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When ‘less is more’: Study of lung-collapse treatment draws international attention

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.

Seeing an opportunity to update treatment guidelines, they launched an ambitious review of 70 years of studies. Co-authors 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 in NEJM Journal watch wrote that the study “serves as notice that the available evidence favors a ‘less is more’ approach.”

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 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charges as recently as 2014, the authors observed that previous guidelines for the best initial treatment strategy were outdated and inadequate.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 large-diameter 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.
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

Using innovative Bayesian statistical techniques to blend the data, they found little difference in success rates. However, the researchers discovered that needle aspiration and narrow-bore chest tubes outperformed large-bore chest tubes on the safety metric.

They propose that future studies undertake a direct comparison of needle aspiration and narrow-bore tubes.

However, Mummadi also noted that modern narrow-bore tube design offers an additional advantage over the other two treatments. They can be fixed to the chest, allowing the patient to be discharged for later follow up in an outpatient setting.

“Due to the improved design of these devices, we are able to discharge these patients from the ER without admitting to the hospital,” he said. “This means reduced risk of complications resulting from hospital stay. Patients are happy, as they can go home.”

In 2018, Drs. Mummadi and Hahn were the first in North America to publish the results of a novel centralized pathway for all patients with pleural disease. Their findings were widely cited and incorporated into textbooks worldwide.

Dr. Mummadi is now on faculty at the Cleveland Clinic. Dr. de Longpre’ joined Mercy Health Muskegon after completing her internal medicine residency at Metro and Dr. Hahn is a former Mayo Clinic pulmonologist and served as chief medical officer at Metro Health before becoming CEO.

Hahn congratulated his co-authors for exploring opportunities for more patient-centric treatments.

“Our best work as physicians is inspired by patients and validated by science,” Hahn said. “This is how innovation and advances in health care become possible.”


About Metro Health – University of Michigan Health: As an affiliate of University of Michigan Health, Metro Health provides a world-class system of leading-edge healthcare services with its patient-centric, holistic approach. The 208-bed hospital anchors Metro Health Village in Wyoming, Michigan, serving more than 250,000 patients annually. More than 61,000 emergency patients are treated each year at the hospital, a Verified Level II Trauma Center. Primary and specialty care services are provided at 30 locations throughout West Michigan. More than 500 staff physicians provide state-of-the-art treatment for a full array of health needs, including for cancer, heart and vascular disease, stroke and trauma. As a certified Comprehensive Stroke Center and accredited Chest Pain Center, Metro Health provides specialty services that include neurosciences, pulmonology, gastroenterology, cardiology, endocrinology, OB/GYN, bariatrics, orthopedics and wound care. In 2020, Metro Health was the only Grand Rapids area hospital included among the “101 Best and Brightest Companies to Work For” by the National Association of Business Resources. The hospital is committed to promoting health and wellness through the Metro Health Hospital Foundation, Live Healthy community outreach classes and educational programs. For more information visit, follow us on Twitter @MetroHealthGr and like the hospital on