This patient has a large left PTX, which based on size will definitely need a chest tube. It is also important to check the position of the mediastinum in all patients with PTX. This mediastinum is shifted AWAY from the PTX, suggesting tension. This is an emergency and this patient needs immediate decompression of the pleural air.

Tension PTX is a medical emergency. In this condition, the air in the pleural space is under pressure, and this results in rapid enlargement of the PTX, but also in shift of the mediastinum AWAY from the side of the PTX. This is the dangerous thing, since the thin-walled veins leading into the heart (the superior and inferior vena cavae) can easily be compressed by the shift and pressure, leading to sudden death. If there is not time to insert a chest tube, initial decompression can be performed by inserting any catheter into the affected side, usually over one of the anterolateral upper ribs. However, tension PTX is a clinical diagnosis, depending on symptoms such as hypotension. The radiologic findings are suggestive but not diagnostic, since some patients may remain asymptomatic even with moderate mediastinal shift and large PTX.