Last updated: August 24, 2012

Chest pain when breathing

Chest pain when breathing: Overview

Chest pain when breathing

Image courtesy of National Cancer Institute

Chest pain when breathing can be from a number of different causes. Sometimes chest pain when breathing can be a sign of life threatening illness. At other times, it can be just from a pulled muscle. The exact cause of chest pain when breathing depends upon the specific situation. In medical terms, chest pain when breathing is a form of pleuritic chest pain. The pleuritic chest pain is thought to originate from the pleural membranes that surround the lungs. Any disease that affects the pleural membrane can cause chest pain when breathing. The pleural membrane is a a double layered membrane that surrounds the lungs. In between the two layers, it has a small amount of fluid that works as a lubricant and helps the lungs minimize friction when they expand with breathing. There are many sensitive nerve fibers on the chest wall side of the pleural membrane and any friction or irritation of the nerves can cause chest pain when breathing.

Chest pain when breathing: Blood clot in the lungs

Pulmonary embolism is the most feared cause of chest pain when breathing. Pulmonary embolism is caused by blood clots that go to the lungs mostly from veins in the leg and get lodged in the blood vessel of the lungs. They can produce inflammation in the lungs that can irritate the nerves in the pleural membrane. This results in chest pain when breathing. Not all patients with pulmonary embolism have chest pain when breathing. The exact type and severity of chest pain when breathing depends on the individual patient. No two patients with pulmonary embolism have the same type of chest pain. To understand how pulmonary embolism is diagnosed, you have to look at some real patients. That is what I intend to do here. As a practicing Internal medicine physician, I frequently admit patients with pulmonary embolism to the hospital. I will describe a few real patients who had chest pain when breathing and were diagnosed with pulmonary embolism. I have changed all the personal information about the patients here to protect the identity of the patients but the cases are real.

Chest pain when breathing: A 32 year old otherwise healthy female

Mrs. Z is a 32 year old female who had a healthy child birth six weeks ago. She did not have any complications from her pregnancy and child birth. She is breast feeding. She was sitting in her recliner in her living room comfortably watching her daughter who was sleeping on a crib nearby. Suddenly, the baby cried and she stood up to check on her. As soon as she stood up, she felt a little weak and lightheaded but she recovered soon and did not fall. She changed the diaper of the baby and held her for a while before putting her back to the crib. She then realized she was not completely back to normal. She was still a little lightheaded. She noticed she had some sharp pain pain in her chest when breathing. She was somewhat alarmed by the chest pain when breathing but just thought she might have slept with the wrong posture and probably pulled some muscle.  She sat down on the straight kitchen chair hoping that it would help her pain. But she continued to have chest pain when breathing. Slow she also started to feel like she was not getting enough air. She tried some deep breathing and that worsened her chest pain when breathing. She got worried and called her husband at work. He came home right away and when he looked at her, she looked different to him. She looked very tired and ill. He called his mother to come home and watch the baby. As soon as she arrived, he drove her to the ER.

In the ER, patient was found to have a slightly lower blood pressure but was not alarmingly low. She was still complaining of chest pain when breathing deep. She seemed to be breathing shallow and fast. She appeared very uncomfortable and they put some oxygen on her which seemed to help her. After doing an EKG and some basic blood work, the ER doctor called me to admit the patient in the hospital for observation as something did not seem quite right with her. I told them to send the patient over to the medical floor where I was working.

She arrived on the medical floor still complaining of chest pain when breathing. I listened to her lungs. They were very clear without any abnormal sounds. I looked at her chest x-ray. It looked clean with clear lungs and normal sized heart. The pain was mostly on the right side of her chest. It was very sharp but it did not hurt when I pushed on her ribs. She was still breathing fast and had chest pain when breathing with almost each breath. The combination of her symptoms and the sudden and abrupt onset of her chest pain when breathing associated with weakness and lightheadedness made think about the possibility of a blood clot. I discussed it with the patient and she agreed to get tested for it. We took her down to the radiology for a special CT scan of her chest that can detect blood clots in the lungs. The results came back. She did have two separate clots on the right side of the chest.

The final diagnosis of her chest pain when breathing was pulmonary embolism. It is the most feared cause of chest pain when breathing but it is not the most common cause of chest pain when breathing. Most patients with chest pain when breathing have less serious causes of chest pain but it is important to rule out serious and potentially life threatening causes of chest pain before making other diagnosis. Certain features of the quality, onset, location and severity of the pain increases the likelihood of a possible pulmonary embolism. In patients with pulmonary embolism who present with chest pain when breathing, the chest x-ray is almost always normal. When the clinical setting is suspicious for pulmonary embolism, next step is to order the CAT scan. Our patient had a slightly higher risk of blood clot as she just had a child birth. According to a study published in the Annals of Internal medicine, recent mothers within 3 months of child birth have about 4.29 times higher incidence of blood clots compared to the general population. Our patient was treated with blood thinners. She was given pain medications to help her with the chest pain when breathing. She was instructed to gradually get back to activity and was encouraged to maintain a physically active lifestyle.

Chest pain when breathing: Pneumonia

Pneumonia is another diagnosis that must be considered in patients who have chest pain when breathing. Pneumonia is the most common diagnosis among patients admitted to the hospital in most hospitals throughout the United States. I take care of patients with pneumonia almost everyday. Some patients with pneumonia do have chest pain with breathing but many patients with pneumonia do not have the typical symptoms. You can read about pneumonia in a 85 year old patient in nursing home here. You can read about aspiration pneumonia in  a patient who had a recent stroke here.

Chest pain when breathing: 52 year old smoker with a bad cough

Mr. R is a 52 year old male who smokes almost two packs of cigarettes a day and he has been smoking for more than thirty years. He does have his usual smoker’s cough every morning but has been feeling worse in the last six days. He has been coughing more and has been coughing through the day. He is starting to have some sputum with his cough and its color has changed. His sputum has become thick and greenish yellowish in color. Just in the last two days, he has noticed a new pain in his chest that is more on the left side of his chest and gets worse with cough. As his cough worsened, he started to have the chest pain when breathing even without any cough. He became very weak and felt very feverish and chilly. He felt like he was going to pass out. He also  started to see small spots of blood tinge in his sputum and got very worried and drove down to the ER with chief complaint of chest pain when breathing.

When Mr. R arrived in the ER, he had a fever of 102 degrees. He appeared very sick and was somewhat short of breath. They put some oxygen on him but he was still complaining of chest pain when breathing. They did some blood work and obtained a chest x-ray. The chest x-ray showed a large pneumonia on the left side of his lungs. I was then called to admit the patient to the hospital. I obtained a bed for him in the medical floor and started him on antibiotics.

He still had the chest pain when breathing as he settled down in his bed. In fact, his chest pain when breathing was so bad that I had to give him a shot of morphine to help his pain. I pulled up a mobile computer next to his bed and pulled up the chest x-ray image on the screen. I showed him the white shaded area on his left lung that covered almost half of the lung. After he looked at the image, he was not surprised that he had chest pain when breathing. The infection was severe and it had caused irritation and inflammation of the pleural membranes and the nerve fibers associated with it. That is why he had such a bad chest pain when breathing. His symptoms improved after 2 days. His fever went away. His chest pain when breathing became less severe. He was off of oxygen and was discharged home. He was strongly advised not to smoke again.

Chest pain when breathing: come back for more.

I have described two most important causes of chest pain when breathing. As you have noticed, it is important to know the patient before knowing the significance of symptoms.  Chest pain when breathing in different patients under different circumstances have very different diagnostic consideration. It is important to look at the bigger picture before jumping into conclusions about the cause of the chest pain when breathing. Please check back soon as I will be uploading more cases of patients with chest pain when breathing.

Chest pain when breathing: Costochondritis

This is probably the most common cause of chest pain when breathing but it is a diagnosis of exclusion. I will explain what that means with patient stories. I will be uploading that case soon.

Thank you

Nabin Sapkota, MD