The Heimlich Valve for Pleural Cavity Drainage
Winston Ominde Makanga1, Andrew Nyaoncha Nyangau2 , Benjamin Njoga Njihia3
St Mary’s Mission Hospital, Elementaita
St Mary’s Hospital, Nairobi
Aga Khan University Hospital, Nairobi
Correspondence to: Dr. Benjamin Njoga Njihia, P.O Box 51982-00200 Nairobi.
Introduction: Traditional chest tube fixation and drainage has been undertaken using standard rigid chest tubes connected to under water seal bottles. These are bulky, cumbersome, expensive, and pose a risk of accidental air suction into the chest. One-way valve systems such as the Heimlich valve are small, portable apparatus that allow regulation of fluid flow and require minimal nursing care other than daily charting. Methods: A retrospective descriptive analysis of all chest drains connected to a Heimlich valve between January 2009 and December 2012. Data on indications, duration of drainage and frequency of complications was collected. Results: Fifty seven chest tubes connected to a Heimlich valve were inserted over the study period. Majority were for pleural effusions. No complications were encountered. Four patients (7%) required thoracotomy. The average duration to removal was 6 days and all patients reported satisfactory comfort and mobility. Conclusion: The Heimlich valve is a feasible and cheap alternative method of chest tube drainage with high rates of success and very low morbidity. We propose their usage in resource-constrained settings.
Keywords: Thoracentesis, Heimlich, Thoracostomy
Ann Afr Surg. 2016;13(2):45-8.
Pleural effusion develops in disease states that lead to altered dynamics of pleural fluid turnover (1). A common clinical presentation in symptomatic patients is difficulty in breathing with variable signs (2). In the Unites States, about 12% of patients with pleural effusions will undergo thoracentesis and historically, improvements in oxygenation, pulmonary mechanics and gas exchange have been cited (3,4). More recent work has also demonstrated that thoracentesis confers patients with better re-adaptation to daily activities (5).
Various methods for venting the pleural cavity include a thoracic catheter attached to an underwater seal drainage system or a one-way valve system such as the Heimlich valve (6,7). These have been shown to be equi-efficacious in draining the pleural cavity (8–10). However, underwater seal drainage systems have been shown to have poor tolerability from the patients’ perspective (11) while the one-way valves allow for outpatient management of pleural drainage (12–14). Although classically described for pneumothoraces, the characteristics of the Heimlich valve allow it to be used for draining fluid as well (10). It is anecdotally known that underwater seal drainage systems are the preferred modality of pleural drainage in Kenya. However, shortcomings such as understaffing and prolonged hospital stay make the case for consideration of alternative ways to drain the pleural cavity (15,16).
The Heimlich chest drainage valve was developed to allow for safe, simple, and efficient drainage the pleural cavity. The Heimlich valve connects to chest tubing and allows fluid and air to pass in one direction only thus can replace the cumbersome underwater drainage bottle system. The valve, which functions in any position, need never be clamped, and 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 to be ambulatory by carrying the bag. The construction and function of the valve is easily understood by medical and nursing staff. It is pre sterilized, stored in a sterile package, and readily utilized on emergency vehicles and in the operating room (17,18). This paper shares our experience with the Heimlich valve in the management of both pneumothoraces and pleural effusions, with a review of the literature.
The retrospective study was conducted at the St Mary’s Mission Hospital, Elementaita over a 4-year surgeon using an aseptic technique under local anesthesia. Where the procedure was not tolerable or the patient was too young to co-operate, additional sedation was used. Following insertion, all chest tubes were connected to a one way Heimlich valve which was in turn connected to a urine bag. The pneumothoraces were connected to a Heimlich valve and to a urine bag that was fenestrated to allow for decompression of expelled gas. All chest tubes inserted had radiographic confirmation of correct placement.
All patients remained inpatients and were followed up until tube removal. Daily charting of the amount of effusion drained was done by the ward nurse. The patients were allowed to ambulate guided by their general health condition. The criteria for removal of a chest drain as per institutional protocol were: 24-hourly drainage of less than 100ml for patients with pleural effusion or hemothorax; complete resolution of drainage for empyema; and auscultation of satisfactory breath sounds for pneumothorax. Before removal of the chest tube, radiographic confirmation of resolution was obtained by a chest radiograph.
Data were extracted from patients records detailing duration to resolution, indication for chest tube insertion, complic