Heimlich Valve Research Articles

Optimizing a Canine Survival Model of Orthotopic Lung Transplantation

Introduction While acute models of orthotopic lung transplantation have been described in dogs, the technical considerations of developing a survival model in this species have not been elaborated. Herein, we describe optimization of a canine survival model of orthotopic lung transplantation. Methods Protocols of orthotopic left lung transplantation and single lung ventilation were established in acute experiments ( n = 9). Four dogs, serving as controls, received autologous, orthotopic lung transplants. Allogeneic transplants were performed in 16 DLA-identical and 16 DLA-mismatched unrelated recipient dogs. Selective right lung ventilation was utilized in all animals. A Malecot tube was left in the pleural space connected to a Heimlich valve for up to 24 hours. To date, animals have been followed up to 24 months by chest radiography, pulmonary function tests, bronchoscopy with lavage, and open biopsies. Results Long-term survival was achieved in 34/36 animals. Two recipients died intraoperatively secondary to cardiac arrest. All animals were extubated on the operating table, and in all cases the chest tube was removed within 24 hours. Major complications included thrombosis of the pulmonary artery and subcritical stenosis of bronchial anastamosis. One recipient underwent successful treatment of a small bowel intussusception. Conclusions We report our experience in developing a survival canine model of orthotopic single lung transplantation. While short-term survival following canine lung transplantation is achievable, we report particular considerations that facilitate animal comfort, early extubation, and lung reexpansion in the immediate postoperative period, further optimizing use of this species for experimental modeling of long-term complications after lung transplantation.

A Novel Device Developed, Tested, and Used for Warming and Maintaining Intravenous Fluids in a Forward Surgical Team during Operation Enduring Freedom

To determine whether an accessory to the Bair Hugger warming unit (BHWU), a piece of equipment intrinsic to the forward surgical team, could be designed and used to warm and to maintain large volumes of intravenous fluids at an optimal infusion temperature in an austere environment. The X-1 is a simple, collapsible, 5-gallon nylon cooler with handles, modified with a port for the BHWU hose and a one-way flutter valve vent. The warming of intravenous fluids to the optimal infusion temperature was accomplished with the BHWU and X-1. The warming time was influenced by the ambient temperature, the starting temperature of the fluids, and the number of bags being warmed. The warmed fluid could be stored and maintained in the X-1. The heat retention of the fluids was influenced by the ambient temperature, the number of bags warmed, and the insulating properties of the X-1. The BHWU can be used with the compact X-1 to warm and to store large volumes of intravenous fluids at the optimal infusion temperature in the field environment and was successfully used by a forward surgical team in Afghanistan, during Operation Enduring Freedom, for the treatment of combat-wounded soldiers.

AIRFIX®: the first digital postoperative chest tube airflowmetry—a novel method to quantify air leakage after lung resection☆

Prolonged air leak after pulmonary resection is a common complication and a major limiting factor for early discharge from hospital. Currently there is little consensus on its management. The aim of this study was to develop and evaluate a measuring device which allows a simple digital bed-side quantification of air-leaks compatible to standard thoracic drainage systems. The measuring device (AIRFIX) is based upon a 'mass airflow' sensor with a specially designed software package that is connected to a thoracic suction drainage system. Its efficacy in detecting pulmonary air-leaks was evaluated in a series of 204 patients; all postoperative measurements were done under standardized conditions; the patients were asked to cough, to take a deep breath, to breathe out against the resistance of a flutter valve, to keep breath and to breathe normally. As standard parameters, the leakage per breath or cough (ml/b) as well as the leakage per minute (ml/min) were displayed and recorded on the computer. Air-leaks within a range of 0.25-45 ml/b and 5-900 ml/min were found. Removal of the chest tubes was done when leakage volume on Heimlich valve was less than 1.0 ml/b or 20 ml/min. After drain removal based upon the data from chest tube airflowmetry none of the patients needed re-drainage due to pneumothorax. The AIRFIX device for bed-side quantification of air-leaks has proved to be very simple and helpful in diagnosis and management of air-leaks after lung surgery, permitting drain removal without tentative clamping.

Simplified stepwise management of primary spontaneous pneumothorax: a pilot study

In primary spontaneous pneumothorax (PSP) requiring intervention, removal of air from the pleural space can be achieved by manual needle aspiration or by pleural drainage after insertion of a chest tube. This study aimed to evaluate the efficacy and safety of a serial-steps approach with a single system (small-calibre catheter/Heimlich valve) in a homogeneous population of patients with a first episode of PSP. All patients had an 8.5 F distally multiperforated polyurethane pigtail catheter inserted via the anterior route, at the bedside without any guidance, using the Seldinger technique. A one-way Heimlich valve was connected to the catheter, allowing the air to flow spontaneously outwards for 24-48 h. Thereafter, if the lung failed to re-expand wall suction was applied. Patients with an air leak persisting for >4 days were referred for surgery. Primary end-points were success rates at 24 h and 1 week, and 1 yr recurrence-free survival. In total, 41 consecutive patients entered the study. They were typically thin, young, smoking males. No procedure-related complications were observed. The need for pain relief medication was minimal. Within the first 24 h, most of the patients were able to walk around and half of them were able to take a shower with their catheter in place. The 24-h and 1-week success rates were 61 and 85%, respectively, and the actuarial 1-yr recurrence rate was 24%. Four patients underwent surgical pleurodesis because of a persistent air leak. The length of stay when excluding the four surgical cases was 2.3+/-1.3 days. When 24-h and 1-week success rates and recurrence at 12 months were taken as end-points, the method described here is as effective as simple manual needle aspiration or a conventional chest tube thoracotomy. These results support further studies assessing this "one system, serial-steps approach" in an outpatient management algorithm.

Evidence for the flutter valve mechanism of the lower oesophageal high pressure zone.

Simultaneous oesophageal manometry and pH monitoring was performed at rest and during abdominal compression in 189 subjects. The force exerted by the high pressure zone (HPZ) and by its intra-abdominal segment was reduced to the same extent in the 102 subjects who refluxed and the 87 who did not. Reflux during abdominal compression occurred in the subjects whose HPZ force fell into a critical range and in whom the contribution by the abdominal segment was reduced to less than 50 per cent of the total force exerted by the HPZ. These results are more in keeping with a mechanical flutter valve theory of lower oesophageal competence than sphincteric reflux control. Furthermore, the results indicate that measurements of oesophageal pressure, length or force in the resting state do not account for reflux or gastrooesophageal competence, but that it is the reserve of pressure, length or force during stress which is responsible.

Pneumothorax as a Complication of Breast Augmentation

Pneumothorax is a recognized complication of breast augmentation which, until now, was thought to be rare. The authors hypothesize that it is more common than generally appreciated. A fax survey was sent to 363 members of the California Society of Plastic Surgeons in 2001, questioning their experience with this complication. The survey response rate was 50 percent, revealing that one in three members of the California Society of Plastic Surgeons had at least one patient who experienced a pneumothorax, and one in 10 had experienced two or more complications of pneumothorax while performing breast augmentation. Sixty-two members reported a total of 83 separate pneumothoraces in their career. No local or hypodermic needle injections were used in 24 percent of these patients. Fifty-five percent of patients were hospitalized, with 71 percent of the cases paid for by insurance companies. Treatment consisted of observation and repeated chest radiograph in 33 percent, needle aspiration alone in 16 percent, and chest tube insertion in 47 percent. The cause is difficult to determine, but causes suspected by respondents included intraoperative laceration of the pleura (43 percent), needle puncture at the time of local injection (37 percent), ruptured pulmonary blebs during or after the procedure (16 percent), and high anesthetic ventilation pressures (3 percent). The authors believe the complication of pneumothorax is more common than generally appreciated and is not necessarily caused by negligence. The authors now include this complication in their consent form and recommend keeping an intracatheter, pigtail catheter, or Heimlich valve in surgical facilities for treatment of a possible tension pneumothorax.

Glutaraldehyde Preserved Autologous Pericardium for Patch Reconstruction of the Pulmonary Artery and Superior Vena Cava

We describe a new employment of glutaraldehyde preserved autologous pericardium for patch reconstruction of the pulmonary artery (PA) and superior vena cava (SVC). This technique was devised to minimize technical problems related to the use of fresh pericardium such as excessive elasticity and tendency to curl. We have successfully employed this procedure in three cases of reconstruction of the PA and in two cases of reconstruction of the SVC.

Comparison between Flutter Valve Drainage Bag and Underwater Seal Device for Pleural Drainage after Lung Surgery

The purpose of the present study was to compare the use of a conventional underwater seal device with suction and a flutter valve drainage bag for pleural drainage after lung surgery. Altogether 59 patients undergoing elective lung surgery except pneumonectomy between February 2001 and April 2002 were prospectively randomized to receive postoperative pleural drainage by 28F chest tube(s) attached to underwater seal device placed on negative pressure of 15 cm of water or flutter valve drainage bag. Following withdrawal of four patients from the study, 55 patients were evaluated (31 patients in the underwater seal device group and 24 patients in the flutter valve drainage bag group). In the conventional underwater seal device group the mean drainage time was 2.6 (SD +/- 2.0) days and in the flutter valve drainage bag group the mean drainage time was 3.3 days (SD +/- 4.0); difference -0.8, 95% confidence interval (CI) -2.4 to 0.9. The mean length of hospitalization in the surgical ward was 3.6 (SD +/- 2.7) and 4.1 (SD +/- 4.4) days respectively (difference -0.5, 95% CI -2.5 to 1.4). The results of this study suggest that flutter valve drainage system is a safe and feasible alternative in managing postoperative air leaks and haemorrhage after lung surgery other than pneumonectomy if air leaks are not extremely massive.

Pneumothorax.

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

Association of Tension Pneumothorax With Use of Small-Bore Chest Tubes in Patients Receiving Mechanical Ventilation

We report the case of a 46-year-old woman who came to our emergency department with generalized weakness and abdominal pain. Shortly thereafter, she became hypotensive and had a respiratory arrest that required endotracheal intubation and mechanical ventilation.The patient had a history of hypertension, migraines, and emphysema. Medications included aspirin, butalbital, and caffeine taken for headaches, and laxatives. A chest radiograph obtained after intubation revealed hyperinflated lungs with diminished vascularity and a flattened diaphragm suggestive of emphysematous lung disease.Within a few hours after intubation, the patient’s respiratory status deteriorated and her oxygen saturation decreased precipitously. Peak airway pressures were elevated and hypotension developed. Because of the potential for pneumothorax, the on-call physician placed a small-bore chest tube connected to a Heimlich 1-way valve. In order for the patient to be transferred for computed tomography, mechanical ventilation was temporarily stopped and aggressive manual ventilation was used. The nursing staff noticed significant resistance during manual ventilation. After placement of the chest tube, computed tomography revealed significant subcutaneous emphysema, a tension pneumothorax, and contralateral mediastinal shift. Multiple bullae and blebs also were present. The patient had a cardiorespiratory arrest and required placement of a conventional large-bore chest tube; resolution of the pneumothorax ensued. Eventually, she was taken to the operating room for bullectomy and repair of ruptured blebs. The postoperative course was complicated by exacerbation of respiratory failure and infection, and the patient died.In this case, placement of a small-bore chest tube did not resolve a pneumothorax. Moreover, the tube could have potentiated the problem by causing tension pneumothorax. The American College of Chest Physicians consensus statement1 supports the use of small-bore catheters (<14F) in patients with small to large pneumothoraces whose clinical status is stable. Some patients whose clinical status is unstable can be managed with a small-bore catheter attached to a Heimlich valve if the catheter can provide rapid evacuation of the pleural space. The American College of Chest Physicians recommends the use of size 24F to 28F catheters in patients who appear to be at risk for a large pleural air leak. However, until the computed tomography scan was obtained, we did not know that our patient was high risk.Small-bore chest tubes, although effective for treating small pneumothoraces, have major limitations.2 The catheter tip is easily occluded by fluid, by placement of the catheter against the chest wall, or by a kink; all these situations could create a tension pneumothorax.2–4 Tension pneumothorax could be catastrophic in a patient receiving positive-pressure ventilation. The user’s manual provided by the manufacturer of the small-bore chest tube that was used did not refer to that complication. After placement of a conventional chest tube and removal of the small-bore chest tube, the tension pneumothorax in our patient resolved.We therefore caution physicians and nurses against the use of small-bore chest tubes with a Heimlich valve in patients who are receiving positive-pressure ventilation. If possible, regular-size thoracotomy tubes should be used instead. Furthermore, nursing staff should be cautious in fervent manual overinflation in patients with severe emphysema who are receiving mechanical ventilation, especially during transportation or resuscitation efforts. Such overinflation could markedly increase intrathoracic pressure and eventually lead to excessive amounts of intrinsic positive end-expiratory pressure.5 In patients with large bullae, blebs, and poor parenchymal integrity, intrinsic positive end-expiratory pressure could cause hypotension, hypoxemia, and poor gas exchange, leading to cardiorespiratory arrest and possibly death. It is therefore recommended that ventilation via a manual resuscitation bag be done with lower tidal volumes and increased time for full exhalation between breaths.

Percutaneous Relief of Tension Pneumomediastinum in a Child

The purpose of this article was to describe the experience of relieving tension pneumomediastinum by a fluoroscopic-guided percutaneous method. We inserted a percutaneous drainage catheter with a Heimlich valve under fluoroscopic guidance to relieve the tension pneumomediastinum in a 2-year-old girl who suffered from dermatomyositis with lung involvement. This allowed immediate relief without the need for surgery. The procedure was repeated for relapsed tension pneumomediastinum. Good immediate results were achieved in each attempt. We conclude that percutaneous relief of pneumomediastinum under fluoroscopic guidance can be performed safely and rapidly in patients not fit for surgery.

Major thoracic surgery in octogenarians: the video-assisted thoracic surgery (VATS) approach.

Thoracic surgery is associated with a high morbidity and mortality rate in the elderly patient population. Appropriate management of thoracic diseases is often avoided because of the inherent risks associated with the access thoracotomy. The purpose of this study was to evaluate the perioperative outcomes of octogenarians who underwent video-assisted thoracic surgery (VATS) for a variety of thoracic conditions. A retrospective chart review was done on all patients who were between 80 and 90 years of age and underwent elective VATS between January 1995 and August 2001. A total of 162 consecutive VATS procedures were performed in 157 patients. Comorbid conditions consistent with their advanced age included chronic obstructive pulmonary disease, hypertension, coronary artery disease, and diabetes. The procedures included 96 lung resections (53 lobectomies, 42 wedge/segment resections), 46 pleurectomies, 8 decortications, 8 mediastinal biopsies, 3 pericardial windows, and 1 drainage of hemothorax. The pathology included 76 primary lung cancers, 35 metastatic diseases, 37 benign conditions, 9 nesotheliomas, and 3 carcinoid tumors. The average operative time and length of hospital stay after surgery were 51 min and 2.6 days, respectively. There were 3 (1.9%) mortalities, 2 from cardiac complications and 1 from pneumonia. Two (1.2%) patients required reexploration for bleeding. Four (2.5%) cases were converted to open thoracotomy thirteen (8.0%) cases had an air leak, of which 11 were managed on an outpatient basis with a Heimlich valve. They were discharged from the hospital an average of 3.3 days postoperatively. With VATS, surgical therapy can be offered to octogenarians with a low morbidity and mortality rate, as well as a short hospital stay.

A válvula de Heimlich no tratamento do pneumotórax

Objetivos: A válvula de Heimlich foi descrita para substituir os sistemas de drenagem sob selo d'água. O Serviço de Cirurgia Torácica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo realizou este estudo com o objetivo de avaliar sua eficiência no tratamento do pneumotórax, bem como a facilidade de manipulação, segurança e tolerância pelo paciente. Métodos: Foram analisados 108 pacientes com pneumotórax de diferentes etiologias, de junho/97 a agosto/2000. A maioria (76%) apresentava pneumotórax classificado radiologicamente como médio ou grande, sendo três deles hipertensivos, dos quais um bilateral. Utilizaram-se para a drenagem da cavidade pleural cateteres plásticos de teflon ou poliuretano tipo pig-tail 10,2F, 14F ou retos 11F conectados à válvula de Heimlich. Nos pacientes pós-toracotomias, a válvula foi conectada diretamente ao dreno torácico. Resultados: O período de permanência da válvula variou de um a 120 dias (mediana de quatro dias). A tolerância ao sistema foi considerada boa por 89% dos pacientes. Não ocorreram complicações atribuíveis ao sistema. A presença de derrame associado em 20 pacientes (18,5%) não impediu o bom funcionamento do sistema. Apenas dois (1,8%) pacientes evoluíram com enfisema subcutâneo progressivo, optando-se então por dreno tubular 36F sob selo d'água. Em um paciente (0,9%) indicou-se toracotomia para descorticação pulmonar. Vinte pacientes (18,5%) foram tratados no ambulatório. Conclusões: A válvula de Heimlich mostrou-se eficiente na resolução do pneumotórax de diferentes etiologias e nas fístulas aéreas pós-operatórias. A manipulação foi mais simples do que as historicamente observadas nos sistemas convencionais. A boa tolerância e segurança referidas pelos pacientes foram fator determinante na precocidade da alta hospitalar e incentivo ao tratamento ambulatorial.

Predictors and treatment of persistent air leaks

Background. Air leaks prolong hospital stay. Methods. A prospective algorithm was applied to patients. If patients were ready for discharge but still had an air leak, a Heimlich valve was placed and they were discharged. If the leak was still present after 2 weeks, the tube was clamped for a day and removed. Results. There were 669 patients. Factors that predicted a persistent air leak were FEV 1% of less than 79% ( p = 0.006), history of steroid use ( p = 0.002), male gender ( p = 0.05), and having a lobectomy ( p = 0.01). Types of air leaks on day 1 that eventually required a Heimlich valve were expiratory leaks ( p = 0.02), leaks that were an expiratory 4 or more ( p < 0.0001), and the presence of a pneumothorax concomitant with an air leak ( p < 0.0001). Thirty-three patients were placed on a Heimlich valve, and 6 patients had a pneumothorax or subcutaneous emphysema develop; all patients had an expiratory 5 leak or larger ( p < 0.0001). Thirty-three patients went home on a valve. Seventeen patients had leaks that resolved by 1 week, 6 by 2 weeks, and the remaining 9 had their tubes removed without problems. Conclusions. Steroid use, male gender, a large leak, a leak with a pneumothorax, and having a lobectomy are all risk factors for a persistent leak. Discharge on a Heimlich valve is safe and effective for patients with a persistent leak unless the leak is an expiratory 5 or more. Once home on a valve, most air leaks will seal in 2 weeks; if not, chest tubes can be safely removed regardless of the size of the leak or the presence of a pneumothorax.

Patient with a chest tube and heimlich valve

Options in Practice presents different management approaches to the same clinical situation. You are invited to submit a brief case description, including the specialty nursing care provided, and several glossy color photographs of the clinical situation. The case material will then be sent to another wound, ostomy, or continence care nurse, who will also address management concerns. Alternative solutions to difficult wound, ostomy, or incontinence clinical situations will be published.

Fast-tracking pulmonary resections

Objective: We streamlined our care after pulmonary resection for quality and cost-effectiveness. Methods: A single surgeon performed 500 consecutive pulmonary resections through a thoracotomy over a 2¾-year period in a university setting. Patients were extubated in the operating room and sent directly to their hospital room. Chest tubes were placed to water seal and removed on postoperative day 2 if there was no air leak and drainage was less then 400 mL/d. Epidural catheters were used and removed by postoperative day 2. The plan for each day and discharge on postoperative day 3 or 4 was reviewed with the patients and families daily during rounds. The patient went home the day the last chest tube was removed. Persistent air leaks were treated with Heimlich valves. Results: There were 500 patients (338 men), with a median age of 58 years (range, 3-87 years). Of these patients, 293 had pre-existing conditions. Seventy-three (15%) patients had been denied operations by at least one other surgeon. Four hundred nineteen (84%) patients had successful placement of a functioning preoperative epidural catheter. Pneumonectomy was performed in 32 (6%) patients, segmentectomy was performed in 16 (3%) patients, and lobectomy, sleeve lobectomy, and/or bilobectomy was performed in 194 (39%) patients. Nonanatomic resections were performed for metastasectomy. This included a single wedge resection in 161 (32%) patients and multiple wedge resections in 97 (19%) patients. A total of 482 (96%) patients were extubated in the operating room, and 380 (76%) patients were sent to their hospital room. The remaining 120 patients went to the intensive care unit for a median of 1 day (range, 1-41 days). Complications occurred in 107 (21%) patients, and operative mortality was 2.0%. Median day of discharge was postoperative day 4 (range, 2-119 days). A total of 327 (65%) patients left the hospital on postoperative day 4 or sooner. By survey, 97% of patients had excellent or good satisfaction with their care at hospital discharge, and 91% were extremely happy or satisfied at the 2-week follow-up contact. Conclusions: Most patients who undergo elective pulmonary resection can be extubated immediately after the operation, go directly to their room and avoid the intensive care unit, be discharged on postoperative day 3 or 4, and have minimal morbidity and mortality with high satisfaction both at discharge and at the 2-week follow-up contact. Techniques that seem to accomplish this include the following: the use of a water seal, removal of epidural catheters on postoperative day 2, early chest tube management, treatment of persistent air leaks with Heimlich valves, and daily reinforcement of the planned events for each day, as well as on the date of discharge with the patients and their families.J Thorac Cardiovasc Surg 2001;122:318-24

Heimlich Valve in the Management of Pneumothorax in Patients With Advanced AIDS

To review therapeutic strategies in the management of pneumothorax in patients with AIDS. Retrospective, 7-year, single institution experience. Forty-seven patients with AIDS were treated for 59 pneumothoraxes. Mean age was 37.4 years, and 70% of patients had prior or current infection with Pneumocystis carinii. All patients had CD4+ counts of < 100, and 28 of 47 patients (59.6%) had CD4+ counts of < 50. Of 59 pneumothoraxes, 14 pneumothoraxes (23.7%) were iatrogenic and 16 pneumothoraxes (27.1%) were bilateral. Patients were treated with conventional strategy (tube thoracostomy [TT] with or without pleurodesis, thoracotomy with blebectomy) or converted to a Heimlich valve (HV) in case of failure of conventional management. Thirty-six of 47 patients (76.6%) were discharged, and only 26 of 36 patients (72.2%) had complete pneumothorax resolution at discharge after conventional treatment. All patients discharged with an HV (10 of 36 patients; 27.8%) had pneumothorax resolution followed by valve removal as outpatients. Mean hospital stay after chest decompression was 12 days for conventional-therapy group survivors and 3 days for patients treated with an HV. Thirteen patients died (27.7%) with follow-up to 60 days. In-hospital mortality was 23.4% (11 of 47 patients), which represented a 29.7% mortality for patients treated with conventional therapy. Patients treated with an HV had no in-hospital mortality and 100% pneumothorax resolution, with two deaths occurring within 60 days of discharge but after removal of the HV. Patients with advanced AIDS and pneumothorax have high associated morbidity and mortality. If no resolution is observed after simple TT, prompt conversion to an HV allows safe and early hospital discharge.

Transthoracic needle biopsy of the lung: results of early discharge in 506 outpatients.

To determine the safety of early discharge (30 minutes) after transthoracic needle biopsy (TTNB) of the lung. In a prospective study of 506 consecutive outpatients who underwent TTNB of the lung, 440 patients underwent fine-needle aspiration biopsy (FNAB) only, and 66 underwent FNAB and core biopsy. Patients were discharged after 30-minute postbiopsy chest radiography if there was no pneumothorax. Patients were discharged after 60-minute chest radiography if they had a stable asymptomatic pneumothorax. These patients were followed up 1 day and/or 1 week after biopsy to identify delayed complications. Patients with a symptomatic or enlarging pneumothorax were treated with an 8-F pigtail catheter attached to a Heimlich valve, discharged, and followed up 24 hours later for chest tube removal. The pneumothorax rate was 22.9% (116 patients). Eighty-one patients (16.0%) had an asymptomatic pneumothorax, and 33 (6.5%) had a pigtail catheter in place. Seven (1.4%) patients developed a symptomatic pneumothorax after discharge; two of them (0.4%) underwent large-bore chest tube insertion. The other five (1.0%) underwent delayed pigtail catheter insertion. There were no deaths or other major complications. Early discharge after outpatient TTNB of the lung is associated with little morbidity and no mortality.

A treatment algorithm for pneumothoraces complicating central venous catheter insertion

Background: We investigated the role of observation or insertion of a small French pigtail catheter with Heimlich valve as alternative management to a tube thoracostomy for iatrogenic pneumothorax complicating central venous catheter (CVC) insertion. Methods: A retrospective review of 9,637 consecutive patients who had had subclavian CVCs inserted on an outpatient basis identified 100 patients with pneumothoraces. Treatment consisted of (1) observation, (2) outpatient insertion of a Heimlich valve, or (3) inpatient tube thoracostomy. Results: The median pneumothorax size was 10% (range 1% to 100%). Fifty-eight patients had observation as initial treatment, and this strategy was successful in 35 (60%). Thirty-four patients were treated initially with Heimlich valves, and this strategy was successful in 29 (85%). Tube thoracostomy as initial therapy was successful in 7 (88%) of 8 patients. Patients in who initial treatment failed were treated with insertion of a Heimlich valve or tube thoracostomy. Conclusions: In appropriately selected patients, pneumothorax after insertion of a subclavian CVC can be successfully managed in the outpatient setting with observation. Patients in whom observation fails can be treated with insertion of a Heimlich valve. Tube thoracostomy can be reserved for refractory PTX or emergent situations.

Pneumoperitoneum after concomitant resection of the right middle and lower lobes (bilobectomy)

Background. Removal of the right middle and lower lobes often leaves a pleural space problem that can cause prolonged air leaks. Methods. A single surgeon prospectively randomized 16 patients who underwent bilobectomy. Eight patients had 1200 mL of air injected under the right hemidiaphragm after bilobectomy and 8 did not. The air was injected through a small transdiaphragmatic opening made in the right hemidiaphragm at the time of pulmonary resection. Results. The age of the patients, preoperative pulmonary function, preoperative comorbidities, indications for surgery, and final pathology were not significantly different between the two groups. On postoperative day #1, a pneumothorax was present in 1 patient (13%) in the pneumoperitoneum group ( P group) and in 4 patients (50%) in the nonpneumoperitoneum group (N- P group). On postoperative day 1, an air leak was present in 1 patient (13%) in the P group and 5 patients (63%) in the N- P group ( p < 0.001). By the third postoperative day, no patient in the P group had an air leak; however, a leak was present in 4 patients (50%) in the N- P group ( p < 0.001). Median hospital stay in the P group was 4 days (range, 3 to 6 days), compared with 6 days (range, 4 to 8 days) in the N- P group ( p < 0.001). Three patients in the N- P group were sent home with a Heimlich valve. There was no operative mortality and no complications from the pneumoperitoneum. Conclusions. We conclude that pneumoperitoneum after bilobectomy is safe and easy to do. It decreases the incidence of air leaks and of pneumothoraces and shortens hospital stay without increasing morbidity. We recommend pneumoperitoneum after bilobectomy at the time of thoracotomy, especially if there are residual small air leaks that cannot be sealed before chest closure.