Unnecessary surgery in many cases of pneumothorax

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In many cases, collapsed lungs can recover better with conservative treatment than with surgery, researchers say.
Pneumothorax treatment varies worldwide, but most medical societies recommend some type of surgical intervention, which usually involves the use of a needle or chest tube to drain the air and allow the lung to expand again. .

However, such an intervention is highly invasive, often extremely uncomfortable and carries a risk of complications. Researchers and doctors have long wondered if it can be safely avoided in cases where the patient has a spontaneous pneumothorax but is not distressed and does not have an underlying lung disease.
To learn more about the potential for conservative treatment as an alternative to surgical intervention, Simon Brown, MBBS, PhD, from the Harry Perkins Center for Clinical Research in Emergency Medicine in Nedlands, Australia, and colleagues conducted a randomized trial that included 316 patients with pneumothorax Their findings were published online on January 29 in the New England Journal of Medicine.

The researchers randomized the patients to a surgical intervention group or a conservative management group. Patients in both groups received analgesia consisting of acetaminophen, ibuprofen and oral or intravenous opioids. For patients who were selected for the intervention, a small Seldinger style chest tube was inserted into the patient's chest cavity to drain the air and re-expand the collapsed lung.

The doctors observed those patients selected for conservative treatment for 4 hours and were discharged if they walked comfortably and did not need supplemental oxygen. They operated on those patients with clinically significant symptoms that persisted despite analgesia, as well as patients who asked not to continue with conservative management treatment. During the study, 25 of the 162 original patients in the conservative treatment group were intervened.
Patients underwent a clinical evaluation without a mask between 24 and 72 hours after randomization and follow-up evaluations 2 weeks, 4 weeks and 8 weeks after treatment. The evaluations took the form of an x-ray and a questionnaire for the patient. Radiographs were not performed if a previous x-ray had shown that the patient's lung had expanded again. The researchers used phone calls and searches of clinical records to assess recurrence 6 and 12 months after the patients had been assigned to the treatment groups.
After 63 days, 94.9% (129 of 136) of the patients in the conservative treatment group reported resolution (reexpansion of the collapsed lung). These results were only slightly lower than those of patients who had undergone surgery, of which 98.5% (134 of 136) reported resolution within 63 days of treatment.

Even more surprising was the effect of conservative treatment on complications and recurrence. "Recurrence during the first 12 months was more frequent in the intervention group than in the conservative treatment group: 25 of 149 patients (16.8%) compared to 14 of 159 (8.8%)," explained the researchers.
The risk of complications was also lower in the conservative treatment group than in the surgical intervention group, with 41 patients who had undergone surgical intervention who reported at least one adverse event compared to only 13 patients in the conservative treatment group. . In addition, patients in the conservative treatment group spent less time in the hospital (an average of 1.6 days versus 6.1 days) and had to take less days off from work (6.0 days versus 10.9 days) than their counterparts who underwent surgery.
The reasons for the high risk of recurrence in the surgical intervention group are unknown. In an attached editorial, V. Courtney Broadus, MD, professor of medicine at the University of California, San Francisco, posits: "One possible explanation is that the drainage of the chest tube interferes with healing by opening the defect in the lung, while that allows the lung to expand slowly by itself allowed the defect to heal. "
Broadus notes that more research is needed on the efficacy of conservative treatment as a treatment for pneumothorax. But preliminary research indicates that, in healthy patients, conservative treatment offers a safe and effective alternative to risky and invasive surgery, he concludes.

Several authors have revealed relationships with the industry, whose full list is available on the magazine's website.

N Engl J Med. Published online January 29, 2020.

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