Chest tube: assisting insertion, the drainage system and care

What it is

A chest tube is placed in the pleural space to remove air (pneumothorax), blood (haemothorax) or fluid, so the lung can re-expand. It connects to a closed drainage unit with three parts: the collection chamber, which holds the drainage; the water seal, which works as a one-way valve; and the suction control, wet (a column of water) or dry (a dial). The nurse helps at insertion and removal, checks the patient and the system on every round, and must recognise what is expected and what is an emergency.

Indications

• Pneumothorax: air in the pleural space.
• Haemothorax: blood in the pleural space, for example after trauma.
• Pleural effusion or empyema that needs drainage.
• After heart or chest surgery.

Contraindications and precautions

• Before insertion, check allergies (latex, antiseptics) and bleeding risk: anticoagulants and the clotting tests in the record.
• Do not strip the tubing: the very high pressure can injure the lung.
• Clamp only when the institutional policy allows (changing the unit, finding a leak, on order before removal) and only briefly.
• Avoid kinks and dependent loops in the tubing: they block drainage.
• Never lift the unit above the chest: fluid can flow back into the pleura.
• For transport, disconnect the suction instead of clamping, unless the order says otherwise.

Equipment

• Chest drainage unit and sterile water to fill the water seal (and a wet suction chamber) to the marks.
• Suction source and tubing, if suction is ordered.
• Sterile insertion tray, gown and gloves, antiseptic, the local anaesthetic the doctor orders, and a dressing.
• At the bedside: two clamps, a bottle of sterile water, petrolatum gauze, sterile gauze and tape.
• Pulse oximeter and vital-sign equipment.

Step by step (and why)

1. Before insertion: consent, identity, time-out, vital signs, saturation, breathing and pain — a baseline to compare with.
2. Fill the water seal to the 2 cm mark and set suction as ordered (often -20 cm H2O) — the water seal is a one-way valve.
3. Position the patient as the doctor asks and keep the field sterile; support the patient — less movement and contamination.
4. After insertion: check the dressing and connections, and that a chest X-ray confirmed placement — position is verified first.
5. Each round: breathing, breath sounds, saturation, pain, dressing and skin for crackling — early signs of a leak or tension.
6. Check the unit: upright, below the chest, no loops, tidaling and bubbling pattern — each finding shows if the system works.
7. Mark the drainage level with date and time, and note colour and amount — the trend shows bleeding or blockage.
8. Encourage sitting up, splinted coughing, deep breaths, the spirometer and walking as ordered — helps the lung re-expand.
9. Removal: prescribed pain relief first, coach the breath-hold, occlusive dressing, then close checks — keeps air out.

Complications

• Air leak: continuous bubbling in the water seal. Check the connections; with a brief clamp at the dressing, if the bubbling stops the leak is at the site or in the chest.
• Tension pneumothorax: sudden breathlessness, low saturation, falling blood pressure, fast heart rate and tracheal deviation.
• Subcutaneous emphysema (crackling under the skin): mark its edges and report it if new or spreading.
• Bleeding: a sudden, large increase in bright red drainage.
• Blockage by clots, infection at the site and pain.

Next step: when to call for help

• If the tubing disconnects: put the end of the tube in sterile water (temporary water seal) or clamp it briefly near the chest as the policy says, call for help and replace the system.
• If the tube comes out: cover the site at once with a sterile occlusive dressing taped on three sides, stay with the patient and call; rapid response if there is distress.
• Call at once for breathlessness, saturation below 90%, chest pain, tracheal deviation, absent breath sounds or new subcutaneous emphysema.
• Call for cloudy drainage, drainage that stops suddenly in the first day, a sudden increase in bright red drainage, or continuous bubbling you cannot correct.
• After removal, check vital signs and breathing often in the first hour and watch the dressing.

Test yourself

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Advanced Skills, 6.3: Nursing Responsibilities for Clients With Chest Tube Drainage Systems (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Nursing Advanced Skills, 6.4: Troubleshooting Problems and Complications (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Nursing Advanced Skills, 6.7: Assisting With Chest Tube Placement (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Nursing Advanced Skills, 6.8: Assisting With Chest Tube Removal (Open RN (Chippewa Valley Technical College), LibreTexts, 2023).

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