Can coughing cause central chest pain in a patient with a history of respiratory issues such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Can Coughing Cause Central Chest Pain?

Yes, coughing absolutely causes central chest pain, primarily through musculoskeletal injury to the chest wall, including intercostal muscle strain, costochondritis, and rib fractures, which occur in up to 82.4% of patients presenting with post-tussive chest pain. 1

Mechanisms of Cough-Related Chest Pain

Musculoskeletal Injury (Most Common)

• Severe coughing fits cause widening of rib spaces, with 44% of patients developing associated rib fractures 1
• The 10th rib is most frequently affected in cough-induced fractures 1
• Intercostal muscle strain and costochondritis are common consequences of repetitive forceful coughing 1
• Point-of-care ultrasound detects rib fractures in 29% of cases after negative chest radiography, indicating these injuries are frequently missed 1

Specific Considerations for Asthma and COPD Patients

• Patients with COPD who have chronic bronchitis experience more severe nocturnal cough episodes and worse quality-of-life scores related to cough 2
• A documented case report describes a 53-year-old patient with severe COPD who developed rupture of intercostal muscles with lung herniation after a severe coughing fit, demonstrating the extreme mechanical forces generated 3
• Chronic cough in COPD patients frequently causes musculoskeletal chest pains as part of the disease burden 1

Clinical Approach to Cough-Related Chest Pain

Red Flags Requiring Immediate Evaluation

Before attributing chest pain solely to cough mechanics, screen for potentially life-threatening conditions:

• Hemoptysis, severe dyspnea, fever, or systemic symptoms 2, 4
• Pulmonary embolism causes cough in nearly half of cases and can present with chest pain 1
• History of cancer, tuberculosis, or AIDS 4
• Weight loss or chest radiograph findings suggestive of mass or malignancy 4

Diagnostic Evaluation

• Chest radiography is the appropriate initial imaging for chronic cough with chest pain 1
• Physical examination should include palpation of the chest wall for point tenderness over ribs or intercostal spaces 1
• Radiographic rib series are more sensitive than standard chest X-rays for detecting rib fractures 1
• Consider point-of-care ultrasound if rib fractures are suspected but not visible on plain films 1

Management Strategy

Address the Underlying Cough

The most effective approach is treating the cause of cough rather than just managing pain:

For patients with asthma:

• Initiate inhaled corticosteroids with or without bronchodilators, even without spirometric evidence of obstruction 4
• Many patients with cough-variant asthma lack sufficient reversibility to meet traditional asthma criteria 4

For patients with COPD/chronic bronchitis:

• Ipratropium bromide 36 μg (2 inhalations) four times daily is first-line therapy, decreasing cough frequency and severity while reducing sputum volume 5
• Short-acting β-agonists can be added as second-line therapy 5
• Smoking cessation is the priority intervention if the patient currently smokes, with 90% reporting cough resolution 5

For other common causes:

• Upper airway cough syndrome accounts for 33.2% of chronic cough cases and should be treated empirically 2, 1
• Gastroesophageal reflux disease requires intensive acid suppression therapy for at least 3 months 4
• Discontinue ACE inhibitors immediately if the patient is taking one, as these cause chronic dry cough in 5-50% of patients 1

Symptomatic Pain Management

• Pain control with NSAIDs or acetaminophen for musculoskeletal pain 1
• Chest wall support or binding may provide symptomatic relief 1
• Central acting antitussive agents like codeine or dextromethorphan can provide short-term relief for severe paroxysms, reducing cough counts by 40-60% 5

Common Pitfalls to Avoid

• Do not assume all chest pain with cough is benign musculoskeletal pain—always screen for red flags including pulmonary embolism, which causes cough in nearly half of cases 1
• Do not rely on chest radiography alone to exclude rib fractures—up to 29% are missed on standard films 1
• Do not overlook medication-induced cough—ACE inhibitors, beta-blockers, and inhaled medications can trigger chronic cough 1
• Do not forget that acute exacerbation of COPD with chest pain requires consideration of cardiac comorbidity such as acute coronary syndrome 6