Initial treatment of traumatic pneumothorax with water seal leads to significantly shorter chest tube durations compared to suction, without increased complications.

• Median initial chest tube duration was 41 hours for water seal vs 51 hours for suction (p = 0.001).
• Total chest tube duration was also reduced, with water seal requiring 44 hours compared to 60 hours for suction (p = 0.011).

These findings suggest considering water seal as the first-line strategy in selected trauma patients, challenging the routine use of suction.