Management of Traumatic Pneumothorax Without Tension

Assessment and Classification

Traumatic pneumothorax should be classified based on size and the patient's clinical stability, with classification criteria including small pneumothorax: <3 cm apex-to-cupola distance on upright chest radiograph, and large pneumothorax: ≥3 cm apex-to-cupola distance on upright chest radiograph, and clinical stability defined as: respiratory rate <24 breaths/min, heart rate >60 and <120 beats/min, normal blood pressure, room air O₂ saturation >90%, and ability to speak in whole sentences between breaths 1

For clinically stable patients with large pneumothoraces, the American College of Chest Physicians recommends insertion of a small-bore catheter (≤14F) or a 16F to 22F chest tube to reexpand the lung, with hospitalization in most instances, and attachment of the catheter/tube to either a Heimlich valve or water seal device 1
For clinically stable patients with small pneumothoraces, observation in the emergency department for 3-6 hours, with repeat chest radiograph to exclude progression, and discharge with careful follow-up instructions within 12 hours to 2 days if no progression, is recommended 1

The British Thoracic Society suggests that serial chest radiographs should be performed to assess pneumothorax resolution and lung re-expansion, and continuous monitoring of respiratory rate, heart rate, blood pressure, and oxygen saturation is crucial 4

The British Thoracic Society recommends that pneumothoraces which fail to respond within 48 hours to treatment should be referred to a respiratory physician, and persistent air leak exceeding 48 hours duration should prompt referral 4