Heimlich Valve for Chronic Pneumothorax Management

Primary Recommendation

The American College of Chest Physicians recommends a Heimlich valve attached to a small-bore chest tube (10-14F) as an acceptable alternative to traditional water seal systems for stable patients with chronic pneumothorax requiring prolonged drainage, enabling outpatient management 1, 2

The British Thoracic Society suggests Heimlich valves work best for stable patients with primary spontaneous pneumothorax without large air leaks 1, 2
Unstable patients or those with large air leaks requiring mechanical ventilation should avoid Heimlich valves and instead use larger bore tubes (24F-28F) with water seal and suction 1

The British Thoracic Society recommends using small-bore chest tubes (10-14F) or catheter-over-guidewire systems (Seldinger technique) connected to the Heimlich valve 2
Recent technical developments allow Heimlich valves to be attached to tubes ranging from 7F to larger bore sizes 2

If the pneumothorax fails to resolve or air leak persists beyond 48 hours, referral to a respiratory physician for consideration of suction, repositioning, or surgical intervention is recommended 2

Switch from Heimlich valve to water seal with suction if lung fails to re-expand after 48 hours or persistent air leak beyond 48 hours 1, 2
Consider surgical intervention (thoracoscopy with bullectomy and pleurodesis) if air leak persists beyond 4 days, as chronic pneumothorax carries significant morbidity risk 1

The American College of Chest Physicians notes "good consensus" but still considers water seal devices the better option for most hospitalized patients 1
The British Thoracic Society acknowledges Heimlich valves are gaining popularity and may replace simple aspiration in certain scenarios 3, 4

The British Thoracic Society guidelines note that catheter aspiration kits with integral one-way valve systems, such as the Heimlich valve, may reduce the need for repeat aspiration in patients with primary spontaneous pneumothorax 5, 6
When attached to small-bore catheters (8F) for catheter aspiration of pneumothorax (CASP), the addition of a Heimlich valve may improve success rates beyond simple aspiration alone, with success rates of 65.5% reported for outpatient management of primary spontaneous pneumothorax using small-bore (8F) chest drains with Heimlich valves 5, 6

Recent technical developments have allowed the addition of Heimlich flutter valves to both small tubes (7-14F) and larger bore tubes, expanding their utility across different pneumothorax scenarios, with small lumen Teflon catheters (2 mm) inserted over needle and guidewire achieving success in 27 of 28 patients with a mean drainage time of 48 hours 7, 8

Never clamp a chest tube with an active air leak (bubbling), whether connected to a Heimlich valve or underwater seal, as this can convert a simple pneumothorax into a life-threatening tension pneumothorax, according to guidelines from the British Thoracic Society and other medical organizations 9

Patients with COPD or those on positive pressure ventilation may require larger bore tubes (16F-28F) with traditional water seal systems, though Heimlich valves can be incorporated, as recommended by the American Thoracic Society and other guideline societies 10, 11