Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases. There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.