Respiratory chest pain
Chest pain can arise from the cardiovascular system, the respiratory system, the oesophagus or the musculoskeletal system. Respiratory chest pain is usually very different from ischaemic chest pain, as it is characteristically sharp, and worse on inspiration.
On enquiring about chest pain ask about the site, nature (sharp, burning, tearing), radiation, precipitating/relieving factors (deep inspiration, coughing, movement) and any associated symptoms such as dyspnoea. Ask also about the time course, i.e. onset, duration, constant or episodic.
Chest pain made worse by inspiration and coughing is called pleuritic pain. It is sharp and usually localised to one area. It is caused by inflamed pleural surfaces rubbing on one another. Causes include infection (may be associated with pneumonia), pneumothorax, pulmonary embolism and mesothelioma or metastatic tumours to the pleura. Pleurisy may also be caused by connective tissue diseases such as rheumatoid arthritis.
Chest wall pain may be easily confused with pleuritic pain, as it is often sharp, but it can be reproduced by movement of the thoracic spine, chest or shoulders, and by eliciting tenderness with mechanical pressure. Common causes include intercostal nerve entrapment, persistent cough, muscular strains, rib fracture and Tietze’s syndrome (costochondritis).
A dull, constant severe chest wall pain may be due to invasion of the thoracic wall by malignancy. Other causes include thoracic herpes zoster – a persistent pain, which may be burning and last several days before the rash appears.
Retrosternal pain may be due to tracheitis or mediastinal disease (lymphoma, mediastinitis) but is more commonly cardiac.
Central chest pain, particularly if radiating to the neck or arms, is more likely to be cardiac. Pericarditis causes a sharp retrosternal/precordial pain which may mimic pleuritic pain as it may be exacerbated by deep inspiration, but is classically relieved by leaning forwards. Pain at the shoulder tip is often referred pain from the diaphragm, and may reflect an abdominal cause such as cholecystitis. Equally, respiratory disease may manifest with abdominal pain, e.g. basal pneumonia causing upper abdominal pain.