Chest Tubes and Pneumothorax

How the drainage system works and what to do when something goes wrong

Respiratory

Collection chamber

Holds drainage. Mark the level and time each shift (or as ordered).

Report >100 mL/hour (or per order) or bright red drainage.

Water seal

One-way valve (~2 cm water). Tidaling (rise and fall with breathing) is normal.

Continuous bubbling = air leak. Intermittent bubbling on exhale/cough can be expected with a pneumothorax.

Suction control

Wet: gentle continuous bubbling (vigorous bubbling only evaporates water). Dry: dial set (often −20 cmH₂O) with the indicator showing.

Do

Keep the unit upright and below chest level.
Keep tubing free of kinks and dependent loops.
Check dressing, insertion site, crepitus (subcutaneous air), breath sounds, SpO₂.
Keep at bedside: sterile water and an occlusive dressing (and clamps if policy).
Encourage coughing, deep breathing, incentive spirometry, pain control.

Don't

Don't clamp routinely (risk of tension pneumothorax): only briefly to find a leak, to change the unit, or if ordered.
Don't strip or milk the tubing routinely.
Don't lift the unit above the chest.

Tidaling stopped?

Either the lung has re-expanded (good: confirm with X-ray), or the tube is kinked, clotted or blocked (check).

Emergencies

Problem	Action
Tubing disconnected from the unit	Put the tube end 2–4 cm under sterile water, then reconnect or replace the unit.
Tube pulled out of the chest	Cover the site with a sterile occlusive dressing (taped on 3 sides if there's an air leak, per policy); stay with the patient; notify; watch for tension pneumothorax.
Unit knocked over	Set it upright; check the water seal level; notify if drainage mixed between chambers.

Pneumothorax types

Spontaneous: tall thin young adults, smokers, lung disease.
Open (sucking chest wound): cover with a vented or 3-sided occlusive dressing.
Tension: air trapped with each breath → shift of the mediastinum. Tracheal deviation away from the affected side, absent breath sounds, JVD, hypotension, severe distress. Emergency: needle decompression, then chest tube.
Hemothorax: blood in the pleural space.

Memory hook Air rises, fluid falls. A tube for air sits higher (apex); a tube for fluid sits lower (base). Many tubes for both are placed at the 4th–5th intercostal space, mid-axillary line.

Removal: patient holds breath or performs Valsalva as instructed; occlusive dressing; chest X-ray after.