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Respiratory Chest Pain in Primary Care

  • Common in GP; most cases non-cardiac, but cardiac cause must be excluded first

  • Respiratory pain often sharp, pleuritic (↑ with deep breath, cough, sneeze, movement)

  • Range from benign (e.g. viral pleurisy) → life-threatening (PE, pneumothorax, severe pneumonia)

  • Always assess ABC, obs, and rule out ACS (acute coronary syndrome) and aortic dissection in parallel.


Typical Respiratory Chest Pain Pattern

Pleuritic pain = pain from pleura / chest wall

  • Sharp, stabbing, well-localised

  • Worse with:

    • Deep inspiration

    • Cough / sneeze

    • Movement, lying on affected side

  • May improve with shallow breathing

  • Often associated: SOB (shortness of breath), cough, ± fever

Contrast: cardiac ischaemia → classically central, pressure/heavy, may radiate to arm/jaw, often exertional, not pleuritic.

Major Respiratory Causes of Chest Pain


Condition Pain & Pattern Key Clues / Typical Context
Viral pleurisy (pleuritis) Sharp, well-localised pleuritic pain; ↑ with inspiration/cough Post-viral, mild fever, otherwise well, normal or near-normal CXR; often young/fit adults
Community-acquired pneumonia Pleuritic pain, often lateral/basal Fever, cough, sputum, ↑RR, focal crackles; any age, more severe in older/comorbid
Pulmonary embolism (PE) ⚠ Sudden pleuritic chest pain; may be subtle Acute SOB, tachycardia, haemoptysis or syncope; often normal chest exam; RFs: recent surgery/immobility, pregnancy, OCP/HRT, cancer, prior VTE
Spontaneous pneumothorax (primary/secondary) ⚠ Sudden unilateral pleuritic pain Acute dyspnoea, ↓ breath sounds, hyperresonance; PSP: tall, thin, smoker; SSP: COPD, ILD, CF; small pneumothoraces can be subtle
Pleural effusion Dull or pleuritic discomfort; "heaviness" Dyspnoea, ↓ breath sounds, stony dull percussion, ↓ expansion; causes: HF, pneumonia, PE, malignancy, liver or inflammatory disease
Empyema / complicated parapneumonic effusion ⚠ Localised pleuritic pain, often severe Persistent fever, night sweats, weight loss, systemic upset; often follows pneumonia; large unilateral effusion signs
Acute bronchitis Central/substernal ache or chest-wall pain from cough Acute cough (± sputum), post-viral, low-grade fever, wheeze; chest wall tender from forceful coughing; usually self-limited
Asthma Chest tightness or "band-like" discomfort (may be described as pain) Episodic wheeze, SOB, cough, diurnal variation; triggers (allergens, exercise, cold air, infection); ↓PEFR/FEV₁ with reversibility
COPD / COPD exacerbation Chest tightness or heaviness Chronic cough, sputum, exertional SOB, smoking history; ↑ chest discomfort during infective exacerbations; overlap with pneumonia/PE risk
Costochondritis / chest wall pain Localised, sharp pain; reproducible on palpation; ↑ with movement/deep breath Normal obs, normal auscultation, no SOB; often post-strain, lifting or prolonged cough; benign MSK pattern once serious causes excluded
Rib fracture (incl. cough fracture) Sharp focal pain; markedly ↑ with breathing/cough Localised tenderness ± bruising/crepitus; consider in trauma, osteoporosis, or chronic severe cough; may limit deep inspiration
Lung cancer Persistent unilateral dull/aching or pleuritic pain Chronic cough, haemoptysis, weight loss, fatigue, recurrent infections, clubbing; abnormal CXR; age >40, smoker/occupational exposure
Pleural malignancy (incl. mesothelioma) Persistent pleuritic or dull chest pain, often unilateral Progressive SOB, large unilateral effusion, weight loss; strong asbestos exposure history
Pulmonary tuberculosis (TB) Subacute/chronic pleuritic or dull chest pain Chronic cough, weight loss, night sweats, fever; abnormal CXR (upper-lobe changes, cavitation, effusion); high-prevalence or immunosuppressed groups
Bronchiectasis Intermittent pleuritic discomfort, esp. in exacerbations Chronic productive "wet" cough, recurrent infections, haemoptysis, crackles; often long-standing respiratory disease
Catamenial pneumothorax Recurrent right-sided pleuritic pain and SOB Within 48–72 h of menstruation; recurrent "spontaneous" pneumothorax; consider thoracic endometriosis
Occupational / environmental lung disease Pleuritic or tight chest discomfort SOB, cough ± wheeze; clear exposure pattern (asbestos, birds, moulds, isocyanates); symptoms fluctuate with work/exposure


1️⃣ History – What to Ask

Onset & character

  • Sudden, sharp, pleuritic pain ↑ with inspiration/cough → PE, pneumothorax, pneumonia, pleurisy

  • Gradual onset, dull/pressure, exertional → consider cardiac until proven otherwise


Provoking / relieving factors

  • Pain reproducible with movement or palpation → chest wall pain (e.g. costochondritis, rib strain)

  • Pain worse on inspiration → pleuritic (pleura/respiratory origin)


Associated symptoms

  • Dyspnoea, cough ± sputum, fever, wheeze

  • Haemoptysis → think PE, malignancy, TB, bronchiectasis

  • Syncope or presyncope → increases suspicion for PE or major cardiopulmonary event


Risk factors

  • PE / VTE: recent immobility or surgery, long-haul travel, pregnancy/postpartum, OCP/HRT, active cancer, prior DVT/PE, leg swelling

  • Pneumothorax: tall/slim, smoker, known lung disease (COPD, ILD, CF), recent central line / procedure

  • Infection: recent URTI, sick contacts, aspiration risk

  • Malignancy / TB: weight loss, night sweats, chronic cough, TB exposure, immunosuppression

  • Occupational / environmental: asbestos, silica, birds, moulds

  • Trauma: blunt chest injury, severe/prolonged coughing (rib fracture)


2️⃣ Examination – What to Look For

Vitals (always)

  • HR, RR, BP, SpO₂, T, GCS

  • Tachycardia, tachypnoea, hypotension, hypoxia, or fever → red flags for serious cardiopulmonary disease


Chest exam

  • Inspection: work of breathing, asymmetry, scars, bruising

  • Palpation

    • Localised, reproducible tenderness → costochondritis / rib pain

    • Tracheal deviation (late sign) → tension pneumothorax

  • Percussion & auscultation

    • Focal crackles → pneumonia

    • ↓ breath sounds, hyperresonant → pneumothorax

    • Stony dull percussion, ↓ breath sounds → pleural effusion

    • Pleural rub → pleurisy / pleural inflammation

    • Wheeze → asthma/COPD/acute bronchitis


Peripheral signs

  • Calf swelling/tenderness → possible DVT (PE risk)

  • Clubbing, lymphadenopathy, cachexia → chronic lung disease / malignancy

  • Peripheral oedema, raised JVP → cardiac cause/heart failure

  • Cyanosis, mottling → severe hypoxia / shock


3️⃣ Red Flags – Immediate ED / 999

  • Sudden severe dyspnoea + pleuritic chest pain + tachycardia → suspect PE or pneumothorax

  • Pleuritic chest pain + haemoptysis, weight loss or night sweats → malignancy or TB until proven otherwise

  • Chest pain + fever, productive cough, tachypnoea → possible pneumonia or pleural infection/empyema

  • Chest pain after major surgery/trauma or central line removal → high risk PE or iatrogenic pneumothorax

  • Any chest pain with hypotension, SpO₂ ↓, severe tachypnoea, altered mental state → emergency transfer


4️⃣ Investigations in Primary Care

Bedside / initial tests

  • Pulse oximetry + full vitals in all patients with pleuritic chest pain

  • ECG – screen for ACS, pericarditis, arrhythmia; important in all undifferentiated chest pain

  • CXR – consider if pneumonia, effusion, pneumothorax, mass, TB, or malignancy is suspected

  • Peak expiratory flow (PEF) / spirometry – if asthma or COPD exacerbation suspected


PE-specific strategy

  • Use Wells score to estimate pre-test probability

  • Use PERC in very low-risk patients to avoid unnecessary testing

  • Low/intermediate probability → D-dimer

    • Age-adjusted cutoff if >50 years: age × 10 ng/mL FEU

  • High probability or positive D-dimer → urgent imaging (usually CTPA; preferred test in adults in UK guidance)


Laboratory tests

  • Full blood count, CRP – support diagnosis and severity of infection/inflammation

  • U&Es, LFTs – baseline before potential contrast imaging / certain therapies

  • Sputum culture – when pneumonia, bronchiectasis exacerbation, or resistant organisms are suspected


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