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

doi:10.1016/0003-4975(96)00034-3

The Annals of Thoracic Surgery

Volume 61, Issue 4, April 1996, Pages 1115-1117

https://doi.org/10.1016/0003-4975(96)00034-3 Get rights and content

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.

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Back to the 60s: The Heimlich Valve A patient- and family-centered care perspective: Back to the 60s: the Heimlich Valve
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In this case report we present a 5-year old boy with a bronchopleural fistula with persistent air leak following complicated empyema. Treatment with antibiotics and pleural drainage did not stop the air leak and consequently prolonged drainage of the pleural cavity was needed. As this would account for weeks of hospitalization, we decided together with the parents, following the main principles of Patient-and-Family Centered Care, to treat the child at home with the use of a Heimlich valve. A Heimlich valve may be an old-fashioned, but effective one-way-valve permitting evacuation of air and fluid from the thoracic cavity without the need of high technology solutions and with minimal risk to the patient. This may prevent prolonged hospitalization, increase quality of life of the patient and save medical costs.
After 2 months the chest tube with Heimlich valve was successfully removed. Recovery was uneventful; long term follow up showed restricted lung function with a total lung capacity of around 78% and fibrotic changes of the right upper lobe on chest CT scan.
Relative incremental costs of complications of lobectomy for stage I non–small cell lung cancer
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To evaluate the relative incremental cost of complications after lobectomy for stage I non–small cell lung cancer (NSCLC).
Patients treated with open or video-assisted thoracoscopic surgery (VATS) lobectomy for stage I NSCLC between 2008 and 2014 were selected. A patient registry was queried for all complications recorded during a 90-day postoperative interval. Hospital cost data for each patient was concatenated with clinical data. Linear regression was used to assess the impact on direct hospital costs of specific complications.
Among the 488 patients included in this study, 34% experienced ≥1 complication and 17% experienced ≥1 major complication. In patients experiencing complications, atrial arrhythmia (13%), prolonged air leak (8.6%), atelectasis (6.4%), and transfusion requirement (4.5%) were most common. Minor complications increased the relative cost of lobectomy by 29% (95% confidence interval [CI], 23%-34%; P < .001) compared to the cost of an uncomplicated lobectomy. Major complications increased costs by 57% (95% CI, 53%-62%; P < .001). The greatest predictor of increased 90-day cost was major pulmonary complications, which increased cost by 111% (95% CI, 96%-126%; P < .001). Prolonged air leak increased relative mean cost by 22% (95% CI, 10%-33%; P < .001) and pneumonia by 96% (95% CI, 75%-117%; P < .001).
Complications, both major and minor, contribute significantly to the total 90-day direct hospital cost of lobectomy for stage I NSCLC. Analysis of 90-day postoperative outcomes more accurately captures costs. Major pulmonary complications, atrial arrhythmia, pneumonia, and prolonged air leak represent 4 high-yield targets for cost reduction. Efforts to control health care spending while improving patient outcomes might optimally focus on reducing complications that incur the greatest relative incremental cost.
Management of Persistent Air Leaks
2017, Chest
Alveolar-pleural fistulas causing persistent air leaks (PALs) are associated with prolonged hospital stays and high morbidity. Prior guidelines recommend surgical repair as the gold standard for treatment, albeit it is a solution with limited success. In patients who have recently undergone thoracic surgery or in whom surgery would be contraindicated based on the severity of illness, there has been a lack of treatment options. This review describes a brief history of treatment guidelines for PALs. In the past 20 years, newer and less invasive treatment options have been developed. Aside from supportive care, the literature includes anecdotal successful reports using fibrin sealants, ethanol injection, metal coils, and Watanabe spigots. More recently, larger studies have demonstrated success with chemical pleurodesis, autologous blood patch pleurodesis, and endobronchial valves. This manuscript describes these treatment options in detail, including postprocedural adverse events. Further research, including randomized controlled trials with comparison of these options, are needed, as is long-term follow-up for these interventions.
Outpatient air leak management after lobectomy: A CMS cost analysis
2016, Journal of Surgical Research
Citation Excerpt :
This shift may improve the capacity of an institution to manage high-acuity patients or to increase surgical volume. These advantages complement previous studies that have demonstrated the feasibility and safety of early discharge with PDS for air leak.16,18,24 Over the past decade, we have made additional adjustments to our clinical practice based on results from this assessment, increasing our comfort level with early discharge on postoperative day 2 or 3 in select patients with PDS for air leak.
Air leaks after lobectomy are associated with increased length of stay (LOS) and protracted resource utilization. Portable drainage systems (PDS) allow for outpatient management of air leaks in patients otherwise meeting discharge criteria. We evaluated the safety and cost efficiency of a protocol for outpatient management of air leaks with a PDS.
We retrospectively assessed patients who underwent lobectomy for non–small-cell lung cancer at our institution between 2004 and 2014. All patients discharged with a PDS for air leak were included in the analysis. The study group was compared to an internally matched cohort of patients undergoing lobectomy for non–small-cell lung cancer managed without the need for outpatient PDS. Study end points included resource utilization, postoperative complications, and readmission.
A total of 739 lobectomies were performed during the study period, 73 (10%) patients with air leaks were discharged with a PDS after fulfilling postoperative milestones. Shorter LOS was observed in the study group (3.88 ± 2.4 versus 5.68 ± 5.7 d, P = 0.014) without significant differences in 30-d readmission (11.7% versus 9.0%, P = 0.615). PDS-related complications occurred in 6.8% of study patients (5/73), and 2.7% (2/73) required overnight readmission. PDSs were used for 8.30 ± 4.5 outpatient days. A CMS-based cost analysis predicted an overall savings of $686.72/patient (4.9% of Medicare reimbursement for a major thoracic procedure), associated with significantly fewer hospital days and resources used.
In patients otherwise meeting discharge criteria, outpatient management of air leaks is safe and effective. This strategy is associated with improved efficiency of postoperative care and a modest reduction in hospital costs. This model may be applicable to other thoracic procedures associated with protracted LOS.
Evidence-Based Suggestions for Management of Air Leaks
2010, Thoracic Surgery Clinics
Postoperative Strategies to Treat Permanent Air Leaks
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: Supported in part by DOE grant DE-f603-91 ER61227, and National Institutes of Health grant R01192.

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The Annals of Thoracic Surgery

Background.

Methods.

Results.

Conclusions.

References (9)

Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease

J Thorac Cardiovasc Surg

A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema

J Thorac Cardiovasc Surg

Pneumothorax: a therapeutic update

Am J Surg

Heimlich valve treatment of Pneumocystis carinii-associated pneumothorax

Chest

Cited by (84)

Back to the 60s: The Heimlich Valve A patient- and family-centered care perspective: Back to the 60s: the Heimlich Valve

Relative incremental costs of complications of lobectomy for stage I non–small cell lung cancer

Management of Persistent Air Leaks

Outpatient air leak management after lobectomy: A CMS cost analysis

Evidence-Based Suggestions for Management of Air Leaks

Postoperative Strategies to Treat Permanent Air Leaks