Chest Tube Nursing Guide 2026: Drainage Systems and Safe Care

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This article was created with AI assistance.

Contents: Indications Water-Seal Drainage System Nursing Assessment Troubleshooting Clamping Rules Removal Care NCLEX High-Yield

Indications for Chest Tube

Indication	What's Draining	Tube Placement
Pneumothorax	Air from pleural space	Anterior (2nd–3rd intercostal space, midclavicular line) or lateral (4th–5th ICS, anterior axillary line)
Hemothorax	Blood from pleural space	Lateral/posterior (5th–6th ICS, midaxillary line) — gravity-dependent
Hemopneumothorax	Blood + air	Lateral placement; drains both
Pleural effusion (large)	Fluid (transudate or exudate)	Lateral/posterior; may use small-bore pigtail catheter
Empyema	Infected fluid/pus from pleural space	Larger bore; may require thrombolytics through tube
Post-cardiac or thoracic surgery	Mediastinal blood + air	Mediastinal + pleural drains placed by surgeon

Water-Seal Drainage System (Pleur-evac/Atrium)

Three-Chamber System

Chamber	Function	Normal Finding
Collection chamber (right)	Collects fluid and blood draining from pleural space	Mark output hourly; normal: serous to serosanguineous; alert physician if >100 mL/hr or bright red blood suddenly increasing
Water seal chamber (middle)	One-way valve: allows air out of pleura, prevents air back in; filled with 2 cm of sterile water	Tidaling (fluctuation with respiration); intermittent bubbling if air leak present; no bubbling if lungs re-expanded
Suction control chamber (left)	Regulates suction; gentling bubbling = suction working; amount of water (not suction dial) controls suction level	Gentle continuous bubbling (not vigorous) = suction at correct level (-20 cm H2O typical); vigorous bubbling is unnecessary and wasteful

Key Observations

Tidaling: Water in the water-seal chamber rises with inspiration and falls with expiration (opposite in mechanically ventilated patients). Normal — shows the tube is patent and in the pleural space
Bubbling in water seal (intermittent): Air leak from the pleural space — expected in pneumothorax; should decrease as lung re-expands
Bubbling in water seal (continuous): May indicate large air leak or air entering system from a loose connection — assess connections first
Bubbling in suction control chamber: Normal — confirms suction is active; should be gentle, not vigorous
No tidaling + no drainage: May indicate tube obstruction (clot, kink, patient position) or lung fully re-expanded

Nursing Assessment

Every Shift / Every 1–2 Hours

Respiratory assessment: breath sounds bilateral, SpO2, RR, work of breathing
Insertion site: dressings intact, no crepitus (subcutaneous emphysema = air tracking into subcutaneous tissue), no sign of infection
Tubing: no dependent loops (fluid pools in loops → reduces drainage); tubing not kinked, clamped, or compressed under patient
Collection chamber: mark fluid level with time; note color (serous, serosanguineous, bloody); report sudden increase in bright red output
Water seal chamber: presence/absence of tidaling; presence/absence of bubbling; document
Suction control chamber: gentle bubbling (if on suction)
Connections: all connections taped or secured; no visible separation
Keep drainage system BELOW the level of the patient's chest at all times — gravity-dependent drainage

Subcutaneous Emphysema

Crackling sensation under the skin around the insertion site or spreading up the neck and face
Caused by air tracking into subcutaneous tissue, often from a poorly sealed insertion site or tube dislodgement
If rapidly spreading: notify physician immediately — can compromise airway if it reaches the neck

Troubleshooting

Problem	Likely Cause	Action
Sudden cessation of tidaling	Tube kinked, clotted, or lung fully re-expanded	Check tubing for kinks; reposition patient; assess breath sounds; notify provider if clinical concern
Continuous bubbling in water seal	Air leak — from lung, or from system (loose connection, dislodged tube)	Check all connections by momentarily clamping tube close to the patient — if bubbling stops, leak is in the system; if continues, leak is in the patient (lung)
Large sudden increase in drainage (>100 mL/hr bright red)	Active hemorrhage	Notify physician STAT; maintain large-bore IV access; type and crossmatch; patient may need surgery
Tube dislodges from chest	Accidental removal	Cover insertion site immediately with gloved hand or petroleum gauze (taped on 3 sides only — creates flutter valve); do NOT use airtight dressing (may cause tension pneumothorax); notify physician STAT; prepare for possible emergency reinsertion or chest x-ray
Drainage system falls and breaks	Accidental	Clamp tube CLOSE to patient immediately; replace with new drainage system ASAP; unclamp once new system connected

Chest Tube Clamping Rules

Never clamp a chest tube for routine transport or ambulation unless specifically ordered by the physician. Clamping a pneumothorax tube can cause a tension pneumothorax, which is rapidly fatal.

Situation	Clamp?	Rationale
Routine transport/patient movement	NO (unless ordered)	Tension pneumothorax risk if clamped with ongoing air leak
System disconnected/broken (emergency)	YES — briefly, while replacing system	Prevents air from entering pleural space; replace system immediately
Identifying air leak source	YES — at the insertion site to test (momentarily)	If bubbling stops, leak is in the system; if continues, leak is from the lung
Chest tube removal (per order)	YES — per physician order to test readiness	Clamp x 24h, then CXR; if no pneumothorax, remove tube

Chest Tube Removal Care

Pre-Removal

Confirm physician order and indication (lung re-expanded, drainage <150–200 mL/day, no air leak for 24h, no bubbling)
Gather: suture removal kit, petroleum gauze (Xeroform), 4x4 gauze, tape, gloves
Administer analgesic or anxiolytic 30–45 minutes before removal (procedure is painful)

During Removal

Position patient in semi-Fowler's or lateral (away from tube side)
Physician removes suture and withdraws tube quickly at end of exhalation (or during Valsalva) — patient instructed: "take a deep breath in, hold it / bear down"
Nurse simultaneously applies petroleum gauze and dry dressing quickly over site to create an airtight seal
Secure with tape on all sides

Post-Removal

CXR within 1–2 hours to confirm no pneumothorax
Respiratory assessment: breath sounds equal bilaterally, SpO2, RR, dyspnea?
Assess dressing: airtight, no air hissing through site
Document removal time, patient tolerance, dressing applied

NCLEX High-Yield Points

Tidaling = normal; shows tube patent and in pleural space; rises with inspiration (spontaneous breathing)
Intermittent bubbling in water seal = air leak from lung (expected in pneumothorax; should decrease)
Continuous bubbling in water seal = may indicate loose connection in system — check connections first
Suction control chamber: GENTLE bubbling = correct; vigorous = turn suction down
NEVER clamp a chest tube for routine transport (tension pneumothorax risk)
Tube falls out: cover with petroleum gauze taped on 3 SIDES (flutter valve, not airtight)
Tube removal: at end of exhalation or Valsalva; apply occlusive dressing immediately; CXR after
Keep drainage system BELOW patient's chest at all times — never lift it above chest level (reverse siphon)

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