“Hands-off” to treat pneumothorax
Findings of a pneumothorax clinical trial are expected to cause a major shift in thinking around how doctors treat the condition with a “hands-off” approach regarded as the best option.
According to a six-year study, involving more than 300 Australian and New Zealand patients, the traditional ‘interventional’ approach to treating a collapsed lung results in significantly longer hospital stays, and greater complications compared to a more hands-off ‘conservative’ approach – treating patients with simple pain relief, observing them and then sending them home to await the lung’s natural re-expansion and recovery.
The research was published in the New England Journal of Medicine (NEJM) earlier this year and was also acknowledged as a joint winner of the 2021 Australian Clinical Trials Alliance Trial of the Year Award.
Study chief investigator and emergency physician Professor Simon Brown, from the Centre for Clinical Research in Emergency Medicine at Royal Perth Hospital, said the study found that “medical intervention is not always in a patient’s best interest”.
It is estimated that up to 3,000 Australians present to emergency departments each year experiencing a collapsed lung, or pneumothorax. This condition can be caused by an underlying lung disease or, more commonly, for no obvious reason at all.
It occurs when a spontaneous leak from the surface of the lung causes air to collect inside the chest, which in turn causes severe pain and breathing difficulties.
“We’ve been putting tubes into people with collapsed lungs since the beginning of the 20th century, thinking we were doing our best to treat the condition,” Professor Brown said.
“Now, this study makes it clear that conservative treatment is the best approach, even when the lung collapse is large. Our study found that 85% of patients did extremely well with no intervention at all.”
A total of 316 patients took part in the trial, conducted by more than 100 clinical researchers in 39 hospitals. Of those 316 patients, 154 received the standard interventional lung drainage management, while the remaining 162 were managed conservatively with just pain killers and observation alone.
The results showed that the latter conservative group’s outcome was ‘non-inferior’ to the interventional group in terms of the pneumothorax resolving within an eight-week timeframe. What’s more, the conservative approach resulted in a significantly lower risk of complications.
The interventional management group of patients had an average hospital length of stay of 6.1 days with 41 patients experiencing one or more adverse events; compared to the conservative group of patients’ average hospital stay of only 1.6 days, with just 13 experiencing adverse events.
Professor Daniel Fatovich, Director of Research at Royal Perth Hospital, thinks the study is a great example of the need for more research in emergency situations where many of the treatments used ‘routinely’ do not have strong evidence to support them.
“Simple studies like this, which challenge the medical status quo, can have far-reaching effects, giving better outcomes for patients, and saving the health system millions of dollars by reducing hospital bed days and complications from misguided interventions”, he said. “A simple summary is: less is more.”
The study was coordinated by the Centre for Clinical Research in Emergency Medicine (Harry Perkins Institute of Medical Research) at Royal Perth Hospital, and in New Zealand by the Medical Research Institute of New Zealand (MRINZ).