Pleurisy: Symptom or Condition?
The management and treatment of pleurisy involve a thorough assessment of the patient, control of pleuritic chest pain, and treatment of the underlying condition (Table 3). Treatment is determined after a detailed patient evaluation, which should include inquiries regarding past medical history, social and family history, and current medications, as well as questions specifically addressing the pleuritic pain the patient is experiencing. Factors to discuss include (but are not limited to) pain onset and duration, type of pain, and relieving factors (drugs or positioning).
For pleurisy and associated pleuritic chest pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed as initial therapy to treat inflammation of the pleural space. NSAIDs are ideal because they do not cause a reduction in respiratory drive or affect the cough reflex. If NSAIDs are ineffective, contraindicated, or not tolerated, opioid analgesics may be used with caution. While it is assumed that a class effect occurs when NSAIDs are used, human studies on the use of NSAIDs to treat pleuritic chest pain have been limited to indomethacin. The recommended dosage of indomethacin for pleuritic chest pain is 50 to 100 mg orally up to three times daily with food or milk.
In 1984, Klein evaluated the use of indomethacin in 17 patients with pleurisy. Patients evaluated their pain relief every 24 hours, rating it as excellent, good, fair, or poor. Eleven patients (65%) obtained good-to-excellent pain relief within 24 hours. Although patients had the option of selecting other analgesic treatments, none chose an alternative method; however, five patients (29%) discontinued indomethacin after failure of pain relief after 24 hours of therapy. Pain nonrecurrence following discontinuation of indomethacin after 72 hours of treatment was noted. Indomethacin was concluded to be a viable and recommended option for the treatment of pleuritic pain.
The use of tricyclic antidepressants or anticonvulsants may have a limited role in the treatment of patients with neuropathic pain and persistent pleuritic pain syndromes. Psychological factors may intensify patients' views and fear of pain. There is a strong relationship between pain intensity and interference with daily activities, thereby reducing overall quality of life. Measures to minimize these psychological factors can be as important as medications in optimizing pain control. Once the cause of pleurisy has been diagnosed, specific treatment modalities should be initiated.
The remainder of this section will discuss specialized treatment of the more common causes of pleurisy.
Pneumothorax, which is the presence of air within the pleural space, may occur spontaneously, after trauma, postsurgery, or iatrogenically. While the specific mechanism of pleuritic chest pain secondary to pneumothorax is poorly understood, it is suggested that air in the pleural space may cause eosinophilic pleural inflammation. Although no defined drug treatments exist for pneumothorax, most cases resolve spontaneously or with conventional management. Immediate attention should be given to patients presenting with tension pneumothorax, as this can be a life-threatening cause of pleuritic chest pain. In cases of spontaneous pneumothorax, intrapleural local anesthetic agents (i.e., bupivacaine) have been studied, with limited results.
Pleuritic chest pain is caused by irritation of the parietal pleura resulting from inflammation of the underlying visceral pleura affected by the embolus. It may arise following the initial symptoms of pulmonary embolism. Prompt identification and management based on current clinical guidelines should be initiated expeditiously.
Pleural malignancies can originate in the pleura and chest wall or may present as metastases from extrapleural cancers (e.g., mesothelioma). Pain management in patients with pleural malignancies is aimed at improving pain, alleviating dyspnea, and enhancing the patient's quality of life. When pharmacologic measures (i.e., NSAIDs, opioid analgesics) cannot control the patient's pain, radiotherapy may be an alternative for palliative alleviation of chest-wall pain. While not fully maintained, radiotherapy has been demonstrated to relieve chest pain in approximately 60% of patients with mesothelioma.
Patients who present with pneumonia, either community-acquired or hospital-acquired, often have pleuritic chest pain that is localized to the area of infection. Brandenburg and colleagues conducted a prospective cohort study assessing features of pneumococcal pneumonia and symptoms 30 days after the infection. Thirteen percent of patients had pleuritic chest pain that persisted for 30 days. Pain that is associated with these infections is thought to develop from pleural inflammation secondary to involvement of the lung parenchyma with infection. Treatment should target the specific causative organism, with appropriate antimicrobial therapy.
Treatment Modalities
The management and treatment of pleurisy involve a thorough assessment of the patient, control of pleuritic chest pain, and treatment of the underlying condition (Table 3). Treatment is determined after a detailed patient evaluation, which should include inquiries regarding past medical history, social and family history, and current medications, as well as questions specifically addressing the pleuritic pain the patient is experiencing. Factors to discuss include (but are not limited to) pain onset and duration, type of pain, and relieving factors (drugs or positioning).
For pleurisy and associated pleuritic chest pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed as initial therapy to treat inflammation of the pleural space. NSAIDs are ideal because they do not cause a reduction in respiratory drive or affect the cough reflex. If NSAIDs are ineffective, contraindicated, or not tolerated, opioid analgesics may be used with caution. While it is assumed that a class effect occurs when NSAIDs are used, human studies on the use of NSAIDs to treat pleuritic chest pain have been limited to indomethacin. The recommended dosage of indomethacin for pleuritic chest pain is 50 to 100 mg orally up to three times daily with food or milk.
In 1984, Klein evaluated the use of indomethacin in 17 patients with pleurisy. Patients evaluated their pain relief every 24 hours, rating it as excellent, good, fair, or poor. Eleven patients (65%) obtained good-to-excellent pain relief within 24 hours. Although patients had the option of selecting other analgesic treatments, none chose an alternative method; however, five patients (29%) discontinued indomethacin after failure of pain relief after 24 hours of therapy. Pain nonrecurrence following discontinuation of indomethacin after 72 hours of treatment was noted. Indomethacin was concluded to be a viable and recommended option for the treatment of pleuritic pain.
The use of tricyclic antidepressants or anticonvulsants may have a limited role in the treatment of patients with neuropathic pain and persistent pleuritic pain syndromes. Psychological factors may intensify patients' views and fear of pain. There is a strong relationship between pain intensity and interference with daily activities, thereby reducing overall quality of life. Measures to minimize these psychological factors can be as important as medications in optimizing pain control. Once the cause of pleurisy has been diagnosed, specific treatment modalities should be initiated.
The remainder of this section will discuss specialized treatment of the more common causes of pleurisy.
Pneumothorax
Pneumothorax, which is the presence of air within the pleural space, may occur spontaneously, after trauma, postsurgery, or iatrogenically. While the specific mechanism of pleuritic chest pain secondary to pneumothorax is poorly understood, it is suggested that air in the pleural space may cause eosinophilic pleural inflammation. Although no defined drug treatments exist for pneumothorax, most cases resolve spontaneously or with conventional management. Immediate attention should be given to patients presenting with tension pneumothorax, as this can be a life-threatening cause of pleuritic chest pain. In cases of spontaneous pneumothorax, intrapleural local anesthetic agents (i.e., bupivacaine) have been studied, with limited results.
Pulmonary Embolism
Pleuritic chest pain is caused by irritation of the parietal pleura resulting from inflammation of the underlying visceral pleura affected by the embolus. It may arise following the initial symptoms of pulmonary embolism. Prompt identification and management based on current clinical guidelines should be initiated expeditiously.
Malignancy
Pleural malignancies can originate in the pleura and chest wall or may present as metastases from extrapleural cancers (e.g., mesothelioma). Pain management in patients with pleural malignancies is aimed at improving pain, alleviating dyspnea, and enhancing the patient's quality of life. When pharmacologic measures (i.e., NSAIDs, opioid analgesics) cannot control the patient's pain, radiotherapy may be an alternative for palliative alleviation of chest-wall pain. While not fully maintained, radiotherapy has been demonstrated to relieve chest pain in approximately 60% of patients with mesothelioma.
Pneumonia or Pleural Infection
Patients who present with pneumonia, either community-acquired or hospital-acquired, often have pleuritic chest pain that is localized to the area of infection. Brandenburg and colleagues conducted a prospective cohort study assessing features of pneumococcal pneumonia and symptoms 30 days after the infection. Thirteen percent of patients had pleuritic chest pain that persisted for 30 days. Pain that is associated with these infections is thought to develop from pleural inflammation secondary to involvement of the lung parenchyma with infection. Treatment should target the specific causative organism, with appropriate antimicrobial therapy.