At all stages of workup and treatment, patient-centered care is to be the standard. The care of the patient with mesothelioma will necessitate consultations with an oncologist, radiation oncologist, and surgeon, among other physician specialists. Effective communication between the referring physician and radiologist is essential to ensure imaging assessment takes place with special attention to the myriad causes of a pleural friction rub.

In the emergency department setting, the clinician must rule out life-threatening causes by obtaining the requisite investigations immediately. Life-threatening causes of pleural friction rub include pulmonary embolus and malignant pleural effusion, and rapid diagnosis and treatment have a marked effect on patient outcomes. Excellent history-taking and documentation will facilitate identifying the cause of the rub. The identification of a pleural friction rub poses a diagnostic dilemma to the clinician this is a non-specific finding with a broad differential. For instance, decreased breath sounds with increased tactile fremitus and history of infective symptoms may increase the clinician’s suspicion for pneumonia. Important factors in the history of the patient include accompanying symptoms, history of infection, and occupational history. The sound does not change after a bout of coughing.Īdditional findings on history and physical exam will be suggestive of the underlying pathology. A typical description of the sound is that it “sounds like walking on fresh snow.” The pleural friction rub is biphasic (heard on inspiration and expiration), usually localized to a small area of the chest, and may be accentuated by increasing the pressure on the stethoscope. On auscultation, pleural friction rub is a non-musical, short explosive sound, described as creaking or grating and likened to walking on fresh snow. The sound may be intermittent or continuous.

The patient may complain of local tenderness with palpation, depending on the underlying etiology. This sensation is suggestive of a pleural rub. Upon palpation of the chest, the clinician may note a sandpaper-rubbing type of sensation. If the underlying cause of the pleural rub is pleural effusion, patients may experience some relief from leaning forward and supporting their upper body with hands placed on the knees or another surface. Patients will often complain of pleuritic chest pain, which is sudden, intense, and worse with movement, such as respiration. The visceral pleura lacks somatic innervation and nociceptors. Somatic nerves innervating the parietal pleura are responsible for this pattern of pain. While the visceral pleura lacks somatic innervation and nociceptors, somatic nerves innervating the parietal pleura relay the sensation of pain. If the site of inflammation is near the diaphragm, pain can refer to the neck or shoulder. Often, pleural friction rub is accompanied by pleuritic chest pain, which is characterized by sudden, intense, and sharp pain that is worse with inspiration.

The characteristic grating sound of the pleural rub is believed to result from the release of energy when the inflamed pleural surfaces overcome the increased friction and slide past one another.

Pleural friction rub occurs when inflammation roughens the surfaces of the visceral and parietal pleura. In this setting, friction between the pleura further increases due to decreased production of lubricating fluid (pleural fluid) by the pleura.

Rhonchi lung sound