HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard J. Fischel Matthew Brenner Arthur F. Gelb Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McKenna, R. J. Articles by Gelb, A. F. Search for Related Content PubMed PubMed Citation Articles by McKenna, R. J., Jr Articles by Gelb, A. F.

Ann Thorac Surg 1996;61:1115-1117
© 1996 The Society of Thoracic Surgeons

---

Original Article: General Thoracic

Use of the Heimlich Valve to Shorten Hospital Stay After Lung Reduction Surgery for Emphysema

Lung Center, Chapman Medical Center, Orange, California

Accepted for publication December 31, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
Background. Prolonged air leak is the major complication after lung reduction surgery for emphysema and the major determinant of hospital length of stay.

Methods. Twenty-five of 107 patients (24%) (mean age, 66 years) with an average forced expiratory volume in 1 second of 0.55 L experienced a prolonged air leak (>5 days) after lung reduction surgery. These persistent air leaks were treated by replacing the chest drainage system with Heimlich valves to facilitate earlier hospital discharge even though 64% of the patients had apical air spaces that measured 1 to 7 cm.

Results. These patients had a mean postoperative stay of 9.1 days. Chest tubes were then removed an average of 7.7 days later. All apical air spaces resolved, and there were no deaths, empyemas, or pneumonias.

Conclusions. In conclusion, the use of the Heimlich valve after operation for emphysema was associated with minimal morbidity and shortened the mean hospital stay for patients with prolonged air leaks by 46%. This study demonstrates an important concept in the postoperative management of these patients-do not use suction on severely emphysematous lung.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
The most common complication after an operation for diffuse emphysema is prolonged air leak [1, 2]. To minimize the air leak from the staples, Cooper [3] developed the use of bovine pericardium strips to buttress staples. These strips, however, do not completely eliminate postoperative air leaks. Cooper and associates [1] reported that 55% of their patients had a postoperative leak greater than 7 days.

Heimlich [4] developed a one-way valve for chest drainage in 1968. This is now used extensively for outpatient management of pneumothorax [5–9]. In 4 patients with air leaks lasting more than 2 weeks after lung reduction surgery, we switched from a chest drainage system to Heimlich valves. The patients were discharged 20 to 39 days postoperatively. The average time to resolution of air leaks and removal of the chest tubes was 9.5 days after discharge. There were no complications.

Based on these encouraging initial results, we began the aggressive use of Heimlich valves to facilitate earlier hospital discharge after operation for emphysema. This study reports the results of a prospective effort to aggressively use the Heimlich valve to facilitate earlier hospital discharge and to avoid a second operation for closure of an air leak.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
From November, 1994, through July, 1995, 107 patients with a heterogeneous pattern of emphysema underwent lung reduction surgery with an operative mortality of 3% and an average hospital length of stay of 11.2 days.

During this time period, 25 patients experienced air leaks that lasted more than 5 days. This group included 21 men and 4 women with a mean age of 66 ± 5.5 years (range, 51 to 76) and a mean forced expiratory volume in 1 second of 0.55 ± 0.187 L (range, 0.3 to 0.86 L). Twenty-one of 25 patients (84%) were taking steroids preoperatively.

Four procedures were unilateral (two rightand two left-sided procedures) because the emphysema on the contralateral side was homogenous, rather than heterogenous, or the patient had a previous operation on the opposite lung. The remaining 21 patients underwent bilateral lung reduction with staples (our standard operation).

Lung reduction surgery was accomplished by video-assisted thoracoscopy with bovine pericardium to buttress the staples. The total tissue resected per side operated on was 40 to 112 g. Each pleural space was drained by two apically placed, straight 28F chest tubes that were attached to a chest drainage system and placed on -10 cm H₂O suction.

Heimlich valves were attached to both chest tubes as soon as the patients appeared to be clinically stable enough to be discharged, except for their prolonged air leaks. This occurred between the 6th and 15th postoperative day. One patient required bilateral Heimlich valves, and the remaining 24 patients had unilateral Heimlich valves. In no patient did the dyspnea increase after the switch to the Heimlich valve. Such a deterioration would have resulted in the resumption of a chest drainage system with suction.

Heimlich valves were used even if there was a large leak. An air leak was graded as small if an occasional bubble was seen, moderate if frequent bubbles were seen, or large if bubbles were continuously seen in the water seal chamber. In 15 patients (60%), the leak was graded as small, and 40% had moderate or large leaks.

Heimlich valves were used even if there was an apical air space. The chest roentgenograms at the time of the conversion to Heimlich valves showed complete lung expansion in only 9 patients (36%). The remaining 16 patients (64%) had an apical air space that measured 1 to 7 cm from the cupula to the top of the lung (mean, 1.9 cm). Six patients (24%) had apical air spaces that measured 5 cm or greater.

After discharge from the hospital, the patients were followed up closely. They returned daily to the hospital for outpatient pulmonary rehabilitation and dressing changes as needed.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
There were no deaths in the patients with Heimlich valves. No patient underwent a second operation for either closure of an air leak or a pleural tent. After hospital discharge, subcutaneous emphysema developed in 1 patient and necessitated readmission to the hospital for 7 days for suction drainage of the chest. His air leak resolved and the tubes were removed. During the follow-up period that ranged from 4 to 7 months, no empyema or pneumonia developed in any patient.

Chest roentgenograms obtained after the placement of the Heimlich valve showed minimal to no change in the size of an apical air space, if any was present. No patient became more dyspneic after the Heimlich valve was placed. In all cases, follow-up chest roentgenograms after removal of the chest tubes and Heimlich valves showed complete resolution of the apical air spaces (Figs 1, 2).

View larger version (154K): [in this window] [in a new window]   Fig 1. . Chest roentgenogram showing a large left apical air space at the time that the chest drainage system was switched to Heimlich valves. The patient had a large air leak.

View larger version (154K): [in this window] [in a new window]   Fig 2. . Chest roentgenogram showing complete expansion of the left lung after resolution of the air leak and the removal of the chest tubes.

	Comments

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
The Heimlich valve shortened the average hospital stay for patients with a persistent air leak after lung reduction operation by 46%, if one assumes that these patients would have remained in the hospital until the day their chest tubes were removed. Early in our series, prolonged air leak caused a hospital stay of 60 and 66 days for 2 patients. Recently, no patient has remained in the hospital more than 19 days. In our first 50 cases, the mean hospital length of stay was 14 days. This has decreased to 8 days in the last 3 months. The use of the Heimlich valve has certainly contributed to this reduced hospital stay.

The use of the Heimlich valve represents a part of the evolution in the management of pleural drainage after lung reduction surgery for emphysema. Doctor Joel Cooper (personal communication) currently does not routinely place the chest drainage system on suction because he believes that suction can either create or prolong an air leak. This is a significant change from his early cases when he even used suction while transporting the patient from the operating room.

Independently, we came to the same conclusion that suction is deleterious for the severely emphysematous lung. Currently, we also do not place the chest drainage system on suction. We switch the chest drainage system to Heimlich valves as early as the third postoperative day. Although an apical air space may increase after the change, the Heimlich valve is used as long as the patient's dyspnea is not increased. Our only indication for the resumption of suction on the chest drainage system is clinical deterioration.

Significant air leaks or incomplete lung expansion have traditionally been considered contraindications to the use of the Heimlich valve [5–9]. In this series, however, the Heimlich valves were used even if the air leak was large or if there was an apical air space as large as 7 cm. Air leaks treated with the Heimlich valve seemed to close faster than expected, although we have no objective data to specifically support this impression.

The traditional thoracic surgical thinking is that the combination of an apical space and the existence of an air leak would lead to a significant risk of empyema; however, to date this has not occurred in our patients.

Earlier in our experience with lung reduction surgery, we tried various other techniques for managing the pleural space. Some air spaces and air leaks persisted for prolonged periods of time despite increasing the suction on the chest drainage system or placement of additional chest tubes. Pneumoperitoneum resolved the space or persistent leak in 5 of 7 cases. Five other patients underwent a second operation for closure of an air leak or pleural tent. These methods have all been abandoned in favor of the Heimlich valve.

The chest cavity is greatly overexpanded in patients with severe emphysema. After lung reduction operation, the chest wall shrinks to accommodate the smaller lung [1]. Because this process can take weeks in some cases, a postoperative apical air space may be present until the chest wall shrinks to the size of the smaller lung. This phenomenon has led Cooper and associates [1] to state that they wish early after the operation that they had taken less lung tissue to avoid a postoperative apical air space, but 6 months later they wish that they had taken more lung tissue to maximize the lung volume reduction.

Cooper and associates [1] reported the use of pleural tents for incomplete lung expansion at the time of the lung reduction surgery or during a second operation for patients with prolonged air leaks associated with apical air spaces. It appears that the Heimlich valve may obviate the need for pleural tents and repeat operations for closure of air leaks.

The use of the Heimlich valve is also psychologically good for emphysema patients because they are prone to anxiety and depression. The Heimlich valve helps them mentally by greatly facilitating ambulation, independence, and discharge from the hospital.

These findings are encouraging and appear to indicate that the use of the Heimlich valve may substantially improve the care of patients undergoing lung volume reduction operation.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
Supported in part by DOE grant DE-f603-91 ER61227, and National Institutes of Health grant R01192.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 
Address reprint requests to Dr McKenna, 1245 Wilshire Blvd., Suite 606, Los Angeles, CA 90017.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comments Acknowledgments References

 

1. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19.[Abstract/Free Full Text]
2. McKenna RJ Jr, Brenner M, Gelb AF, et al. A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317–22.[Abstract/Free Full Text]
3. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.[Abstract]
4. Heimlich HJ. Valve drainage of the pleural cavity. Dis Chest 1968;53:282–6.
5. Cannon WB, Mark JBD, Jamplis RW. Pneumothorax: a therapeutic update. Am J Surg 1981;142:26–9.[Medline]
6. Schweitzer EJ, Hauer JM, Swan KG, Bresch JR, Graeber GM. Use of the Heimlich valve in a compact autotransfusion device. J Trauma 1987;27:537–42.[Medline]
7. Driver AG, Peden JG, Adams HG, Rumley RL. Heimlich valve treatment of Pneumocystis carinii-associated pneumothorax. Chest 1991;100:281–2.[Abstract/Free Full Text]
8. Valee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M. Sequential treatment of a simple pneumothorax. Ann Emerg Med 1988;17:936–42.[Medline]
9. Perlmutt LM, Braun SD, Newman GE, et al. Transthoracic needle aspiration: use of a small chest tube to treat pneumothorax. Am J Radiol 1987;148:849–51.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. R. Abdul Rahman, O. S. Min Joanna, A. M. Fikri, S. M. Adeeb, and D. M. Zamrin Pocket-sized Heimlich valve (Pneumostat) after bullae resection: a 5-year review. Ann. Thorac. Surg., September 1, 2009; 88(3): 979 - 981. [Abstract] [Full Text] [PDF]

				K. M. Rieger, H. A. Wroblewski, J. A. Brooks, Z. T. Hammoud, and K. A. Kesler Postoperative Outpatient Chest Tube Management: Initial Experience With a New Portable System Ann. Thorac. Surg., August 1, 2007; 84(2): 630 - 632. [Abstract] [Full Text] [PDF]

				M. Brenner, N. M. Hanna, R. Mina-Araghi, A. F. Gelb, R. J. McKenna Jr, and H. Colt Innovative Approaches to Lung Volume Reduction for Emphysema Chest, July 1, 2004; 126(1): 238 - 248. [Abstract] [Full Text] [PDF]

				M. S. Allen, D. E. Wood, R. W. Hawkinson, D. H. Harpole, R. J. McKenna, G. L. Walsh, E. Vallieres, D. L. Miller, F. C. Nichols III, W. R. Smythe, et al. Prospective randomized study evaluating a biodegradable polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection Ann. Thorac. Surg., May 1, 2004; 77(5): 1792 - 1801. [Abstract] [Full Text] [PDF]

				R. A. Maxfield New and Emerging Minimally Invasive Techniques for Lung Volume Reduction Chest, February 1, 2004; 125(2): 777 - 783. [Abstract] [Full Text] [PDF]

				E. Vallieres, X. Gonzalez, K. M. Pedersen, G. K. Sears, and S. C. Springmeyer Novel surgical system for reducing lung tissue and preventing air leaks Ann. Thorac. Surg., December 1, 2003; 76(6): 2071 - 2074. [Abstract] [Full Text] [PDF]

				T. Fabian, J. A. Federico, and R. B. Ponn Fibrin glue in pulmonary resection: a prospective, randomized, blinded study Ann. Thorac. Surg., May 1, 2003; 75(5): 1587 - 1592. [Abstract] [Full Text] [PDF]

				K. J. Woodside, E. vanSonnenberg, K. S. Chon, D. B. Loran, I. M. Tocino, and J. B. Zwischenberger Pneumothorax in Patients With Acute Respiratory Distress Syndrome: Pathophysiology, Detection, and Treatment J Intensive Care Med, January 1, 2003; 18(1): 9 - 20. [Abstract] [PDF]

				M. Brenner, X. Gonzalez, B. Jones, R. Ha, K. Osann, R. McKenna, and J. Milliken Effects of a Novel Implantable Elastomer Device for Lung Volume Reduction Surgery in a Rabbit Model of Elastase-Induced Emphysema Chest, January 1, 2002; 121(1): 201 - 209. [Abstract] [Full Text] [PDF]

				R. Lodi and A. Stefani A new portable chest drainage device Ann. Thorac. Surg., April 1, 2000; 69(4): 998 - 1001. [Abstract] [Full Text] [PDF]

				S. R. Eachempati and P. S. Barie Minimally Invasive and Noninvasive Diagnosis and Therapy in Critically Ill and Injured Patients Arch Surg, November 1, 1999; 134(11): 1189 - 1196. [Abstract] [Full Text] [PDF]

				D A Waller, J G Edwards, and P B Rajesh A physiological comparison of flutter valve drainage bags and underwater seal systems for postoperative air leaks Thorax, May 1, 1999; 54(5): 442 - 443. [Abstract] [Full Text]

				R. J. Fischel and R. J. McKenna Jr Bovine Pericardium Versus Bovine Collagen to Buttress Staples for Lung Reduction Operations Ann. Thorac. Surg., January 1, 1998; 65(1): 217 - 219. [Abstract] [Full Text] [PDF]

				R. B. Ponn, H. J. Silverman, and J. A. Federico Outpatient Chest Tube Management Ann. Thorac. Surg., November 1, 1997; 64(5): 1437 - 1440. [Abstract] [Full Text]

				R. J. McKenna Jr., M. Brenner, R. J. Fischel, and A. F. Gelb SHOULD LUNG VOLUME REDUCTION FOR EMPHYSEMA BE UNILATERAL OR BILATERAL? J. Thorac. Cardiovasc. Surg., November 1, 1996; 112(5): 1331 - 1339. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard J. Fischel Matthew Brenner Arthur F. Gelb Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McKenna, R. J. Articles by Gelb, A. F. Search for Related Content PubMed PubMed Citation Articles by McKenna, R. J., Jr Articles by Gelb, A. F.