Effect of Heimlich valve and underwater seal on lung expansion after pulmonary resection

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1 IJTCVS Bar et al 183 Original article Effect of Heimlich valve and underwater seal on lung expansion after pulmonary resection Ilan Bar 1, MD, Michael Papiashvilli 1, MD, Boris Kurtzer 2, MD, Murat Bahar 2, MD 1 General Thoracic Surgery Unit and 2 Department of Anesthesiology, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Abstract Background: A study was undertaken to compare the physiologic and clinical effects of Under Water Seal (UWS) versus Heimlich Valve (HV) pleural drainage systems in the treatment of patients following pulmonary resection. Methods: Twenty patients post pulmonary resection (lobectomy - 13, wedge resections 6, bullectomy - 1) were studied. The relative intrapleural pressures were measured by a flow meter that was subsequently connected to a UWS and to an HV through straight and curved chest tubes. The quantity of the air leak, if present, was also gauged by a flow meter, and the degree of lung expansion was recorded by chest radiography. Results: At resting tidal volume the relative intrapleural pressures measured when using an HV were more negative than those measured when using a UWS. The differences between end-inspiratory and endexpiratory relative intrapleural pressures were greater with a UWS than with an HV. The forced endexpiratory pressures were higher with an HV than a UWS. Conclusions: The HV maintains more negative intrapleural pressure than a UWS, promotes more effective removal of excess air from the pleural space and ensures more complete expansion of the lung. The HV is superior to a UWS in physiologic postoperative conditions, and may also be preferable in the management of patients with an air leak and residual spaces. (Ind J Thorac Cardiovasc Surg 2009; 25: ) Key words: Lung, Chest, Surgery Introduction Underwater seal (UWS) drainage systems maintain a one-way flow of fluid and air and are widely used in the management of patients after pulmonary resection. The drawbacks of UWS systems are the dead air space within the separate collection bottles and tubes and the limits of gravity. Flutter valves are one-way valves with a vented outlet that allow air and fluid to escape from, but not enter, the pleural cavity; and have been favorably used in the treatment of patients following Lung Volume Reduction (LVR) surgery 1. A comparison Address for correspondence: Dr. Ilan Bar Head, General Thoracic Surgery Unit, Assaf Harofeh Medical Center, Zerifin 70300, Israel Ph: ; Fax: fredricag@asaf.health.gov.il IJTCVS /76 OA of drainage bags [a Heimlich Valve (HV) connected to a drainage bag] or other flutter valve devices with UWS drainage systems found flutter valves to be safe and effective, permitting early mobility 2,3. McKenna et al 1 hypothesized that the air leaks were treated faster by flutter valves. Later, Waller et al 4 found that flutter valves maintain more negative intrapleural pressure than UWS drainage systems and are useful in the treatment of a postoperative air leak in the presence of an expanded lung. Moreover, Cerfolio et al 5 recommended discharging selected patients with a persistent air leak after pulmonary resection with an HV. In our study, we measured and compared the Relative Intrapleural Pressures (RIPPs) when using UWS and HV drainage systems in patients after lung surgery in order to investigate the superiority of HVs compared to UWSs in physiologic postsurgical conditions. Received - 02/07/09; Review Completed - 03/11/09; Accepted - 09/11/ /18/2009, 4:10 PM

2 184 Bar et al IJTCVS Heimlich valve and underwater seal 2009; 25: Materials and Methods Institutional Review Board approval was not obtained, but individual consent was obtained. Twenty (20) patients who underwent pulmonary resection (14 right, six left) during the period were studied. Mean age was 60.2 years (range 24 to 79); 13 patients were post lobectomy, six post wedge resection and one post bullectomy. The underlying reasons for surgery were lung cancer in 13 cases, lung metastasis in three, benign lung lesions in three, and lung bulla in one. There were 18 men and two women. All patients were breathing spontaneously after surgery. Two chest drainage tubes (a straight one located at the apex of the chest cavity, and a curved one located at the diaphragm) were inserted in 16 patients (after lobectomy, bullectomy and more extended wedge resections) and only one straight drainage tube in four patients (after less extended wedge resections). The chest tubes were connected to a UWS drainage system and were not attached to a suction pump. Forty-eight hours postoperatively (after significant reduction of pleural excretions) the upper and lower RIPPs were gauged by a flow meter connected to a UWS through the straight and curved chest tubes (in the four patients with one straight tube, only upper RIPPs were measured). Thereafter, the chest tubes were reconnected to HVs and new measurements were taken in the same manner. After measurements, the chest drainage tubes were reconnected from HVs to the UWS. All the procedures were performed under sterile conditions. The following measurements were recorded: RIPP differences at resting Tidal Volume (TV) when using a UWS and an HV (Figs. 1-4); and forced expiratory pressures when using a UWS and an HV (Tables 1 and 2). Χ Fig. 2. 1st measurement (48 h postoperatively). RIPPs (mm Hg) measured through curved chest tubes when using a UWS and an HV in 16 patients. Fig. 3. 2nd measurement (96 h postoperatively). RIPPs (mm Hg) measured through straight chest tubes when using a UWS and an HV in nine patients. Fig. 1. 1st measurement (48 h postoperatively). RIPPs (mm Hg) measured through straight chest tubes when using a UWS and an HV in 20 patients. Fig. 4. 2nd measurement (96 h postoperatively). RIPPs (mm Hg) measured through curved chest tubes when using a UWS and an HV in seven patients. 184

3 IJTCVS Bar et al 185 Table 1. Differences between the two systems on the first measurement Measurements No of Cell Standard p value patients means deviation (straight chest tube) (straight chest tube) (curved chest tube) (curved chest tube) (straight chest tube) <0.001 (straight chest tube) (curved chest tube) <0.001 (curved chest tube) : relative intrapleural pressure measured when using a Heimlich valve, IPP/UWS: relative intrapleural pressure measured when using an underwater sea, : forcedexpiratory pressure measured when using a Heimlich valve, : forced-expiratory pressure measured when using an underwater seal Flow Meter The flow meter (Wright respirometer, UK) (an expiratory flow meter) consists of two scales: the outer scale is divided into 10 ml volumes and the inner one measures volume by liters 6. A net metal reservoir, which serves the function of absorbing the humidity or fluids that are present in the pleural drains, is connected to the flow meter by a silastic tube. A second silastic tube connects the flow meter during measurements to the suction port of the UWS or to the air port of the HV (Figs. 5 and 6). The flow meter facilitates the detection of pleural air leaks that are more than 10ml/breath (outer scale). The air leak and RIPPs can be measured during normal breathing, deep breathing or coughing and the total quantity of the leak can be measured in litres/min (inner scale). Table 2. Differences between the two systems on the second measurement Measurements No of Cell Standard p value patients means deviation (straight chest tube) (straight chest tube) (curved chest tube) (curved chest tube) (straight chest tube) <0.001 (straight chest tube) (curved chest tube) <0.001 (curved chest tube) ; relative intrapleural pressure measured when using a Heimlich valve, RIPP/ UWS: relative intrapleural pressure measured when using an underwater seal, : forced-expiratory pressure measured when using a Heimlich valve, : forcedexpiratory pressure measured when using an underwater seal The quantity of the air leak (L/min), if present was also gauged. The measurements were carried out 48 h postoperatively (20 patients) and repeated 96 h postoperatively (nine patients). Patients with an air leak 96 h postoperatively were connected to HVs (four patients). A Chest X-ray was obtained every two days postoperatively for documentation of the degree of lung expansion. The patient was discharged after removal of the chest tubes (16 patients) or with HVs (four patients). All 20 patients were followed up 3, 6 and 12 months postoperatively. Fig. 5. Flow meter connected to the suction port of the underwater seal. 185

4 186 Bar et al IJTCVS Heimlich valve and underwater seal 2009; 25: Fig. 6. Flow meter connected to the air port of the Heimlich valve. Statistical Analysis Data were analyzed using BioMeDical Package (BMDP) Statistical Software 7. We used analysis of variance with repeated measures to determine significant differences between the two methods (UWS and HV). A p-value of <0.05 was considered significant. Results At the time of the first measurement (48 h after surgery), in the 20 patients studied, the RIPP differences measured through the straight chest tube at resting TV when using a UWS were higher than those measured when using an HV (p=0.027) (Fig. 1, Table 1). The same measurements through the curved chest tubes (in 16 patients) did not reveal any statistical significance (p=0.43) (Fig. 2, Table 1). The Forced-Expiratory Pressure (FEXP) measured through an HV was significantly higher than FEXP measured through a UWS with both straight chest tubes in 20 patients (p<0.001) and curved chest tubes in 16 patients (p<0.001) (Table 1). After the first measurement (48 h postoperatively), 11 patients had full lung expansion on chest radiography, no air leak and the chest tubes were removed after reduction of pleural secretions, 3-6 days postoperatively (mean 5.4 days). Of the nine remaining patients, three had an air leak and six had different sized residual spaces without a leak: these patients underwent a second measurement 96 h postoperatively. Similar results were found: higher RIPPS with a UWS than with an HV when using straight chest tubes (nine patients) (p=0.07) (Fig. 3, Table2), but without any statistical significance with curved chest tubes (seven patients) (p=0.27) (Fig. 4, Table 2); significantly higher FEXP with an HV than with a UWS when using straight chest tubes (nine patients) (p<0.001) and curved chest tubes (seven patients) (p<0.001) (Table 2). After the second measurement (96 h postoperatively), five out of nine patients showed re-expansion of the lungs on chest radiography with resolution of the air leak and were discharged 6-8 day postoperatively after removal of the chest tubes (mean 7.4 days). The final four patients with an air leak and residual spaces were connected to an HV and discharged, with subsequent resolution of the air leak during the following 3-7 days, reduction or obliteration of the residual spaces and removal of the chest drains. The quantity of the air leak was gauged by a flow meter through the HV and UWS during every measurement, but was detected generally on HV ( L/min after the first measurement; L/min after the second measurement). Discussion At the end of normal expiration there is still a volume of air in the lungs called the Functional Residual Capacity (FRC). At FRC, the inward elastic force of the lung is balanced by the outward elastic force of the chest wall so that the relaxation pressure is zero or atmospheric. When the lung is inflated above FRC, the force of the lung tending to empty it is greater than that of chest wall tending to fill it, and the relaxation pressure is positive. At lung volumes below FRC, the pull of the chest wall in an inspiratory direction is greater than the pull of the lungs in an expiratory direction and so the relaxation pressure is negative 8. At the end of both expirium and inspirium there is no air flow, at which point the pleural pressure is equal to the elastic pressure of the lungs. Supported by this fact, we measured the pressures at resting TV, because they are most similar to pleural pressure. However, because of the existence of some threshold resistance to air flow produced by the HV and water in the UWS drainage systems, we believe that the pressures gauged by a flow meter are relative and a little lower than normal intrapleural pressures (less positive on end expirium and less negative on end inspirium). We refer to these as RIPPs. The differences between endexpiratory and end-inspiratory RIPPs at resting tidal volume demonstrate the possible physiologic advantages of an HV over a UWS systems in normal conditions (pulmonary resection without complications), and possibly in pathologic conditions (air leak, pleural spaces). It is interesting that the RIPP differences were more negative with an HV than a UWS early postoperatively 186

5 IJTCVS Bar et al 187 (Figs. 1 and 2) and continued to equalization later, but remained more negative with HVs (Figs. 3 and 4). These findings in our opinion describe the physiologic process of postoperative lung expansion with HVs, which promote breathing with nearly equal end inspiratory and end expiratory pressures and more negative pleural pressures, which together are two significant components for lung expansion. The data showing that FEXP when using a HV is higher than when using a UWS (Tables 1 and 2) suggests that the escape of excess air from the pleural space during breathing is more efficient with an HV than a UWS. This finding, together with the minimal dead space of an HV compared to a UWS, may contribute to more effective lung expansion with an HV, especially in cases of an air leak or residual spaces. The equalization of RIPPs on the subsequent measurements (Figs. 1-4) demonstrates lung expansion and residual space obliteration. The smaller changes in pressures measured through the curved chest tubes (Figs. 2 and 4) compared to the straight chest tubes (Figs. 1 and 3) may suggest more effective lung expansion of the lungs in the lower part of the thoracic cavity. The fact that the leak is usually detectable only when using an HV is also suggestive of more effective lung expansion. In conclusion, all the above data regarding the physiological changes observed during measurements of RIPPs when using UWS and HV drainage systems may suggest some advantages of the HV system over the UWS system. These advantages comprise breathing with more negative pressures, more effective escape of excess air, and reduction of RIPPs, all of which in our opinion may facilitate lung expansion not only in physiologic postoperative conditions, but also in cases of air leaks and residual spaces References 1. McKenna RJ Jr, Fischel RJ, Brenner M, Gelb AF. Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Ann Thorac Surg 1996; 61: Graham AN, Cosgrove AP, Gibbons JR, McGuigan JA. Randomised clinical trial of chest drainage systems. Thorax 1992; 47: Lodi R, Stefani A. A new portable chest drainage device. Ann Thorac Surg 2000; 69: Waller DA, Edwards JG, Rajesh PB. A physiological comparison of flutter valve drainage bags and underwater seal systems for postoperative air leaks. Thorax 1999; 54: Cerfolio RJ, Bass CS, Pask AH, Katholi CR. Predictors and treatment of persistent air leaks. Ann Thorac Surg 2002; 73: Bar I, Friedman T, Kurtzer B, Bahar M. Accuracy in air leak measuring. Isr Med Assoc J 2004; 6: Dixon WJ, editor. BMDP statistical software. Los Angeles LA: University of California Press, Cherniak RM. Pulmonary mechanics. In: Cherniak RM, editor. Pulmonary function testing. Philadelphia: W.B. Saunders Company, p , /18/2009, 4:12 PM

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