It’s the basic rule of medicine all doctors follow – ‘first do no harm’.
New research from a collaboration between Australian and New Zealand researchers backs that premise, showing that a novel ‘hands off’ approach to treating a common lung condition not only lessens pain, but significantly reduces injury, infection and time spent in hospital.
“This study found that medical intervention is not always in a patient’s best interest, and that if doctors step back and do less, patients do better” says study chief investigator and emergency physician Professor Simon Brown from the Harry Perkins Institute of Medical Research’s Centre for Clinical Research in Emergency Medicine (CCREM) at Royal Perth Hospital.
Every year an estimated 2500-3000 Australians turn up at hospital emergency departments suffering from a collapsed lung (pneumothorax). The condition can be caused by an underlying lung disease or most 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. For decades now, standard hospital treatment for a pneumothorax has been ‘interventional’, with doctors inserting a plastic tube into the patient’s chest to drain the collected air to help the lung reinflate. Not only is this treatment often painful, but it can lead to organ injury, bleeding, infection and sometimes additional surgery if the air leak continues.
But a six year study involving more than 300 Australian and New Zealand patients, published today in the prestigious New England Journal of Medicine (NEJM), shows that this 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.
“These findings are a game-changer in terms of how this common lung problem lung should now be treated” says Professor Brown.” 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. 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 1 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.
“We’ve demonstrated that this ‘hands off’ approach is safe” says Professor Brown. “Patients can be sent home to recover, get back to work and get on with their normal lives more efficiently and effectively, avoiding all the complications that go along with sticking a tube into the chest such as infections and bleeding. What’s more, we found that by treating the patient with observation and painkillers only, we halved the rate of the collapsed lung recurring”.
The findings are expected to cause a major shift in thinking around how doctors treat pneumothorax worldwide. Study co-author, respiratory physician and the doctor who came up with the idea for the study, Dr Graham Simpson at Cairns Base Hospital, says this research will change medical practice for the treatment of a collapsed lung and have worldwide impact. “Doctors have often assumed this is a serious condition if it is not treated, but in reality it is essentially a nuisance rather than dangerous. It is gratifying to finally see some really good scientific proof that doing less is often the best approach”, he said.
Professor Daniel Fatovich, Director of Research at Royal Perth Hospital and head of CCREM, 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 mis-guided 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). Funding for the Australian arm of the study was provided by the Royal Perth Hospital Research Foundation, the State Health Research Advisory Council (Western Australia), the Emergency Medicine Foundation, and the National Health and Medical Research Council (NHMRC).