The presence of air in the pleural cavity is called pneumothorax. The incidence of traumatic pneumothorax accounts for approximately 15-50% in blunt trauma and 30-87.6% in penetrating injuries. In the vast majority of cases, the air in pneumothorax originates from the lung being punctured by the fractured ends of ribs (superficial cases are termed lung rupture, while deeper cases involving small bronchi are called lung lacerations). It can also result from violent forces causing contusions or lacerations of the bronchi or lung tissue, or from a sudden increase in airway pressure leading to rupture of the bronchi or lungs. Sharp or firearm injuries penetrating the chest wall and damaging the lungs, bronchi, trachea, or esophagus can also cause pneumothorax, often presenting as hemopneumothorax or pyopneumothorax. Occasionally, closed or penetrating diaphragmatic ruptures accompanied by gastric perforation can lead to pyopneumothorax. Based on the state of the air passage and changes in pleural cavity pressure, pneumothorax is classified into three types: closed, tension, and open pneumothorax.

bubble_chart Etiology

1. Closed Pneumothorax

Pneumothorax mostly results from lung rupture caused by blunt trauma, or from lung rupture due to minor penetrating thoracic injuries, or when air enters through a small chest wall wound that subsequently closes, leaving the pleural cavity still isolated from the outside. The pressure within the pleural cavity remains lower than atmospheric pressure, i.e., still negative.

2. Tension Pneumothorax

A one-way valve-like wound exists on the chest wall, lung, bronchus, or esophagus, communicating with the pleural cavity. During inhalation, the valve opens, allowing air to enter the pleural cavity, while during exhalation, the valve closes, preventing air from escaping. As a result, with each breath, the pressure in the affected pleural cavity continuously increases until it exceeds atmospheric pressure, forming a tension pneumothorax, also known as a pressure pneumothorax or valvular pneumothorax. The affected lung tissue is severely compressed, pushing the mediastinum toward the healthy side and compressing the healthy lung as well. This reduces the ventilatory area and causes intrapulmonary shunting, leading to severe respiratory insufficiency and hypoxemia. Simultaneously, mediastinal displacement twists the great vessels, compounded by increased intrathoracic pressure and often accompanying mediastinal emphysema compressing the heart, major veins, and pulmonary vessels (extrapericardial cardiac tamponade). This obstructs venous return to the heart, reduces cardiac output, and results in severe circulatory dysfunction or even shock.

Caused by gunshot wounds or sharp instrument injuries that create a defect in the chest wall, the pleural cavity directly communicates with the external atmosphere, allowing air to freely enter and exit the pleural cavity with breathing, forming an open pneumothorax. The pressure in the affected pleural cavity equals atmospheric pressure, causing lung collapse. The degree of collapse depends on lung compliance and the presence of pleural adhesions. The healthy pleural cavity remains under negative pressure, lower than the affected side, shifting the mediastinum toward the healthy side and causing some degree of collapse in the healthy lung. Additionally, since the pressure in the healthy pleural cavity fluctuates with the respiratory cycle, mediastinal swing (or flutter) and air trapping (or pendelluft) occur, leading to severe ventilation and gas exchange dysfunction. Mediastinal swing causes twisting of the great vessels and impairs thoracic negative pressure, obstructing venous return and reducing cardiac output.

bubble_chart Clinical Manifestations

1. Closed Pneumothorax

Based on the amount of air accumulation in the pleural cavity and the degree of lung collapse, it can be classified into small, moderate, and large pneumothorax. A small pneumothorax refers to lung collapse of less than 30%, and the patient may not exhibit obvious respiratory or circulatory dysfunction. A moderate pneumothorax involves lung collapse of 30–50%, while a large pneumothorax involves collapse of more than 50%. Both can present symptoms of hypoxemia such as chest tightness and shortness of breath. Physical examination may reveal tracheal deviation toward the unaffected side, tympanic percussion sounds on the injured side, and significantly weakened or absent breath sounds. A small number of patients may develop subcutaneous emphysema, often at the site of rib fractures. Chest X-rays are an important diagnostic tool for closed pneumothorax, but small pneumothoraces, especially in cases where the patient cannot undergo upright posteroanterior imaging, may be misdiagnosed as fistula disease. Thoracentesis can aid in diagnosis and also serves as a treatment method.

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Patients often exhibit severe dyspnea and cyanosis, with hyperresonant percussion sounds and absent breath sounds on the injured side. If a syringe is inserted into the second or third intercostal space, the plunger may be pushed out by air. These findings are diagnostic. Additionally, examination may reveal a weak pulse, decreased blood pressure, significant tracheal deviation toward the unaffected side, fullness of the injured chest wall, flattened intercostal spaces, and markedly weakened respiratory movements. Subcutaneous emphysema may also be observed in the chest, neck, and upper abdomen, with crepitus on palpation. In severe cases, subcutaneous emphysema may extend to the face, abdomen, scrotum, and limbs. Although chest X-rays can directly show a large accumulation of air in the pleural cavity, lung collapse into a small mass, significant mediastinal shift toward the unaffected side, and emphysema in the mediastinum, pectoralis muscles, and subcutaneous tissues, it must be emphasized that reliance on or waiting for X-ray results should not delay treatment, as this may lead to adverse outcomes.

3. Open Pneumothorax

Patients with open pneumothorax often rapidly develop severe dyspnea, anxiety, weak and rapid pulse, cyanosis, and shock after injury. Examination reveals an obvious wound in the chest wall communicating with the pleural cavity, and a "hissing" sound of air entering and exiting with respiration may be heard. The injured side exhibits tympanic percussion sounds and absent breath sounds, and sometimes, mediastinal flutter may be audible.

bubble_chart Treatment Measures

1. Closed Pneumothorax

A small closed pneumothorax may resolve on its own without special treatment, but close monitoring of its progression is necessary. For moderate to large pneumothorax, thoracentesis may be performed first. If the air cannot be completely aspirated, if the pneumothorax recurs shortly after aspiration, if there is pneumothorax on the contralateral side, if hemothorax is present, if general anesthesia or mechanical ventilation is required, or if the patient has poor baseline lung function or is elderly, or has severe concomitant injuries (e.g., severe head trauma or Grade III shock), a closed thoracic drainage should be placed. A proactive approach should be taken in managing closed pneumothorax in such cases. Be vigilant for the development of tension pneumothorax during treatment. Simple closed pneumothorax is not life-threatening.

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Emergency treatment for tension pneumothorax involves rapid thoracic decompression. A large-bore needle may be inserted into the pleural cavity at the second or third intercostal space along the midclavicular line for immediate decompression. After fixing the needle with a hemostat, connect a latex tube to its end and attach it to a water-seal bottle. If a water-seal bottle is unavailable, place the distal end of the latex tube into the bottom of an infusion bottle containing 100–200 mL of saline and secure it with adhesive tape to prevent slippage, creating a temporary closed thoracic drainage. If the patient requires transport, tie a rubber finger cot to the needle’s end and cut a slit at its tip to create a one-way valve for air release. Specially designed thoracic drainage trocars and closed drainage systems are now available, pre-packaged and sterilized for immediate use and suitable for evacuation. If the tension pneumothorax is caused by a small penetrating wound on the chest wall, immediately seal, dress, and secure the wound.

After emergency treatment, the patient should generally be hospitalized for further evaluation and management. If the pneumothorax persists, insert a 0.5–1.0 cm rubber tube under local anesthesia at the second or third intercostal space along the midclavicular line for closed drainage, followed by X-ray examination. If the lung fully re-expands, the chest tube can be removed 24–48 hours after air leakage stops. If the lung fails to re-expand, investigate the cause. Suspected severe lung laceration, bronchial rupture, or esophageal perforation (confirmed by observing methylene blue in the chest drainage or oral iodized oil contrast) warrants thoracotomy. Mediastinal emphysema and subcutaneous emphysema usually require no treatment and often stop progressing after thoracic decompression, eventually resolving spontaneously. In rare cases of severe mediastinal emphysema, especially when pleural adhesions prevent obvious pneumothorax, make a 2–3 cm transverse incision at the suprasternal notch, layer-by-layer through the skin, superficial cervical fascia, and platysma muscle, bluntly dissecting the neck muscles until the pretracheal fascia is reached. Place a gauze strip in the incision for drainage, allowing gas to escape.

3. Open Pneumothorax

Depending on the conditions at the scene, the patient or others should quickly seal the chest wall wound, converting an open pneumothorax to a closed one. Use a large emergency dressing, multiple layers of clean cloth, or thick gauze pads to cover the wound at the end of deep expiration and secure it firmly. Vaseline gauze or sterile plastic sheeting is preferable. The dressing must be thick enough to prevent air leakage but should not be packed into the wound. It should extend at least 5 cm beyond the wound edges and be securely fastened. During transport, monitor the dressing for loosening or displacement and avoid unnecessary changes, remaining alert for tension pneumothorax. Upon hospital arrival, administer blood transfusion, fluid resuscitation, and oxygen therapy to correct respiratory and circulatory dysfunction while further assessing the injury. Once the patient’s condition stabilizes, perform debridement under endotracheal anesthesia as soon as possible and place closed thoracic drainage. Debridement should be thorough while preserving healthy tissue, and the pleural cavity must be tightly closed. For large chest wall defects, use muscle or skin flaps for repair. If severe intrathoracic injuries (e.g., lung, bronchus, heart, or major vessel damage) are present, perform exploratory thoracotomy promptly.