Iatrogenic tension pneumothorax complicating outpatient Heimlich valve chest drainage

Tension Pneumothorax During Rigid Bronchoscopy for Chronic Foreign Body Removal in a Child: A Case Report

Rigid bronchoscopy for chronic foreign body removal can cause rare but life-threatening complications in the form of tension pneumothorax. A two-year-old child who developed sudden cardiac arrest during the procedure required urgent chest tube insertion. Integrated team effort with effective communication prevented devastating neurological sequelae from hypoxic ischemic encephalopathy.

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study

Objective

This study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax.

Materials and Methods

From November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16–64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance.

Results

Technical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0–5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3–13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016.

Conclusion

TV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications

INTRODUCTION

Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method.

METHODS

A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer.

RESULTS

Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs.

CONCLUSION

Our classification method provides further clarity and systematic standardization for reporting TT complications.

Heimlich valve and pneumothorax

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 instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary. The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag. In the current mini review we will present the Heimlich valve system and method of insertion.

Portable chest drainage systems and outpatient chest tube management

Ambulatory treatment of pleural problems such as pneumothorax and malignant pleural effusions has been extensively described and is commonly used. On the contrary, outpatient management of chest tubes after lung resection is less frequently performed. Because prolonged air leak after lobectomy is a common problem, early discharge of these patients under pleural drainage can avoid many hospital days without compromising the quality of care. In this article, general rules for outpatient chest tube management are described and available portable devices are reviewed.

Tension pneumothorax--time for a re-think?

This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.

Management of pneumothorax with a mini-drain in ambulatory and hospitalized patients

OBJECTIVE

To test the clinical performance of a miniaturized drainage system and compare the effect on pain and mobility between the new system and a standard system. One aim was to try ambulatory treatment in patients with uncomplicated pneumothorax (35/55), another to see if patients with more severe diseases and pneumothorax could be mobilized better while in hospital.

DESIGN

Follow-up of 55 patients treated with the new system. Detailed analysis of a subgroup of 20 of those patients compared with 17 patients treated with a standard system.

RESULTS

No major complications occurred. Minor complications were haematomas and bleeding in three patients. In 12% the unit had to be replaced due to blockage by clots, obstruction of the tube, or sub-optimal performance. There were nine recurrences (16%), so patients had to have a standard drain or be referred for operation. In the subgroup of 35 patients with uncomplicated primary pneumothorax, 31 (88.5%) could be managed on an outpatient basis resulting in considerable cost reductions. Many of those patients could lead a normal life, including work during the treatment time. The new drain system was significantly less painful during activities related to sleep, hygiene, toilet visits and extraction.

CONCLUSION

The function of the mini-drain was satisfactory in the majority of cases, but cases with pleural fluid should be avoided. The recurrences were more due to the severe nature of the pulmonary leak rather than to inadequacy of the drain. The side effects mostly occurred in the first patients, so there was a learning curve. The new system should be tried in all patients presenting with an uncomplicated pneumo-thorax allowing ambulatory treatment. Patients with other diseases complicated by pneumothorax could have the new system in order not to be confined to bed. The new system has no place in patients bedridden due to other severe diseases.

A new portable chest drainage device

BACKGROUND

Persistent air leak is a frequent complication in lung operation. The Heimlich valve is the standard system for venting the pleural cavity. The device achieves good results and is well tolerated, but the main problem is when air leak is associated with fluid leakage.

METHODS

In order to improve the outpatient management of persistent air and fluid drainage after resectional procedures, we developed an original device. It is a portable system provided with a one-way valve connected to the chest tube for drainage of air and fluid, a reservoir for collecting fluid, and a one-way exhaust valve to evacuate air from the bag.

RESULTS

We analyze the advantages of our device versus the Heimlich valve in the first series of 18 selected patients. Our system is drier and cleaner, easier to manage, and ambulatory visits are seldom needed. There is also a cost savings.

CONCLUSIONS

Our device enhances ambulation, independence, and the quality of life of the patients, and decreases the need for hospital and outpatient care.

Patient-induced complications of a Heimlich flutter valve

Heimlich flutter valves have gained widespread acceptance in the treatment of pneumothorax. However, some features of their design may predispose them to inadvertent misuse. A case of tension pneumothorax is described which resulted from the insertion of a drinking straw into the Heimlich flutter valve assembly.

Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.