Traumatic pneumothorax is by definition air in the pleural space caused by trauma resulting in partial or complete lung collapse. According to latest Advanced Trauma Life Support (ATLS) 10th edition guideline, it is best managed by performing chest tube thoracostomy. We report a case of traumatic pneumothorax which was managed conservatively with good outcome.
A 77-year-old Malay gentleman was referred from district clinic to rule out closed fracture of the right ribs following an alleged fall from 4-feet height. He subsequently complained of shortness of breath, associated with right sided pleuritic chest pain. On examination, he was alert, not tachypnoeic and hemodynamically stable. Examination of the respiratory system showed crepitus at right upper and lower zones of the lung. There was also reduced air entry over the right lung, but no tracheal deviation. Chest X ray revealed right sided pneumothorax along with right lateral chest wall subcutaneous emphysema and crowding of right lateral ribs, suspicious of fractures. Patient was admitted to surgical ward for observation. He remained comfortable and asymptomatic in the ward. Thus, he was discharged the next morning with an outpatient appointment to repeat Chest X ray. Repeated Chest X ray confirmed right lateral 3rd to 7th ribs fractures but the right pneumothorax and subcutaneous emphysema have resolved.
Although chest tube thoracostomy is preferred in traumatic pneumothorax, initial hospitalization and close observation may be appropriate and more tolerable in small asymptomatic traumatic pneumothorax. This was not only mentioned in ATLS, but also in BMJ and MCD Manual. A meta-analysis published in Journal of European Resuscitation Council have proven that observation is at least as safe and as effective as tube thoracostomy for management of occult pneumothorax.
In conclusion, small asymptomatic traumatic pneumothorax doesn’t necessarily warrant a chest tube thoracostomy. Instead, vigilant observation and hospitalization is recommended.