A pneumothorax occurs when air collects in the interpleural space. It can be caused by blunt or penetrating thoracic trauma. The most common cause is lung laceration from a rib fracture with air leak.


Clinical signs

Patients with massive or tension pneumothoraces are generally unstable – this should be detected clinically (as part of the primary survey)

Smaller simple pneumothoraces may have subtle clinical findings

  • Decreased air entry of affected side
  • Hyper-resonant percussion note
  • Subcutaneous emphysema



Chest x-ray is a usual first line modality for the detection of pneumothorax.

In studies, the sensitivity of CXR for detecting pneumothorax ranges from 28-75%1. Small or occult pneumothoraces might not be apparent. In supine CXRs – look for the “deep sulcus sign”


Case courtesy of Dr Craig Hacking, From the case rID: 10885

Above: Left hemithorax deep sulcus sign on a supine CXR (note patient also has multiple left sided rib #s)


Ultrasound is more sensitive than CXR for detecting pneumothoraces 86-98%1.


CT is almost 100% sensitive for detecting pneumothoraces. Occult pneumothoraces are frequently detected on imaging of other body areas that capture some imaging of the thorax (eg: cervical spine or abdomen).


Omar HR, Abdelmalak H, Mangar D, Rashad R, Helal E, Camporesi EM. Occult pneumothorax, revisited. Journal of trauma management & outcomes. 2010 Oct 29;4(1):12. Published online: CC BY 2.0

A – CXR shows no pneumothorax, B – CT performed immediately after CXR shows occult right pneumothorax



Patients with moderate to large traumatic pneumothoraces will require drainage, usually with insertion of a tube thoracostomy via a blunt dissection technique.

Size of intercostal catheter

Controversy exists is terms of what size catheter to place in patients with traumatic pneumothorax.

Very large drains (36-40F) drains were traditionally advocated for trauma patients, but research has shown that smaller drains (28-32F) are just as effective.2

Patients with pneumothoraces associated with haemothorax or significant thoracic injuries (multiple rib fractures, flail chest, pulmonary contusions) should have a 28-32F tube thoracostomy placed by the blunt dissection method.

In patients with a simple isolated traumatic pneumothorax (without haemothorax), a small pigtail catheter (12-14F) is probably acceptable – discuss with the admitting trauma team.

There are different kits available for small bore chest drain insertion – here is a video link for the insertion via the seldinger technique


Treatment of small/occult pneumothoracs

Traditionally it was taught that all patients with traumatic pneumothoraces, regardless of size, should be treated with tube thoracostomy.

However, there is evidence that asymptomatic, haemodynamically stable patients with occult (pneumothorax detected on CT but not seen on CXR) can be observed without chest drain insertion.3,4 Small pneumothoraces that are visible on CXR might also be amenable to observation4, however there is no universally accepted radiological measurement of what a “small” pneumothorax is. A commonly quoted measurement is >2cm of pneumothorax measured from the chest wall to the hilum corresponds to a 50% pneumothorax, and is therefore “large”.Note that there are no RCTs on the observational management of “small” traumatic pneumothoraces.

There is some controversy surrounding the treatment of occult pneumothoraces in patients that are to have positive pressure ventilation. The concern is that PPV may lead to a tension pneumothorax – the literature is conflicting and RCTs are awaited.3,6,7

The decision whether to place a thoracostomy tube in these patients should be made in conjunction the treating intensivist or anaesthetist.




Disposition – interhospital transfer guidelines

Most patients with a simple traumatic pneumothorax will require admission either for observation (occult or small) or for ongoing management of the inserted chest drain.

Simple pthx





    1. Gentry Wilkerson R, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Academic Emergency Medicine. 2010 Jan 1;17(1):11-7.


    1. Inaba K, Lustenberger T, Recinos G, Georgiou C, Velmahos GC, Brown C, Salim A, Demetriades D, Rhee P. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. Journal of Trauma and Acute Care Surgery. 2012 Feb 1;72(2):422-7.



    1. Mowery NT, Gunter OL, Collier BR, Jose’J Jr D, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice management guidelines for management of hemothorax and occult pneumothorax. Journal of Trauma and Acute Care Surgery. 2011 Feb 1;70(2):510-8.


    1. Johnson G. Traumatic pneumothorax: is a chest drain always necessary?

    Emergency Medicine Journal 1996;13:173-174.


    1. MacDuff, Andrew; Arnold, Anthony; Harvey, John; et al. (BTS Pleural Disease Guideline Group) (December 2010). “Management of spontaneous pneumothorax: British Thoracic Societypleural disease guideline 2010″. Thorax. 65 (8): ii18–ii31


    1. Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. Journal of Trauma and Acute Care Surgery. 1993 Nov 1;35(5):726-30.


    1. Brasel KJ, Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. Journal of Trauma and Acute Care Surgery. 1999 Jun 1;46(6):987-91.


About this guideline

Published: February 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years