Conventionally, thoracic impairments, such as pneumothorax (primary or secondary) and hemothorax, are managed with large CT placement independent of the size [1]; and historically, there is a belief that large-bore chest tubes show an increased rate of success in the management of these pathologies, even in pleural effusions [1, 4].

However, the present-day literature focuses on the less invasive techniques in the management of traumatic or spontaneous pneumothorax [7,8,9,10]. Kulvatunyou et al. [11], in a randomized clinical trial, showed that there is no difference in clinical outcomes comparing PC versus CT in patients with traumatic pneumothorax, with benefit in pain relief in patients with PC, with the lesser failure rate. [10]. Other studies evaluated the impact of the large/small CT in the management of hemo/pneumothorax; however, according to Inaba et al. [12], there are no differences in clinical outcomes, such as efficacy, rate of complications, and needs for additional procedures. All these data impact the clinical guidelines of ATLS, which recommends small CT placement for all cases of pneumothorax [1, 2].

The use of less invasive techniques is increasing, such as the utilization of PC in the management of pneumothorax. Multiple studies [7,8,9,10] are now evaluating the advantages and benefits of this approach; Bauman et al. [5] show that in terms of failure rates there is no difference between CT and PC, with a better patient’s experience, comparable results with Kulvatunyou et al. [11].

Chang et al. [4] in a meta-analysis concluded that placement of PC for traumatic or non-traumatic pneumothorax shows less rate of complications, shorter duration of the drainage and hospital stay with statistically significant differences, compared with large CT, these results could impact in the clinical outcomes of the patients and financial burden. According to Fang et al. [8] meta-analysis increases the evidence in favor of the advantages of PC in the management of pneumothorax independent of the cause or size, showing a success rate between 72 and 88% and complication rates between 9 and 18%.

However, other authors include PC in the management in other pathologies, such as pleural effusions, Rodriguez Lima et al. [13] with a prospective study including patients critically ill, with associated pleural effusions, showing a 1.2% complications rate, lesser than the reported in the literature, with comparable rates of success.

Tsai et al. [14] in a retrospective study reported that treatment failure rates were 42.9%, 25.9%, and 15.5% in patients with pneumothorax sizes > 62.6%, 38–62 0.6%, and < 38%. The median pneumothorax size in this case series was 20.5%, which may partly explain our 100% success rate. However, in different observational studies the diameter of the drain does not seem to be the most important factor for successful re-expansion [15,16,17]. As in the technique described by us, we found an adequate success rate despite being one of the smallest diameters reported in the literature. In addition, it seems more important for the success of the re-expansion that the tip of the drain is located at the apex of the pleural cavity, regardless of the type of drain inserted [18].

Benton et al. [18] in a descriptive study demonstrated displacement was higher with small bore (21% vs 8%); however, in our series we did not observe any unplanned removal. All PCs were fixed to the skin with silk 2–0.

Our paper describes the operative technique with real-time ultrasound guided of #8.3 French PC in the management of pneumothorax independent of the cause and the size. Our initial results show a success rate slightly higher than the one described in the literature (82% vs 100%). Some series of cases report a complication rate between 1.2% and 9%; in our series of cases, no complications secondary to the procedure were evidenced. Duration of the drainage was similar to those reported in Chang et al. [4] with a mean of 3 days ± 1.41 days. Also, no recurrence rates were defined, and any patient required CT placement or invasive procedures after the PC with real-time ultrasound approach.

To the best of our knowledge, this is the first study that describes the operative technique of PC with real-time ultrasound-guided placement for the management of pneumothorax with small-size PC. These initial results show promising outcomes, with a low rate of complications and morbidity, as well, a high rate of success, with shorter in-hospital stay and duration of the drainage.

Limitations of our study include the retrospective nature and the small number of patients. However, this paper describes the operative technique with real-time ultrasound that shows the advantages of the use of less invasive techniques in traumatic or spontaneous pneumothorax.