Pain With Deep Breathing: Symptoms, Causes, and Diagnosis

Understanding Pleuritic Chest Pain (Pleurisy)

women who is having pain with a deep breath
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If you are having pain with breathing, whether normal breathing or when taking a deep breath, you’re likely feeling worried. Doctors describe the kind of pain that occurs with taking a deep breath as “pleuritic chest pain" or "pleurisy." The name comes from one of the common causes of this pain: irritation of the pleura, the membranes lining the lungs. But there are actually many possible causes of this kind of pain.

What are some of the causes, when could your symptoms be an emergency, and what tests might your doctor recommend to diagnose your symptoms?

Pain With Deep Breathing: Pleuritic Chest Pain

As noted above, physicians use the phrase "pleuritic chest pain" to describe pain in the chest region which occurs with breathing. The pain may occur only with breathing or may be present all the time and become more pronounced when taking a deep breath. Pleuritic chest pain often feels sharp, rather than dull or heavy, but there are exceptions to this general rule.

When Is Pain With Breathing an Emergency?

Before discussing the possible causes of pain with breathing, it's important to be aware of when you should call 911. If you have any of the following symptoms along with painful breathing, read no further and call for emergency medical care:

  • Pain which is severe or that came on suddenly
  • Difficulty catching your breath or severe shortness of breath
  • Pain, swelling, or redness in either of your legs (which could be a blood clot) along with pain with breathing
  • Lightheadedness or fainting
  • Coughing up blood, even if only a small amount (even a teaspoon is considered a medical emergency)
  • A feeling of impending doom: If you can't explain what you mean but feel like what you are experiencing is an emergency, trust your instinct and call 911

    One of the more common causes of pleuritic chest pain is a pulmonary embolus, a blood clot that breaks off in the legs and travels to the lungs. This is a life-threatening emergency and can rapidly lead to death if untreated. In a 2017 study it was noted that 5 to 21 percent of people who went to the emergency room with pleuritic chest pain were found to have a pulmonary embolus.

    Mechanisms of Pleuritic Chest Pain (Pain with Breathing)

    Before going into the possible causes of pain with breathing, it's helpful to talk about the mechanisms that might cause this kind of pain. Pain with breathing may occur with conditions affecting almost any of the structures present in the chest. These include:

    • The ribs
    • The ligaments, muscles, and other soft tissues of the chest
    • The thoracic spine
    • The lungs and the lining of the lungs
    • The heart and the lining of the heart (pericardium)
    • The esophagus
    • The breast

    Painful Breathing vs Pleuritic Chest Pain vs Pleurisy

    If you have been reading about painful breathing or painful respiration, you may find this topic confusing. This is because painful breathing can be called many different things. The term "pleuritic chest pain" is usually used to describe any pain which occurs with respiration.

    In contrast, the term pleurisy may be used in a few different ways. Pleurisy is sometimes used to describe any sharp pain which occurs with a deep breath, but other times is used specifically to describe inflammation of the pleura, the two membranes that line and protect the lungs during respiration. There is overlap in using these terms. For example, some conditions such as pneumonia may cause the specific condition of pleurisy (irritation and inflammation of the pleura), but may also cause pain with breathing due to other mechanisms such as bruised or even fractured ribs and muscle strains from coughing.

    Possible Causes of Pain with Breathing

    There are many possible causes of pain with breathing which range from being simply a nuisance to very serious in nature. Some of the more common causes are broken down below by body system.

    Lung-Related Causes of Painful Breathing

    While the lungs themselves do not have pain receptors, medical conditions involving the lungs can cause pain in several ways, including those that cause irritation of the pleura. Some of these include:

    • Pleurisy: As noted above, inflammation of the pleura, referred to as "pleurisy," is a common cause of pain with breathing. Pleurisy may occur alone or be related to another condition such as those mentioned below. It may also occur following an upper respiratory infection, and seem to last forever.
    • Viral infections: The most common viruses that can cause pleuritic chest pain include Coxsackie virus, respiratory syncytial virus (RSV), influenza, parainfluenza, mumps, adenovirus, cytomegalovirus (CMV), and the Epstein Barr virus (that causes infectious mononucleosis).
    • Pneumonia: Infections in the lung, especially those in the outer regions of the lungs near the pleural lining, can cause pain with breathing.
    • Lung cancer: It's thought that roughly half of people diagnosed with lung cancer have pain somewhere in their chest region at the time of diagnosis. It's not uncommon for this pain to change with breathing, especially if a tumor is located in the outer regions of the lungs near the pleura. Currently, the most common type of lung cancer, lung adenocarcinoma, tends to grow in the periphery of the lung near the pleura. This is the type of lung cancer that is most common in people who have never smoked, women, and young adults with lung cancer.
    • Tuberculosis (TB): TB is a relatively uncommon cause of pain with breathing in the United States, but is a very common cause worldwide.
    • Pleural effusions: Fluid collections between the layers of the pleura, referred to as pleural effusions, are a common cause of pain with breathing. Yet, just as pain with breathing is a non-specific symptom, pleural effusions can be related to any number of diseases, ranging from lung disease and heart disease to autoimmune conditions such as rheumatoid arthritis, and cancer. Malignant pleural effusions are pleural effusions which contain cancer cells. These may occur in people with lung cancer, breast cancer, and other cancers which spread to the lungs.
    • Pneumothorax: A pneumothorax is a collapse of part or all of a lung. The collapse may be very small and asymptomatic, or it may be large and cause not just pain with breathing but also severe shortness of breath and even subcutaneous emphysema, a condition in which the skin of the chest feels like bubble wrap due to the escape of air from the lungs. A pneumothorax may occur as a complication of emphysema, other lungs diseases, or trauma, or may occur spontaneously in otherwise healthy adults.
    • Pulmonary embolus: A potentially life-threatening condition, pulmonary emboli occur when clots break off in the veins of the legs (deep vein thrombosis) and travel to the lungs. As with a pneumothorax, symptoms can range from minimal to severe, and this condition is a medical emergency. Risk factors for pulmonary emboli include recent surgery, many chronic diseases, pregnancy, and long distance travel by car or plane. As noted above, a pulmonary embolus is common finding in people who go to an emergency room with pleuritic chest pain.
    • Mesothelioma: Mesothelioma is a cancer which arises in the pleura and is most common in people who have had exposure to asbestos on the job.

    Heart-Related Causes of Painful Breathing

    Since the heart lies near the lungs (and pleura) and moves with respiration, heart conditions may cause pain with breathing. Some heart-related conditions which cause pleuritic chest pain include:

    • Pericarditis: Pericarditis refers to an inflammation of the membranes lining the heart (pericardium) that are similar to those lining the lungs. Pericarditis has many causes including infections, cancer (most commonly lung cancer and breast cancer), autoimmune conditions such as lupus, and kidney disease. Around 15 percent of people who have a heart attack develop pericarditis as well.
    • Heart attacks: Most often, the pain associated with a heart attack is not associated with breathing, yet an increase in pain with a deep breath may occur, especially if the heart attack is accompanied by pericarditis as noted above.
    • Aortic dissection: An aortic dissection is a condition where a weakening in the aorta allows blood to spill into the lining "dissect" the inner lining of the aorta, and is a medical emergency. it often causes a severe, tearing type of pain that may be felt in the chest and the back. It often occurs in people with Marfan syndrome, frequently men who are very tall and lean.
    • Pulmonary hypertension: Pulmonary hypertension is a serious condition in which the blood pressure in the pulmonary artery is elevated. (It is different than the hypertension most people are familiar with and is diagnosed with an echocardiogram rather than a blood pressure cuff.) The pulmonary artery is responsible for carrying blood from the heart to the lungs to pick up oxygen. Pulmonary hypertension can, in turn, be caused by a number of conditions including heart disease, lung disease, connective tissue disorders, and some medications.

    Musculoskeletal Causes of Painful Breathing

    Conditions involving any of the bony or soft tissue structures in the chest may cause pain which occurs or gets worse with breathing. Some of these include:

    • Rib fractures: A rib fracture as a cause of pain with breathing is often obvious, but sometimes these fractures may occur with coughing or with only minimal trauma in people with osteoporosis. A rib stress fracture, a type of overuse injury, however, may not be as obvious. The pain of a rib stress fracture often comes on gradually and is worse with a deep breath and with coughing.
    • Costochondritis and Tietze syndrome: Costochondritis and Tietze syndrome are conditions which involve inflammation of the region where the ribs join together and/or where the ribs connect with the sternum (the breastbone). With costochondritis, there may be swelling of this region, whereas with Tietze syndrome there is not. The chest pain associated with these conditions has often been mistaken for a heart attack. Since the ribs, and hence the rib junctions move with each breath, the pain is often related to breathing, especially taking a deep breath.

    Other Possible Causes of Painful Breathing

    • Shingles: When the chickenpox virus "reactivates" in the distribution of a nerve which supplies the chest, it may lead to chest pain and—depending on the location—the pain may change with respiration. While shingles usually involves a rash, the pain often precedes the rash by a few days, making the diagnosis unsure at first.
    • Acid reflux: Pain that occurs due to gastroesophageal reflux disease (GERD) is not usually associated with breathing, but may worsen with a deep breath.

    Associated Symptoms

    There are a number of symptoms which may occur along with painful breathing that can help you and your doctor determine the cause of your pain. Some of these include:

    Questions Your Doctor May Ask You

    In addition to asking about the possible associated symptoms above, your doctor will likely ask you:

    • Did you, or have you ever, smoked?
    • Have you had any injuries or trauma, including even minor trauma?
    • Have you had a respiratory infection such as a cold or the flu?
    • When did the symptoms begin, and how long have they been going on?
    • Have you ever had similar symptoms in the past?
    • What other medical problems do you have?
    • What medical conditions run in your family?
    • Have you started a new exercise program, or engaged in any physical activity that could have put strain on the muscles and other structures in your chest?
    • Do the symptoms occur all the time, or only at specific times, such as going outside when it is cold?

    Tests Your Doctor May Order

    Depending on your symptoms, there are a number of different tests your physician may recommend. These include:

    • A chest x-ray: Keep in mind that a chest x-ray may help to diagnose a condition, but it cannot exclude a condition. For example, a pulmonary embolus or lung cancer may be present despite a normal chest x-ray. In fact, small lung cancers are commonly missed on an x-ray and not discovered until they reach a stage when they are no longer curable. A missed pulmonary embolus is also serious, and can be catastrophic if not diagnosed promptly.
    • Rib x-rays.
    • Ventilation-perfusion scan: This is a test done to look for evidence of a pulmonary embolism.
    • Chest CT scan: A chest CT scan may be used to evaluate several chest related conditions. It may be done, as well, to get a more accurate view of the ribs and bony structures in the chest.
    • CT angiography.
    • Electrocardiogram (EKG)
    • Echocardiogram: An echocardiogram (an ultrasound test of your heart) may be done to look for inflammation or fluid in the membranes lining the heart (pericarditis or a pericardial effusion).
    • Oximetry: An oximetry is a test that is used to measure the oxygen level in your blood. It can sometimes give clues to underlying lung or heart conditions.
    • Pulmonary function tests.
    • A D-dimer test.

    Treatments for Painful Breathing

    The treatment options for painful breathing will depend on the specific cause. It's important to listen to your body if you are having pleuritic chest pain, and not "mask" your symptoms by using pain medications until you have had a thorough exam.

    Bottom Line on Pain With Breathing

    As noted above, there are many potential causes of painful breathing or pain with a deep breath that range from those that are primarily a nuisance to those that are life-threatening. It's important to remember that pain is a signal from our body telling us that something is wrong. It can be frustrating if you do not get a diagnosis right away, as often occurs with pain such as this, but continue to talk with your doctor until you have an answer. Ask for a referral to a specialist or get a second opinion if you still don't have a proper explanation for your discomfort. What is true with painful breathing is true of any medical condition—it’s important to be your own advocate in your health care to stay healthy.

    Sources:

    Berchuck, J., and S. Patel. An Often-Overlooked Etiology of Pleuritic Chest Pain. Journal of General Internal Medicine. 2016. 31(1):138.

    Jany, B. Pulmonary Causes of Chest Pain. Internist. 2017. 58(1):22-28.

    Reamy, B., Williams, P., and M. Odom. Pleuritic Chest Pain: Sorting Through the Differential Diagnosis. American Family Physician. 2017. 96(5):306-312.

    Yan, G., Littlewood, A., and M. Latimer. Unusual Cause of Pleuritic Chest Pain in a Child. BMJ Case Reports. 2016. pii: bcr2016217307.