What could be causing sharp chest pain during inhalation?

Sharp Pain When Breathing: Differential Diagnosis and Management

Sharp chest pain that worsens with inspiration (pleuritic pain) suggests a lower likelihood of cardiac ischemia but requires immediate evaluation to exclude life-threatening conditions including pulmonary embolism, pneumothorax, acute pericarditis, and in certain populations, atypical presentations of acute coronary syndrome. 1

Immediate Life-Threatening Causes to Exclude First

Pulmonary Embolism (PE)

• PE is the most common serious cause of pleuritic chest pain, found in 5-21% of emergency department presentations with this symptom. 2
• Classic presentation includes sharp chest pain worsening with deep breathing, dyspnea, and tachycardia 3
• Use validated clinical decision rules (Wells score or Geneva score) to determine pretest probability 4
• Obtain D-dimer with age-adjusted cutoffs if low-to-intermediate probability; proceed directly to CT pulmonary angiography if high probability or elevated D-dimer 4
• Risk factors include recent immobilization, surgery, malignancy, or prior DVT 3

Pneumothorax

• Characterized by sudden-onset sharp, pleuritic chest pain with dyspnea 3
• Listen for decreased breath sounds on the affected side 4
• Chest radiography confirms diagnosis, showing radiolucent hemithorax 5
• Primary spontaneous pneumothorax typically occurs in young, tall, thin males 6

Acute Pericarditis

• Sharp chest pain that increases with inspiration and lying supine, improves when sitting forward 1, 3
• Listen for pericardial friction rub on examination 3
• ECG shows diffuse ST elevation and PR depression 4
• Troponin may be mildly elevated if myopericarditis present 4

Acute Coronary Syndrome (ACS)

• Sharp chest pain does NOT exclude ACS, particularly in women, elderly patients (≥75 years), and those with diabetes who frequently present with atypical symptoms 3, 7
• Obtain ECG within 10 minutes of presentation and measure cardiac troponin immediately 3, 4
• Associated symptoms suggesting ACS include dyspnea, diaphoresis, nausea, lightheadedness, or upper abdominal discomfort 3
• Serial troponin measurements at 3-6 hours if initial troponin negative but symptoms persist 4

Aortic Dissection

• Sudden-onset "ripping" or "tearing" pain radiating to the back 3
• Check for pulse differentials between extremities and blood pressure differences >20 mmHg between arms 3
• This is less likely with purely pleuritic pain but must be considered with severe, sudden-onset pain 1

Common Non-Life-Threatening Causes

Pleuritis/Pleurisy

• Sharp, localized chest pain worsening with deep breathing or coughing 4
• May be associated with viral infection, pneumonia, or autoimmune conditions 4
• Viruses are common causative agents including Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 2

Pneumonia

• Pleuritic chest pain with dyspnea, fever, and productive cough 3
• Chest radiography shows infiltrate 2
• Document radiographic resolution with repeat chest radiography six weeks after treatment in smokers, those >50 years, or those with persistent symptoms 2

Musculoskeletal Causes

• Precordial catch syndrome (Texidor's twinge): brief, sharp discomfort associated with inspiration, typically benign and self-limited 1
• Costochondritis: inflammation of ≥1 ribs and/or cartilages with reproducible chest wall tenderness 1
• Intercostal myofascial injury: trauma to connective tissues between ribs 1
• Point tenderness on palpation strongly suggests musculoskeletal origin 1

Diagnostic Algorithm

Step 1: Immediate Assessment (Within 10 Minutes)

• Obtain vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation 4
• Perform 12-lead ECG within 10 minutes 3, 4
• Draw cardiac troponin immediately 3, 4
• Assess hemodynamic stability 4

Step 2: Characterize the Pain

• Nature: Sharp, stabbing pain related to breathing suggests pleuritic origin 1
• Onset: Sudden onset suggests pneumothorax or PE; gradual onset over minutes suggests cardiac ischemia 1
• Positional changes: Pain improving when sitting forward suggests pericarditis; positional pain generally suggests non-ischemic origin 1
• Duration: Fleeting pain (seconds) unlikely to be cardiac; persistent pain requires further evaluation 1
• Associated symptoms: Dyspnea, fever, cough, hemoptysis 1

Step 3: Risk Stratification

• Age, hypertension, diabetes, smoking, family history of CAD 3
• Risk factors for PE: immobilization, surgery, malignancy, prior DVT 3
• Recent viral illness suggests pleuritis 2

Step 4: Targeted Testing Based on Pretest Probability

• If PE suspected: Wells/Geneva score → D-dimer (if low-intermediate risk) → CT pulmonary angiography 4
• If ACS suspected: Serial troponins, serial ECGs 4
• If pneumothorax suspected: Chest radiography 5
• If pneumonia suspected: Chest radiography, consider sputum culture 2

Treatment Based on Diagnosis

For Pleuritic Pain from Viral Pleuritis or Nonspecific Causes

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are appropriate for pain management 2
• Avoid NSAIDs if contraindications exist (renal disease, GI bleeding history, cardiovascular disease) 8

For Life-Threatening Causes

• PE: Anticoagulation immediately if high probability, even before imaging confirmation 4
• Pneumothorax: Needle decompression if tension pneumothorax; chest tube for significant pneumothorax 9
• Pericarditis: NSAIDs and colchicine 3
• ACS: Dual antiplatelet therapy, anticoagulation, urgent cardiology consultation 3

Critical Pitfalls to Avoid

• Never dismiss pleuritic chest pain as benign without proper workup, as PE remains a significant risk 4
• Do not use nitroglycerin response as a diagnostic criterion; esophageal spasm and other conditions also respond to nitroglycerin 1, 7
• Women and elderly patients require heightened vigilance, as they frequently present with atypical symptoms of ACS 4, 7
• Pain described as sharp and pleuritic does NOT exclude ACS in high-risk populations 3
• Always consider cardiac comorbidity in patients with COPD exacerbation presenting with chest pain 6
• In patients with persistent symptoms, smokers, and those >50 years with pneumonia, document radiographic resolution at six weeks 2