American Board of Internal Medicine (ABIM) Certification Practice Exam

What should be done for a clinically unstable primary spontaneous pneumothorax, irrespective of its size?

1. Observation and outpatient management

2. Needle decompression followed by thoracostomy tube insertion

3. Immediate thoracotomy

4. High-flow oxygen therapy

The correct answer is: Needle decompression followed by thoracostomy tube insertion

In cases of a clinically unstable primary spontaneous pneumothorax, immediate intervention is crucial due to the potential for significant respiratory compromise and hemodynamic instability. The appropriate management involves needle decompression to rapidly relieve intrathoracic pressure, which can alleviate respiratory distress and improve oxygenation. After needle decompression, insertion of a thoracostomy tube (chest tube) is indicated to continuously evacuate air from the pleural space until the lung can fully re-expand and stabilize. The need for this approach is underscored by the fact that observation and outpatient management would not be appropriate for a patient exhibiting clinical instability, as this could lead to further deterioration. Immediate thoracotomy is typically reserved for more complex cases or if there are additional complications such as significant injury or bleeding; it is not the primary treatment for a primary spontaneous pneumothorax. High-flow oxygen therapy can support oxygenation but would not address the underlying problem of the pneumothorax, making it insufficient as a sole intervention. Thus, needle decompression followed by thoracostomy tube insertion is the most appropriate and effective management strategy in this clinical scenario.