In a patient with a large pneumothorax (>20%), what is the preferred definitive management?

• A. Evacuation by needle aspiration
• B. Chest tube thoracostomy
• C. Oxygen therapy only
• D. Mechanical ventilation with PEEP

Answer: (B)

When a pneumothorax is large, the primary problem is a significant amount of air in the pleural space compressing the lung and reducing ventilation. The goal is to rapidly evacuate that air and allow the lung to re-expand, while preventing further air from leaking into the space. A chest tube thoracostomy provides continuous drainage of intrapleural air and allows the lung to re-expand reliably, making it the definitive treatment for a large pneumothorax.

Removing air with a needle or using oxygen alone does not address the persistent space-occupying air in a large pneumothorax, so those approaches are not definitive. Oxygen accelerates air resorption but doesn’t immediately drain the pleural space. Mechanical ventilation with PEEP can actually worsen the pneumothorax by increasing intrathoracic pressures and promoting air leakage, so it’s not appropriate as the primary management for a large pneumothorax.