Pneumothorax after rupture of pulmonary blisters is a common clinical emergency. Most of the pulmonary blisters are located in the apical part of the lung, and the pulmonary blisters in the apical part of the lung may form adhesions with the pleura, and trophoblastic vessels may be formed in the adhesion zone. When the pulmonary blister ruptures, it can cause pneumothorax and collapse of lung tissue, and it may also tear the trophoblastic vessels and cause bleeding in the thoracic cavity, which is quite violent due to high pressure and negative pressure in the thoracic cavity. Since hemothorax may not occur immediately after the onset of pneumothorax, it may be an insidious late bleeding due to further collapse of the lung or tearing of the trophoblastic vessels during activity, which is more likely to be overlooked clinically with serious consequences. All five patients in this group showed no obvious signs of intrathoracic hemorrhage on admission, and their general condition was relatively good, with less severe pulmonary compression, so they did not undergo closed thoracic drainage first because surgical treatment would be performed soon. Since some patients had poor sleep, poor sleep and mental atrophy before admission, it was easy to confuse the clinical judgment of blood loss. Since the admission diagnosis is pneumothorax but no combined hemothorax is found, this often leaves hidden problems. For the surgical treatment of pneumothorax combined with hemorrhage, thoracoscopic surgery has many advantages. The technique is widely accepted as it allows surgery through a very small incision with minimal trauma, short operative time, low intraoperative bleeding, and mild postoperative pain, and also reduces the incidence of postoperative pulmonary complications. Although Milanehi et al. considered preoperative hemodynamic stability as an important condition for thoracoscopic surgery. However, through this group of cases, we found that the thoracoscopic field is well exposed, the location of the thoracic apex is satisfactorily exposed, and the magnification of the thoracoscope allows for more rapid and exact detection of the bleeding site and exact hemostasis, less surgical trauma, faster postoperative recovery, shorter hospital stay, and lower medical costs for patients. These are more advantageous than the traditional open-heart surgery. Due to the large amount of occult intrathoracic hemorrhage and often inadequate preoperative expectation, and at this time the patient is often in hemorrhagic shock, timely blood transfusion is the most effective measure in treatment, and rapid replenishment of blood volume and maintenance of circulatory stability are the keys to save life. At present, various autologous blood transfusion techniques are being increasingly used in clinical practice. We have achieved satisfactory results with the blood recovery instrument. In this group of patients, intra-thoracic hemorrhage was not diagnosed before surgery, and when a large amount of blood was suddenly found in the thoracic cavity, the installation of the blood recovery instrument was completed within 2 min, and the recovery was started, and the red blood cell washing was performed, and the return of the washed autologous red blood cells was started within 5 min, and the blood volume was quickly replenished and the circulation was stabilized by the return of blood cells while recovery. This autologous transfusion method eliminates the need for systemic heparinization, greatly reduces the transfusion volume, saves blood resources, and reduces transfusion complications, while being fast and efficient. In conclusion, spontaneous pneumothorax combined with occult severe intrathoracic hemorrhage is a delayed hemorrhage, which is easily overlooked in clinical practice. Patients with pneumothorax, especially those without closed chest drainage, should be closely observed during preoperative or conservative treatment, focusing on the possible manifestations of increased chest tightness, increased heart rate, and irritability after blood loss, and timely review of X-ray chest radiographs, closed chest drainage, or surgical treatment as soon as possible can promptly confirm the diagnosis and reduce the associated risks. Thoracoscopic surgery for hemostasis and resection of pulmonary blisters is safe and effective. The timely application of intraoperative blood recovery device is helpful to stabilize circulation and reduce blood transfusion, which is worthy of wide clinical application.