Chest Pain with Breathing: Immediate Assessment and Management
If you are experiencing chest pain that worsens with breathing (pleuritic chest pain), you need immediate medical evaluation to rule out life-threatening conditions—call 911 or go to the emergency department immediately, especially if the pain is severe, sudden-onset, or accompanied by shortness of breath, sweating, or lightheadedness. 1, 2, 3
Life-Threatening Causes That Must Be Ruled Out First
Pleuritic chest pain (sharp, stabbing pain worsening with inhalation/exhalation) can indicate several serious conditions requiring urgent intervention:
Pulmonary Embolism: The most common serious cause of pleuritic chest pain, found in 5-21% of emergency department patients with this symptom 4. Presents with sudden dyspnea and sharp chest pain, particularly in patients with risk factors like recent immobilization, surgery, or cancer 1, 2.
Pneumothorax/Pneumomediastinum: Characterized by abrupt, continuous pain of short duration (1-2 days), more common in older adolescents and young adults 5. These air-leak syndromes require careful radiographic examination as they can be easily missed 5.
Acute Coronary Syndrome: While typically presenting as pressure-like retrosternal discomfort, ACS can present with atypical pleuritic features, especially in women, elderly patients, and those with diabetes 1, 2. Pericarditis associated with myocardial infarction can cause pleuritic pain 4.
Aortic Dissection: Presents with sudden tearing or ripping pain, often radiating to the back 1, 2. The ADD score should be used for risk assessment 1.
Pericarditis: Sharp chest pain that worsens with breathing and lying flat, improves when sitting forward 1, 4. Must be considered before administering fibrinolysis for presumed STEMI 1.
Immediate Actions Required
Within First 10 Minutes:
Obtain 12-lead ECG immediately within 10 minutes of arrival at any medical facility to identify STEMI, pericarditis, or other acute changes 1, 2, 3.
Measure cardiac troponin as soon as possible if acute coronary syndrome is suspected 1, 2.
Assess vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation 1, 3.
Perform focused cardiovascular examination looking for diaphoresis, tachypnea, tachycardia, hypotension, jugular venous distension, crackles, new murmurs, or signs of tamponade 1, 2, 3.
Critical History Elements to Obtain:
Onset and duration: Sudden onset (seconds to minutes) suggests pneumothorax, pulmonary embolism, or aortic dissection 1, 4, 5. Gradual onset over minutes suggests ACS 2.
Pain characteristics: Sharp, stabbing pain worsening with breathing is classic for pleuritic causes 4, 6. Tearing/ripping quality suggests aortic dissection 2.
Associated symptoms: Dyspnea, syncope, diaphoresis, nausea, or hemodynamic instability indicate high-risk conditions requiring urgent intervention 1, 2, 7.
Risk factors: Recent surgery/immobilization (PE), smoking history (pneumothorax), cardiovascular risk factors (ACS), connective tissue disorders (aortic dissection) 1, 4.
Transport and Setting Considerations
If evaluated in an office setting, immediate transfer to the emergency department by EMS is mandatory—do not delay for additional testing. 1, 2
Transport by EMS provides critical advantages:
- Trained personnel can administer treatment and defibrillation en route 1, 2
- Prehospital ECG acquisition reduces mortality and in-hospital delays 2, 3
- Shorter travel time to appropriate facility 1
Initial Medical Management (If in Emergency Setting)
Administer aspirin 160-325 mg (chewed) immediately unless contraindicated by active bleeding or known allergy 2, 3.
Consider sublingual nitroglycerin only if systolic blood pressure >90 mmHg and heart rate 50-100 bpm—but recognize this does NOT diagnose cardiac ischemia, as esophageal and other conditions may respond similarly 2, 3.
Administer morphine intravenously for severe pain, titrated to effect 3.
Continuous cardiac monitoring with defibrillator readily available 3.
Special Population Considerations
Women:
- At higher risk for underdiagnosis of ACS 1, 2
- More likely to present with accompanying symptoms like nausea, fatigue, and dyspnea rather than classic chest pressure 1, 2
Older Adults (≥75 years):
- May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1, 2
- ACS should be strongly considered even with atypical presentations 1
Younger Patients:
- Air-leak syndromes (pneumothorax/pneumomediastinum) are more common in older adolescents 5
- Do not assume young age excludes serious cardiac disease—ACS can occur even in adolescents 2
Critical Pitfalls to Avoid
Do not rely on nitroglycerin response as a diagnostic tool—esophageal spasm and other conditions may also respond 2, 7.
Do not delay transfer from office settings for troponin or other testing when ACS is suspected 1, 2.
Do not assume sharp, pleuritic pain excludes ACS—pericarditis and atypical presentations can occur 2, 4.
Do not miss pneumomediastinum on chest X-ray—requires careful examination as it can be radiologically subtle 5.
Serial ECGs are essential if initial ECG is nondiagnostic but clinical suspicion remains high—repeat every 15-30 minutes or with symptom changes 1, 2.
Diagnostic Algorithm for Risk Stratification
If life-threatening causes are ruled out and patient is stable:
Use validated clinical decision rules for pulmonary embolism (Wells score, PERC rule) to guide D-dimer testing and CT angiography 4.
Consider viral pleuritis if patient has recent upper respiratory symptoms—common viral causes include Coxsackievirus, RSV, influenza, and adenovirus 4.
Evaluate for musculoskeletal causes (costochondritis, chest wall pain) if pain is reproducible with palpation and other serious causes excluded 8, 4.
NSAIDs are appropriate for pain management in virally-triggered or nonspecific pleuritic chest pain once serious causes are excluded 4.
The key principle: pleuritic chest pain requires immediate evaluation to exclude life-threatening conditions before considering benign diagnoses. 9, 4, 6