TürkçeOpen pneumothorax is a life-threatening emergency in which atmospheric air enters directly into the pleural cavity through a full-thickness opening in the chest wall, causing the lung to collapse. This condition may result from traumatic injuries, sharp or penetrating objects, or gunshot wounds. The main signs include a sucking sound coming from the open wound, severe shortness of breath, tachycardia, and progressive cyanosis. Treatment includes preventing further air entry in the emergency department with a three-sided occlusive dressing, followed by tube thoracostomy and definitive surgical repair performed by thoracic surgery specialists. These interventions aim to restore respiratory mechanics and eliminate the risk of obstructive shock and cardiac arrest.
How Does Open Pneumothorax Damage the Normal Respiratory System?
To understand the effect of open pneumothorax on the body, it is helpful first to examine how a healthy respiratory system works. Our lungs are elastic, sponge-like organs located within the chest cavity. However, the lungs do not have the ability to contract and relax on their own or breathe independently. This essential function is performed by the chest wall surrounding the lungs like armor and by the muscular diaphragm located directly beneath them. Between the thin membrane covering the outer surface of the lungs and the membrane lining the inner surface of the chest wall lies a very narrow space measuring only a few millimeters. This area, known medically as the pleural cavity, contains negative pressure, or a type of vacuum effect, that keeps the lungs firmly attached to the chest wall.
To visualize this vacuum effect, imagine two smooth glass plates separated by a thin layer of water. The plates can slide easily from side to side, but pulling them apart requires considerable force. In the same way, when we inhale and the chest cavity expands, this vacuum force pulls the lungs outward with it. As a result of this expansion, fresh air enters the lungs through the airways. When we exhale, the chest cavity tends to contract and the lungs return to their previous size. This negative pressure is one of the most fundamental principles of breathing. When an external opening forms in the chest wall and outside air enters this closed system, the powerful vacuum effect is largely lost. Once the vacuum disappears, the lung begins to collapse inside the chest cavity, much like a balloon shrinking when its opening is released, and it can no longer function properly.
In Which Situations Does Open Pneumothorax Usually Occur?
This delicate and closed pressure system in the human body is generally damaged by severe external trauma. When cases of open pneumothorax presenting to emergency departments are examined, the underlying cause is usually a physical force that penetrates the chest wall. During high-impact collisions, the sharp ends of fractured ribs may tear the skin from the inside outward, or a hard object from outside may directly pierce the chest wall. These situations are more common among adolescents and adults because of their more active lifestyles and greater likelihood of exposure to external hazards. Although most injuries affect only one side of the chest, rarer and more complex bilateral cases may also occur.
The main situations that may lead to open pneumothorax include:
- Traffic accidents
- Sharp-object injuries
- Penetrating-object injuries
- Gunshot wounds
- Industrial workplace accidents
- Falls from height
- Severe physical collisions
What Symptoms Occur in a Person with Open Pneumothorax?
When an opening forms in the chest wall and creates a direct connection with the outside environment, both the symptoms experienced by the patient and the visible signs are usually very pronounced. Any situation that makes breathing difficult naturally causes intense fear and distress. Because the patient feels unable to obtain enough air, they begin breathing rapidly and shallowly. This effort, combined with the heart’s attempt to pump more blood, causes a marked increase in heart rate. The body activates stress hormones to compensate for falling oxygen levels, causing the skin to become cold and sweaty. If insufficient oxygen reaches the tissues, changes in skin color gradually appear. However, the most characteristic feature distinguishing this condition from other injuries is the sound coming from the wound. The airflow through the opening may produce a hissing or sucking sound.
Symptoms commonly observed during open pneumothorax include:
- Severe chest pain
- Rapid breathing
- Feeling unable to take a deep breath
- Palpitations
- Cold sweating
- Bluish discoloration of the lips
- Bluish discoloration of the fingertips
- Air sound coming from the wound
- Severe anxiety
What Does Pendelluft Mean in the Mechanism of Open Pneumothorax?
What makes open pneumothorax particularly serious is not only the loss of function in one lung but also the disruption of the entire airflow balance within the chest cavity. One of the best-known consequences of this imbalance is a phenomenon referred to in medical literature as pendelluft. Under normal circumstances, inhaled air passes through the trachea and is distributed evenly to both lungs. However, when a large opening exists in the chest wall, the pressure relationships inside the chest become severely disrupted. During inhalation, the healthy lung strongly draws air inward while also pulling toward itself some of the stagnant, oxygen-depleted air trapped inside the collapsed lung on the injured side. During exhalation, some of this oxygen-poor gas from the healthy lung is pushed back toward the collapsed lung. Instead of receiving fresh oxygen, the body begins circulating old air back and forth between the two lungs like a pendulum. This process causes oxygen levels to fall rapidly.
Another physical change that frequently accompanies this process is mediastinal flutter. The central area between the lungs containing the heart and major blood vessels is called the mediastinum. In a healthy person, this region remains centered because pressure is equal on both sides. In open pneumothorax, however, a large and continuously changing pressure difference develops between the right and left sides of the chest during breathing. This pressure difference causes the heart and major blood vessels to swing from side to side with each breath. Such movement may cause the vessels to bend and reduce the amount of blood returning to the heart. When insufficient blood reaches the heart, the volume of blood pumped to the body also decreases, leading to circulatory problems such as low blood pressure.
How Is Open Pneumothorax Diagnosed in the Emergency Department?
The evaluation of a patient brought to the hospital with suspected open pneumothorax varies according to their overall condition. In emergency medicine, time management is critically important. If the patient has severe hypotension, marked respiratory distress, and signs of shock, the diagnosis can usually be made largely through a careful physical examination. Visualization of the open chest wound, hearing the characteristic sucking sound, and detecting reduced breath sounds on the affected side are often sufficient to justify immediate treatment. In such cases, instead of transferring the patient to radiology for detailed imaging, stabilization is started directly at the bedside.
Once initial treatment has been provided and blood pressure and heart rate have stabilized, imaging techniques can be used to evaluate the internal structures more clearly. Bedside ultrasonography allows physicians to assess pleural movement within seconds. Chest X-rays then help reveal the margins of the collapsed lung and the amount of air accumulated inside the chest. Computed tomography provides the most detailed information. CT imaging can identify even very small air collections, associated bone fractures, and other possible injuries to the lung tissue layer by layer.
Methods frequently used during diagnosis include:
- Detailed physical examination
- Bedside trauma ultrasonography
- Chest X-ray
- Computed tomography
- Oxygen saturation measurement
- Blood gas analysis
Which Steps Are Followed During Emergency Treatment of Open Pneumothorax?
When providing first aid to a patient with open pneumothorax at the scene or in the emergency department, the main objective is to restore impaired respiratory mechanics as quickly as possible and increase the amount of oxygen reaching the tissues. One of the first and most important steps is to provide high-concentration oxygen through a mask. This high-concentration oxygen reduces the proportion of nitrogen in the blood and helps accelerate the absorption and elimination of trapped air within the chest cavity.
While oxygen therapy continues, the open sucking wound in the chest wall must be isolated from the outside environment. The most practical method developed for this purpose is a three-sided occlusive dressing. A clean, airtight material is placed over the wound. Only three edges are secured to the skin with medical tape, while the fourth edge is left free. This simple design acts as a one-way valve over the wound. During inhalation, the negative pressure inside the chest pulls the dressing against the wound and largely prevents outside air from entering. During exhalation, pressure inside the chest increases and trapped air is expelled through the untaped edge. If all four sides of the dressing are mistakenly sealed, air inside the chest cannot escape and becomes trapped under pressure. This may place severe pressure on the heart and lungs and worsen the patient’s condition.
The standard steps followed during emergency treatment include:
- Administration of high-flow oxygen
- Application of a three-sided occlusive dressing
- Establishment of secure intravenous access
- Intravenous fluid replacement
- Monitoring of vital signs
- Administration of pain-relieving medications
How Is a Chest Tube Inserted as Part of Open Pneumothorax Treatment?
After the patient has been stabilized, treatment proceeds to the essential stage of evacuating the chest cavity. One of the cornerstones of open pneumothorax management is tube thoracostomy, commonly known as chest tube insertion. Before the wound is surgically closed, accumulated air and sometimes blood must be safely drained from the chest cavity. Thoracic surgery teams generally perform this procedure in a sterile treatment room or operating room. Local anesthesia is applied to the procedural area to prevent pain.
An important medical detail is that the tube is not inserted through the existing open wound. Because the wound has been exposed to the outside environment, it is considered contaminated. Inserting the tube through this wound would increase the risk of introducing infection directly into the pleural cavity. In addition, a tube inserted through the wound may not reach the correct anatomical position. Therefore, surgeons usually choose a clean and anatomically safe location around the level of the armpit. A small incision is made between the ribs, and a flexible tube is advanced into the chest cavity. The external end is then connected to a closed underwater drainage system. This system allows air to leave the chest while preventing outside air from flowing back in, functioning like a one-way valve. Bubbles in the water indicate that air is being evacuated from the chest.
Materials required for chest tube insertion include:
- Sterile cleansing solutions
- Local anesthetic medications
- Surgical scalpel and instruments
- Silicone chest tube
- Fixation sutures
- Underwater drainage bottle
How Is Surgical Repair of Open Pneumothorax Performed?
Once the chest tube has been successfully inserted and the lung has begun to re-expand, repair of the chest wall opening is performed. The exact method depends on the size of the wound, the degree of tissue damage, and the amount of time that has passed since the injury. Devitalized, crushed, or contaminated tissues around the wound are surgically removed. This cleaning process is essential for preventing future infection. If the wound is relatively clean and there is little tissue loss, the muscle and skin layers are brought together and sutured appropriately. In very large injuries, special patch materials or muscle flaps transferred from other areas of the body may be needed to reconstruct the chest wall.
In some cases, air leakage from the lung continues for several days despite chest tube drainage, bleeding does not stop, or additional internal organ injuries are suspected. In such situations, minimally invasive thoracic surgery techniques such as VATS are used. Through very small openings in the chest wall, camera-equipped instruments are introduced and the damaged area is examined in detail on a monitor. Tears in the lung tissue are closed with specialized stapling devices, and bleeding is controlled. With advances in technology, these procedures are increasingly performed through minimally invasive approaches rather than large incisions.
Situations that may require advanced surgical intervention in open pneumothorax include:
- Persistent air leakage
- Excessive and ongoing bleeding
- Failure of the lung to re-expand despite tube drainage
- Suspected tracheal injury
- Possible esophageal rupture
- Accumulation of blood clots inside the chest
What Can Be Expected During Recovery After Open Pneumothorax Surgery?
After surgical treatment has been completed, the patient’s period of rest and recovery on the hospital ward begins. One of the most important issues closely monitored by the thoracic surgery team is proper management of the chest tube. The drainage bottle connected to the tube must be kept below chest level for the system to function correctly. Patients are frequently reminded not to raise or overturn the bottle because gravity could cause fluid inside the bottle to flow back toward the chest cavity.
It may take some time for the lungs to regain their previous elasticity and capacity after surgery. Lung tissue that has experienced trauma and remained collapsed for a period is highly prone to accumulating secretions. If these secretions cannot be cleared, the risk of lung infection increases. The most effective way to prevent this is by performing regular breathing exercises. Patients are given small plastic devices that encourage deep inhalation and are instructed to use them at regular intervals throughout the day. Controlled coughing, despite some discomfort, also helps remove accumulated mucus and keeps the lungs clear.
Steps patients are expected to follow during recovery include:
- Regular breathing exercises
- Controlled coughing exercises
- Frequent walking during the day
- Increasing fluid intake
- Regular use of prescribed pain medication
- Keeping the drainage bottle below chest level
What Should Patients Pay Attention to After Discharge Following Open Pneumothorax?
Discharge planning begins once the chest tube has been removed and the wound has started healing. Although patients are often very happy to return home, it is important to remember that recovery continues for some time. During the first few weeks, the re-expanded and repaired lung tissue and surrounding pleural membrane remain sensitive to sudden pressure changes. Activities that place extra strain on the lungs, abruptly increase pressure inside the chest, or expose the body to changes in external pressure may stress the repaired area and increase the risk of recurrence.
For this reason, patients are advised to maintain a calm lifestyle for a period and avoid excessive physical exertion. Healthy nutrition and avoiding crowded, poorly ventilated environments help support immunity and reduce the risk of infection. Attending follow-up appointments as scheduled and monitoring the lung with follow-up imaging are extremely important for completing recovery safely.
Activities that are generally recommended to be avoided for a period after discharge include:
- Air travel
- Scuba diving
- Lifting heavy objects
- High-impact contact sports
- Activities causing severe straining
- Playing wind instruments
- Prolonged loud speaking
A healthy respiratory system is one of the foundations of quality of life. Individuals who recover from such urgent and difficult conditions have a strong chance of returning to a normal and active lifestyle if they follow their physicians’ recommendations. The human body has a remarkable ability to heal, and when modern medical support is combined with the patient’s patience and effort, these severe injuries can often remain only as memories.
Frequently Asked Questions
Open pneumothorax may present with sudden chest pain, shortness of breath, an open chest wound, rapid breathing, and bluish discoloration. Because it can be life-threatening, it requires immediate medical attention.
Open pneumothorax usually develops after stab wounds, gunshot injuries, traffic accidents, or other trauma that penetrates the chest wall. The underlying cause is air entering the pleural cavity through the opening in the chest wall.
Diagnosis is initially based on physical examination and the patient’s clinical findings. When the patient’s condition allows, chest X-ray or computed tomography may be used to evaluate the size of the pneumothorax and any accompanying injuries.
Treatment first aims to control air entry and secure breathing. A chest tube may be inserted, and when necessary, surgery is performed to repair the chest wall injury and allow the lung to re-expand.
If treatment is delayed, severe respiratory failure, low oxygen levels, circulatory collapse, and life-threatening tension pneumothorax may develop. Therefore, open pneumothorax requires immediate medical evaluation.
No. The need for surgery depends on the size of the injury, whether the air leak continues, and whether there is associated organ damage. In some patients, chest tube drainage is sufficient, while others require surgical treatment.
Recovery time varies according to the severity of the injury, the treatment performed, and the patient’s overall health. Regular follow-up and adherence to medical recommendations contribute to a healthy recovery process.
Smoking should be avoided, strenuous physical activity should be restricted for a period, and follow-up appointments should not be missed. If shortness of breath, chest pain, or fever develops, medical attention should be sought immediately.
The recurrence risk of traumatic open pneumothorax depends on the underlying cause. Protecting lung health, avoiding smoking, and attending regular medical follow-up may help reduce the risk of complications.
In open pneumothorax, there is an opening in the chest wall that communicates directly with the outside environment, allowing air to enter the chest cavity. In closed pneumothorax, air leaks from the lung without a direct connection to the outside environment.
Prof. Dr. Alper Fındıkcıoğlu graduated from Istanbul University Faculty of Medicine and completed his thoracic surgery residency at Dr. Siyami Ersek Hospital. He began his academic career at Başkent University in 2005; he received the title of associate professor in 2014 and professor in 2022. He has extensive experience in lung cancer, chest wall diseases, and minimally invasive surgery. Since 2024, he has been continuing his professional work at Acıbadem Hospital.
