Last updated: November 30, 2017

Chest pain when breathing

Chest pain when breathing infographic

Chest pain when breathing infographic

 

Chest pain when breathing: Overview

Chest pain when breathing can be from a number of different causes. Sometimes chest pain when breathing can be the sign of a life threatening illness. At other times, it may just be a chest muscle strain. The exact cause of chest pain when breathing depends upon the specific situation. When you take a deep breath, it can stretch and cause pain in any of the following structures inside your chest:

  1. Chest wall muscle
  2. Rib Case
  3. Lung lining (Pleural membrane)
  4. Heart lining (Pericardial membrane)

Muscular pain in chest

Chest muscle strain can cause sharp pain in the chest that worsens when you take a deep breath. Sharp chest pain on left side could be related to strained chest wall muscle on that side. Chest muscle strain can happen on left side or right side.

How to tell if chest pain is muscular? It is not always possible to tell with certainty whether your chest pain ( right side or left side ) is muscular. Chest pain resulting from strained chest wall muscle is usually sharp and localizing. You can usually pinpoint the exact spot on your chest where the pain is. Chest muscle pain, left side, can be localized to an exact spot on the left side of your chest. Similarly chest pain, right side, can be localized to a particular spot on the right side if it is due to chest muscle strain.

Rib case

Problems in the rib case may cause chest and back pain that worsens when breathing. Sharp chest pain ,left side, a few hours after you had a minor chest trauma on your left chest could be due to an injury to your left rib. You may have chest and back pain together if your injured rib is located on your left side or right side towards the back. Pain in center of chest bone that worsens with breathing can be related to a condition called costochondritis. Pain in center of chest bone from costochondritis is usually reproduced by pressing on the exact painful spot. Sharp stabbing pain in chest that comes and goes with each breath could be the result of a broken rib.

The lining of the heart

Inflammation of the lining of the heart (pericarditis) can also cause chest pain that comes and goes with breathing. Some people describe it as a sharp pain in right side of chest and shoulder that gets worse with inhalation and lying down. Others may have dull chest pain right side of left side while taking in deep breaths. Some may have burning sensation in left side of chest or burning sensation in chest and throat that worsens with deep breath. Some people with pericarditis describe burning chest pain in middle of chest that worsens with inspiration or swallowing and improves with leaning forward. Some people may confuse pericarditis pain with anxiety chest pain or anxiety chest tightness.

Lining of the lungs (Pleura)

The most important site of chest pain with inhalation and exhalation is the pleural membrane. Any disease that affects the pleural membrane can cause chest pain that comes and goes with 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 sharp chest pain when breathing (also called pleuritic chest pain). Lung cancer invading the pleura, pneumonia touching the lining of the lungs, and blood clot in lungs are some of the serious causes of pleuritic chest pain. Pleuritic chest pain may be felt as sharp chest pain left side or right side depending on where the disease is located. Some people may describe pleuritic chest as “lung pain in back” when the pain is felt more towards the back of chest but significantly worsens when taking deep breaths. You can read two real life examples of serious chest pain with breathing (see below) to better understand pleuritic chest pain.

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 depends on the individual patient. As a practicing Internal medicine physician, I frequently admit patients with pulmonary embolism to the hospital. I will describe the case of one such patient who had chest pain when breathing and was diagnosed with pulmonary embolism.

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

Mrs. Z was 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 was breast feeding. She was sitting in her recliner in her living room comfortably. Her daughter 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 in the crib. She then realized she was not completely back to normal. She was still a little lightheaded. She noticed she had chest pain on left side. It was a sharp pain in her chest that worsened with breathing. She was somewhat alarmed by the chest pain but just thought she might have chest muscle strain. She continued to have chest pain on left side. She tried some deep breathing but that worsened her chest pain. 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 drove her to the ER.

In the ER, she was found to have a slightly lower than normal blood pressure but it 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 to 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 left side of her chest. Pain was very sharp but it did not hurt when I pushed on her ribs. She was still breathing fast and had chest pain with almost each breath. The combination of her symptoms and the sudden and abrupt onset of her chest pain 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. The results came back. She did have two separate clots on the left side of her chest.

The final diagnosis of her chest pain on left side was pulmonary embolism. It is the most feared cause of chest pain when breathing but it is not the most common one. Most patients with chest pain when breathing have less serious causes of chest pain. However, it is important to rule out serious and potentially life threatening causes of chest pain before considering 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.

Our patient was treated with blood thinners. She was given pain medications to help her with the chest pain on left side. She was instructed to gradually get back to normal activity and was encouraged to maintain a physically active lifestyle.

Chest pain when breathing: Pneumonia

Pneumonia is another diagnosis that needs to 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 do not have the typical symptoms.

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

Mr. R was a 52 year old male who smoked almost two packs of cigarettes a day and had been smoking for more than thirty years. He did have his usual smoker’s cough every morning but he had felt worse in the last six days. He had been coughing more and his sputum had become thick and greenish yellowish in color. For the last two days, he noticed a new pain on the right side of his chest. It was worse with cough and deep breaths. He became very weak and felt feverish and chilly. He also saw small spots of blood tinge in his sputum and got very worried. He drove to the ER right away with chief complaint of “chest pain, right side”.

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 (right side) when breathing. They did some blood work and obtained a chest x-ray. The chest x-ray showed a large pneumonia on the right side. I was then called to admit the patient to the hospital. I secured 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 hospital bed. In fact, his chest pain was so bad that I had to give him a shot of morphine. 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 right 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 surrounding nerve fibers. That is why he had such bad chest pains when breathing.

His symptoms improved after 2 days. His fever went away. His chest pain improved and he was discharged home. He was strongly advised not to smoke again.

I have described two most important causes of chest pain when breathing. As you can see, 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. Do not dismiss your chest pain when breathing by simply thinking about anxiety chest pain, chest muscle stain or chest pain due to gas. You may have serious life threatening conditions.

Nabin Sapkota, MD