Overview

A chest tube evacuates air or fluid from the pleural space to restore negative intrapleural pressure and re-expand the lung. The drainage system has three chambers: collection (measures output), water-seal (a one-way valve that lets air exit but not re-enter), and suction control (regulates negative pressure, typically -20 cm H2O). Tidaling — the rise and fall of fluid in the water-seal chamber with respirations — is the normal, reassuring sign that the tube is patent and communicating with the pleural space.

Indications

pneumothorax

tension pneumothorax

pleural effusion

hemothorax

post-thoracotomy drainage

post-lobectomy drainage

During — Monitoring

Assess drainage color, amount, and rate every 1-2 hours post-insertion; timestamp the level on the collection chamber to trend output. Keep the entire system upright and below chest level at all times to maintain gravity drainage and prevent backflow. Do not routinely milk or strip the tubing — it generates dangerous negative intrapleural pressure.

Interpretation

Bubbling: which chamber are you watching?

Water-seal chamberSuction-control chamber

Intermittent bubblingNormal early — air leaving pleural spaceN/A

Continuous bubblingAir leak — abnormal, trace the systemNormal — confirms correct suction

Tidaling (fluid rises/falls with breathing)Normal — tube patentN/A

Water-seal chamber

Intermittent bubbling: Normal early — air leaving pleural space
Continuous bubbling: Air leak — abnormal, trace the system
Tidaling (fluid rises/falls with breathing): Normal — tube patent

Suction-control chamber

Intermittent bubbling: N/A
Continuous bubbling: Normal — confirms correct suction
Tidaling (fluid rises/falls with breathing): N/A

Technique

prepare drainage system before insertion

position client with arm raised

maintain sterile field during insertion

connect tube to drainage system immediately

verify placement post-insertion

premedicate for pain before removal

Valsalva maneuver during tube removal

prevents air entry into pleural space

apply petroleum gauze occlusive dressing after removal

After — Complications

tension pneumothorax

risk if tube clamped without order

air leak

tube obstruction from kink or clot

hemorrhage

pneumothorax recurrence after removal

Patient Teaching

do not clamp tube unless ordered

clamping can convert simple to tension pneumothorax

keep drainage system below chest level

report increasing dyspnea immediately

milking and stripping no longer routine

removal readiness: no air leak, minimal drainage, lung re-expansion on imaging, sustained expansion off suction

Report Nowescalate immediately

continuous bubbling in water-seal chamber

air leak — inspect all connections, notify provider

sudden cessation of drainage with absent tidaling

obstruction from kink or clot

bloody drainage exceeding 70-100 mL/hour> 70-100 mL/hr

possible hemorrhage

accidental tube disconnection

submerge tube end in sterile water; do NOT clamp

accidental tube dislodgement from site

cover with petroleum gauze taped on three sides (flutter valve)

new or worsening dyspnea with falling SpO2

Clinical Pearl

Water-seal chamber: tidaling is good, continuous bubbling is an air leak. Suction-control chamber: gentle continuous bubbling is correct. Know which chamber you are watching — and never clamp without an order.

Chest Tube Management

Overview

Indications

During — Monitoring

Interpretation

Technique

After — Complications

Patient Teaching

The water-seal chamber is bubbling continuously — is that expected or is the system broken? Your answer determines whether the patient's lung re-expands or collapses further.

Key Distinctions

Clinical Pearl

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