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The Heimlich valve is a small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases or fluids into the pleural space. The Heimlich valve is less than 13 cm (5 inches) long and facilitates patient ambulation. Currently there are several systems in the market. It can be used in many patients...
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... introduced in 1965, the Heimlich flutter valve is a one- way portable device that was designed for use as a drainage procedure in order to avoid the need for intrapleural suction after thoracotomy (1). The inventor of the valve was Henry Heimlich, an American thoracic surgeon who also first described the Heimlich maneuver. Soon, it became very popular in the outpatient management of patients with prolonged air-leakage from various causes (2), and has also been used in emergency treatment of pneumothorax in battle fronts (3). As already mentioned, it is a one-way valve, thus it prevents the evacuated air from travelling back to the thoracic cavity along the attached chest tube. The valve is made of a plastic case with a rubber sleeve inside. It has two nozzles, the inlet nozzle which allows the air to pass in the valve through the chest drainage tube attached to it, and the outlet nozzle which allows the air to pass to the environment or a collecting device during expiration. The rubber sleeve is attached to the inlet nozzle in such a manner that, during inhalation, it closes off, thus preventing air to be sucked in, through the valve, to the pleural cavity ( Figure 1 ). The free end of the rubber sleeve is compressed, so that the two sides remain in contact with each other, in order to achieve this function. When the air passes through the inlet nozzle in the rubber sleeve, the latter one opens allowing the air to escape during expiration. But during inhalation the free end remains closed, due its compression, preventing the air to be sucked back in the thoracic cavity. This way pneumothorax is safely evacuated. By the same mechanism, the Heimlich flutter valve may also facilitate the evacuation of fluid. The inlet nozzle is securely attached to one end of a chest drainage tube, while the other one lies within the patient’s pleural cavity. The attachment may be secured with pieces of adhesive tape. The valve is also attached to the patient’s chest wall, but care must be taken that the distal end, the outlet nozzle, remains unimpeded (1). When air passes through the valve, a distinct “flutter” sound can be heard, ensuring that the device is working properly. Absence of the sound accompanied with no movement of the rubber sleeve during placement means that no air passes through the valve, which indicates either the resolution of pneumothorax or possible clogging of the chest tube. Auscultation of the chest or a chest X-ray might be helpful. The Heimlich flutter valve has some significant advantages compared to under water seal drainage, the most important being its small size and its portability, allowing this way the immediate ambulation of the patient, a very important factor in the successful treatment of pneumothorax (1). It can function in any position and doesn’t need clamping (4). It has a small production cost, thus allowing it to be a disposable device, with no need of re-sterilization. Its function is easily understood both by the medical staff and the patient, due to the distinct sound and movement of the rubber sleeve. If there is need for fluid evacuation, the distal end may be attached to a collecting device, e.g., a bag or Bulau device. Also negative pressure or under water suction may be applied to the outlet nozzle if needed (1). The size of the drainage chest tubes that it can be attached to, may vary (small or large calibre tubes) (5). It may be used over a long-term period in cases that air- leakage is persistent and surgical treatment is excluded, allowing the outpatient management of these patients. Full expansion of the lung is indicated by absence of the “flutter” sound and the immobilization of the rubber tube of the valve during breathing and coughing. After full expansion is diagnosed and confirmed, the system (chest tube drainage and valve) may be removed from the patient. Small recurrences of pneumothorax have been described in the literature but they are usually insignificant ( Figure 2 ). Probably the most important thing about the Heimlich flutter valve is that it only functions properly under a specific orientation. This means that if it’s connected wrongly at the chest tube drainage it will not function at all. Furthermore, the patient undergoes great risk of developing tension pneumothorax, a very serious complication that may be fatal. If the outlet nozzle is attached to the tube, the rubber sleeve can’t open (due to its compression), the air can’t be evacuated and is accumulated in the pleural space, sometimes leading in tension pneumothorax. Case reports have been published describing this complication (6-8). For this reason, all the valves have distinct markings on the casing indicating clearly the inlet and outlet nozzles and the proper orientation of the valve during placement, so that reversal of the valve may be avoided. Care must also be taken during attachment of bags or other collecting devices in the outlet nozzle, in order to not block the nozzle and prevent the evacuation of air (9). During outpatient management period, frequent inspection of the valve from the medical staff is mandatory. Another major complication of the Heimlich flutter valve is the increased risk of developing chest empyema (10,11). This occurs through infection of the pleural space, mainly because of the prolonged remaining time of the chest tube drainage and the valve. The placement of the valve needs to be performed under sterile conditions (the valve itself is pre-sterilized) and all the attachments need to be secured and air-tight, in order to avoid further infection. Accidental dislodgements of the valve have been reported in the literature (2). In such case, re-attachment of the valve may be associated with increased risk of infection. There isn’t any reported death in the literature, even in cases of accidental reversal of the valve and the development of tension pneumothorax. This proves that, if used correctly, and if the patient and the medical staff are properly instructed, the Heimlich flutter valve is a safe and efficient procedure for treating pneumothorax. There is not any specific contraindication for the use of a Heimlich flutter valve in the literature. Relevant contraindications may be large hydro-pneumothorax with large volumes of fluid in the pleural space or thick secretions and blood which may cause occlusion of the rubber tube due to adhesions or clots, preventing the outflow of air (1,8). If such a case occurs, replacement of the valve or under water seal drainage is mandatory. Studies have proved the safe use, with good results, of the valve in cases of primary pneumothorax treatment (1,12-30) and in many different cases of secondary pneumothorax in patients with Pneumonocystis carinii, AIDS, cystic fibrosis, lung metastases etc. (2,10,31-45). The technological advances nowadays have allowed the construction of small, portable under water seal drainage devices, which also facilitate the immediate ambulation of the patient after placement and have lesser complications than the Heimlich flutter valve in cases where pneumothorax is accompanied by large volumes of fluid or blood (42,46-58). This has led to limited use of the valve over the recent years, but still holds a place in the outpatient management of patients with prolonged air-leakage, for whom further surgical treatment is not an ...
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In recent years, single-port VATS (video-assisted thoracoscopic surgery) applications have become widespread in the surgical treatment of spontaneous pneumothorax. In this study, the results of 16 patients with spontaneous pneumothorax who were treated by single-port VATS were analyzed retrospectively. Fourteen (87.5%) of the patients were male, 2...
The aim of this retrospective study was to evaluate single-incision thoracoscopic surgery (SITS) for primary spontaneous pneumothorax (PSP).
Among 141 patients who underwent surgery for PSP from July 2009 to December 2013, a total of 100 patients underwent SITS. Their data were examined for clinical characteristics and surgical results.
More patien...
Citations
... This approach not only facilitates a more active postoperative period but also supports the psychological well-being of patients by allowing them to return to their daily routines more quickly. These devices are particularly beneficial for managing PAL when traditional chest tube management would otherwise require prolonged hospitalization [63][64][65][66]. Moreover, Dinjens supported that treatment of PAL in an ambulatory setting using a digital monitoring device achieved a high success rate with minimal complications [67]. ...
Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient’s needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.
... A Heimlich valve is installed at the left hemithorax in patient with PAL18 Following Heimlich valve discharge, it is recommended to conduct weekly chest radiographs.To assess the presence of PAL, patients should submerge the Heimlich valve tip in water while performing passive or forced breathing exercises. The absence of bubbles confirms PAL resolution and signals the safe removal of the chest tube. ...
In cases of pneumothorax in the chest tube, the presence of air in the pleural cavity that lasts more than 5 to 7 days can be suspected as a persistent air leak (PAL), especially if an increased amount of air is obtained accompanied by the appearance of bubbles in the water seal drainage (WSD) system. This is the most common complication after surgery (8–26%), although it can be primary spontaneous pneumothorax (PSP) (26%) or secondary spontaneous pneumothorax (SSP) (39%). One condition that often causes difficulties in PAL therapy is infection due to direct contact with the fistula. The presence of PAL is associated with higher morbidity and mortality, prolonged chest tube inserted, and longer hospitalization. Observations of air production in PAL are expected to occur spontaneously within 4 days, if the leak persists, pleurodesis is recommended. If it was possible, surgery is needed to close the leak. Bronchoscopy treatment is only recommended in special circumstances where surgery is contraindicated or the patient refuses the surgical procedure.
... A rubber sleeve is attached to the inlet end in such a way that, during inhalation, the valve closes, thereby preventing air from re-entering through the valve into the intrapleural. 13,14 The working mechanism of the Heimlich valve looks like Figure ...
An adequate chest drainage system is the main goal of fluid and air evacuation and restoring negative pressure intrapleural so it can help lung development. The intrapleural is a closed, airtight space filled with a small amount of fluid as a lubricant for lung movement during the breathing process. Accumulation of intrapleural air is known as pneumothorax, and one of the initial management options is the implantation chest tube. Chest tubes, which are connected to a water seal, conventionally show varying results and have shortcomings because they require monitoring and limit patient mobility, so the safety of their use in outpatient settings is questionable. Lungs that are not inflated or have an inflated water seal still show air bubbles even though it has been installed. A chest tube adequate for 48 hours is a condition known as persistent air leak, thus requiring extended usage time from chest tube to the drainage management complex. Use of ambulation management through the use of various tools and equipment devices which can be connected with a chest tube can be an option with the aim of reducing treatment time, lowering funding, increasing comfort and hopefully providing better external results.
... Heimlich valves are used for the ambulatory treatment of pneumothorax (including patients with persistent air leaks or tension pneumothorax). [8] 2. Vacuum cylinders -the drainage of the pleural fluid is performed by connecting the external one-way valve to a vacuum cylinder. The cylinders are supplied by the manufacturer with capacity of 1 L or alternatively, disposable vacuum drainage bottles -Redon (capacity 200 ml, 400 ml, and 600 ml) can be used. ...
Introduction : Pleural cavity drainage is a crucial component of the surgical management of patients with various chest diseases. Digital drainage systems are increasingly used in contemporary thoracic surgical procedure, which is likely a result of their effectiveness in achieving early postoperative ambulation, cutting down on hospital stays and lowering costs. The vast majority of thoracic surgeons worldwide prefer digital drainage systems to traditional ones. The advantages of the former, however, are disputed by some researchers.
Aim : The objective of this study was to compare the two types of pleural drainage mechanisms, conventional and digital, in terms of duration of pleural drainage in days, financial cost, and postoperative air leak duration.
Materials and methods : The study focused on 80 patients who underwent various thoracic surgical interventions in the Clinic of Thoracic and Abdominal Surgery at St George University Hospital in Plovdiv. They were divided into two groups: group 1 consisted of 42 patients who were postoperatively attached to a conventional non-mobile pleural drainage system, and group 2 consisted of 38 patients in whom a mobile digital pleural drainage system was used. The main analyzed data were duration of pleural drainage, duration of postoperative air leak, hospital stay, and financial costs.
Results : The average duration of pleural drainage, regardless of surgery and type of drainage system applied was 4.86±0.8 days. The average duration of pleural drainage in patients attached to the mobile digital drainage system was shorter than that in patients with a conventional pleural non-mobile drainage system, regardless of the type of surgery done. This difference was statistically significant in favor of the digital pleural drainage system. The study also found a statistically significant difference in terms of financial costs in favor of digital draining system. The average cost of a hospital stay for patients attached to a mobile digital drainage system was BGN 119.40±7.15, whereas the average cost of a hospital stay for patients connected to a traditional pleural drainage system (PDS) was BGN 159±10.50. Regarding the duration of postoperative air leak, the difference between the types of pleural drainage mechanism used was not convincing.
Conclusions : Digital pleural drainage systems provide clinicians with an opportunity to assess the postoperative air leak more precisely, track its dynamics, shorten hospital stays, reduce postoperative costs, and optimize the time to remove the chest drain. Based on these features, they will undoubtedly continue to enter everyday surgical practice.
... 7 Patient safety can be improved in the following ways: using differently sized (not interchangeable) connections; labeling the tubes; using different tube route lines, [8][9][10] or using one-way release valves. 11 Providing information sheets to the patients with an explicit warning about the consequences of self-handling the tubes and catheters is also recommended. ...
A rare and fatal complication of suction drainage of secondary spontaneous pneumothorax is reported. The patient, likely by a mistake, arbitrarily connected the oxygen supply tube to the thoracic drain. The sharp increase of intrapleural pressure combined with the atmospheric intraalveolar environment caused diffuse lung injury and cardiopulmonary collapse without a direct lung injury. The conflicting interests of patient autonomy and patient safety require further consideration.
... The drain tube is maintained for 3-5 days. It is attached to a one-way Heimlich [26]/Vygon valve [27] or to a suction device. Suction drainage can be passive (Béclère kit) or active (suction battery) [1,25]. ...
Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.
... The numeric pain score for patients supports the effectiveness of this method in achieving adequate analgesia. We also replaced the under-water seal bottle with a one-way valve that allows air and fluids to be drained in one-way out of the chest (Heimlich valve) [21] and which is connected to a bile bag. The use of Heimlich valve connected to a bile bag immediately removed the hindrance of the under-water seal bottle and facilitated early mobilisation. ...
... The avoidance of opioids has removed the confusion and drowsiness side effects, thus aiding early mobilisation. The effectiveness of using a Heimlich valve in our study was compatible with what has been shown in the literature in relation to safety and practicality of this technique in chest surgery [21]. We introduced the technique carefully, initially replacing the underwater drainage system with the valve on the second postoperative day then gradually moving to use of valve alone immediately at the end of surgery, which became our standard protocol during the study period. ...
Introduction
Oesophagogastric resections continue to be a major surgical challenge with high morbidity, this has led to a worldwide trend for centralisation of these complex surgeries. However, there is no clear agreement on what constitutes a high-volume centre, leading to worldwide disparity. We evaluate our experience of oesophagogastric resection in a small volume unit to seek other factors that influence patient outcome.
Methods
We analysed 173 consecutive oesophagogastric resection from 2010 to 2020. The primary outcome was 30-day mortality and secondary outcome included peri-operative morbidity, length of stay, lymph node harvest, R0 resection. Collected continuous data were compared using the Mann-Whitney test and categorical data using the chi-squared test and expressed as p value.
Results
Of the 173 patients, 94 (54%) underwent hybrid minimal invasive esophagectomy (HIMO) and 79 (46%) underwent gastrectomy. 135 (78%) patients received Neoadjuvant therapy. The site of tumour was GOJ in 29%, distal stomach in 26% and distal oesophagus in 20%. Perioperative morbidity was observed in 18 (19%) after esophagectomy and 9 (11.4%) after gastrectomy. The median lymph node harvest was 18 (range 5–42) and 168 patients (97%) had longitudinal R0 resection. The most common complication was neurological seen in 3.6% followed by pulmonary complication and anastomotic leak seen in 5 patients (3%) each. The median in hospital stay was 6 days and the 30 day mortality was 2.9% with one year survival of 87%.
Conclusion
Small volume centres can produce comparable results. The outcomes depend on multifold parameters which include surgeon's experience in the field, ability to adhere to protocols and procedures and strong interpersonal relationship with individual patients.
... It is about 13 cm (5 inches) in size and weighs 22.5 grams. 5 The small tube is a single transparent chamber made from PVC (Polyvinyl chloride). The transparent material makes it easy to observe valve motion. ...
... of fluid (massive pleural effusion) or thick pleural fluid secretion (empyema). Thick pleural fluid/empyema increases the risk of adhesions/ blockages, which can lead to tension pneumothorax.5,7,10 ...
... There have been no reports of serious complications associated with the use ofHeimlich valve documented. This shows that if used properly and informed correctly to health care workers and patients, Heimlich valve is a safe and efficient procedure.5 ...
Pneumothorax or fluidopneumothorax is a critical condition when there is some air or/and fluid in the plural cavity. The symptoms may include shortness of breath, chest pain, blue discoloration of the skin or lips, increased heart rate, and loss of consciousness. Pleural cavity drainage is management therapy with the concept of Water Seal Drainage (WSD), which requires a long hospital stay. Heimlich valve is a non-return valve that allows fluid and air to exit the thoracic cavity (on inspiration) and prevents fluid and air from re-entering (during expiration). Heimlich valve is a viable, inexpensive, convenient, safe, effective, and efficient alternative in the management of ambulation of patients requiring prolonged pleural cavity drainage. The use of Heimlich valve is an alternative option for patients with persistent pneumothorax or fluidopneumothorax. It can shorten the time of treatment in the hospital, lowering treatment costs, and minimize the presence of nosocomial infections. Relative contraindications include fluidopneumothorax with massive pleural effusion or empyema. The risks and complications are dislodgement or improper reattachment, leaking valve, adhesion, and blockage, thus becoming tension pneumothorax or pleural cavity infection. Currently the latest innovation also improves the patient’s convenience, like Thoracic Vent, Pneumostat, or Mini Mobile Dry Seal Drain.
... As another example, Heimlich valves are one-way portable devices designed to prevent retrograde airflow in patients requiring respiratory support. 11 These valves may sometimes be attached to urine collection bags or colostomy bags to facilitate fluid drainage in mobile patients. Assembly of "home-made" continuous positive airway pressure systems and other respiratory devices is often implemented in institutions with limited resources and in areas where there are shortages of approved devices. ...
... Some clinicians use common medical devices in nonstandard ways and/or improvise workarounds to mitigate pragmatic challenges to the efficient delivery of patient care. [9][10][11][12][13][14] Despite being well intended, unapproved modification of medical devices, such as the iNO delivery system, can increase the risk of life-threatening complications for patients. Underreporting and non-detection (eg, "near-misses") of medical errors are major barriers to patient safety. ...
Over the past decade, international organizations have instituted strict regulations for the safe use of connected medical devices. The International Organization for Standardization and the Medical Device Single Audit Program instituted certifications to ensure that connected devices are compatible and operate within their proper clinical parameters. These efforts came about, in part, as a consequence of clinicians’ decisions to use nonstandard, modified, or improvised devices for purposes outside the original manufacturers’ approved parameters. Unapproved device modifications can be associated with increased risk of dosing errors, monitoring errors, tubing misconnections and serious or potentially fatal adverse events; furthermore, health care providers who implement unapproved device modifications may assume legal and financial liability should harm come to patients as a consequence of the modification. Using the inhaled nitric oxide delivery system as an example, the objective of this paper is to raise awareness of the potential dangers associated with unapproved modification and interfacing of therapeutic gas delivery systems and ventilators in the neonatal intensive care unit setting. The paper also highlights the rationale and necessity for rigorous validation processes that ensure that interfaced medical devices perform as intended in the clinical setting.
... La válvula tiene dos boquillas, la boquilla de entrada que permite que el aire pase por la válvula a través del tubo de drenaje torácico conectado a ella, y la boquilla de salida que permite que el aire pase al ambiente o un dispositivo colector. Su principal utilidad es reemplazar el sistema de drenaje pleural (trampa de agua), pero en general, requiere la inserción de un tubo de tórax al cual posteriormente se conecta 26 . En el momento actual, no se recomienda su inserción por el riesgo de generación de aerosoles. ...
Introducción: La transmisión del SARS-CoV-2 principalmente se da por gotas y contacto cercano con las personas infectadas, pero los aerosoles parecen ser también una fuente de infección. El neumotórax espontáneo o secundario puede presentarse en pacientes con COVID-19, ayudado por patologías de base como la enfermedad pulmonar obstructiva crónica. Es necesario garantizar procedimientos seguros para los pacientes y buscar todas las medidas posibles para la protección del personal de la salud, por eso el drenaje de neumotórax con catéter pleural en lugar de sonda de toracostomía puede ser una de ellas.
El objetivo de este estudio es presentar a los cirujanos una alternativa a la toracostomía tradicional, mediante la utilización de catéteres de menor diámetro, para la resolución de la ocupación pleural.
Aspectos Técnicos: Se presenta el protocolo para inserción segura de un catéter pleural para el drenaje de neumotórax, mediante un sistema completamente cerrado, y se dan recomendaciones sobre el uso de filtros virales y solución viricida en el sistema de drenaje pleural conectado al catéter.
Conclusión: El estado de pandemia por COVID-19 y el riesgo que representa para los profesionales de la salud la exposición a fuentes de transmisión durante procedimientos generadores de aerosoles, hace que se deban extremar las medidas para evitar el contagio.
