Ambulatory chest drain / pneumothorax device

A patient sent home with a small chest device for a pneumothorax comes back. Check the one-way valve and, above all, exclude a tension pneumothorax.

AdultAirwayGuideline

Also called: Pleural Vent, ambulatory pneumothorax device, Rocket Pleural Vent, one-way valve chest drain, ambulatory chest drain, Heimlich valve

What it is

A patient treated for a primary spontaneous pneumothorax may be managed as an outpatient with a small-bore device carrying a one-way valve, rather than being admitted with a conventional underwater-seal drain. The device lets air out of the pleural space and not back in, and the patient goes home and is reviewed.

The device trialled in the UK RAMPP study was the Rocket Pleural Vent; as a review of that trial describes, patients were randomised on a 1:1 basis to either ambulatory care with a Rocket Pleural Vent or standard care. Patients return to the ED when the device fails, dislodges, fills, or when the pneumothorax is not resolving.

How to recognise it

A small device fixed to the chest wall with a one-way (flutter) valve and sometimes a small collection chamber, in a patient recently seen for a spontaneous pneumothorax.
Discharge paperwork for ambulatory pneumothorax management and a planned review date.
The patient reports increasing breathlessness, the device bubbling or filling, surgical emphysema, or the device having come loose.

What it gets confused with

Two look-alikes that are managed differently. A conventional intercostal drain with an underwater seal (a bottle that bubbles/swings) is a bigger drain on an admitted patient. A tunnelled indwelling pleural catheter (IPC - e.g. PleurX), used for recurrent malignant or other effusions, drains fluid, not a pneumothorax - the 'never clamp / watch for tension' logic here does not apply to it in the same way. Confirm which device you are looking at, and why it was placed, before acting.

What goes wrong

Tension pneumothorax

Rapidly worsening breathlessness, hypoxia, haemodynamic compromise, tracheal deviation - air trapped under pressure because the valve or device has failed to vent.

Red flag
This is the emergency that overrides everything else. A patient still venting through a one-way device can tension if that device blocks or fails, which is why ambulatory patients need clear safety-netting and prompt review. Tension is the complication that kills: decompress it clinically, and do not wait for imaging.

Device blockage or valve failure

The pneumothorax is not resolving, or is enlarging, with a device that is no longer venting - blocked, kinked or a failed valve.

Red flag
A device that has stopped working on an unresolved pneumothorax can progress to tension. Reassess the patient and the device together.

Dislodgement or malposition

The device has pulled out or moved; there may be an air leak at the skin, surgical emphysema, or loss of function.

Red flag
A dislodged device on an unresolved pneumothorax leaves the patient without a vent. Treat the pneumothorax on its merits and get the pleural/respiratory team.

Surgical emphysema or site problems

Crackling air under the skin around the device, pain, bleeding or infection at the insertion site.

Red flag
Expanding surgical emphysema can signal an ongoing leak with inadequate drainage - assess for an underlying tension or a non-functioning device.

The first ten minutes

Exclude a tension pneumothorax first. If the patient is compromised with signs of tension, decompress clinically without waiting for a chest X-ray.
Assess the device and the patient together: is the valve venting, is it blocked, kinked, dislodged or full, and is the pneumothorax resolving, static or enlarging?
Give oxygen titrated to target - high-concentration aiming 94-98% for a hypoxic patient, or 88-92% if they are at risk of hypercapnia - and treat symptomatically while you reassess.
Image once the patient is stable to size the pneumothorax and check device position, and compare with the films from their initial presentation.
Involve the pleural / respiratory team, who own the ambulatory pathway and decide whether to re-site, convert to a formal drain, admit or continue ambulatory care.

Do not

Do not clamp the device.

Clamping a one-way valve on a pneumothorax that is still leaking air can convert a simple pneumothorax into a tension pneumothorax. Leave it open and venting.

Do not treat the device as the diagnosis.

The question is the pneumothorax - resolving, static or tensioning - and the device is only one input. A reassuring-looking device on a deteriorating patient does not exclude tension.

Do not delay decompression for imaging in a compromised patient.

Tension pneumothorax is a clinical diagnosis and an immediate threat to life, and a patient still venting through a one-way device can tension if that device fails. Decompress on clinical grounds rather than waiting for a film.

Do not re-site or remove the device as a reflex.

Re-siting, conversion to a formal drain or removal are pleural-team decisions once tension is excluded. Your job is to stabilise and refer.

Who owns it

The pleural / respiratory team (or the service that set up the ambulatory pathway) owns the device and the decision on what happens next; ED and critical care own an acute tension. Tell them the device type, how it is behaving, the size and trend of the pneumothorax, and the date of initial presentation.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first: Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established: Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours: Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought: Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud: The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it: Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways: The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

NTSP manual — Red flags · read in full

What the patient will be carrying

The patient should have discharge paperwork for ambulatory pneumothorax management with a review date and advice on when to return. Ask for it - it names the device and the responsible team.

Scope of this page

This page covers the patient who returns with an in-situ ambulatory pneumothorax device: exclude tension, assess whether the device is venting, stabilise, image and refer. It does not teach insertion of the device or formal chest-drain procedures (those are in the ED Procedures tool), nor the selection criteria for who is suitable for ambulatory management in the first place.