Objective To explore the effect of the distance between pulmonary nodules and pleura on the occurrence of pneumothorax after thoracoscopic resection (VATS). Methods Patients with pulmonary nodules who received VATS treatment in our hospital from May 2022 to May 2024 were selected as the research subjects, there were 92 patients with pneumothorax and 89 patients without pneumothorax during postoperative follow-up. Propensity score matching (PSM) method was used to match 70 subjects in each group at a 1∶1 ratio and compare their general information. Compared the general information and imaging features of two groups of patients. Used a hierarchical regression model to explore the correlation between other factors and the distance from nodules to pleura. By using a multiple factor logistic regression model, two sets of data with nodules or without distance from the pleura were analyzed to screen for independent risk factors for postoperative pneumothorax, and a postoperative pneumothorax prediction model was constructed based on this. Based on this, a predictive model for postoperative pneumothorax was constructed. Evaluated the predictive performance of different models using the area under the receiver operating characteristic curve (AUC-ROC), the comprehensive discriminant improvement index (IDI), and the net reclassification index (NRI); Use Hosmer Lemeshow test to evaluate the goodness of fit of different models. Interval likelihood ratio was used to compare the risk of pneumothorax at the distance between nodules and pleura. A restricted cubic spline model combined with threshold effect analysis was used to explore the correlation between the distance between nodules and pleura and postoperative pneumothorax.Results There were statistically significant differences in nodule location, nodule density, distance between nodules and pleura, postoperative time of carrying chest catheterization, postoperative VAS score, and resection range (P<0.05). The location and density of nodules, the duration of postoperative chest catheterization, and the extent of resection had a positive impact on the distance between nodules and pleura (P<0.05). The independent risk factors for postoperative pneumothorax included nodule location, nodule density, time of carrying the thoracic catheter after surgery, resection range. The AUC-ROC value for postoperative pneumothorax in Model 1 was 0.746 (95%CI:0.715~0.779). After incorporating the distance between the nodule and the pleura into the model, the AUC-ROC value increased to 0.822 (95%CI: 0.788~0.865) (P<0.05); Compared with Model 1, the IDI value increased to 0.082 (95%CI: 0.042~0.115) and the NRI increased to 0.619 (95%CI: 0.521~0.694) after incorporating the distance between nodules and pleura into the model (P<0.05). Compared with Model 1, Model 2 had AUC-ROC values of 0.812 (95%CI: 0.775~0.837), IDI values of 0.068 (95%CI: 0.049~0.086), and NRI values of 0.601 (95%CI: 0.537~0.691), all of which had been improved (P<0.05). According to the Hosmer Lemeshow test, the P-value of Model 1 was 0.682; The P-value of Model 2 is 0.864, indicating that both models had ideal goodness of fit. As the distance between the nodule and the pleura increases, the risk of pneumothorax increased. As the distance between the nodule and the pleura increased, the risk of pneumothorax increased. When the distance between the nodule and the pleura was greater than 20 mm, the risk of pneumothorax was 67.14%, which was higher than when the distance between the nodule and the pleura was less than 10 mm or 10-20 mm. Further threshold effect analysis showed a significant positive correlation between the distance between the nodule and the pleura and the occurrence of postoperative pneumothorax.Conclusion The distance between the nodule and the pleura is positively correlated with the occurrence of pneumothorax after VATS of pulmonary nodules. Including it in the prediction model can help accurately evaluate the risk of postoperative pneumothorax in clinical practice, and improve surgical safety and patient prognosis