The use of prehospital tube thoracostomy (TT) for the treatment of suspected tension pneumothorax (TPtx) in trauma patients is controversial. A study is presented that reviews a 6-year experience with the use of needle catheter aspiration (NA) and chest tubes performed in the field by air medical personnel. Prehospital flight charts and hospital records from 207 trauma patients who underwent one or both of these procedures in the field were retrospectively reviewed. The clinical indications used to determine treatment are presented for both procedures. Improvement in clinical status of patients observed by flight personnel were similar for both treatment groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had failed NA attempts prior to chest tube placement. Average time on scene (T.O.S.) was significantly greater for the TT group (25.7 min versus 20.3 min for NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT treatment compared to NA alone (7% versus 19%, respectively). Injury severity scores, number of hospital complications, length of stay (L.O.S.), and total hospital costs were not different between the two groups. There were no cases of lung damage or empyema formation associated with prehospital TT treatment. Overall mortality was similar for both groups. From these data, we conclude that NA is a relatively rapid intervention in the treatment of suspected TPtx in the prehospital setting; however, TT is an effective adjunct for definitive care without increasing morbidity or mortality. A better understanding of the physiology of intrapleural air masses is needed to determine the most effective decompression requirements prior to aeromedical transport.