Iatrogenic tension pneumothorax complicating outpatient heimlich valve chest drainage

doi:10.1016/0736-4679(94)90343-3

The Journal of Emergency Medicine

Volume 12, Issue 4, July–August 1994, Pages 477-479

https://doi.org/10.1016/0736-4679(94)90343-3 Get rights and content

Abstract

Use of new technology makes possible the outpatient management of conditions previously requiring inpatient treatment. With increased use of such modalities comes a greater chance that the emergency physician will encounter patients with device-related complications. We report a case of such a complication, a tension pneumothorax presenting to the emergency department following misguided manipulation of a modified Heimlich chest drainage system. It is recommended that physicians opting to utilize such out-patient technology refrain from improvised modifications that may be unfamiliar to subsequent providers.

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Cited by (13)

Comparative Effectiveness of Interventions in Initial Management of Spontaneous Pneumothorax: A Systematic Review and a Bayesian Network Meta-analysis
2020, Annals of Emergency Medicine
Citation Excerpt :
The rest of the trials routinely admitted patients, raising the risk of hospitalization-related complications. A second explanation is that current iterations of commercially available stand-alone Heimlich valves (used in 2 trials included in the analyses)9,32 have design issues,60 which can lead to potentially life-threatening consequences.60-62 We recommend redesign of the stand-alone Heimlich valve before its role is studied.
The best initial strategy for nontension symptomatic spontaneous pneumothorax is unclear. We performed a systematic review and meta-analysis to identify the most efficacious, safe, and efficient initial intervention in adults with nontension spontaneous pneumothorax.
MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched from January 1950 through December 2019 (print and electronic publications). Randomized controlled trials evaluating needle aspiration, narrow-bore chest tube (<14 F) with or without Heimlich valve insertion, and large-bore chest tube (≥14 F) insertion in spontaneous pneumothorax were included. Network meta-analyses were performed with a Bayesian random-effects model.
Twelve studies were included in this review (n=781 patients). Analyses of efficacy (n=12 trials) revealed no significant differences between the interventions studied: narrow- versus large-bore chest tubes, odds ratio (OR) 1.05 (95% credible interval [CrI] 0.38 to 2.87); large-bore chest tube versus needle aspiration, OR 1.25 (95% CrI 0.65 to 2.62); and narrow-bore chest tube versus needle aspiration, OR 1.32 (95% CrI 0.54 to 3.42). Analyses of safety (n=10 trials) revealed a significant difference between needle aspiration and large-bore chest tube interventions: OR 0.10 (95% CrI 0.03 to 0.40). No differences were observed in needle aspiration versus narrow-bore chest tube (OR 0.29 [95% CrI 0.05 to 1.82]), and narrow- versus large-bore chest tube comparisons (OR 0.35 [95% CrI 0.07 to 1.67]). Analyses of efficiency were not pursued because of variation in reporting the length of stay (n=12 trials). Narrow-bore chest tube (<14 F) had the highest likelihood of top ranking in terms of immediate success (surface under the cumulative ranking curve=64%). Needle aspiration had the highest likelihood of top ranking in terms of safety (surface under the cumulative ranking curve=95.8%).
In the initial management of nontension spontaneous pneumothorax, the optimal strategy between the choices of a narrow-bore chest tube (<14 F, top ranked in efficacy) and needle aspiration (top ranked in safety) is unclear. Complications were more common in large-bore chest tube (≥14 F, including 14-F tube) insertions compared with needle aspiration.
Portable Chest Drainage Systems and Outpatient Chest Tube Management
2010, Thoracic Surgery Clinics
Citation Excerpt :
The Heimlich valve is the simplest method of outpatient pleural drainage. Some problems related to patient-induced malposition of the valve, leading to tension pneumothorax and emergency readmission, have been published in the literature.22,23 Fortunately, these problems are rare, and the reliability of flutter valves for pleural drainage after lung resection has been demonstrated in the literature.24–27
The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax
2008, Journal of Emergency Medicine
Citation Excerpt :
Outpatient treatment is also possible with the use of a Heimlich valve (61). However, misguided manipulation of a Heimlich valve by a health care provider in an outpatient setting has resulted in tension pneumothorax (67). Problems encountered in insertion include catheter kinking, clogging, and malpositioning within the major fissure.
According to an American College of Chest Physicians consensus statement published in 2001, it is recommended that chest tubes should be used for the drainage of primary spontaneous pneumothoraces. However, more recent expert opinions and guidelines suggest that simple aspiration is increasingly recognized as an acceptable alternative treatment. Studies have shown that the success rates and recurrence rates of simple aspiration are comparable to, if not more favorable than, those of chest tube drainage and small-bore catheter aspiration. Simple aspiration is the least invasive modality and it has economic cost-saving benefits, particularly with respect to admission rates and hospital length of stay. Its complication rate is low. However, a larger size of pneumothorax seems to be associated with increased likelihood of failure of simple aspiration. The author reviews the available evidence relating to the use of simple aspiration as a modality for treating primary spontaneous pneumothorax.
A new portable chest drainage device
2000, Annals of Thoracic Surgery
Citation Excerpt :
The gauzes over the open end of the valve were always wet and had to be replaced. The same problem was reported by other authors [6, 7]. This limitation restricts the usefulness of the Heimlich valve and increases the risk of infection.
Background. Persistent air leak is a frequent complication in lung operation. The Heimlich valve is the standard system for venting the pleural cavity. The device achieves good results and is well tolerated, but the main problem is when air leak is associated with fluid leakage.
Methods. In order to improve the outpatient management of persistent air and fluid drainage after resectional procedures, we developed an original device. It is a portable system provided with a one-way valve connected to the chest tube for drainage of air and fluid, a reservoir for collecting fluid, and a one-way exhaust valve to evacuate air from the bag.
Results. We analyze the advantages of our device versus the Heimlich valve in the first series of 18 selected patients. Our system is drier and cleaner, easier to manage, and ambulatory visits are seldom needed. There is also a cost savings.
Conclusions. Our device enhances ambulation, independence, and the quality of life of the patients, and decreases the need for hospital and outpatient care.
Patient-induced complications of a Heimlich flutter valve
1998, Chest
Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: A case series
1997, Journal of Emergency Medicine
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.

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Clinical communicationIatrogenic tension pneumothorax complicating outpatient heimlich valve chest drainage

Abstract

Ann Emerg Med.

Dis Chest.

Ann Thorac Surg.

Am J Surg.

Am J Sur.

Clinical communication
Iatrogenic tension pneumothorax complicating outpatient heimlich valve chest drainage