Supplemental oxygen (non-rebreather mask) initially for all
Needle decompression followed by chest tube insertion
Observation (majority) vs. aspiration
Chest tube if become symptomatic
Needle decompression followed by chest tube insertion
Use thoracentesis or "pig-tail" kit, if available
Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
Withdraw air with syringe until no more can be aspirated
Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
Once no further air can be aspirated:
Option 1
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Option 2
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
If 2.5 L of air has been aspirated, and a significant PTX remains, tube thoracostomy is indicated
NEJM video on needle aspiration of pneumothorax.
Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
Option 1
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Option 2
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
Place closed stopcock and secure catheter to the chest wall
Obtain CXR four hours later
If adequate lung expansion has occurred, remove catheter
Following another two hours of observation, obtain another CXR
If the lung remains expanded, may discharge patient
Leave catheter in place
Attached a Heimlich (one-way) valve
May discharge with follow-up within two days
Most spontaneous pneumothorax (primary and secondary)
Most<unk> 
Alveolar-pleural fistulae (small air leak)<unk>  air
Traumatic pneumothorax
Traumatic hemothorax ("any acute hemothorax visible on chest radiograph")
Pneumothorax on mechanical ventilation
Non-traumatic tension pneumothorax
Malignant effusion
Trauma/bleeding (hemothorax/hemopneumothorax)
Bronchial-pleural fistulae (large air leak)
Malignant fluid
Empyema
Thick pus
Iatrogenic pneumothorax
Tension pneumothorax
Spontaneous pneumothorax
Traumatic pneumothorax
Catamenial pneumothorax
Hemothorax
Fat embolism syndrome
Pulmonary barotrauma