In traumatic pneumothorax, larger tubes (28 F, 9.3 mm) are used. When chest tubes are placed due to either blunt or penetrating trauma, antibiotics decrease the risks of infectious complications.Chest tubes are required in PSPs that have not responded to needle aspiration, in large SSPs (>50%), and in cases of tension pneumothorax. They are connected to a one-way valve system that allows air to escape, but not to re-enter, the chest. This may include a bottle with water that functions like a water seal, or a Heimlich valve. They are not normally connected to a negative pressure circuit, as this would result in rapid re-expansion of the lung and a risk of pulmonary edema ("re-expansion pulmonary edema"). The tube is left in place until no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung.If after 2–4 days there is still evidence of an air leak, various options are available. Negative pressure suction (at low pressures of –10 to –20 cmH2O) at a high flow rate may be attempted, particularly in PSP; it is thought that this may accelerate the healing of the leak. Failing this, surgery may be required, especially in SSP.Chest tubes are used first-line when pneumothorax occurs in people with AIDS, usually due to underlying pneumocystis pneumonia (PCP), as this condition is associated with prolonged air leakage.
This involves the administration of local anesthetic and inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are removed. If there has been significant reduction in the size of the pneumothorax on subsequent X-ray, the remainder of the treatment can be conservative. This approach has been shown to be effective in over 50% of cases. Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital admission, without increasing the risk of complications.Aspiration may also be considered in secondary pneumothorax of moderate size (air rim 1–2 cm) without breathlessness, with the difference that ongoing observation in hospital is required even after a successful procedure. American professional guidelines state that all large pneumothoraces – even those due to PSP – should be treated with a chest tube. Moderately sized iatrogenic traumatic pneumothoraces (due to medical procedures) may initially be treated with aspiration. Chest tube
A chest tube (or intercostal drain) is the most definitive initial treatment of a pneumothorax. These are typically inserted in an area under the axilla (armpit) called the "safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimus dorsi and pectoralis major). Local anesthetic is applied. Two types of tubes may be used. In spontaneous pneumothorax, small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the Seldinger technique, and larger tubes do not have an advantage.