What is the mechanism of pleuritic chest pain?

From the Guidelines

Pleuritic chest pain is primarily caused by the inflammation of the pleura, leading to irritation and roughening of the pleural surfaces, which in turn causes sharp, stabbing pain that worsens during inspiration, as seen in conditions such as pulmonary embolism 1. The mechanism of pleuritic chest pain involves the inflammation of the pleura, which is the thin membrane surrounding the lungs and lining the chest cavity. This inflammation, known as pleuritis or pleurisy, causes the normally smooth pleural surfaces to become rough and irritated.

Key Points

• When a person breathes, these inflamed surfaces rub against each other, triggering sharp, stabbing pain that worsens during inspiration.
• The pain is typically localized to the affected area and may be accompanied by a friction rub that can be heard with a stethoscope.
• Common causes of pleuritic chest pain include viral or bacterial infections, pulmonary embolism, pneumothorax, autoimmune disorders like lupus or rheumatoid arthritis, and malignancies.
• According to the guidelines on the diagnosis and management of acute pulmonary embolism, pleuritic chest pain is one of the most frequent presentations of pulmonary embolism, usually caused by pleural irritation due to distal emboli causing a so-called pulmonary infarction, an alveolar haemorrhage, sometimes accompanied by haemoptysis 1.

Treatment and Management

• Treatment depends on addressing the underlying cause, with options including NSAIDs for pain relief, antibiotics for bacterial infections, anticoagulants for pulmonary embolism, or specific treatments for autoimmune conditions.
• In some cases, a thoracentesis may be performed to drain pleural effusions if present.
• Understanding this mechanism helps differentiate pleuritic pain from other types of chest pain like angina, which is typically pressure-like and related to cardiac ischemia rather than respiratory movements.

Clinical Presentation

• Evaluating the likelihood of pulmonary embolism in an individual patient according to the clinical presentation is of utmost importance in the interpretation of diagnostic test results and selection of an appropriate diagnostic strategy 1.
• In 90% of cases, suspicion of pulmonary embolism is raised by clinical symptoms such as dyspnoea, chest pain, and syncope, either singly or in combination.
• Knowledge of which predisposing factors for venous thromboembolism are present is essential in the evaluation of the likelihood of pulmonary embolism, which increases with the number of predisposing factors present 1.

From the Research

Mechanism of Pleuritic Chest Pain

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling 2. The underlying causes of pleuritic chest pain can be diverse, including:

• Pulmonary embolism, which is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain 2
• Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax, which are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography 2
• Viral infections, such as Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus, which are common causative agents of pleuritic chest pain 2

Diagnostic Approach

The diagnostic approach to pleuritic chest pain involves:

• Employing a validated clinical decision rule for pulmonary embolism to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography 2
• Using clinical symptoms and signs, such as the Wells’ score, to select the most appropriate investigation(s) 3
• Ruling out other serious causes, such as coronary artery disease, using validated clinical decision rules 2

Management

The management of pleuritic chest pain is guided by the underlying diagnosis, and may include:

• Nonsteroidal anti-inflammatory drugs for pain management in those with virally triggered or nonspecific pleuritic chest pain 2
• Documenting radiographic resolution with repeat chest radiography six weeks after initial treatment in patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia 2