How do you manage a chest tube and know when something is wrong?
NCLEX-RN topic: Complications of tests, treatments, procedures
- Keep the unit upright, below the chest, kink-free, water seal at 2 cm.
- Tidaling in the water seal is good; continuous bubbling there suggests a leak.
- Report bright red drainage over 200 mL/hour, cloudy drainage or new subcutaneous emphysema.
- Tube out? Cover with a sterile occlusive dressing taped on three sides.
- Never strip the tube; do not clamp it routinely or for transport.
Key facts
- A chest drainage system has a collection chamber, a water seal chamber filled to 2 cm, and a wet or dry suction control (often set at -20 cm of water).
- Tidaling, water rising and falling with breathing in the water seal, shows the tube is patent; the pattern is reversed on a mechanical ventilator.
- Continuous bubbling in the water seal chamber suggests an air leak; gentle, constant bubbling in a wet suction control chamber is expected.
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- Notify the provider for cloudy drainage, drainage that stops in the first 24 hours, or bright red drainage of more than 200 mL/hour.
- If the tube comes out of the chest, cover the site with a sterile occlusive dressing taped on three sides and get help while staying with the client.
- Keep two rubber-tipped clamps, sterile dressings and sterile water at the bedside and with the client during transport.
- A Jackson-Pratt drain holds smaller amounts (about 25–50 mL) and a Hemovac up to 500 mL; both are compressed after emptying to restore suction.
Quick check1 question · 2 more at the end
A client had a chest tube placed for a hemothorax 3 hours ago. For each of the last 2 hours, 250 mL of bright red drainage has collected in the drainage unit. What should the nurse do?
Correct answer: C.
A sudden increase in bright red drainage of more than 200 mL per hour may mean a vascular injury that needs surgical repair. The nurse obtains vital signs, assesses the client's heart and lung status and reports the amount and color of the drainage to the provider. Clamping, stripping and lifting the unit above the chest are all unsafe.
A Routine clamping is not recommended because it risks a tension pneumothorax.
B Stripping creates high pressure in the tube that can cause a life-threatening pneumothorax.
C Correct: more than 200 mL/hour of bright red drainage is assessed and reported at once.
D The unit stays below the chest so drainage does not flow back into the chest.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Keep the chest drainage unit upright, below the chest and free of kinks, with the water seal at 2 cm. Tidaling in the water seal is expected; continuous bubbling there suggests an air leak. Report drainage over 200 mL/hour, cloudy drainage or new subcutaneous emphysema, and never strip the tube or clamp it routinely.
1 How does a chest tube drainage system work?A chest tube removes air or fluid from the pleural space so the lung can re-expand. 1 min
A chest tube removes air or fluid from the pleural space so the lung can re-expand. It connects to a closed, airtight unit that lets air and fluid out but not back in.
| Chamber | What you see | What it means |
|---|---|---|
| Collection | Drainage level marked with date and time | Amount and type of drainage |
| Water seal | Water at 2 cm; level rises and falls with breathing (tidaling) | One-way valve; tidaling shows the tube is patent |
| Suction control | Wet: water at the prescribed level with gentle, constant bubbling. Dry: dial and indicator at the ordered setting | Applies the prescribed suction |
If tidaling stops, the tubing may be kinked or blocked, or the lung may have re-expanded; assess the client to tell which.
2 What do you check every shift?Every shift starts with the client, then follows the tubing from the chest to the unit. 1 min
Every shift starts with the client, then follows the tubing from the chest to the unit. Get baseline vital signs, SpO2, lung sounds, work of breathing and trachea position. Check the dressing, and feel around the site for crepitus, the crackling of subcutaneous emphysema.
Then check the system:
- Unit upright and below the chest, on its stand or secured so it cannot tip.
- Tubing free of kinks and dependent loops; connections taped.
- Water seal at 2 cm, tidaling present, no continuous bubbling.
- Suction at the prescribed level.
- Two rubber-tipped clamps, sterile dressings and sterile water at the bedside.
3 Which findings mean trouble?Continuous bubbling, heavy bright red drainage and new respiratory distress are key findings to act on. 1 min
Continuous bubbling, heavy bright red drainage and new respiratory distress are key findings to act on. Respiratory distress always comes first.
| Finding | What it may mean | What you do |
|---|---|---|
| Continuous bubbling in the water seal | Air leak | Check connections and the site; notify if not fixed |
| Bright red drainage over 200 mL/hour | Vascular injury | Vital signs, assess, notify the provider |
| Drainage stops in the first 24 hours | Clot or kink | Straighten tubing, sit client up, unit low; notify if unresolved |
| Cloudy drainage | Infection | Notify the provider |
| New or spreading crepitus | Worsening air leak | Mark the edges, notify the provider |
| SpO2 below 90%, sudden dyspnea, tracheal deviation | Respiratory distress, such as a tension pneumothorax | Notify the provider at once; get emergency help |
4 What do you do when the system fails?When the system fails, keep air out of the chest and get help without leaving the client. 1 min
When the system fails, keep air out of the chest and get help without leaving the client. If the tube comes out of the chest, cover the site at once with a sterile occlusive dressing. Tape it on three sides so air can escape, and prepare for reinsertion.
If the tubing disconnects from the unit, put the end in sterile water or clamp it briefly near the chest while a new unit is set up. A tipped unit is set upright and the water seal refilled.
Do not strip the tube, and do not clamp it routinely, because clamping risks a tension pneumothorax. For transport, disconnect the suction source instead of clamping.
5 What happens at removal, and how are wound drains managed?A provider removes the chest tube, and the nurse prepares the client and watches closely afterward. 1 min
A provider removes the chest tube, and the nurse prepares the client and watches closely afterward. Give prescribed pain medicine about 30 minutes before, and do not clamp the tube beforehand. Teach the client to take a deep breath and hold it as the tube comes out. Afterward, assess at least every 15 minutes for the first hour for distress and subcutaneous emphysema.
Wound drains such as a Jackson-Pratt bulb or a Hemovac collect fluid from the surgical site. Empty them, squeeze the reservoir flat before closing it to restore suction, pin with slack, keep the reservoir below the wound and record the drainage as output. Report cloudy or foul drainage, a bulb that will not stay flat, or drainage that suddenly stops.
6 What the nurse doesThe nurse checks the client first, then the system, and acts fast on distress. 1 min
The nurse checks the client first, then the system, and acts fast on distress.
- Assess: breathing, SpO2, lung sounds, site and drainage trends against baseline.
- Priority action: for distress or a dislodged tube, stay, call for help and protect the airway and site.
- Teach: report any breathing trouble at once, sit upright, splint the site with a pillow when coughing and use the incentive spirometer.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Disconnect the suction source for transport, not clamp the chest tube.
Watch out: Continuous bubbling in the water seal is a problem, not the gentle bubbling in a wet suction control chamber.
Watch out: Keep the tubing free of kinks and dependent loops, not strip it; stripping creates pressures that can cause a pneumothorax.
Watch out: Loss of tidaling can mean a kink or blockage, or simply that the lung has re-expanded, so assess the client before deciding.
How to remember it
A short rhyme separates the normal water-seal sign from the warning sign.
Memory hook: "Tidal is vital, bubbles are trouble" (in the water seal chamber).
Self-check:
- Name the three chambers and what each shows.
- State the drainage rate that is reported at once.
- Describe the dressing for a tube that has come out.