**5.3 Thoracostomy only**

Primary spontaneous pneumothorax may also be managed with a chest tube that is left in place for 1 or more days or by attaching the catheter to a one-way Heimlich valve or water-seal device and using it as a chest tube. The last method is reserved for patients in whom Heimlich valves fail or those who have coexisting respiratory conditions that reduce the ability to tolerate a recurrent pneumothorax [38]. After treatment, persistent air leaks are not common in primary spontaneous pneumothorax. Seventy five percent of air leaks resolve after 7 days, and 100% resolve after 15 days [38]. When the air leak persists for 4 to 7 days, surgery comes to consideration. In a study from Kim, selection of patients with primary spontaneous pneumothorax and persistent air leaks for immediate surgery must be done according to the presence or absence of bullae, detected by high-resolution chest computed tomographic (HRCT) scanning [44].
