A pleural friction rub is a loud, coarse, grating, creaking, or squeaking sound auscultated over one or both lungs, usually during late inspiration or early expiration. It arises from inflammation of the visceral and parietal pleura, which causes the normally lubricated surfaces to rub together.

Pleural friction rubs are commonly associated with pulmonary disorders or trauma. Sometimes intermittent, they may resemble crackles or a pericardial friction rub.

Best auscultation: Low axilla or anterior, lateral, or posterior lung bases with the patient upright, breathing deeply and slowly through the mouth.

Emergency interventions

• Assess for respiratory distress: shallow respirations, crowing/wheezing/stridor, dyspnea, accessory muscle use, intercostal or suprasternal retractions, cyanosis, nasal flaring.

• Check vital signs: hypotension, tachycardia, decreased level of consciousness.

• Maintain airway, provide supplemental oxygen, and prepare for endotracheal intubation if needed.

• Establish a large-bore IV for fluids and drugs.

• Elevate head of the bed 30 degrees and monitor cardiac status constantly.

History and Physical Examination

If the patient is stable:

1. Chest pain assessment

   • Location, severity, duration

   • Radiation (shoulder, neck, upper abdomen)

   • Triggers: breathing, movement, coughing, sneezing

   • Relief: splinting, breath-holding, pressure, lying on affected side

2. Past medical history

   • Rheumatoid arthritis, respiratory or cardiovascular disorders

   • Recent trauma, asbestos exposure, or radiation therapy

   • Smoking history (pack-years)

3. Auscultation

   • Patient sitting upright, breathing deeply and slowly

   • Determine unilateral or bilateral rub

   • Listen for absent or diminished breath sounds

   • Observe if abnormal sounds clear with coughing

4. Physical signs

   • Clubbing, pedal edema (chronic disorder)

   • Palpate for decreased chest motion

   • Percuss for flatness or dullness

Medical causes

Special considerations

• Monitor respiratory status and vital signs frequently.

• Administer antitussive if dry, hacking cough is tiring (avoid opioids).

• Provide oxygen and antibiotics as needed.

• Prepare patient for diagnostic tests (chest X-ray, CT scan).

Patient counseling

• Explain pain relief strategies.

• Discuss symptoms that require urgent reporting, such as worsening dyspnea, hemoptysis, or cyanosis.

Pediatric pointers

• Auscultate for pleural friction rub in children with grunting respirations, chest pain, or chest protection behaviors.

• In children, a rub is usually an early sign of pleurisy.

Geriatric pointers

• Intensity of pleuritic chest pain may mimic cardiac chest pain.

• Careful assessment needed due to age-related comorbidities.

References

• Buttaro, T. M., Tybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2008). Primary Care: A Collaborative Practice (pp. 444–447). St. Louis, MO: Mosby Elsevier.

• Colyar, M. R. (2003). Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis.

• McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier.

• Sommers, M. S., & Brunner, L. S. (2012). Pocket Diseases. Philadelphia, PA: F.A. Davis.