticoagulation therapy, such as heparin, low molecular weight heparin, or direct oral anticoagulants. For pain management, acetaminophen is typically used first, while NSAIDs are generally avoided due to potential bleeding risk in anticoagulated patients, and opioids may be considered for severe pain but should be used cautiously due to respiratory depression concerns 1.
From the Research
Pleuritic Pain as a Symptom of Pulmonary Embolism
- Pleuritic chest pain is a frequent complaint in patients with pulmonary embolism, as noted in studies 2, 3, 4, 5, 6.
- The presence of pleuritic chest pain in a patient with a pleural effusion is highly suggestive of pulmonary embolism 2.
- Approximately 75% of patients with pulmonary emboli and pleural effusion have pleuritic chest pain 4.
- Severe pleuritic pain associated with pulmonary embolism may indicate subclinical infarction of tissue near the visceral pleura with an increased risk of pleural effusion and the subsequent development of a haemothorax 5.
Diagnosis and Treatment
- Spiral computed tomography pulmonary angiography (CTPA) is the best way to evaluate the possibility of pulmonary embolism in a patient with a pleural effusion 2.
- d-Dimer testing is a good screen for pulmonary emboli, and if results are positive, a spiral computed tomograph should be obtained to confirm the diagnosis 4.
- Low-molecular-weight-heparin has become the initial treatment of choice for patients with pulmonary emboli and pleural effusion 4.
- Patients with severe pain and pleural effusion should be monitored closely, especially if they are outpatients, even though initial radiological findings are not significant 5.
Clinical Implications
- The presence of bloody pleural fluid is not a contraindication for the administration of anticoagulant therapy 2.
- Pulmonary embolism is probably responsible for a significant percentage of undiagnosed exudative pleural effusions 2.
- The treatment protocol of the patient with pleural effusion secondary to pulmonary embolism is the same as that for any patient with pulmonary embolism 2.