What should I do if I have sharp chest pain with an upper respiratory infection (URI) and cough?

Sharp Chest Pain with URI and Cough: Clinical Approach

You need to immediately rule out life-threatening causes of chest pain, particularly pneumonia, pulmonary embolism, and cardiac causes, before attributing symptoms to a simple upper respiratory infection. 1

Immediate Red Flag Assessment

First, evaluate for emergency conditions that require urgent intervention:

• Pneumonia: Suspect when acute cough occurs with new focal chest signs, dyspnea, tachypnea (≥24 breaths/min), fever >4 days, or tachycardia (≥100 bpm) 1
• Pulmonary embolism: Consider if patient has history of DVT/PE, immobilization in past 4 weeks, malignancy, hemoptysis, or pulse >100 1
• Cardiac causes: Evaluate for acute coronary syndrome, especially with diaphoresis, radiation of pain, or cardiac risk factors 1
• Pneumothorax: Look for unilateral absent breath sounds and dyspnea with inspiration 1

Diagnostic Algorithm

If pneumonia is suspected based on the above criteria, obtain a chest radiograph to confirm diagnosis 1. The presence of focal chest signs increases pneumonia probability from 5-10% to 39%, while their absence reduces it to 2% 1.

Key Clinical Distinctions

• Pleuritic pain (sharp, stabbing pain worse with breathing) suggests pleural involvement from pneumonia, PE, or viral pleurisy 2
• Fever persisting >4 days with cough strongly suggests pneumonia rather than simple viral URI 1
• Vital sign abnormalities (heart rate ≥100, respiratory rate ≥24, temperature ≥38°C) significantly increase pneumonia likelihood 1

Management Based on Findings

If Life-Threatening Causes Ruled Out

For persistent cough after URI with chest discomfort, inhaled ipratropium bromide is the first-line treatment (Grade A recommendation) 3. This works through anticholinergic activity in airways with minimal systemic absorption 3.

Do NOT use:

• Systemic corticosteroids (no evidence of benefit in acute bronchitis in healthy adults) 4
• Central cough suppressants like codeine or dextromethorphan (limited efficacy, Grade D) 3
• Over-the-counter combination cold medications (unproven effectiveness) 3

If Pneumonia Confirmed

Antibiotic treatment is indicated with first-choice agents being tetracycline or amoxicillin 1. Consider macrolides (azithromycin, clarithromycin) if penicillin allergy and local resistance rates are low 1.

Critical Pitfalls to Avoid

• Do not assume purulent sputum indicates bacterial infection requiring antibiotics in otherwise healthy adults with acute bronchitis 4
• Do not delay transfer to emergency department if acute chest pain with suspected serious cause is initially evaluated in office setting 1
• Do not confuse viral acute bronchitis with asthma or COPD exacerbations, which may benefit from bronchodilators and corticosteroids 4, 1
• Consider underlying chronic lung disease if patient has ≥2 of: wheezing, prolonged expiration, smoking history, allergy symptoms—these patients may need pulmonary function testing 1

When to Escalate Care

Transport urgently to ED by EMS (not personal vehicle) if: 1

• Clinical evidence of ACS or life-threatening cause
• Abnormal vital signs with respiratory symptoms
• Inability to obtain ECG in office setting within 10 minutes

Obtain ECG within 10 minutes for any acute chest pain unless clearly non-cardiac cause is evident 1. For stable chest pain in office, ECG should still be performed or patient referred to ED 1.

The chest pain with URI and cough is most commonly viral pleurisy (self-limited), but the sharp quality mandates systematic exclusion of pneumonia and PE before symptomatic treatment 2, 1.