bubble_chart Overview

The accumulation of air in the pleural cavity due to chest trauma is called traumatic pneumothorax. It is often caused by severe chest injuries that damage the pleura, lungs, or bronchi. Common causes include crush injuries to the chest, rib fractures, and penetrating chest wounds. The incidence of traumatic pneumothorax in chest injuries is second only to rib fractures. Pneumothorax frequently occurs with rib fractures and is often accompanied by hemothorax.

bubble_chart Type

Based on the state of the air passage, changes in pleural cavity pressure, and the degree of impact on the respiratory and circulatory systems, traumatic pneumothorax is classified into the following three categories.

1. Closed pneumothorax: The wound in the chest wall or lung closes rapidly after air enters the pleural cavity, preventing further air entry. The pleural cavity pressure remains lower than atmospheric pressure. The injured lung is partially collapsed, while the healthy lung can compensate functionally, resulting in relatively mild effects on respiration and circulation.
2. Open pneumothorax: The wound in the chest wall or lung is large, allowing free communication between the pleural cavity and the external environment. The pleural cavity pressure equals atmospheric pressure. The injured lung collapses, and the pressure in the injured pleural cavity becomes higher than that in the healthy side, causing the mediastinum to shift toward the healthy side, which also experiences varying degrees of compression. The severity of open pneumothorax depends on the size of the wound. If the diameter of the chest wall wound exceeds the size of the glottis (2.75 cm in adults), the large volume of air entering and exiting can cause severe respiratory and circulatory disturbances. The larger the chest wall wound, the more severe the tendency of the disease and the higher the mortality rate.
3. Tension pneumothorax (high-pressure pneumothorax): The wound in the chest wall, lung, or bronchus acts as a one-way valve, opening during inhalation to allow air into the pleural cavity and closing during exhalation to prevent air from escaping. As a result, with each breath, the volume of air in the injured pleural cavity continuously increases, raising the pleural pressure above atmospheric pressure. The injured lung is completely collapsed, and the mediastinum is pushed toward the healthy side, compressing the healthy lung and significantly reducing ventilation. Due to mediastinal displacement and increased pleural pressure, the vena cava becomes twisted, reducing venous return and cardiac output, leading to respiratory and circulatory failure. Because the superior and inferior vena cava and the right atrium are adjacent to the right pleural cavity, right-sided tension pneumothorax is more dangerous than left-sided. Occasionally, high-pressure air in the pleural cavity enters the mediastinum and spreads to subcutaneous tissues, causing subcutaneous emphysema in the neck, face, or chest.

All types of pneumothorax, especially open and tension pneumothorax, if heavily contaminated or improperly managed, can easily lead to pulmonary consolidation, lung infection, or empyema.

bubble_chart Clinical Manifestations

1. Closed pneumothorax: Small pneumothorax with lung compression less than 30% may present no obvious symptoms. If lung compression exceeds 30%, symptoms such as chest tightness, shortness of breath, or dyspnea may occur. Signs: With lung compression less than 30%, there may be no obvious signs. If lung compression exceeds 30%, respiratory movement on the affected side weakens, and the trachea and cardiac dullness shift toward the healthy side. Percussion of the affected chest reveals tympany, with diminished or absent breath sounds. When combined with hemopneumothorax, tympany is heard on percussion in the upper part, while dullness is heard in the lower part.
2. Open pneumothorax: Symptoms include rapid breathing, palpitation, and dyspnea, even cyanosis or shock. Signs: Rapid breathing, an open wound on the chest wall, and a sucking sound of air freely entering and exiting the pleural cavity with respiration may be heard. The trachea and cardiac dullness shift toward the healthy side. Percussion of the affected chest reveals tympany, with absent breath sounds.
3. Tension pneumothorax: Severe dyspnea that progressively worsens, cyanosis, or even shock. Signs: Restlessness, cyanosis, or even unconsciousness. Jugular and peripheral venous distension, fullness of the affected chest, widened intercostal spaces, weakened respiratory movement, and possible subcutaneous emphysema. The trachea and cardiac dullness shift markedly toward the healthy side. Percussion of the affected chest reveals hyper-resonance, with absent breath sounds.

bubble_chart Diagnosis

1. History of chest trauma.
2. Closed pneumothorax: If lung compression is less than 30%, there may be grade I tachypnea or no obvious symptoms. If lung compression exceeds 30%, symptoms may include chest tightness and shortness of breath. Percussion reveals tympany on the injured side, with diminished or absent breath sounds. X-ray shows pneumothorax, lung collapse, and mediastinal shift on the affected side.
3. Open pneumothorax: Respiratory distress is more pronounced, with possible cyanosis and shock. An open wound is present on the chest wall, and the sound of air entering and exiting through the wound can be heard, indicating communication between the pleural cavity and the external environment.
4. Tension pneumothorax: Severe respiratory distress, even cyanosis and shock. Mediastinal shift is extremely prominent, with over 80% of cases presenting subcutaneous emphysema.
5. Thoracentesis yields gas, and in tension pneumothorax, high-pressure gas rushes outward.

bubble_chart Treatment Measures

1. Closed pneumothorax: If lung compression is less than 30% and there are no obvious symptoms, no intervention is necessary. Encourage the patient to perform lung expansion exercises, and the accumulated air will be absorbed spontaneously within 1–2 weeks. If lung compression exceeds 30%, perform thoracentesis to aspirate air from the affected side at the midclavicular line of the second rib. If symptoms grade I alleviate after aspiration but soon worsen again, closed thoracic drainage should be performed. Administer antibiotics to prevent infection.
2. Open pneumothorax: Immediately seal the chest wall wound at the end of the patient’s exhalation using an emergency kit or sterile gauze, then secure it with a bandage or adhesive tape to convert it into a closed pneumothorax. Once the condition is relatively stable, perform debridement and suturing as soon as possible, followed by closed thoracic drainage. If there is severe injury to intrathoracic organs, exploratory thoracotomy should be performed promptly. For significant loss of blood, administer blood transfusions, and routinely provide antibiotics and TAT.
3. Tension pneumothorax: Emergency treatment is required to immediately decompress the chest. Insert a tube at the midclavicular line of the second intercostal space on the injured side for closed thoracic drainage. For on-site first aid, a thick needle can be inserted into the pleural cavity at the midclavicular line of the second intercostal space (upper edge of the rib) to allow gas escape, and connect it to a water-seal bottle with a sterilized rubber tube for continuous drainage. However, this thick needle should be promptly replaced with a thoracic drainage tube to prevent lung injury upon re-expansion.
4. If the drainage tube continuously discharges a large amount of gas, consider the possibility of tracheal or bronchial rupture and proceed with further examination and treatment.
5. For cases complicated by hemothorax, perform closed thoracic drainage in the lower chest or take corresponding measures.

In the management of combined or multiple injuries, prioritize the treatment of pneumothorax with existing respiratory distress using simple methods to alleviate symptoms. Simultaneously, actively address life-threatening injuries, such as anti-shock measures and surgery to control massive bleeding. For closed pneumothorax, first aspirate air at the midclavicular line of the second intercostal space on the injured side. If symptoms grade I improve after aspiration but soon worsen again, proceed with closed thoracic drainage. For open pneumothorax, on-site first aid is critical—immediately seal the open chest wound with a large dressing to convert it into a closed pneumothorax, then proceed with thoracentesis or closed thoracic drainage. Once the condition stabilizes, perform wound debridement. Tension pneumothorax requires urgent decompression without delay or waiting for chest X-rays. If hypotension occurs due to tension pneumothorax, cardiac arrest may follow within minutes. For on-site rescue, insert a thick needle into the pleural cavity at the midclavicular line of the second intercostal space (upper edge of the rib) for decompression, then replace it with a thoracic catheter for closed drainage to prevent lung injury upon re-expansion. If tension pneumothorax leads to tension mediastinal emphysema with mediastinal compression symptoms and significant subcutaneous emphysema, make a transverse incision one fingerbreadth above the suprasternal notch under local anesthesia, incise the pretracheal fascia, and bluntly separate the loose tissue of the superior mediastinum with a finger. Leave the incision unsutured or insert a rubber tube (with side holes and serrated ends) for drainage.

bubble_chart Cure Criteria

1. Cure: Symptoms and signs disappear (chest wall wound healed). X-ray examination shows resolution of intrathoracic air and fluid, lung re-expansion, and no mediastinal shift.
2. Improvement: Symptoms and signs are alleviated, and other complications improve.
3. No cure: Symptoms and signs show no improvement, other complications persist, and X-ray examination reveals persistent intrathoracic air and fluid.