VENTED OR NON-VENTED CHEST SEALS? Who cares, just get it done!

VENTED OR NON-VENTED CHEST SEALS? 

Who cares, just get it done.


By Jonathan Willis

    
   Tension pneumothorax is the number two leading cause of treatable traumatic death in the United States. Aside from needle decompression, which is generally unadvised for the layperson, the simple chest seal is the best tool at our disposal to prevent this life threatening condition. As an instructor of emergency response to trauma/medical incidents I get asked a lot of questions about what folks might choose to add to their kit. Specific to the topic of chest seals, I get asked often about vented versus non-vented, and even improvised solutions. In my Real World Trauma course I make it a point to make every student understand the exact pathophysiology of pneumothorax, tension pneumothorax, and management of respiratory trauma. People are often surprised when I tell them, "I don't care what kind of chest seal you use, just get it done."



    That may sound flippant at first, but, if you truly understand the injury patterns, the treatment, and the physiology, it's just not that big of deal in our domestic world of work. For example, most people taking up the mantle of trauma management nowadays are doing it from a background of regurgitating material absorbed from a two day course they spent a few hundred dollars for. (Please stop the TCCC LARP.) For some of us, chest seals and tension pneumothorax management were a need LONG before it came en vogue. Firefighter/Paramedics across the country were carrying tourniquets years before their protocols allowed for or provided them, and they "acquired" expired defibrillation pads to use as chest seals, before fancier versions hit the mainstream. A friend and well respected trauma doc and educator told me of an experience as a young Paramedic where an individual had been blasted with 00 buck. He noted the 9, 32 cal holes in dude's chest and proceeded to place 9 small EKG electrodes over each of the holes. Are they vented? No. Are they "chest seals?" Hell yes they are. Does it matter from a clinical standpoint? I HIGHLY doubt it. Trauma IS grey, and you must be prepared to pivot and manage the patient. 

    As it pertains to respiratory trauma management, we've tried to reduce its management to the lowest common denominator. "Seal the box" is often use to help people remember what they are to do as one of the highest immediate priorities of trauma management after massive hemorrhage. This is good, but we should strive for a higher level of understanding. If you think taking a "set it and forget it" approach to chest seals because you've opted for a specific vented model, this article will likely open your eye to the flaw in that thought process. Beyond that, let's discuss why it simply does not matter what chest seal you choose. The ONLY things that matter is getting a chest seal placed, and monitoring your patient. Now, let's get nerdy. 

    Our common indications for the application of a chest seal is any open insult to the chest anterior, posterior, or lateral chest wall. Simply put, anywhere there's ribs (generally from below the neck to above the belly button to cover your bases) if you see a hole, put a seal on it. Generally speaking, a hole needs to have a total open size greater than a nickel to become what's known as a "sucking chest wound." Cover that too. Certain guidelines state that if you use a NON-vented chest seal that after application you should monitor you patient for subsequent development of tension pneumothorax. This article is going to explain in detail why that verbiage, for the everyday layperson especially, should be completely ignored. It should read as follows; "Following the application of ANY chest seal (vented or non) monitor the patient for subsequent development of tension pneumothorax." I will share with you the alarming failure rates of vented chest seals presently on the market, and the techniques to make the potential failures a non-issue. Moreover, we'll discuss further why vented chest seals in the domestic context, simply don't matter. 

     So as to not make generalizations about chest seal performance, we must recognize the two types of chest seals presently available on the market. Most people simply think vented and non-vented and leave it at that. Sorry, but it's not that simple. There are two types of vented chest seal; One Way Valve and Laminar-Channel. Laminar-Channel chest seals test most effective at remaining functional in both pneumothorax and hemopnuemothorax conditions. Some popular one way valve style vented chest seals  have performance efficacy int hemopnuemothorax studies between ZERO and 25%, due to clogging and detachment. The Laminar-Channel Hyfin still only performed at 67% efficacy in the same study. This should clarify that vented chest seals are absolutely NOT a sure thing. 


               


    We talk a great deal aboutpneumothorax, but very rarely does anyone mention HEMOpnuemothorax. Both are big, one is bigger. Across trauma literature, hemothorax accompanies pneumothorax in 25%-50% of trauma cases. This number is higher in penetrating trauma. Trauma registry reviews that include chest tube output data show meaningful blood in the pleural space in greater that 50% of penetrating chest trauma. Blunt trauma still showed between 20% and 30%. This is a significant amount of blood presence, hemothorax, that yields a high probability of clogging your vented chest seal. 

    This is a really nerdy way to provide a clinical background to "Who gives a shit what chest seal you choose?" If someone is overly adamant about this that or the other brand, they are likely unaware of these realities of chest trauma. Less aware of actual performance of common market available chest seals. 

    Remember this. If apply ANY chest seal to a chest wound, monitor your patient for development of tension pneumothorax. Those signs include; Rapid breathing and heart rate, decrease air movement/chest expansion on the effected side, increased "work of breathing", subcutaneous emphysema, just to name a few. The oft thrown out trachea deviation and jugular venous distention are indeed clear signs of tension pneumothorax, but these are later occurring indicators, not to be waited for or relied upon for diagnosis. 


                                         


    These clinical and product realities are why I was comfortable using the Beacon non-vented chest seal in my RWT POCKET KIT. This allowed me to reduce the space required for this important tool AND it can be pressed into use as an occlusive dressing for a neck wound or other such injury. In larger kits I use Hyfin vented chest seals. Not because they're vented, but because they come in a cost effective two pack. I'm just as happy with a big, plain, ventless HALO if the kit allows for it because it just doesn't matter. 

    I hope this helps someone, in some small way, have a better understanding of the how's and why's of chest seals in relation to the tension pneumothorax/hemothorax injury pattern. Please prioritize trauma/medical training in your efforts, as this is THE highest probability emergency event in all of our lives. Join me for any of my offerings of Real World Trauma throughout 2026. I also HIGHLY recommend joining my friend Greg Ellifritz for his expert offerings on the topic, as well as the wonder assembly of experts over at Tactical Anatomy Summit. 

    

      

      

   

    

    

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