Heimlich valve treatment of Pneumocystis carinii-associated pneumothorax

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.

Value innovation: an important aspect of global surgical care

Introduction

Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.

Review

Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.

Conclusion

Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.

Pleural disease in patients with acquired immune deficiency syndrome

Given the multiple impairments in host defense that occur during HIV infection, patients with AIDS are at risk for a variety of pleural infections and neoplasms. Of infectious causes, bacterial parapneumonic effusions and empyemas and tuberculous pleurisy occur more frequently than effusions caused by P. carinii. In each case, therapy is directed at eradication of the causative organisms. In the setting of systemic Kaposi's sarcoma, pleural involvement is common, although diagnosis is difficult and therapeutic options are limited. Pleural effusions caused by non-Hodgkin's lymphoma often occur in the setting of pulmonary parenchymal disease and can be diagnosed cytologically. The recently described entity of primary effusion lymphoma occurs in the absence of solid-organ involvement. The development of a spontaneous pneumothorax in a HIV-infected individual should prompt a search for P. carinii infection. Although these pneumothoraces often recur and are difficult to manage, recent series suggest that surgical approaches to bronchopleural fistulas are reasonable in selected patients.

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.

Management of AIDS-related pneumothorax

BACKGROUND

Pneumothorax (PTX) occurs in 5% of patients with acquired immunodeficiency syndrome (AIDS) infected with Pneumocystis carinii pneumonia, and up to 50% of those will die during hospitalization. The treatment strategies for managing AIDS-related PTXs are often complex and ineffective at treating the PTX, and they can prolong hospitalization.

METHODS

We reviewed our experience with 36 male patients with AIDS treated for 44 PTXs over a 2.5-year period to determine if a particular therapeutic approach could allow for an earlier recovery and effective treatment of the PTX. All patients had current or prior history of Pneumocystis carinii pneumonia infection, and the CD4+ T-lymphocyte counts were less than 100/microL in 100%.

RESULTS

Twenty-seven patients with 31 PTXs were discharged from the hospital. Of these 31 PTXs, 21 had resolved at the time of the patient's discharge from the hospital, and the other 10 PTXs were converted from Pleurevac (Deknatel, Inc, Fall River, MA) drainage to a Heimlich valve for persistent bronchopleural fistula after more than 15 days of conventional treatment. The PTXs were effectively managed by tube thoracostomy alone in 18/44 PTXs (41%), tube thoracostomy plus sclerosing therapy in 2/8 PTXs (25%), and thoracotomy with blebectomy and pleurodesis in 1/3 PTXs (33%). Nine of 11 of the procedure-related PTXs responded to tube thoracostomy alone; the other 2 PTXs were converted from Pleurevac drainage to a Heimlich valve and allowed for patient discharge from the hospital in less than 10 days. Nine patients with 13 PTXs died during hospitalization. Four of these 9 patients (44%) had bilateral PTXs, and 8/9 (89%) were being treated by tube thoracostomy with Pleurevac suction for persistent bronchopleural fistula in the intensive care unit at the time of death. The 8 patients treated for 10 PTXs with a Heimlich valve had effective management of the PTX, had no morbidity associated with the Heimlich valve and no in-hospital mortality, and were discharged from the hospital to home or a hospice setting.

CONCLUSIONS

The management of AIDS-related PTXs is complex and often associated with a destructive pulmonary process and other systemic disease conditions related to AIDS that result in ineffective resolution of the PTX, a prolonged hospitalization, and a high mortality. In our experience, there is a lesser role for managing the PTXs with sclerosing therapy or thoracotomy. Patients with advanced AIDS complicated by PTXs with bronchopleural fistula can be converted from a Pleurevac drainage system to a Heimlich valve with no apparent morbidity or mortality, and managed as an outpatient, thereby potentially shortening hospitalization and facilitating an earlier discharge from an acute care setting.

Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema

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.

AIDS-related spontaneous pneumothorax. Risk factors and treatment

OBJECTIVE

To define risk factors and optimum therapy for AIDS-related spontaneous pneumothorax (PTX).

DESIGN

Case-control study.

SETTING

Tertiary care center.

PATIENTS

Thirty-five patients with AIDS who developed spontaneous PTX between January 1, 1988 and December 31, 1991, of whom 27 (77.1%) did so in the setting of Pneumocystis carinii pneumonia (PCP). Forty-one patients who were diagnosed as having PCP and did not develop PTX served as the control group.

RESULTS

Using logistic regression, a history of cigarette smoking, aerosolized pentamidine treatment, and the observation of pneumatoceles by chest radiography were associated with an increased risk of PTX. Although not associated with an increased risk of occurrence of PTX, the use of systemic corticosteroids for PCP treatment was associated with a longer requirement for chest tube drainage. Although chest tube drainage alone was often successful, chemical and surgical pleurodesis was often effective in treating prolonged air leaks and was associated with a lower incidence of recurrent PTX, although this difference did not achieve statistical significance (p = 0.07).

CONCLUSIONS

Patients at high risk of developing AIDS-related spontaneous PTX can be identified. Systemic corticosteroids may increase the risk of morbidity from AIDS-related PTX. Chemical and surgical pleurodesis may be of value in short-term treatment and in reducing the risk of recurrence.

Spontaneous pneumothorax in children with AIDS

The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.

Idiopathic, bilateral pneumothorax: case report in a young child

Unilateral, idiopathic pneumothorax (IP) is relatively common and occurs predominantly in males in their teens and twenties, with 85% presenting before age forty. In contrast, bilateral IP occurs rarely, with only three cases reported from 1977-87. To our knowledge, only one case of bilateral IP has been reported in the pediatric population, an adolescent male with likely recurrent disease. We present a case of a 7-year-old child with bilateral IP and discuss the diagnosis, pathophysiology, and treatment of this entity.

Accuracy, alarm limits and rise times of 12 oxygen analysers

The Comité Européen de Normalisation recently proposed a new standard for 'the particular requirements of oxygen monitors for medical use'. The feasibility of this proposed standard was tested in respect of (1) accuracy of alarm activation (2) accuracy of oxygen display value during both continuous and cyclical gas flows (3) rise time during rapid changes in oxygen concentration in the following 12 analysers: Datex Capnomac II and Servomex 570A (paramagnetic); Brüel & Kjaer 1304 (magnetoacoustic); Criticare Poet II, Multinex, Dräger Oxydig, Dräger PM 8030, Megamed 046A (part of the Megamed 700 ventilator), Ohmeda 5120, Spacelabs Multigas, Teledyne TED 200 (galvanic); Kontron OM 810 (polarographic). All the analysers tested displayed an oxygen reading which was within +/- 3 vol% of the actual oxygen concentrations of the test gases (15, 21, 40, 60 and 100 vol%). A cyclical pressure of between -1.5 to +8 kPa did not affect the measured oxygen concentration as displayed by the Brüel & Kjaer 1304, Datex Capnomac II and Servomex 570A analysers. The remainder, however, showed, depending on their measuring principle, a display error of between -1 and +6 vol%. After exposure to high pressure all the oximeters functioned normally. Some of the tested devices showed more than 2% of deviation between their alarm activation and the preset alarm limits. Only the Kontron OM 810, the Megamed 046A and the Spacelabs Multigas monitors satisfied the requirements at all the tested oxygen concentrations. The time required by the oxygen analyser to display the rise from 29 to 92 vol % after a sudden change of concentration from 21 to 100 vol % O2 is defined as "rise time" and must not, according to the Comité Européen de Normalisation standard proposal, exceed the manufacturers' specification by more than a factor of 1.15.(ABSTRACT TRUNCATED AT 250 WORDS)

Heimlich valve treatment and outpatient management of bilateral metastatic pneumothorax

A 51-year-old man was treated for bilateral pneumothorax secondary to pulmonary metastases from malignant fibrous histiocytoma. After failure of regular therapy, Heimlich flutter valves were used producing disappearance of the bilateral pneumothorax and adequate outpatient management.

Doxycycline pleurodesis for pneumothorax in patients with AIDS

Since first described in 1984, nontraumatic pneumothoraces in patients with AIDS has become more common. When compared with spontaneous pneumothorax in the general population, pneumothoraces in patients with AIDS are often complicated by prolonged air leaks as well as higher recurrence rates. Chemical pleurodesis has an important role in the management of these complications. The most experience with chemical pleurodesis uses tetracycline hydrochloride as the sclerosing agent; however, this agent is no longer available. Doxycycline has been used in pleurodesis of malignant effusions, but its use in managing pneumothoraces is limited. We present five patients who have AIDS with a total of seven pneumothoraces. Each patient experienced a persistent air leak. Six of the pneumothoraces were managed successfully with doxycycline. Although the follow-up period was limited, there were no recurrences noted and the only side effect seen was chest pain in four which was easily controlled with narcotics. Doxycycline sclerotherapy can be used effectively for pleurodesis in the management of nontraumatic pneumothorax in the patient with AIDS.