Synopsis
Use pleuritic pain as a localisation clue rather than a diagnosis, rapidly exclude pulmonary embolism, pneumothorax, pneumonia, acute coronary disease and aortic or pericardial emergencies, then treat the established cause safely.
- Pleuritic pain is sharp and worsened by inspiration or cough, reflecting movement of pain-sensitive pleura, pericardium, chest wall or nearby structures; lung parenchyma itself is largely insensitive.
- Pulmonary embolism, pneumothorax and pneumonia are key thoracic causes, but acute coronary syndrome, pericarditis and acute aortic syndrome can present atypically and must remain in the first assessment.
- Sudden pain with dyspnoea, venous-thromboembolism risk or haemoptysis requires a Wells-led PE pathway; neither reproducible tenderness nor a normal saturation safely excludes embolism.
Key red flags
Sudden pleuritic pain, unexplained breathlessness, tachycardia, haemoptysis, syncope or hypoxaemia with thrombosis risk raises probability. A normal chest radiograph, normal ECG or reproducible tenderness cannot independently exclude it.
Investigation priorities
Identify respiratory failure, shock or another need for immediate monitored care.
Management branches
Any new pleuritic chest pain before a benign cause is secure.
- Use ABCDE, measure oxygenation and haemodynamics, obtain ECG and examine for asymmetric air entry, infection, venous thrombosis, pericardial disease and aortic signs.
- Treat clinically unstable tension pneumothorax immediately; activate the relevant emergency pathway for shock, acute coronary disease, tamponade, sepsis or suspected acute aortic syndrome.
Stable observations, negative emergency assessment and findings supporting chest-wall or uncomplicated viral pleural pain.
Key medicines
Non-opioid analgesiaUse paracetamol or an anti-inflammatory medicine at the lowest effective formulary dose for the shortest necessary course when individual contraindications allow.
Interim therapeutic anticoagulation for delayed PE testingWhen NICE criteria are met and diagnostic imaging or D-dimer is delayed, use an appropriate therapeutic anticoagulant selected for renal function, bleeding risk and local pathway.