ACS: No pull-out pneumothorax with ‘party balloon Valsalva’




CHICAGO – Investigators have come up with a simple way to reduce and maybe even eliminate pull-out pneumothoraces during chest tube removal.

Instead of standard inhale or exhale Valsalva maneuvers, they have their patients blow up a party balloon as the tube is pulled.

Courtesy Dr. Puwadon Thitivaraporn

That produces the same Valsalva effects as the standard maneuvers, but with two significant advantages. First, it’s easy to explain and for patients to understand and do – not much more instruction is required than “blow up the balloon” – and, secondly, the inflating balloon is a visual check to make sure patients are doing the maneuver correctly. “It’s easy. Everyone can do it,” said lead investigator Dr. Puwadon Thitivaraporn, who developed the technique with Dr. Kritaya Kritayakirana and colleagues at King Chulalongkorn Memorial Hospital in Bangkok, Thailand.

To see how well it works, the team randomized 10 women and 38 men about equally to four removal techniques: the standard expire Valsalva, the standard inspire Valsalva, and two balloon maneuvers – blowing the balloon up after a deep breath and blowing it up with residual lung volume after an initial exhalation.

The subjects were trauma patients 15-64 years old, with a mean age of 38 years. Lung injuries, rib fractures, and tube suction were a bit more common in the standard maneuver groups. Patients with tracheotomies, chronic lung disease, and Glasgow Coma Scores below 13 were excluded from the study. Hemopneumothorax was the most common indication for tube placement.

Dr. Puwadon Thitivaraporn

Dr. Puwadon Thitivaraporn

Two patients in each of the standard groups (16%) developed a pull-out pneumothorax within 24 hours of tube removal, confirmed by x-ray. One required chest tube reinsertion, and all four ended up spending extra time in the hospital. Similar problems have been reported in American medicine (J Trauma. 2001 Apr;50[4]:674-7).

Meanwhile, not a single balloon patient had a lung collapse when their tube was pulled.

Because of the small number of subjects, the differences weren’t statistically significant, but they came close in a group comparison of standard patients with balloon patients (P = .11). The investigators estimated they would need almost 600 hundred subjects to reach statistical significance.

Even so, the party balloon technique appears to be “easier and safer” than standard maneuvers, as well as “reproducible and cheap, and it can prevent recurrent pneumothorax. It can be used as an alternative to the classic Valsalva,” said Dr. Thitivaraporn, a cardiothoracic surgery resident at the Bangkok hospital.

The balloon method is being used there now in nontrauma patients, as well, but the standard maneuvers are also being used until the balloon technique shows statistically significant benefits, he said.

With manometry, the team found that a party balloon’s internal pressure builds quickly as it’s inflated from a starting diameter of about 4.5 cm to about 9 cm, peaking at about 60 mm Hg; pressure trails off to about 40 mm Hg as inflation continues past 9 cm.

The investigators have no relevant disclosures.

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