Initial treatment for pneumothorax may consist of observation alone, placement of a chest tube, or needle thoracentesis Tension pneumothorax, however, should always be treated with immediate needle decompression This is performed by insertion of a large-bore intravenous (IV) catheter in the midclavicular second intercostal space of the ipsilateral side, or in the fourth or fifth intercostal space in the anterior axillary line If there is a tension pneumothorax, an immediate release of air should be noted Evacuation can be facilitated by attaching the catheter to a two-way stopcock and 60-cc syringe, allowing air to be continuously pulled from the pleural space although the placement of the catheter alone should temporarily resolve the tension physiology until tube thoracostomy can be performed When using a stopcock and syringe, care must be taken to avoid leaving the stopcock in place but closed after evacuation of air to prevent recurrence of pleural air and potentially tension physiology Chest Tube Tube thoracostomy is indicated in the symptomatic patient with pneumothorax or those requiring air transport Management of asymptomatic pneumothoraces identified on CT but not visible on plain radiograph is controversial, but tube thoracostomy does not appear to be required, even in patients undergoing positive pressure ventilation Tube thoracostomy should be done in the midaxillary line at the level of the fifth intercostal space (nipple level) If the pneumothorax is not relieved and a significant air leak continues after chest tube placement, a tracheobronchial rupture must be considered Evidence suggests that for a simple pneumothorax, placement of a pigtail catheter instead of a chest tube has similar efficacy while causing less pain to the patient While data in children are lacking, pigtail catheter placement is often preferred to surgical tube thoracostomy for management of pneumothoraces due to less need for procedural sedation and postprocedural pain medication Tube thoracostomy, and not pigtail catheter placement, is the treatment of choice in patients with a hemothorax in order to evacuate blood from the pleural cavity, reexpand the lung, and prevent or treat any mediastinal shift Many hemothoraces may actually represent hemopneumothoraces As with a pneumothorax, the chest tube is placed in the midaxillary line at the level of the fifth intercostal space (nipple level) Patients should be typed and crossed for packed red blood cells and adequately volume resuscitated, preferably with two large IV lines in place For larger hemothoraces, donor blood should be at the patient’s bedside prior to tube thoracostomy if time permits After placement of a