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Objective: It is conventionally thought that patients with pneumothoraces (PTX) require tube thoracostomy prior to air medical transport (AMT), especially in un-pressurized rotor-wing aircraft, to prevent deterioration from expansion of the pneumothorax and possible development of tension pneumothorax. We hypothesized that patients with pneumothorax(ces) transported without prior tube thoracostomy tolerate AMT without serious deterioration. Methods: We conducted a retrospective case-series of trauma patients transported via helicopter with radiographically confirmed PTX between September 2002 and September 2005. Charts were evaluated for signs of deterioration including hypotension, hypoxemia, respiratory distress, intubation, needle thoracostomy or cardiac arrest during transport. In addition, duration of flight and altitude change was recorded. Results: During the study period, 55 patients with confirmed PTX underwent rotor-wing AMT with an average altitude gain of 1950 feet and average duration of 22 minutes (range 3 to 70). 12 of 55 (22%) were transported between hospitals with the remainder (43/55, 88%) coming from scenes or small clinics. 37 of 55 PTX (67%) were suspected and 3 (5%) confirmed prior to transport. 8/55 patients (15%) were intubated prior to transport. All patients received oxygen during AMT. Six of the 55 patients (11%) had needle thoracostomies placed prior to flight. Four of these 55 patients (7%) deteriorated during AMT: 1 patient suffered a cardiac arrest but was resuscitated before arrival at hospital without needle or tube thoracostomy, 1 patient developed hypotension and 2 patients developed increased respiratory difficulty for which 1 of the 2 required needle thoracostomy with good results. 3 of these 4 complications were likely or possibly due to PTX. Conclusions: In this retrospective case-series, only 3/55 (5%) of patients with PTX deteriorated and no patients died during un-pressurized rotor-wing AMT despite long transport times and large altitude changes. Routine placement of tube thoracostomy before rotor-wing AMT may not be necessary.