WHEN ‘LESS IS MORE’ STUDY OF LUNG - COLLAPSE TREATMENT DRAWS INTERNATIONAL ATTENTION in NEJM Journal watch wrote that the study “serves as notice that the available evidence favors a ‘less is more’ approach.”
Dr. Peter Hahn
Treating patients at Metro Health – University of Michigan Health for certain types of sudden lung collapse, the three doctors noticed something interesting: Less-invasive treatments appeared just as effective as the usually recommended approach.
S
eeing an opportunity to update treatment guidelines, they launched an ambitious review of 70 years of studies. Coauthors Dr. Sri Mummadi, Dr. Jennifer de Longpre’ and Dr. Peter Hahn, CEO of Metro Health, published their findings earlier this year in the Annals of Emergency Medicine. The study has since attracted widespread attention for commentary in other leading medical journals: the British journal BMJ, the New England Journal of Medicine’s NEJM Journal Watch and an upcoming issue of Ontario-based ACP Journal Club, published by the American College of Physicians. The review 18
T R I A D | S P R I N G 2020
When air leaks from the lung and gets trapped in the chest wall, the pressure prevents the lung from inflating completely. It becomes impossible to fully inhale. When this occurs without an injury such as blunt trauma, it is called spontaneous pneumothorax – the focus of the study. Patients who are suffering spontaneous pneumothorax usually end up in the emergency room with chest pain and shortness of breath. Noting that the condition accounted for $1.4 billion in inpatient charges as recently as 2014, the authors observed that previous guidelines for the best initial treatment strategy were outdated and inadequate. When the three doctors worked together at Metro Health – University of Michigan Health, they saw success with innovations such as using very small chest tubes, as narrow as a coffee straw, to remove air pressure inside the chest of spontaneous pneumothorax patients. At the time, American guidelines favored largediameter chest tubes.
“Obviously, from a patient’s point of view, having a coffee straw inside the chest is much more easily tolerated than having a garden hose,” Mummadi said.
At the other end of the spectrum, British guidelines recommended removing the air with needle aspiration. This approach is less invasive but has a drawback: Patients must be observed for six hours or more before being discharged. This is not practical in an American emergency room setting.
1,880
published papers
12
selected studies
781
patients
3
treatments
Inspired to measure the different approaches, the three doctors undertook a meticulous worldwide search of medical studies. They reviewed 1,880 published papers, including some that had to be translated from Chinese and Korean. They focused on randomized controlled studies, the gold standard in science, finally selecting 12 for review. The studies involved 781 patients. The doctors then compared outcomes of the three treatments – needle aspiration, narrow-bore chest tube and large-bore chest tube – based on: • Efficacy – which treatment produces the most success • Safety – which treatment carries the least risk of complication
