|Other names||Pleuritis, pleuritic chest pain|
|Figure A shows normal anatomy. Figure B shows lungs with pleurisy in the right lung and a pneumothorax of the left lung.|
|Symptoms||Sharp chest pain|
|Causes||Viral infection, pneumonia, pulmonary embolism|
|Diagnostic method||Chest X-ray, electrocardiogram (ECG), blood tests|
|Differential diagnosis||Pericarditis, heart attack, cholecystitis|
|Treatment||Based on the underlying cause|
|Medication||Paracetamol (acetaminophen), ibuprofen|
|Frequency||1 million cases per year (United States)|
Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae).This can result in a sharp chest pain with breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever or weight loss, depending on the underlying cause.
Inflammation is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molecular mediators. The function of inflammation is to eliminate the initial cause of cell injury, clear out necrotic cells and tissues damaged from the original insult and the inflammatory process, and initiate tissue repair.
The lungs are the primary organs of the respiratory system in humans and many other animals including a few fish and some snails. In mammals and most other vertebrates, two lungs are located near the backbone on either side of the heart. Their function in the respiratory system is to extract oxygen from the atmosphere and transfer it into the bloodstream, and to release carbon dioxide from the bloodstream into the atmosphere, in a process of gas exchange. Respiration is driven by different muscular systems in different species. Mammals, reptiles and birds use their different muscles to support and foster breathing. In early tetrapods, air was driven into the lungs by the pharyngeal muscles via buccal pumping, a mechanism still seen in amphibians. In humans, the main muscle of respiration that drives breathing is the diaphragm. The lungs also provide airflow that makes vocal sounds including human speech possible.
The pulmonary pleurae are the two pleurae of the invaginated sac surrounding each lung and attaching to the thoracic cavity. The visceral pleura is the delicate serous membrane that covers the surface of each lung and dips into the fissures between the lobes. The parietal pleura is the outer membrane which is attached to the inner surface of the thoracic cavity. It also separates the pleural cavity from the mediastinum. The parietal pleura is innervated by the intercostal nerves and the phrenic nerve.
The most common cause is a viral infection.Other causes include pneumonia, pulmonary embolism, autoimmune disorders, lung cancer, following heart surgery, pancreatitis, chest trauma, and asbestosis. Occasionally the cause remains unknown. The underlying mechanism involves the rubbing together of the pleurae instead of smooth gliding. Other conditions that can produce similar symptoms include pericarditis, heart attack, cholecystitis, and pneumothorax. Diagnosis may include a chest X-ray, electrocardiogram (ECG), and blood tests.
Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Typically symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable.
Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. Symptoms of a blood clot in the leg may also be present, such as a red, warm, swollen, and painful leg. Signs of a PE include low blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever. Severe cases can lead to passing out, abnormally low blood pressure, and sudden death.
Lung cancer, also known as lung carcinoma, is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. This growth can spread beyond the lung by the process of metastasis into nearby tissue or other parts of the body. Most cancers that start in the lung, known as primary lung cancers, are carcinomas. The two main types are small-cell lung carcinoma (SCLC) and non-small-cell lung carcinoma (NSCLC). The most common symptoms are coughing, weight loss, shortness of breath, and chest pains.
Treatment depends on the underlying cause.Paracetamol (acetaminophen) and ibuprofen may be used to decrease pain. Incentive spirometry may be recommended to encourage larger breaths. About one million people are affected in the United States each year. Descriptions of the condition date from at least as early as 400 BC by Hippocrates.
Paracetamol, also known as acetaminophen and APAP, is a medication used to treat pain and fever. It is typically used for mild to moderate pain relief. There is mixed evidence for its use to relieve fever in children. It is often sold in combination with other medications, such as in many cold medications. Paracetamol is also used for severe pain, such as cancer pain and pain after surgery, in combination with opioid pain medication. It is typically used either by mouth or rectally, but is also available by injection into a vein. Effects last between 2 to 4 hours.
Ibuprofen is a medication in the nonsteroidal anti-inflammatory drug (NSAID) class that is used for treating pain, fever, and inflammation. This includes painful menstrual periods, migraines, and rheumatoid arthritis. It may also be used to close a patent ductus arteriosus in a premature baby. It can be used by mouth or intravenously. It typically begins working within an hour.
Hippocrates of Kos, also known as Hippocrates II, was a Greek physician of the Age of Pericles, who is considered one of the most outstanding figures in the history of medicine. He is often referred to as the "Father of Medicine" in recognition of his lasting contributions to the field as the founder of the Hippocratic School of Medicine. This intellectual school revolutionized medicine in ancient Greece, establishing it as a discipline distinct from other fields with which it had traditionally been associated, thus establishing medicine as a profession.
The defining symptom of pleurisy is a sudden sharp, stabbing, burning or dull pain in the right or left side of the chest during breathing, especially when one inhales and exhales.It feels worse with deep breathing, coughing, sneezing, or laughing. The pain may stay in one place, or it may spread to the shoulder or back. Sometimes, it becomes a fairly constant dull ache.
Depending on its cause, pleuritic chest pain may be accompanied by other symptoms:
Fever, also known as pyrexia and febrile response, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.5 and 38.3 °C. The increase in set point triggers increased muscle contractions and causes a feeling of cold. This results in greater heat production and efforts to conserve heat. When the set point temperature returns to normal, a person feels hot, becomes flushed, and may begin to sweat. Rarely a fever may trigger a febrile seizure. This is more common in young children. Fevers do not typically go higher than 41 to 42 °C.
Shortness of breath, also known as dyspnea, is the feeling that one cannot breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity", and recommends evaluating dyspnea by assessing the intensity of the distinct sensations, the degree of distress involved, and its burden or impact on activities of daily living. Distinct sensations include effort/work, chest tightness, and air hunger.
Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal or abnormal.
Pleurisy is often associated with complications that affect the pleural space.
In some cases of pleurisy, excess fluid builds up in the pleural space. This is called a pleural effusion. The buildup of excess fluid, will more often than not force the two layers of the pleura apart so they don't rub against each other when breathing. This can relieve the pain of pleurisy. A large amount of fluid can result in collapse of the lung. This can make it difficult to breathe.
In some cases of pleural effusion, the excess fluid becomes infected and turns into an abscess. This is called an empyema.
Pleural effusion involving fibrinous exudates in the fluid may be called fibrinous pleurisy, which sometimes occurs as a later stage of pleurisy.
A person can develop a pleural effusion in the absence of pleurisy. For example, pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural effusion.
Air or gas also can build up in the pleural space. This is called a pneumothorax. It can result from acute lung injury or a lung disease like emphysema. Lung procedures, like surgery, drainage of fluid with a needle, examination of the lung from the inside with a light and a camera, or mechanical ventilation, also can cause a pneumothorax.
The most common symptom is sudden pain in one side of the lung and shortness of breath. A pneumothorax also can put pressure on the lung and cause it to collapse.
If the pneumothorax is small, it may go away on its own. If large, a chest tube is placed through the skin and chest wall into the pleural space to remove the air.
Blood also can collect in the pleural space. This is called hemothorax. The most common cause is injury to the chest from blunt force or surgery on the heart or chest. Hemothorax also can occur in people with lung or pleural cancer.
Hemothorax can put pressure on the lung and force it to collapse. It also can cause shock, a state of hypoperfusion in which an insufficient amount of blood is able to reach the organs.
The pleural space can be invaded by fluid, air, and particles from other parts of the body, which fairly complicates diagnosis.Viral infection (coxsackie B virus, HRSV, CMV, adenovirus, EBV, parainfluenza, influenza) is the most common cause of pleurisy. However, many other different conditions can cause pleuritic chest pain:
When the space between the pleurae starts to fill with fluid, as in pleural effusion, the chest pain can be eased but a shortness of breath can result, since the lungs need room to expand during breathing. Some cases of pleuritic chest pain are idiopathic, which means that the exact cause cannot be determined.
A diagnosis of pleurisy or another pleural condition is based on a medical history, physical examinations, and diagnostic tests.The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so that the underlying disorder can be treated.
A doctor uses a stethoscope to listen to the breathing. This method detects any unusual sounds in the lungs. A person with pleurisy may have inflamed layers of the pleurae that make a rough, scratchy sound as they rub against each other during breathing. This is called pleural friction rub.
Depending on the results of the physical examination, diagnostic tests are sometimes performed.
A chest X-ray takes a picture of the heart and lungs. It may show air or fluid in the pleural space. It also may show the cause (e.g., pneumonia, a fractured rib, or a lung tumor) of the pleurisy.
Sometimes an x-ray is taken while lying on the painful side. This may show fluid, as well as changes in fluid position, that did not appear in the vertical x-ray.
Blood tests can detect bacterial or viral infections, pneumonia, rheumatic fever, a pulmonary embolism, or lupus.
Electrocardiography test can determine if a heart condition contributes to the symptoms.
Ultrasonography uses sound waves to create an image. It may show where fluid is located in the chest. It also can show some tumors. Although ultrasound may detect fluid around the lungs, also known as a pleural effusion, sound waves are scattered by air. Therefore, an actual picture of the lungs cannot be obtained with ultrasonography.
A CT scan provides a computer-generated picture of the lungs that can show pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor.
Magnetic resonance imaging (MRI), also called nuclear magnetic resonance (NMR) scanning, uses powerful magnets to show pleural effusions and tumors.
In arterial blood-gas sampling, a small amount of blood is taken from an artery, usually in the wrist. The blood is then checked for oxygen and carbon-dioxide levels. This test shows how well the lungs are taking in oxygen.
Once the presence of an excess fluid in the pleural cavity, or pleural effusion, is suspected and location of fluid is confirmed, a sample of fluid can be removed for testing.The procedure to remove fluid in the chest is called a diagnostic thoracentesis. The doctor inserts a small needle or a thin, hollow, plastic tube in the chest wall and withdraws fluid.
Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is used to guide the needle to the fluid that is trapped in small pockets around the lungs.
Thoracentesis usually does not cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following:
The lung fluid is examined under a microscope and is evaluated for the presence of chemicals and for its color and texture. The degree of clarity is an indicator of infection, cancer, or other conditions that may be causing the buildup of fluid or blood in the pleural space.
If tuberculosis or cancer is suspected, a small piece of the pleura may be examined under a microscope to make a definitive diagnosis. This is called a biopsy.
Several approaches to taking tissue samples are available
Treatment has several goals:
If large amounts of fluid, air, or blood are not removed from the pleural space, they may cause the lung to collapse.
The surgical procedures used to drain fluid, air, or blood from the pleural space are as follows:
A couple of medications are used to relieve pleurisy symptoms:
There may be a role for the use of corticosteroids (for tuberculous pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of pleurisy. Further studies are needed.
The following may be helpful in the management of pleurisy:
Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease.
The treatment for pleurisy depends on its origin and is prescribed by a physician on a base of an individual assessment.Paracetamol (acetaminophen) and amoxicillin, or other antibiotics in case of bacterial infections, are common remedies dispensed by doctors to relieve the initial symptoms and pain in the chest, while viral infections are self-limited. Non-steroidal anti-inflammatory drugs (NSAIDs), preferably indometacin, are usually employed as pain control agents.
A number of alternative or complementary medicines are being investigated for their anti-inflammatory properties, and their use in pleurisy. At this time, clinical trials of these compounds have not been performed.
Extracts from the Brazilian folk remedy Wilbrandia ebracteata ("Taiuia") have been shown to reduce inflammation in the pleural cavity of mice.The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs.
Pleurisy and other disorders of the pleurae can be serious, depending on what caused them. Generally, pleurisy treatment has an excellent prognosis, but if left untreated it can cause severe complications. For example, a resulting pulmonary heart disease cor pulmonale, which manifests itself with an inflammation of the arms and legs, can lead to heart failure. If the conditions that caused the pleurisy or other pleural disorders were adequately diagnosed and treated early, one can expect a full recovery. Help of a pulmonologist (respiratory physician in the U.K. and Australia) may be enlisted to address the underlying cause and chart post-illness rehabilitation.
The pleural cavity is the thin fluid-filled space between the two pulmonary pleurae of each lung. A pleura is a serous membrane which folds back onto itself to form a two-layered membranous pleural sac. The outer pleura is attached to the chest wall, but is separated from it by the endothoracic fascia. The inner pleura covers the lungs and adjoining structures, including blood vessels, bronchi and nerves. The pleural cavity can be viewed as a potential space because the two pleurae adhere to each other under all normal conditions. Parietal pleura projects up to 2.5 cm above the junction of the middle and medial third of the clavicle
The thorax or chest is a part of the anatomy of humans and various other animals located between the neck and the abdomen. The thorax includes the thoracic cavity and the thoracic wall. It contains organs including the heart, lungs, and thymus gland, as well as muscles and various other internal structures. Many diseases may affect the chest, and one of the most common symptoms is chest pain.
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, it can result in death. Very rarely both lungs may be affected by a pneumothorax. It is often called a collapsed lung, although that term may also refer to atelectasis.
A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess fluid can impair breathing by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are hydrothorax, hemothorax (blood), urinothorax (urine), chylothorax (chyle), or pyothorax (pus) commonly known as pleural empyema. In contrast, a pneumothorax is the accumulation of air in the pleural space, and is commonly called a "collapsed lung".
Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae.
Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It may affect part or all of a lung. It is usually unilateral. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often called a collapsed lung, although that term may also refer to pneumothorax.
A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax include chest pain and difficulty breathing, while the clinical signs include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury but may occur spontaneously: due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to a collapsed lung, or rarely in association with other conditions.
A chylothorax is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct. In people on a normal diet, this effusion can be identified by its turbid, milky white appearance, since chyle contains high levels of triglycerides. It is important to distinguish chylothorax from pseudochylothorax, which has a similar appearance, but is caused by more chronic inflammatory processes, and has a different treatment. The condition is rare but serious. It results from leakage of lymph fluid from the thoracic duct or one of its tributaries. There are many treatments, both surgical and conservative. About 2 to 3 percent of pleural effusions are chylothoraces.
Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.
Respiratory disease is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, and the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, acute asthma and lung cancer.
Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart function. A pericardial effusion with enough pressure to adversely affect heart function is called cardiac tamponade. Pericardial effusion usually results from a disturbed equilibrium between the production and re-absorption of pericardial fluid, or from a structural abnormality that allows fluid to enter the pericardial cavity.
The costodiaphragmatic recess, also called the costophrenic recess or phrenicocostal sinus, is a potential space in the pleural cavity, at the posterior-most tips of the cavity, located at the junction of the costal pleura and diaphragmatic pleura. It measures approximately 5 cm vertically and extends from the eighth to the tenth rib along the mid-axillary line.
Subcutaneous emphysema is when gas or air is in the layer under the skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies; this sensation of air under the skin is known as subcutaneous crepitation.
Fibrothorax is a medical condition characterised by scarring (fibrosis) of the pleural space surrounding the lungs that is severe enough to cause reduced movement of the lung and ribcage. The main symptom of fibrothorax is shortness of breath. There also may be recurrent pleural effusions. Fibrothorax may occur as a complication of many diseases, including infection of the pleural space known as an empyema or bleeding into the pleural space known as a haemothorax. Fibrosis in the pleura may be produced intentionally using a technique called pleurodesis to prevent recurrent punctured lung or pneumothorax, and the usually limited fibrosis that this produces can rarely be extensive enough to lead to fibrothorax. The condition is most often diagnosed using an X-ray or CT scan, the latter easier to detect in mild cases. Fibrothorax is often treated conservatively with watchful waiting but may require surgery. The outlook is usually good as long as there is no underlying pulmonary fibrosis or complications following surgery. The disease is highly uncommon.
Rheumatoid lung disease is a disease of the lung associated with RA, rheumatoid arthritis. Rheumatoid lung disease is characterized by pleural effusion, pulmonary fibrosis, lung nodules and pulmonary hypertension. Common symptoms associated with the disease include shortness of breath, cough, chest pain and fever. It is estimated that about one quarter of people with rheumatoid arthritis develop this disease, which are more likely to develop among elderly men with a history of smoking.
Tumor-like disorders of the lung pleura are a group of conditions that on initial radiological studies might be confused with malignant lesions. Radiologists must be aware of these conditions in order to avoid misdiagnosing patients. Examples of such lesions are: pleural plaques, thoracic splenosis, catamenial pneumothorax, pleural pseudotumor, diffuse pleural thickening, diffuse pulmonary lymphangiomatosis and Erdheim-Chester Disease.
Tracheal deviation is a clinical sign that results from unequal intrathoracic pressure within the chest cavity. It is most commonly associated with traumatic pneumothorax, but can be caused by a number of both acute and chronic health issues, such as pneumonectomy, atelectasis, pleural effusion, fibrothorax, or some cancers and certain lymphomas associated with the mediastinal lymph nodes.
Thoracic endometriosis is a rare form of endometriosis where endometrial tissue is found in the lung parenchyma and/or the pleura. It can be classified as either pulmonary, or pleural, respectively. Endometriosis is characterized by the presence of tissue from the lining of the uterus forming abnormal growths elsewhere in the body. Usually these growths are found in the pelvis, between the rectum and the uterus, the ligaments of the pelvis, the bladder, the ovaries, and the sigmoid colon. The cause is not known. The most common symptom of thoracic endometriosis is chest pain occurring right before or during menstruation. Diagnosis is based on clinical history and examination, augmented with X-ray, CT scan, and magnetic resonance imaging of the chest. Treatment options include surgery and hormones.