Pneumothorax: Pneumothorax refers to the presence of air within the pleural space and may occur spontaneously, after trauma, post-surgery, or viaiatrogenic means. Spontaneous pneumothorax may develop in patients without a known underlying lung disease (primary pneumothorax) and in those with diagnosed underlying lung disease (secondary pneumothorax), especially COPD. A spontaneous pneumothorax of either cause is likely to present with a sudden onset of ipsilateral pleuritic chest pain, with varying degrees of breathlessness (Brims, Davies et al. 2010).
Demographics: In the United States in 2006, 10% of all admissions to emergency departments were a result of diseases of the respiratory system, and chest pain was the most frequent presenting complaint (Brims, Davies et al. 2010). The age adjusted incidences of primary and secondary pneumothorax in the United States of America is estimated to be 4.2 and 3.8 cases per 100 000, respectively. The incidence of primary spontaneous pneumothorax was 7.4 per 100 000 in men and 1.2 per 100 000 in women (a male/female ratio of 6.2:1), and that of secondary spontaneous pneumothorax was 6.3 per 100 000 in men and 2 per 100 000 in women (a male/female ratio of 3.2:1) (Rivas de Andres, Jimenez Lopez et al. 2008).
Clinical Presentation: Most cases of pneumothorax, the classic presentation of pleuritic pain is pain that increases with forceful breathing movement, such as taking a deep breath, talking, coughing, or sneezing, exacerbates the pain as the rib cage is expanding. Typically, they will assume a posture that limits motion of the affected area. The chief complaints are pain with respiration and shortness of breath or dyspnea (Kass, Williams et al. 2007). The pain referral pattern is to the ipsilateral scapula.
Differential Diagnosis: It is important to remember that a through subjective exam is imperative. Pulmonary disease is rarely manifested as a pain syndrome without associated symptoms of disease being present (Boissonnault and Bass 1990). Due to the large variety of conditions that cause pleuretic pain.
It is important to note that gastrointestinal disorders such as biliary colic and acute appendicitis have similar pain referral patterns. It is also important to rule out other causes of pleuritic pain. Refer to pulmonary page.
Physical Examination: Should include percussion and auscultation of the chest, which may reveal signs of hyperresonance with percussion and decreased breath sounds are indicators of a pneumothorax. The presence of constitutional signs and symptoms indicate systemic illness.
Bottom Line:Refer out A patient that presents to physical therapy with the fore-mentioned presentation should be referred to their primary physician for further testing. A patient with a positive Wells Test should be sent immediately to the Emergency Room. A follow up with the referring physician is important, as the patient may have true musculoskeletal pain in the thoracic region as a result of faulty pain postures, but should not be treated in physical therapy until the systemic illness is resolved.
Please refer to the "Pneumothorax" section of the reference list.