What is the most appropriate next step in evaluating and managing a 47‑year‑old woman three days after pulmonary wedge resection who has persistent pleuritic chest pain?

Evaluation and Management of Persistent Pleuritic Chest Pain 3 Days Post-Wedge Resection

Obtain a chest radiograph immediately to rule out pneumothorax, and if negative or equivocal, proceed to CT chest to evaluate for pulmonary embolism, empyema, or other serious complications—while simultaneously optimizing multimodal analgesia with scheduled NSAIDs and regional nerve blocks. 1, 2

Immediate Diagnostic Workup

First-Line Imaging

• Chest radiography (PA and lateral) is mandatory as the initial test, though it has relatively low diagnostic accuracy for post-resection complications 1
• Common radiographic findings include atelectasis, pleural effusion, and elevated hemidiaphragm, but these are non-specific 1
• CT chest with contrast should be obtained when radiographic findings are subtle or equivocal, as it allows more accurate identification of life-threatening complications 1

Life-Threatening Complications to Exclude

Pulmonary Embolism (PE)

• PE is the most common serious cause of pleuritic chest pain, occurring in 5-21% of patients presenting with this symptom 3
• Pleuritic pain in PE results from pleural irritation caused by distal emboli producing alveolar hemorrhage 4
• Dyspnea combined with tachypnea occurs in >90% of PE cases 4
• Apply Wells criteria or revised Geneva score to stratify pre-test probability 4
• In low-to-intermediate probability patients, obtain age- and sex-adjusted D-dimer; a negative result safely excludes PE 4
• If high probability or positive D-dimer, proceed directly to CT pulmonary angiography 4

Pneumothorax

• Presents with dyspnea and pleuritic pain with unilateral absence of breath sounds 5
• Persistent air leak is a common complication following wedge resection 1
• Chest radiography typically identifies pneumothorax, but CT is more sensitive 1

Empyema

• Develops from infected pleural fluid and requires urgent drainage 2
• Suspect if fever, leukocytosis, or worsening clinical status accompanies the pain 2
• Ultrasound-guided thoracentesis is the intervention of choice if pleural fluid is present 2

Bronchopleural Fistula

• A serious complication that differs according to time elapsed since surgery 1
• CT chest is superior to radiography for detection 1

Pain Management Strategy

Multimodal Systemic Analgesia

• Paracetamol (acetaminophen) and NSAIDs should be administered pre-operatively or intra-operatively and continued postoperatively 2
• NSAIDs (ibuprofen or naproxen) are the treatment of choice for pleuritic pain, providing both analgesic and anti-inflammatory effects 6, 3
• Cyclo-oxygenase-2-specific inhibitors are an alternative if traditional NSAIDs are contraindicated 2
• Opioids should be reserved as rescue analgesics in the postoperative period 2

Regional Analgesic Techniques

• Paravertebral block or erector spinae plane block is recommended as first-choice regional technique for post-VATS pain 2
• Serratus anterior plane block can be administered as a second-choice option 2
• These regional techniques are specifically recommended for VATS procedures and provide superior analgesia compared to systemic medications alone 2
• Thoracic epidural analgesia is NOT recommended for postoperative analgesia after VATS 2

Adjunctive Measures

• Intravenous dexmedetomidine infusion may be used intra-operatively when basic analgesia and regional techniques cannot be given 2

Clinical Assessment Priorities

Key Historical Features

• Assess timing: early postoperative effusions (<7 days) are more often related to surgical trauma and bleeding, while late effusions suggest immune-mediated response 2
• Evaluate for "clinically significant" symptoms: increased respiratory support requirements, worsening dyspnea, cough, tachypnea beyond baseline 2
• Document any fever, hemoptysis, or hemodynamic instability 4, 1

Physical Examination Findings

• Tachypnea (respiratory rate >20/min) occurs in approximately 70% of PE patients 4
• Assess for unilateral decreased breath sounds (pneumothorax) or pleural friction rub (pleural inflammation) 5
• Normal oxygen saturation does NOT exclude PE—20-40% of PE patients have normal SaO₂ 4

Intervention Thresholds for Pleural Effusion

• Large or symptomatic pleural effusions (>25-33% of hemithorax on frontal radiograph) typically prompt intervention 2
• Ultrasound-guided thoracentesis has replaced surgical tube thoracostomy as the initial intervention of choice and is well tolerated 2
• Consider intervention if estimated pleural effusion volume >400-480 mL or if symptomatic with smaller volumes 2
• Recurrence occurs in approximately 21% of cases despite initial drainage 2

Critical Pitfalls to Avoid

• Never assume pleuritic pain is benign without proper workup—PE and other life-threatening conditions can present atypically 6
• Do not rely solely on chest radiography; CT is frequently necessary for accurate diagnosis of post-resection complications 1
• Individual clinical signs and symptoms have limited diagnostic value—no single feature has predictive value >80% 4
• The simultaneous absence of dyspnea, tachypnea, and pleuritic pain occurs in only 3% of PE cases, making PE very unlikely when all three are absent 4
• Do NOT prescribe antibiotics reflexively unless there is clear evidence of infection (fever, leukocytosis, purulent drainage) 6
• Adequate pain control is essential to prevent splinting, atelectasis, and secondary complications 2, 5

Follow-Up and Monitoring

• Document radiographic resolution if symptoms persist beyond expected postoperative course 3
• Repeat imaging at 6 weeks if pneumonia was diagnosed to ensure resolution 3
• Protocolized follow-up with intervention thresholds for pleural effusions may reduce length of stay by 3±1.5 days 2