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Open Pneumothorax

What Is It, Diagnosis, and More

Author: Lily Guo

Editors: Alyssa Haag, Ian Mannarino, MD, MBA

Illustrator: Jillian Dunbar

Copyeditor: Joy Mapes


What is an open pneumothorax?

An open pneumothorax happens when air builds up in the pleural cavity, the fluid-filled space that directly surrounds the lungs, due to a hole in the chest wall. When an individual with such a hole inhales, air enters both the lungs and the pleural cavity, and this puts pressure on the lung. If the hole is large enough, it may draw enough air into the pleural cavity to make the lung collapse.

What is the difference between an open and closed pneumothorax?

An open pneumothorax describes when an injury creates a hole in the chest wall that allows air from the environment to enter the pleural cavity, whereas a closed pneumothorax refers to air that enters the pleural cavity from the lungs themselves. A closed pneumothorax occurs due to a defect of or damage to the pulmonary parenchyma, the portions of the lungs involved in gas exchange, including the alveoli, alveolar ducts, and respiratory bronchioles. A lung disease -- such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung cancer, or pneumonia -- can be the source of the damage. However, damage can also occur spontaneously in predisposed individuals, a phenomenon called “spontaneous pneumothorax.”

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How does an open pneumothorax occur?

An open pneumothorax is often due to forceful impact with a dull object (i.e., blunt trauma) or piercing impact from a sharp object (i.e., penetrating trauma). Blunt or penetrating trauma can happen in situations such as physical attacks or car crashes.

In addition, an open pneumothorax may be iatrogenic, or caused by a medical professional during diagnosis or treatment. For example, a clinician could unintentionally injure the chest wall during a transtracheal aspiration, a procedure that requires inserting a needle into the lung tissue; a lung biopsy, in which a portion of the lung tissue is removed; or during a tube thoracostomy, where a tube is placed in the pleural cavity.

What are the signs and symptoms of an open pneumothorax?

The signs and symptoms of an open pneumothorax include sudden chest pain, shortness of breath, rapid and shallow breathing, a fast heart rate, and low oxygenation of body tissues (i.e., hypoxia). Sometimes, individuals with this condition may feel weak, dizzy, restless, or agitated. An open chest wound may be visible, or a sucking sound may be audible when air enters the wound. 

If air continues to enter the pleural space without being able to escape, the individual may develop a tension pneumothorax, which can lead to cardiovascular collapse, loss of blood flow to the heart and body, and death. As the pressure in the chest increases, blood pressure can decrease drastically, which may lead to shock.

How is an open pneumothorax diagnosed?

An open pneumothorax can be diagnosed based on a thorough review of the individual’s medical history, physical examination, and symptoms. During auscultation, when the clinician listens to the individual’s lungs with a stethoscope, the presence of hyperresonant (i.e., high pitched) sounds and the absence of breath sounds in the individual’s back indicate air or fluid in the pleural space

Imaging can also assist in diagnosis -- the extended focused abdominal sonography for trauma (E-FAST) exam is one potential diagnostic tool. Computerized tomography (CT) and chest X-ray are also options, although an ultrasound is typically more useful than a chest X-ray. If a patient is very unstable with a suspected open pneumothorax, treatment is typically initiated before imaging is used to confirm the diagnosis.

How is an open pneumothorax treated?

An open pneumothorax is treated by applying a three-way dressing to the wound, which involves taping the dressing on only three of the edges. The intent is to prevent the individual from breathing in air through the opening in the chest wall while allowing them to exhale air from their lungs. An inserted chest tube will further assist the individual in breathing. If the dressing is not properly applied, and it allows air into the chest space without allowing it to escape, a tension pneumothorax may develop. Supplemental oxygen may be required if hypoxia is severe. Long-term treatment involves surgical intervention to repair the open wound or defect in the chest.

What are the most important facts to know about open pneumothorax?

An open pneumothorax happens when air builds up in the pleural cavity, the fluid-filled space that directly surrounds the lungs, due to a hole in the chest wall. It differs from a closed pneumothorax, during which air enters the pleural cavity from the lungs themselves. An open pneumothorax can occur as a result of direct trauma or unintentional injury in a healthcare setting during a procedure. Symptoms include sudden shortness of breath, pain when breathing, shallow and rapid breathing, and potential shock, and diagnosis involves a thorough examination by a clinician and confirmation via imaging. Treatment of the pneumothorax often requires application of a three-way dressing and insertion of a chest tube. Surgery may be required to repair the hole in the chest wall that caused the open pneumothorax.

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Related links

Pneumothorax
Pneumothorax: Clinical practice
Chest trauma: Clinical practice
Pleural effusion
Pleural effusion, pneumothorax, hemothorax and atelectasis: Pathology review

Resources for research and reference

Jalota, R., & Sayad, E. (2021, January 23). Tension pneumothorax. In StatPearls [Internet]. Retrieved July 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK559090/ 

Mahabadi, N., Goizueta, A. A., & Bordoni, B. (2021, February 7). Anatomy, thorax, lung pleura and mediastinum. In StatPearls [Internet]. Retrieved July 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519048/ 

Maritato, K. C., Colon, J. A., Kergosien, D. H. (2009). Pneumothorax. Compendium (Yardley, PA), 31(5): 232-242. 

McKnight, C. L., & Burns, B. (2020, November 16). Pneumothorax. In StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441885/

Pneumothorax. (n.d.). In ScienceDirect. Retrieved May 11, 2021, from https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/pneumothorax 

Weiser, T. G. (2020). Open pneumothorax (sucking chest wound). In Merck manual: Consumer version. Retrieved May 11, 2021, from https://www.merckmanuals.com/home/injuries-and-poisoning/chest-injuries/open-pneumothorax