Pneumothorax: Clinical

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Pneumothorax: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 23-year-old male presents to the emergency department after being stabbed in the chest. The patient's primary survey is notable for decreased breath sounds over the right chest. Secondary survey reveals a single stab wound to the right lateral thorax, tracheal deviation, and jugular venous distension. Temperature is 37.0°C (98.6°F), pulse is 126/min, and blood pressure is 77/42 mmHg. Respiratory rate is 26/min, and oxygen saturation is 90% on room air. Which of the following best describes the correct anatomic space for emergent intervention to manage this patient's condition?


The pleura is the blanket that covers our lungs, and it’s made of two layers, the inner visceral pleura and the outer parietal pleura. In between those two layers is a space.

If air gets in that space, it’s called a pneumothorax. Pneumothoraces can be classified into two broad categories: spontaneous or traumatic.

Spontaneous pneumothorax is further subclassified into primary and secondary. A primary spontaneous pneumothorax occurs without a triggering event in an otherwise normal lung.

Most commonly, an individual at risk of primary spontaneous pneumothorax is a tall, thin, young male presenting with symptoms that started at rest.

This is because there are more mechanical shear forces at the apex of the lung, that can make the pleura rupture, especially after for some reason holding their breath like diving or inhaling and holding a recreational drug or medication in their lungs.

Another risk factor for a primary pneumothorax is smoking cigarettes and systemic syndromes like Marfan disease.

Then there’s a secondary pneumothorax; that is a spontaneous pneumothorax that occurs in a lung with pre-existing lung disease, like chronic obstructive pulmonary disease or COPD, asthma, interstitial lung disease, tuberculosis, cystic fibrosis, or lung cancer.

In COPD, destruction of the alveolar sacs leads to formation of large alveolar blebs, which are small balloons that can eventually rupture, leaking air into the pleural space.

Traumatic pneumothorax occurs secondary to injury of the pleura after blunt or penetrating trauma to the chest like a stab wound, or as a complication of a procedure, such as a lung biopsy, thoracentesis, central line insertion, or mechanical ventilation.


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