European Journal of Cardio-thoracic Surgery 25 (2004) 859864

www.elsevier.com/locate/ejcts

A prospective analysis of occult pneumothorax, delayed pneumothorax

and delayed hemothorax after minor blunt thoracic traumaq
P. Misthos*, S. Kakaris, E. Sepsas, K. Athanassiadi, I. Skottis
1st Thoracic Surgical Department, General Hospital for Chest Diseases SOTIRIA, Athens, Greece
Received 7 October 2003; received in revised form 26 January 2004; accepted 29 January 2004

Abstract
Objectives: A prospective analysis was conducted to define the incidence of occult pneumothorax (OPX), delayed pneumothorax (DPX)
and delayed hemothorax (DHX) and to propose an algorithm for surveillance. Methods: During the last 2 years 709 consecutive patients who
did not fulfill the indications for intrahospital management were examined at our emergency department for blunt thoracic injury. All patients
were subjected to expiration posteroanterior chest radiograph (eCXR) and were scheduled for reevaluation after 24, 48 h and at 7, 14 and
21 days. Results: OPX was present in 28 patients (4%) detected only with eCXR on admission, 14 patients developed DPX (2%) at 24 48 h
later, and 52 patients presented up to 14 days later with DHX (7.4%). Of all DHX 42 (80.7%) required chest tube drainage, eight thoracentesis
(16%) and only two (4%) were subjected after 1 month to decortication. No related morbidity was recorded. All the patients with the DHX
had at least one rib fractured. Only one death among the DHX patients was documented. Conclusions: A safe algorithm is recommended:
eCXR for every patient who suffered blunt thoracic injury with at least one rib fracture detected and is treated as an outpatient or in case
his/her compliance with the reevaluation schedule will be suboptimal. Close follow-up is also suggested since these entities do exist, cannot
be ignored and their treatment is early evacuation of the pleura cavity.
q 2004 Elsevier B.V. All rights reserved.
Keywords: Blunt thoracic trauma; Occult pneumothorax; Delayed hemothorax

1. Introduction
Blunt chest trauma is a frequent cause for thoracic
surgical consultation at the emergency department. It
comprises 70% of all thoracic injuries [1,2]. Clinical
examination along with chest imaging is often sufficient
for diagnosis and proper treatment [3,4]. Since thoracic
trauma has a high mortality rate (20 25% of all trauma
deaths) overlooked chest injuries carry serious consequences [2]. In order to examine the accuracy of our
diagnostic tools in patients with blunt thoracic trauma, who
are treated on an outpatient basis, the authors conducted a
prospective study to define the incidence and type of
undetected injuries such as occult pneumothorax (OPX),
q
Presented at the joint 17th Annual Meeting of the European Association
for Cardio-thoracic Surgery and the 11th Annual Meeting of the European
Society of Thoracic Surgeons, Vienna, Austria, October 12 15, 2003.
* Corresponding author. Address: 7 P. Dimitrakopoulou Street, 11141
Athens, Greece. Tel./fax: 30-210-252-9048.
E-mail address: [email protected] (P. Misthos).

1010-7940/$ - see front matter q 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2004.01.044

delayed pneumothorax (DPX) and delayed hemothorax

(DHX) and to suggest an algorithm for surveillance.

2. Material and methods

From July 2001 through July 2003, 1114 consecutive
patients were admitted at the emergency department for
thoracic surgical consultation. The indications for intrahospital management were fulfilled in 288 patients (25.8%).
The criteria for outpatient management were: two or less rib
fractures, age less than 65 years, no lung parenchyma injury,
no other system injury and absence of any concomitant or
comorbid diseases.
Minor blunt chest trauma includes all the cases of chest
injury where the lesions are confined to minor chest wall
injury (abrasions, muscle contusion, echymoses) with no
more than two rib fractures and without flail chest, lung,
heart or other mediastinal organ injury in an otherwise
healthy person. Moreover, no other system injury must be
detected.

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P. Misthos et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 859864

Although 826 patients (74.2%) were discharged to be

managed as outpatients, only 709 (63.6%) were included in
the study group, because the rest 117 either did not comply
with our follow-up schedule or never entered that schedule
because no chest involvement at the accident was detected
or were injured longer than 24 h before admission or finally
OPX was diagnosed at abdominal CT scan.
After clinical examination all patients were ordinarily
subjected to upright posteroanterior, lateral and expiration
posteroanterior chest radiograph (eCXR) and to arterial
blood gases analysis. Besides they were scheduled for
reevaluation after 8, 24, 48 h and, if nothing was noted, at 7,
14 and 21 days. Depending on clinical findings or even
suspicion the follow-up was modified according to the
clinical situation encountered. All patients were discharged
on analgesic and mucolytic treatment.
All cases with OPX, DPX and DHX were recorded and
analyzed. OPX was defined as the pneumothorax, which
was not detected on routine upright inspiration CXR but
only as subtle pleural air collection detected on expiration
CXR or at thoracic/abdominal CT scan. OPX detected only
at abdominal CT scanning, despite normal chest radiology,
was excluded. DPX was defined as the pneumothorax not
clinically or radiologically detected upon admission, not
even evident at eCXR but detected on routine CXR later.
The size of a pneumothorax (PNX) was calculated through a
nomogram, by using the sum of three roentgenographic
measurements divided by three: the maximal interpleural
distances between the visceral and parietal pleura at the
apex, middle upper and lower half of the thorax in the
frontal plane [5,6]. DHX was defined as blood collection in
the pleural space that becomes clinically or radiologically
evident one or more days later despite normal CXRs upon
admission.
Age, gender, type and severity of injury, mechanism of
injury, interval from the incident to diagnosis or presentation, associated thoracic injuries, treatment modality
employed and mortality rate of patients who developed
OPX, DPX or DHX were recorded, in order to define their
incidence and recommend an algorithm for surveillance.
Indications for CT scanning during follow-up were
undiagnosed lung field opacities, suspicious diaphragm
configuration and identification of the hemothorax source.
Patients injured longer than 24 h before admission were
excluded from the study.
Treatment protocol included: (a) For a PNX, if the
estimated size was less than 15% expectant policy was
employed, if 15 30% thoracentesis was conducted and if
larger than 30% chest tube thoracostomy was performed [5].
In case PNX recurred in less than 6 h after thoracentesis,
chest tube thoracostomy was performed too. (b) For a HMX,
if the estimated blood amount was less than 300 400 ml
thoracentesis was performed, whereas if larger than 500 ml
chest tube thoracostomy was employed. The amount of
pleural effusion was estimated by the upright CXR: if the
collection just filled the ipsilateral costophrenic angle

the amount was calculated to 300 400 ml, whereas any

larger effusion was estimated as more than 500 ml. The
indications for surgical management of HMX was continuing bleeding (more than 200 ml for 4 h) or clot formation
and lung entrapment or empyema thoracis development.

3. Results
The total number of patients studied was 709. This group
included 471 men (66.4%) and 238 women (33.6%) whose
age ranged from 17 to 91 years (mean 58 years). The
characteristics of this group is described in Table 1.
OPX was encountered in 28 patients (4%) (Table 2). The
most frequent associated thoracic injury was chest wall
muscle contusion (78.6%), followed by no other injury or
minor cutaneous trauma (46.4 and 17.8%, respectively).
Surprisingly, rib fractures were found in only a small
percentage of cases (10.8%). Expectant management was
the initial treatment of all OPX. Expectant management was
employed in nine (32%) patients, with a successful outcome
in eight of them (88.8%), whereas one patient needed
thoracentesis. Among the 16 (57.1%) patients subjected to
thoracentesis 13 (46.4%) patients were successfully treated
(81.25%). All seven patients (25%) managed with chest
tube thoracostomy had an excellent outcome. No mortality
was recorded in this group during the first posttraumatic
month. No surgical management was needed.
DPX was detected in 14 patients (2%) (Table 2). The
most frequent associated injury with DPX was found to be
one or two rib fractures (50%) that might have a causative
relationship with DPX. In 35.7% no other thoracic
posttraumatic lesion was found. The most frequent injury
mechanism were fall in 50% of cases (mostly to the ground
or not more than 2 m height) and sports accidents (21.4%).
In both OPX and DPX cases, right side was observed to be
predominant (71%), a fact without any clinical implication.
In the DPX group no deaths were recorded during the first
posttraumatic month. No surgical management was needed.
Table 1
Minor blunt chest trauma group characteristics
(a) Concomitant thoracic injuries (%)
Muscle contusion
Chest wall hematoma
One rib fractured
Two ribs fractured
Skin abrasions and/or echymoses
Extrapleural hematoma
None

614 (87)
51 (7.2)
287 (40.5)
119 (16.8)
302 (42.6)
9 (1.3)
53 (7.5)

(b) Mechanism of injury (%)

Motor vehicle collision
Fall
Assault
Sports accident
Pedestrian

197 (27.8)
422 (59.5)
31 (4.4)
38 (5.4)
21 (2.9)

P. Misthos et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 859864

Table 2
Occult and delayed pneumothorax characteristics

Number of patients (%)

Age (years)
Gender (%)
Male
Female
Duration from injury to
diagnosis (h)
Duration from admission to
detection (h)

861

Table 3
Delayed posttraumatic hemothorax characteristics

OPNX

DPNX

28 (4)
19 68 (mean 41)

14 (2)
2768 (mean 55.1)

21 (75)
7 (25)
1 13 (mean 5.4)

9 (64.3)
5 (35.7)

848 (mean 23.4)

Size at 24 h from diagnosis (OPNX)/at diagnosis (DPNX) (%)

, 15%
9 (32)
7 (50)
1530%
15 (53.5)
5 (35.7)
. 30%
4 (14.5)
2 (14.3)
Final treatment (%)
Chest tube thoracostomy
Thoracentesis
Expectant
Surgery

7 (25)
13 (46.4)
8 (28.6)
0

4 (28.5)
2 (14.3)
8 (57.1)
0

Type of thoracic injury (%)

None
Skin abrasions/echymoses
Chest wall muscle contusion
One rib fractured
Two ribs fractured
Chest wall hematoma

5 (17.8)
13 (46.4)
22 (78.6)
2 (7.1)
1 (3.7)
0

5 (35.7)
0
5 (35.7)
5 (35.7)
2 (14.3)
1 (7.1)

Injury mechanism (%)

Motor vehicle collision
Fall
Sports accident
Assault
Pedestrian
Mortality

11 (39.3)
9 (32)
4 (14.5)
2 (7.1)
2 (7.1)
0

2 (14.3)
7 (50)
3 (21.4)
0
2 (14.3)
0

DHX proved to be a much more common incident

(Table 3). Fifty-two patients (7.4%) presented up to 14 days
after injury with delayed pleural blood collections despite
the normal clinical and radiologic findings during the
first 36 posttraumatic hours. The diagnosis of DHX was set
2 14 days (mean 7.32 days) later (Table 4). At least one rib
fracture was detected in the patients with DHX (65.4% with
one rib fracture and 34.6% with two). Motor vehicle
accidents and pedestrians ones proved to be the major injury
mechanism (80.9%). Twelve patients were managed with
thoracentesis (23%). The success rate was 66.6%
(8 patients), while four patients were further managed
with chest tube thoracostomy. Forty-four patients (84.6%)
were finally subjected to chest tube thoracostomy. It was
successful in 41 patients (93.2%). Two patients (3.9%) were
subjected to thoracotomy due to ongoing hemorrhage and
clot formation, which needed decortication. One patient

Number of patients (%)

Age (years)

52 (7.4)
1782 (mean 39.2)

Gender (%)
Male
Female
Duration from injury to admission (h)
Duration from admission to detection (days)

43 (82.6)
9 (17.4)
124 (mean 4.9)
214 (mean 7.3)

Amount (%)
# 300 ml
300500 ml
$ 500 ml

11 (21.2)
40 (76.9)
1 (1.9)

Final treatment (%)

Chest Tube Thoracostomy
Thoracentesis
Thoracostomy

42 (80.7)
8 (15.4)
2 (3.9)

Type of thoracic injury (%)

None
Skin abrasions/echymoses
Chest wall muscle contusion
One rib fractured
Two ribs fractured
Chest wall hematoma
Extrapleural hematoma

0
0
16 (30.8)
34 (65.4)
18 (34.6)
2 (3.8)
1 (1.9)

Injury mechanism (%)

Motor vehicle collision
Fall
Sports accident
Assault
Pedestrian
Mortality

28 (53.8)
4 (7.6)
1 (1.9)
5 (9.6)
14 (27.1)
1 (1.9)

(1.9%) died 18 days after the accident due to intercostal

artery bleeding because of thrombus lysis.
DPX was detected during the first 2 days (peak within the
first day, i.e. 78.5%) and DHX was most frequently
diagnosed on the seventh day (78.8%) (Table 4). The latest
follow-up was the 21st day. No patient after that period
returned to the hospital with DPX or DHX.
CT scans were conducted in 191 patients (26.9%) mostly
after motor vehicle accidents (126 patients, 66%). CT scan
diagnosis contributed in only one case (0.9%), where DPX
was detected. No other traumatic lesion (e.g. diaphragmatic
rupture, mediastinal injury, vascular injury, etc.) was found.
Analysis of associated injuries and mechanism of injury
in each entity did not reveal any reliable prognostic factor,
but a strong correlation between rib fractures and DHX.
Among all motor vehicle and fall accidents only 20 (3.2%)
led to OPX and among those with chest wall muscle
contusion only 22 (3.6%) developed OPX (Tables 1 and 2).
DPX was described in 10 patients after fall or sports
accidents (2.2%). It is important to mention that in 10 cases

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P. Misthos et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 859864

Table 4
Time of diagnosis
Time

OPNX (%)
DPNX (%)
DHMX (%)

0h

8h

24 h

48 h

7 days

14 days

21 days

28 (100)

2 (14.2)
0

11 (78.5)
0

1 (7.3)
5 (9.7)

0
41 (78.8)

0
6 (11.5)

0
0

out of 42 OPX and DPX (23.8%) no other injury was traced

except ipsilateral subtle chest discomfort at the end of deep
inspiration. However, in 18.9% of all patients classified with
no associated chest injury, OPX or DPX was detected
(Tables 1 and 2). DHX was more frequently observed after
motor vehicle collisions or pedestrian accidents (80.9%),
while only 5.2% of such accidents developed DHX
(Tables 1 and 3). At least one rib fracture was present
when DHX was developed. Fifty-two patients out of 406
with rib fractures developed DHX (12.8%).
The 2-week follow-up algorithm was modified only in
the 66 cases (9.3%) of DPX and DHX, since the process of
the injury determined the subsequent follow-up.

4. Discussion
Although several reports have been published reviewing
delayed presentation or missed diagnosis of injuries
associated with blunt thoracic trauma [3,7,8], OPX, DPX
and DHX have been scarcely studied in the literature
[9 12]. Moreover, most of these studies were retrospective
ones and no collective prospective study is within our
knowledge concerning these entities after minor blunt
thoracic trauma. The incidence of OPX, DPX and DHX
proved to be 4, 2 and 7.4%, respectively. These findings are
in accordance with previous series [11 17]. These figures
showed that these entities should be anticipated.
The suggested mechanism is common in both OPX and
DPX. We believe that lung parenchyma rupture was mostly
due to valsava mechanism in OPX cases along with laceration caused from a rib fracture in DPX cases. The air leak was
so small that no air collection was detected on the initial
inspiration CXR. Among the 42 patients who developed a
posttraumatic air leak, in 28 (66.6%) the detection was
possible at admission with eCXR. According to the abovementioned observations, we recommend expiration chest
radiograph upon admission for every patient with blunt chest
injury since no prognostic factor was found to predict which
patient would develop pneumothorax and since eCXR
detected the majority of air leaks during the first thoracic
surgical involvement. It is our belief that eCXR turned out to
be a very helpful diagnostic tool along with routine
examination especially for patients on an outpatient basis.
Although CT scan proved to be a significant diagnostic
tool for exclusion after ambiguous clinical and radiographic

findings, it did not offer any contribution (only 0.9%) to the

detection of these lesions [2,11,15,16]. Consequently, CXR
including eCXR on admission is sufficient for the follow-up
of these patients. Since only CXR is needed, the suggested
algorithm is easily conducted and is also cost-effective.
CXR use leads to 90 euros cost, while CT scan use would
increase expenses up to 145 euros.
As far the mechanism of injury is concerned, the small
incidence of these entities cannot constitute any mode of
accident to be prognostic for the type of pleural disease that
will be developed. However, there are some points to be
taken under consideration: (a) DHX was detected mostly
after motor vehicle collisions or pedestrian accidents
(80.9%) but of all these accidents only 5.2% developed
DHX; (b) motor vehicle collisions along with falls were the
most common accidents for OPX, while only 3.2% of such
incidents caused subclinical pneumothorax; (c) fall was the
most frequent mechanism for DPX (50%). Only 1.6% of all
falls developed DPX.
Two conclusions from the associated injuries analysis
deserve to be noted: (a) all DHX are related to at least one
rib fracture (65.4% one rib and 34.6% two ribs fractured).
The incidence of DHX among all rib fractures recorded was
12.8% and that should be taken under consideration for
minor blunt chest trauma decision-making. Rib fractures
were easily diagnosed on CXR. Moreover, they were the
main cause of bleeding in the pleural space; (b) in 23.8% of
patients who developed either OPX or DPX no other
associated injury was diagnosed. However, a pneumothorax
was developed in 18.9% of all cases in whom no injury was
detected.
Available treatment modalities can be summarized in
four categories: expectant management, thoracentesis, chest
tube thoracostomy and surgical treatment [5,13,18 22]. In
case of OPX/DPX chest tube thoracostomy was performed
in 25 28%, which is in accordance with previous reports
[17,18,21,23]. In case of DHX the major goal of management was immediate evacuation of pleural space in order
that serious complications can be avoided [24]. The earlier
the detection of hemothorax and the sooner the pleural
drainage, the better the patients outcome.
The authors suggest that blunt chest injury, even when
not initially serious, might hide a lot of perils for patients
life and surgeons reputation. Therefore, a routine follow-up
for all patients is recommended irrespectively of the
severity of initial findings.

P. Misthos et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 859864

No prognostic factor was detected in order to classify

patients in different follow-up algorithms. All patients who
do not fulfill the criteria for intrahospital management after
minor blunt chest trauma should be closely followed for at
least 2 weeks after the accident. This is supported by the
facts that OPX, DPX and DHX should be anticipated,
cannot be predicted and have excellent prognosis if detected
in time. In conclusion, patients who suffered minor blunt
thoracic injury should be closely screened for OPX, DPX
and DHX. In case, they are treated as outpatients the authors
recommend a feasible and cost-effective follow-up algorithm: Every patient who will be managed on an outpatient
basis should be subjected to expiration chest radiograph
upon admission and scheduled to a strict follow-up timetable that extends up to 2 weeks, which will include clinical
and radiographic check-up even if no pathologic findings
are recorded at initial examination on admission or at
intermediate examinations.
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Appendix A. Conference discussion

Dr T. Ferguson (St. Louis, MI, USA): I think the take-home
message here is very important, particularly for emergency units that see
patients and send them home without follow-up. At least that happens in our
country.
Dr M. Ahmed (Khartoum, Sudan): In your method, apart from the chest
X-ray, you suggested that you have to do arterial blood gases. Are you
expecting for occult pneumothorax taking arterial blood gases, and what are
the findings of your arterial blood gases?
Dr Misthos: Well, in our department and the emergency department at
our hospital, arterial blood gas evaluation for every patient with blunt chest
trauma is a routine examination to evaluate the baseline for pulmonary
function. I mean one of the parameters to decide which possible treatment
modality will follow has to do with the underlying pulmonary function. I
mean with a patient with COPD, you wont do thoracentesis or observe a
pneumothorax, but we think that you should insert a chest tube. So there
was no statistical difference between any groups of arterial blood gases. It
was just a routine examination.
Dr G. DiRienzo (Bari, Italy): When faced with chest trauma with stable
patients with a modest hemothorax, and you showed some surgical
treatment, essentially chest drainage positioning, what is your strategy in
these patients? Do you perform a video-thoracoscopic access or do you just
place a chest drainage?
Dr Misthos: It has to do with a combination of time and amount of
blood collection. I mean if its a large hemothorax, we very cautiously
begin with videoscopic treatment, but actually we have in mind the case of
an open thoracotomy. If it is a moderate or a small hemothorax and it is very
early, I mean not more than 3 or 4 days, we begin with thoracentesis. We
have observed that there is a very low percentage of recurrence and, of
course, you avoid general anesthesia. If there is recurrence, then we proceed
to VATS, video-thoracoscopic evacuation.
Dr DiRienzo: You dont use the VATS procedure under local
anesthesia to correctly place the drainage, to look at the situation in the
pleural cavity, and also for a safe drainage?
Dr Misthos: No, no.
Dr I. Cordos (Bucharest, Romania): Its uncommon that chest trauma
with less percent of rib fractures has so high a percent of pneumothorax.
How can you explain it?

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P. Misthos et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 859864

Dr Misthos: Valsava mechanism. This is the only mechanism we do

suggest.
Dr Cordos: Have you studied another disease of the lung, chronic
obstruction or another disease of the lung that can explain a
pneumothorax in this type of patient?
Dr Misthos: You mean if there was chronic obstructive disease?
Dr Cordos: Yes another lung disease, chronic lung disease.
Dr Misthos: Nothing statistically significant, no.
Dr R. Jakovic (Belgrade, Yugoslavia): Concerning rib fractures, did
you analyze the status of the underlying lung tissue at the first

examination? What was the status of the lung tissue concerning rib
fracture?
Dr Misthos: Do you mean whether theres lung laceration?
Dr Jakovic: Did you realize or did you reveal any contusion of the lung
on the first X-ray?
Dr Misthos: Yes, I see what you mean. From CT scans, there was not a
statistically significant difference from any other group. Possibly its our
opinion that there should be a laceration. I mean there is a causative relation
between the rib fractures and either pneumothorax or hemothorax through
laceration.