17 y/o with chest pain

This guy developed chest pain about 1 week ago after playing basketball, felt SOB with exercise only. He saw his PMD on day of presentation who did outpt xrays. Below is his repeat ACMC CXR.


The reading is a complete left sided PTX, if the image isn't clear. So, how do you treat it? It's a simple PTX, not trauma. Does it require a chest tube, catheter aspiration, or even needle aspiration?

At the time, I thought it was too big for anything other than a chest tube. It had also enlarged from a few hours earlier (from about 70% to complete collapse), although the patient was stable (comfortable at rest, normal VS, and normal O2 sats). Looking it up afterwards, some teaching points.

1) Aspiration is successful in about 65-80% of simple PTX (no underlying lung disease, no trauma). The rate of PTX recurrence is the same as if a chest tube was placed.

2) If you put a catheter in the chest, it should be small (14 F or smaller). A chest tube should also be small (16 to 22 F).  You can put a Heimlich valve on the end if the lung seems to expand well, instead of suction.

3) For a small (<2 cm) PTX that isn't causing "breathlessness", don't do anything but monitor per British Thoracic Society.

4) BTS advocates needle aspiration for all simple PTX regardless of size. Most studies (few patients) had patients with small to moderate PTX. Either way, the patient will need 6 hrs obs in the ED and repeat CXR. Leaving a catheter in place so more air could be aspirated is a nice option.

5) Patients with underlying lung disease (eg COPD) probably won't do as well, but BTS advocates giving aspiration a shot.

What did I do? Put in a 20 F chest tube (with ketofol) to wall suction. His lung went to 95% inflated immediately. Maybe next time I'll try 14F catheter aspiration. see http://emedicine.medscape.com/article/1959416-overview#aw2aab6b4 for technique