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Ann Thorac Surg 2000;69:1001
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: GENERAL THORACIC

Invited commentary

^a Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0016, USA

e-mail: robert.cerfolio{at}ccc.uab.edu

	Introduction

Top Introduction

 
Doctor Lodi and associates have attempted to solve a common problem that many general thoracic surgeons face who use Heimlich valves. The authors have designed a clever device that collects the fluid that drains from Heimlich valves. Although this system is unique and well-designed, there are other simpler systems currently available. In most patients the drainage is minimal, and a gauze sponge, changed daily, is usually sufficient. I am unaware of any data that has shown an increased risk of infection with this method. In the remaining few patients whom do have significant drainage, we have over the last 4 years used a Foley leg bag (Mallincrodt, St. Louis, MO) attached to the Heimlich valve. We cut a very small hole in the top of the bag. This allows the air to escape, but collects fluid. I favor this technique because it is inexpensive, widely available, and nurses, staff and patients have an easy time instructing and learning how to use it and empty it.

Although the authors did not mention the cost of their system, I believe eliminating several unnecessary features could reduce that cost. I do not believe the air filter is necessary, since there have been few if any described empyemas in patients who have had Heimlich valves attached to conventional systems for several weeks. Similarly, the attachment that allows one to sample fluid for culture is probably not needed.

Surprisingly, the authors have excluded patients with high chest tube outputs. I believe the main advantage of their system is the ability to discharge the patient with a high output (once analysis of the effluent proves it is not blood, chyle, or cerebral spinal fluid). These patients can be managed safely at home even with outputs as high as 600 to 750 cc per day. They can be easily taught to drain their bag themselves, and they do not suffer electrolyte imbalance. The authors are to be commended for following their patients so closely, but they probably do not need to see patients 3 days after discharge or once per week. A phone call or clinic visit once, every 1 to 2 weeks, is usually sufficient.

The authors did not address the problem of the patient who develops a new pneumothorax when placed on a Heimlich valve. In our experience, if the patient is asymptomatic he can be left on the valve. However, if he becomes dyspneic with the new or enlarging pneumothorax we have used bedside chemical pleurodesis, with talc or doxycycline. This creates adhesions and has enabled some patients to be discharged home on a Heimlich valve without developing a symptomatic pneumothorax the next day. Moreover, this technique may even eradicate an air leak if it is small and if the patient has parietal-visceral pleural apposition. We do not use talc if there is a significant chance for reoperation or if the patient has poor pulmonary reserve.

The authors describe 1 patient who still had an air and fluid leak after 28 days. We have found that chest tubes can usually be removed, even if there is an air leak with little to no consequence after 3 weeks. The indwelling tube probably creates adhesions and partitions, or compartmentalizes the pleura space so a tension pneumothorax does not occur. Finally, I do not believe there is a certain amount of drainage above which chest tube removal is contraindicated. Few if any patients who have had chest tubes removed that were draining 400 or 500 cc per day, return with symptomatic pleural effusions.

Doctor Lodi and associates have invented and designed an ingenious, compact and useful system. The device controls drainage extremely well. It is probably too elaborate for the routine patient with a prolonged air leak, who goes home on a Heimlich valve. I believe that their system, with its ability to provide some suction, may have a role in the outpatient management of some patients with malignant pleural effusions as well.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert J. Cerfolio Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cerfolio, R. J. Search for Related Content PubMed Articles by Cerfolio, R. J.