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Ann Thorac Surg 2000;69:998-1001
© 2000 The Society of Thoracic Surgeons

ORIGINAL ARTICLES: GENERAL THORACIC

A new portable chest drainage device

Renzo Lodi, MDa, Alessandro Stefani, MDa

a Department of Cardiothoracic Surgery, University of Modena, Reggio Emilia, Modena, Italy

Address reprint requests to Dr Lodi, Department of Cardiothoracic Surgery, University Hospital, Largo del Pozzo 71, 41100 Modena, Italy
e-mail: rlodi{at}unimo.it


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Prolonged air leak is the most common complication after resectional lung procedures, and increases hospital stay [1, 2].

Many authors have used the Heimlich valve for outpatient management of pneumothorax [3–5]. Some authors however, remain reluctant to use this valve in secondary spontaneous pneumothorax and postresectional air leaks, because in such patients large volumes of fluid or viscous secretions may be drained [1, 6, 7]. Heimlich valves do not manage pleural fluid, and this limits some home discharges. Therefore, there is a need for a portable system that can manage both air leaks and pleural fluid at home. In order to solve these problems, we developed an original chest drain system.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
One-way valve drainage system
This system has been designed to drain air and fluid through a chest tube. We describe technical details of the device (Figs 1, 2).



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  		Fig 1. The drawing represents the plan of the device and shows its peculiar technical aspects: (1) protection cap, (2) conic connection, (3) drawing point, (4) air filter, (5 & 8) one-way valve, (6) air and fluid stop balls, (7) drip chamber, (9) collection bag.

 


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  		Fig 2. Photograph of the device.

 
The device is connected to the chest tube by a conic connection. The connector is provided on one side with a pierceable button to draw fluid in a sterile way for laboratory tests, without piercing the seal system or changing the whole device (Figs 1, 3).



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  		Fig 3. Photograph of the conic connector with the button and the one-way valve.

 
The one-way valve is a seal system allowing drainage of air and fluids. When the air passes through, the valve gives out a sound. The valve allows the drainage of air and fluids, not only under pressure, but even under the force of gravity alone (Figs 1, 3).

The connection between the valve and the bag is a small tube made of soft rubber. This tube can be pressed with the fingers, and a little suction is exerted and transmitted through the valve. This facilitates fluid drainage (Figs 1, 2).

The reservoir is a bag directly connected to the rubber tube that allows collection of fluid from the pleural cavity. The bag has a maximum capacity of 700 mL (Figs 1, 2).

The one-way exhaust valve allows evacuation of air from the bag. The valve is provided with two balls. The lower ball allows air evacuation from the bag and prevents air entry from outside. The upper one prevents fluid leak from the bag when it is turned upside down. The end of the rubber tube is provided with an air filter, which works as an antibacterial filter also (Figs 1, 4). By pressing the bag with the hands, one can facilitate air evacuation.



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  		Fig 4. Photograph of the one-way exhaust valve.

 
Patients
We began to use the device in March 1998. The criteria for using this outpatient chest tube management were: pulmonary resection procedures (except pneumonectomies); prolonged air and fluid leak; and patients who were clinically stable and ready to be discharged (that is hospitalized only because of air and/or fluid leak). A prolonged air leak was defined as an air leak requiring more than 6 days of postoperative chest tube drainage.

When these criteria were fulfilled, we switched from a chest drainage system to the portable device. The valve was connected to the chest tube, which was already in place. No dressing covers or gauzes were needed over the end of the exhaust valve. The patients remained hospitalized for one more day to become familiar with the system, to give them instructions for home management, and to make sure they could tolerate and safely manage the system.

After discharge, the patients received oral pain medication and prophylactic oral antibiotic treatment as long as the tube was in place. They returned one or two times a week (depending on the amount of fluid leakage) to our ambulatory clinic for physical examination and for replacing the system with a new one. Swelling of the bag and the sound from the valve showed the persistence of air leak. When there was no longer an air leak, we waited 1 day and then took a chest roengtenogram before removing the tube.

The system was used even if there was a large air leak or an apical air space on chest roengtenograms. No patient had a daily fluid leakage greater than 150 mL. This was considered a contraindication to this kind of outpatient management. Even when fluid leakage was minimal, we applied our device.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
During the period between March 1998 and March 1999, outpatient management with our chest drain valve was applied to 18 patients. They account for 7.2% of overall pulmonary resections performed in the same period (n = 248). This group included 14 men (78%) and 4 women, with a mean age of 62 years (range, 35 to 76 years). They had undergone lobectomy (n = 11), bilobectomy (n = 1), wedge resection (n = 5), and unilateral bullectomy (n = 1), and were operated on for bronchogenic carcinoma (n = 15), bronchiectasis (n = 2), and bullous emphysema (n = 1).

In 16 of the 18 patients (89%), prolonged air leak was the only morbidity identified, and the single reason for hospital stay. In these cases, 6 days after the operation the valve system was applied, and the next day the patient was discharged. In the remaining 2 patients, hospital stay was prolonged until the ninth and thirteenth postoperative days, because of supraventricular arrhythmia and contralateral pneumonia, respectively. The valve system was applied on the sixth postoperative day, and the patients were then discharged with it. In all cases, there was a daily fluid leakage from the chest tube.

All patients were seen 3 days after discharge, and then once a week if fluid leakage was less than 300 mL during the first 3 days. This occurred in 15 patients. In 3 cases, fluid leakage was more than 300 mL, and the patients were seen twice a week, until reduction of leakage to under 300 mL every 3 to 4 days. The pleural drains were removed between 4 and 32 days after hospital discharge (mean 11.5 days). One patient is still being managed for an air fluid leak 28 days after operation. In 4 cases, the tube was removed the day after the first ambulatory visit. No patients in this series developed pneumonia, empyema, or subcutaneous emphysema during outpatient management. No patients developed a pneumothorax after removal of the device. All patients were satisfied, and managed and tolerated the system well.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Persistent parenchymal air leak is a frequent, but not severe complication following pulmonary operation. Rice and Kirby reported an incidence of 15.2% in a heterogeneous population [8], and Nagasaki and colleagues reported 1.8% [9]. Other authors reported an incidence of 23% in patients undergoing lung volume reduction procedures [1], 5% in resectional operation for bronchiectasis [10], 26% in right upper lobectomy [2]. Although most air leaks seal spontaneously with conservative management, prolonged air leaks result in an increase in length of postoperative hospital stay. The use of the Heimlich valve shortens the hospital stay, allowing outpatient management. Outpatient tube care is psychologically good for these patients, because it helps them to recover ambulation and independence and, in addition, is cost effective.

We have used the Heimlich valve for many years, but the main problem we observed was that, when a fluid leak is also present, it may cause dysfunction of the system, discomfort for the patient, and the need for close ambulatory follow-up. 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.

We point out the following advantages of our device with respect to other systems: the bag allows fluid drainage and collection. This makes the management of the system easier and more comfortable for the patient, and neither daily medications nor frequent changes of the valves are needed. The system is drier and cleaner. Moreover, the fluid leak, collected in the graduate and transparent bag, can be monitored; the whole system, though not completely sealed, is more sterile than the Heimlich valve. The air filter of the exhaust valve represents the only open part and it is provided with an antibacterial filter; it is possible to draw fluid in a sterile way; and it is possible to exert a gentle suction, to facilitate fluid drainage, by pressing the rubber tube.

There were two main problems: the collected fluid tends to exit from the exhaust valve, when the bag is kept upside down for a long time, so the patient needs to keep the system upright; and when the air leak is very large, the exhaust valve cannot evacuate the air rapidly. Pressure in the bag may impede the one-way valve, and limit air evacuation from the pleural cavity. In these cases the patient must compress the bag frequently.

In conclusion, this device is designed to enhance early mobility and discharge of patients undergoing pulmonary resection with prolonged air and fluid leak, while decreasing the need for costly hospital and outpatient care.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. McKenna R.J., Jr, Fischel R.J., Brenner M., Gelb A.F. Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Ann Thorac Surg 1996;61:1115-1117.[Abstract/Free Full Text]
  2. Abolhoda A., Liu D., Brooks A., Burt M. Prolonged air leak following radical upper lobectomy. Chest 1998;113:1507-1510.[Abstract/Free Full Text]
  3. Monami H., Saka H., Senda K., et al. Small caliber catheter drainage for spontaneous pneumothorax. Am J Med Sci 1992;304:345-347.[Medline]
  4. Ponn R.B., Silvermann H.J., Federico J.A. Outpatient chest tube management. Ann Thorac Surg 1997;64:1437-1440.[Abstract/Free Full Text]
  5. O’Rourke J.P., Yee E.S. Civilian spontaneous pneumothorax. Chest 1989;96:1302-1306.[Abstract/Free Full Text]
  6. Crocker H.L., Ruffin R.E. Patient-induced complications of a Heimlich flutter valve. Chest 1998;113:838-839.[Abstract/Free Full Text]
  7. Mariani P.J., Sharma S. Iatrogenic tension pneumothorax complicating outpatient Heimlich valve chest drainage. J Emerg Med 1994;12:477-479.[Medline]
  8. Rice T.W., Kirby T.J. Prolonged air leak. Chest Surg Clin North Am 1992;2:803-811.
  9. Nagasaki F., Flehinger B.J., Martini N. Complications of surgery in the treatment of carcinoma of the lung. Chest 1982;82:25-29.[Abstract/Free Full Text]
  10. Ashour M., Al-Kattan K.M., Jain S.K., et al. Surgery for unilateral bronchiectasis. Tuber Lung Dis 1996;77:168-172.[Medline]
Accepted for publication October 7, 1999.


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This Article
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