Predicting the need for tube thoracostomy in blunt trauma patients with occult pneumothorax: Observation versus intervention.

Objectives: Occult pneumothorax is increasingly diagnosed in trauma patients due to widespread use of computed tomography (CT), yet its optimal management remains controversial. This study aimed to identify clinical and radiological predictors of deterioration requiring tube thoracostomy and to develop a predictive model to guide management decisions.

Methods: In this retrospective single-center study, 166 patients with blunt trauma-associated occult pneumothorax were analyzed. Clinical and radiological variables-including subcutaneous emphysema, haemothorax volume, pneumothorax size, mechanical ventilation, and rib fractures-were evaluated for association with delayed tube thoracostomy. A weighted multivariable logistic regression model addressed class imbalance, and model performance was assessed using receiver operating characteristic (ROC) analysis.

Results: Of 166 patients, 17 (10.2%) required delayed tube thoracostomy. Subcutaneous emphysema (OR 20.10, p = 0.001) and mechanical ventilation (OR 17.30, p = 0.002) were the strongest independent predictors of deterioration. Haemothorax volume also showed a significant association (OR 1.06, p = 0.045). Other factors, including pneumothorax size, rib fractures, age, and sex, were not predictive. The predictive model demonstrated excellent discrimination (AUC = 0.97), suggesting potential for clinical risk stratification.

Conclusions: Physiological indicators such as subcutaneous emphysema and mechanical ventilation are superior to anatomical parameters in predicting deterioration among patients with occult pneumothorax. Our findings support a selective management strategy and highlight the utility of predictive modelling to guide tube thoracostomy decisions. Prospective multicentre studies are warranted to validate these results.