When it comes to treating lung patients, less may be more.
Dr. Peter Hahn, CEO of Metro Health, co-authored a study alongside Dr. Sri Mummadi, pulmonologist with Cleveland Clinic, and Dr. Jennifer de Longpre, hospitalist at Mercy Health Muskegon, revealing less invasive treatment is just as effective as the usually recommended approach to spontaneous pneumothorax.
The study, which reviewed 70 years of data, was published earlier this year in the Annals of Emergency Medicine.
Spontaneous pneumothorax is a condition where air leaks from the lung and gets trapped in the chest wall. The pressure prevents the lung from inflating completely, and it becomes impossible for the patient to fully inhale.
“One of the reasons we got interested in this is there’s a lot of variability in terms of treating pleural diseases in general,” Hahn said. “Depending on where a patient lives, it can be variable how they get treated for a pneumothorax.”
Mummadi said military medicine has a long history of treating pneumothoraxes caused by battlefield trauma, but spontaneous pneumothorax occurs more frequently in people with underlying lung conditions.
“It’s not unique to COVID by any means,” Mummadi said. “Folks with asthma can develop a spontaneous reaction. There are genetic factors, smoking, underlying lung disease — I would say a three-way coordination between these would be the best way for determining someone’s risk.”
Additionally, there are specifically two types of spontaneous pneumothorax: primary, when there is no visible underlying lung disease, and secondary, when there is a known underlying condition like the ones previously mentioned.
According to the study, spontaneous pneumothorax accounted for $1.4 billion in inpatient charges in 2014. Traditionally in the U.S., treatment involves inserting a 14 F bore into the chest cavity to allow the air to escape. F divided by three is the diameter of the bore in millimeters.
Mummadi said 14 F is considered a small bore tube in the U.S., but the study — along with doctors in Europe and Australia — considers 14 F to be a large bore, and doctors in these regions use 8 F bores as narrow as a coffee straw.
“In the past people used to get 30 F,” Mummadi said. “People slowly migrated to 20 F and then 14 F.”
“That procedure is very invasive, and the patient stays in the hospital usually up to four days.” Hahn added.
The authors of the study 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, 8 F chest tube and 14 F chest tube – based on efficacy and safety of the patient.
British guidelines recommend removing the air with needle aspiration. This approach is even less invasive, but patients must be observed for six hours or more to ensure all the air has escaped before being discharged, which can create bottlenecks in the ER.
Following the Bayesian model of statistics, the authors found little difference in success rates between 14 F and 8 F tubes. However, the researchers did discover needle aspiration and 8 F chest tubes outperformed 14 F chest tubes on the safety metric.
Bayesian statistics is a model that relies on prior knowledge to calculate probability; similar to how previous experience driving on icy roads increases a driver’s likelihood of avoiding an accident.
“It’s based on prior experience, shapes our future thinking and has gained increased traction in the health care world,” Mummadi said.
In terms of cost savings to health care systems, there is not conclusive data, Hahn said, but he expected the cost difference to be significant.
“There’s not a lot of great U.S. data in terms of comparing the costs, because we’re usually managing charges,” Hahn said. “But if you look at the traditional treatment with a 14 F tube, and they’re repeatedly admitted to the hospital, versus having that narrow tube placed and then sending the patient home and having them return for a follow up — I think there’s more to come, but obviously there’s a significant difference in cost.”
Mummadi agreed with Hahn’s prediction that less invasive treatment should lead to a cost benefit to a hospital’s bottom line.
“At the end of the day, it’s getting things that can be safely managed in the community taken care of that increases the bottom line for the hospital,” Mummadi said. “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.”