A chest tube is a flexible tube inserted into the pleural space to remove air, blood, pus, or fluid. The pleural space is the small space between the lung and the chest wall. Normally, this space helps the lungs expand smoothly during breathing. When air or fluid collects there, the lung can collapse or fail to expand properly.
Chest tubes are used in conditions such as pneumothorax, hemothorax, pleural effusion, empyema, and after thoracic or cardiac surgery. The main goal is to drain the pleural space, relieve pressure, restore negative pressure, and allow the lung to re-expand. Chest tube placement and care require careful monitoring because problems like air leaks, blockage, bleeding, infection, or tube dislodgement can become serious fast. Chest tubes are widely used for pleural space problems, including pneumothorax, hemothorax, empyema, pleural effusion, and postoperative drainage.
You need to understand the drainage chamber, water seal chamber, and suction control chamber. You also need to know what bubbling means, when tidaling is expected, when to notify the provider, and what to do if the chest tube comes out or the system disconnects.
What Is a Chest Tube?
A chest tube, also called a thoracostomy tube, is inserted through the chest wall into the pleural space. It drains unwanted air or fluid and helps the lung expand again.
The tube connects to a closed drainage system. This system usually has chambers that collect drainage, prevent air from moving backward into the chest, and control suction if ordered.
Main Purpose of a Chest Tube
A chest tube helps to:
- Remove air from the pleural space
- Remove blood from the pleural space
- Drain infected fluid or pus
- Drain excess pleural fluid
- Re-expand a collapsed lung
- Restore normal pressure in the chest
- Monitor drainage after surgery
- Reduce respiratory distress
What Is the Pleural Space?
The pleural space is the space between two pleural layers:
- Visceral pleura, which covers the lung
- Parietal pleura, which lines the chest wall
This space normally contains a small amount of lubricating fluid. It also maintains negative pressure, which helps keep the lungs expanded during breathing. When air, blood, or fluid enters this space, normal lung expansion becomes difficult.
Chest Tube Insertion Site
A common chest tube insertion area is the 4th or 5th intercostal space at the midaxillary or anterior axillary line. This area allows access to the pleural space while reducing the risk of injury to nearby structures.
Many references describe the usual safe area as the fifth intercostal space between the anterior and midaxillary lines, with care taken to insert above the rib border to avoid the neurovascular bundle.
Chest tube insertion must be performed by trained clinicians using sterile technique and proper imaging or clinical guidance when needed.
Indications for Chest Tube Placement
Chest tubes are used when air or fluid must be removed from the pleural cavity.
Common Indications
| Indication | Meaning | Why Chest Tube Helps |
|---|---|---|
| Pneumothorax | Air in the pleural space | Removes air and re-expands lung |
| Hemothorax | Blood in the pleural space | Drains blood and relieves lung compression |
| Pleural effusion | Fluid buildup in the pleural space | Removes fluid and improves breathing |
| Empyema | Pus or infected fluid in pleural space | Drains infection and prevents fibrosis |
| Post-op drainage | Fluid or air after chest surgery | Prevents buildup after surgery |
Pleural drains are commonly indicated for pneumothorax, pleural effusion, traumatic hemothorax or pneumothorax, empyema, and postoperative drainage after thoracic, cardiac, esophageal, or spinal surgery.
Pneumothorax and Chest Tubes
A pneumothorax occurs when air collects in the pleural space. This air pushes against the lung and may cause partial or complete lung collapse.
Common Causes
- Chest trauma
- Lung disease
- Mechanical ventilation
- Spontaneous air leak
- Medical procedures
- Rib fracture
- Penetrating injury
Symptoms
- Sudden chest pain
- Shortness of breath
- Reduced breath sounds
- Fast breathing
- Low oxygen saturation
- Anxiety
- Unequal chest movement
A chest tube removes trapped air and helps the lung expand again.
Hemothorax and Chest Tubes
A hemothorax is blood in the pleural space. It usually occurs after trauma, surgery, or blood vessel injury.
Why It Is Serious
Blood in the pleural space can:
- Compress the lung
- Reduce oxygenation
- Cause shock if bleeding is severe
- Increase infection risk
- Form clots that prevent lung expansion
Chest tubes drain blood and allow clinicians to monitor the amount and rate of bleeding.
Pleural Effusion and Chest Tubes
A pleural effusion is excess fluid in the pleural space. It can happen due to infection, cancer, heart failure, liver disease, kidney disease, or inflammation.
Symptoms
- Shortness of breath
- Chest heaviness
- Reduced breath sounds
- Cough
- Low oxygen saturation
- Difficulty lying flat
A chest tube may be used when the effusion is large, infected, recurrent, complicated, or needs continuous drainage.
Empyema and Chest Tubes
Empyema means pus or infected fluid in the pleural space. It often develops after pneumonia or lung infection.
Why Drainage Matters
Empyema can cause:
- Fever
- Chest pain
- Sepsis
- Thick pleural fluid
- Lung restriction
- Pleural scarring
Drainage helps remove infected material and supports antibiotic treatment. Empyema often requires drainage because pus inside the pleural space can prevent recovery and lead to fibrosis.
Chest Tube Drainage System
A traditional chest tube drainage system has three main chambers:
- Drainage chamber
- Water seal chamber
- Suction control chamber
Each chamber has a different job.
Drainage Chamber
The drainage chamber collects fluid, blood, or pus from the pleural space. It is calibrated, so the healthcare team can measure output.
What to Monitor
Monitor:
- Amount of drainage
- Color of drainage
- Consistency
- Sudden increases
- Sudden decreases
- Bright red blood
- Clots
- Foul odor
Drainage Color Meaning
| Drainage Appearance | Possible Meaning |
|---|---|
| Serous | Clear or pale yellow fluid |
| Serosanguineous | Pink or light bloody fluid |
| Sanguineous | Bloody drainage |
| Purulent | Thick infected drainage |
| Bright red blood | Possible active bleeding |
Nurses should assess and document the amount, color, and characteristics of drainage in the collection chamber. Marking the drainage level with date and time helps track changes during the shift.
Water Seal Chamber
The water seal chamber acts like a one-way valve. It allows air to leave the pleural space during exhalation but prevents air from entering during inhalation.
This chamber is critical because air must not flow backward into the chest.
Main Functions
The water seal chamber:
- Allows air to exit
- Prevents air from re-entering
- Helps maintain negative pressure
- Shows tidaling
- Helps detect air leaks
The water seal chamber is filled with sterile water, commonly to the 2 cm mark, and works as a one-way valve. Tidaling may be seen as water rises and falls with breathing.
What Is Tidaling?
Tidaling is the up-and-down movement of water in the water seal chamber with breathing.
Normal Tidaling
Tidaling usually means the system is patent and responding to breathing.
- Water rises and falls with respiration
- Movement may be more visible with deep breathing
- Tidaling may decrease as the lung re-expands
If Tidaling Stops
No tidaling can mean:
- Lung has re-expanded, which is good
- Tube is blocked, which is bad
- Tubing is kinked
- Suction is too strong
- System is not working properly
You must assess the patient first. Check breath sounds, oxygen saturation, respiratory effort, tube position, and tubing patency.
Bubbling in the Water Seal Chamber
Bubbling has different meanings depending on where it occurs.
Intermittent Bubbling
Intermittent bubbling in the water seal chamber can be expected with a pneumothorax because air is leaving the pleural space.
Continuous Bubbling
Continuous bubbling in the water seal chamber is abnormal. It usually suggests an air leak.
Possible causes include:
- Loose connection
- Tube dislodgement
- Leak at insertion site
- Crack in the drainage system
- Ongoing air leak from lung tissue
Continuous bubbling in the water seal chamber may indicate an air leak, and the nurse should check tubing connections, insertion site, and notify the provider if the leak cannot be corrected.
Suction Control Chamber
The suction control chamber regulates how much suction is transmitted to the pleural space. Not every patient needs suction. Suction is used only when ordered.
There are two main types:
- Wet suction
- Dry suction
Wet Suction System
In a wet suction system, suction is controlled by the height of water in the suction control chamber.
Key Points
- Suction depends on water level
- Common adult setting is often around -20 cm H2O when prescribed
- Gentle bubbling is expected
- Excessive bubbling is not helpful
- Water evaporates and must be monitored
Gentle bubbling in the wet suction chamber means suction is working. Vigorous bubbling can cause water evaporation and may not improve suction.
A wet suction system controls suction by the water level in the suction chamber, and gentle bubbling is expected when connected to suction.
Dry Suction System
In a dry suction system, suction is controlled by a dial, not by water height.
Key Points
- No water is used in the suction control chamber
- Suction is set by a control dial
- A bellows or indicator confirms suction function
- The collection chamber and water seal chamber are still present
- Always check manufacturer instructions
Dry suction systems use a regulator or dial to adjust suction, and indicators such as a bellows or float show whether suction is working.
Wet Suction vs Dry Suction
| Feature | Wet Suction | Dry Suction |
|---|---|---|
| Suction control | Height of water column | Suction control dial |
| Water needed in suction chamber | Yes | No |
| Normal suction sign | Gentle bubbling | Bellows or suction indicator |
| Main nursing check | Water level and bubbling | Dial setting and indicator |
| Evaporation issue | Yes | No suction-water evaporation |
| Still has water seal chamber | Yes | Yes |
Chest Tube Nursing Interventions
Chest tube care requires frequent assessment. Small changes can signal serious complications.
Priority Nursing Actions
- Keep the drainage system below the chest tube insertion site
- Keep the system upright
- Maintain a closed system
- Check all tubing connections
- Avoid dependent loops in tubing
- Do not strip or milk tubing unless ordered
- Do not clamp tubing unless specifically ordered
- Encourage coughing and deep breathing
- Monitor lung sounds
- Monitor respiratory rate and work of breathing
- Monitor oxygen saturation
- Assess insertion site
- Check dressing
- Measure drainage output
- Document color and amount of drainage
- Assess pain
- Assist with mobility as allowed
Routine clamping is not recommended because it can increase the risk of tension pneumothorax. Chest tubes may be briefly clamped only under specific facility policy or provider direction, such as during system change, air leak assessment, or removal.
Why the Drainage System Must Stay Below Chest Level
The drainage system should stay below the insertion site. This helps drainage flow by gravity and prevents fluid from moving backward into the chest.
If the system is lifted above the chest, fluid may return toward the patient, increasing infection and respiratory risk.
Why You Should Not Strip the Chest Tube
Stripping or aggressive milking can create high negative pressure inside the tube. This can injure tissue or worsen patient discomfort.
Only manipulate tubing if it is ordered and allowed by facility policy.
Monitoring Lung Sounds
Lung sounds help show whether the lung is expanding and whether complications are developing.
Assess For
- Diminished breath sounds
- Crackles
- Wheezing
- Unequal chest movement
- New shortness of breath
- Sudden respiratory distress
- Increased oxygen need
A sudden change in breath sounds can mean pneumothorax, tube blockage, fluid buildup, or tube displacement.
Monitoring the Insertion Site
The insertion site should be checked often.
Assess For
- Bleeding
- Drainage
- Redness
- Swelling
- Loose sutures
- Dressing saturation
- Tube movement
- Air leaking around the site
- Subcutaneous emphysema
Subcutaneous emphysema feels like crackling or popping under the skin. It can happen when air leaks into soft tissue.
When to Notify the Provider
Notify the provider promptly if you notice:
- New or worsening shortness of breath
- Sudden chest pain
- Low oxygen saturation
- Cyanosis
- Sudden bright red drainage
- Rapid increase in drainage
- Drainage suddenly stops soon after insertion
- Continuous bubbling in water seal chamber
- Tube dislodgement
- Subcutaneous emphysema
- Signs of infection
- Fever or chills
- Loose or disconnected tubing
- New tracheal deviation
- Severe anxiety or restlessness
Some nursing guidance flags drainage that averages more than 200 mL/hour for 4 hours as concerning for vascular injury. Many teaching protocols also require provider notification for sudden bright-red blood or output above facility-defined limits.
What to Do If the Chest Tube Falls Out
If the chest tube comes out of the patient:
- Stay with the patient.
- Call for help.
- Cover the insertion site with sterile gauze or an occlusive dressing per facility policy.
- Assess breathing and oxygen saturation.
- Notify the provider immediately.
- Prepare for possible reinsertion.
- Monitor for tension pneumothorax.
Many protocols recommend taping the dressing on three sides to allow air to escape while helping prevent tension pneumothorax, but you should follow local policy.
What to Do If the Drainage System Disconnects
If the tubing disconnects from the drainage system:
- Keep the tube from touching contaminated surfaces.
- Place the end of the chest tube into sterile water or sterile saline to create a temporary water seal.
- Call for help.
- Reconnect to a new sterile drainage system.
- Assess the patient.
- Notify the provider.
- Document the event and patient response.
A small container of sterile water or saline is often kept available to create a temporary water seal if tubing disconnects from the drainage system.
Common Chest Tube Complications
| Complication | What Happens | Warning Signs |
|---|---|---|
| Air leak | Air enters system or pleural space | Continuous bubbling, hissing sound |
| Tube blockage | Drainage cannot move | No tidaling, sudden stop in output |
| Infection | Germs enter insertion site | Fever, redness, pus, pain |
| Bleeding | Vessel injury or ongoing hemothorax | Bright red drainage, hypotension |
| Tube dislodgement | Tube moves or falls out | Respiratory distress, exposed hole |
| Subcutaneous emphysema | Air leaks under skin | Crackling under skin |
| Tension pneumothorax | Air trapped under pressure | Severe distress, low BP, tracheal shift |
Chest Tube Removal
Chest tube removal is done when the provider determines it is safe.
Common Removal Criteria
- Lung has re-expanded
- Air leak has resolved
- Drainage has decreased
- Patient is stable
- Chest X-ray supports removal
- Provider criteria are met
Nursing Role During Removal
The nurse may assist by:
- Preparing supplies
- Explaining the procedure
- Giving pain medicine if ordered
- Monitoring vital signs
- Teaching breathing instructions
- Applying dressing after removal
- Watching for respiratory distress
Patients may be asked to perform a Valsalva maneuver or hold their breath during removal, depending on provider preference and facility policy. This helps reduce air entry into the pleural space.
Patient Education for Chest Tubes
Teach the patient to:
- Report sudden shortness of breath
- Avoid pulling on the tube
- Avoid lying on tubing
- Keep tubing free of kinks
- Cough and deep breathe as instructed
- Use incentive spirometry if ordered
- Call staff before getting out of bed
- Report increased pain
- Report bubbling sounds or loose tubing
- Report dizziness or chest tightness
Good patient education reduces anxiety and helps prevent accidental dislodgement.
Documentation for Chest Tube Care
Accurate documentation supports safe care.
Document
- Chest tube location
- Drainage amount
- Drainage color
- Drainage consistency
- Water seal level
- Presence or absence of tidaling
- Bubbling pattern
- Suction setting
- Air leak monitor reading if present
- Dressing condition
- Insertion site condition
- Lung sounds
- Respiratory rate
- Oxygen saturation
- Patient pain level
- Patient teaching
- Provider notifications
FAQs
1. What is a chest tube used for?
A chest tube is used to drain air, blood, pus, or fluid from the pleural space. It helps relieve pressure and allows the lung to re-expand. It is commonly used for pneumothorax, hemothorax, pleural effusion, empyema, and postoperative drainage.
2. Where is a chest tube usually inserted?
A chest tube is commonly inserted around the 4th or 5th intercostal space near the midaxillary or anterior axillary line. The exact site depends on the reason for insertion and the patient’s condition. Placement must be done by trained clinicians using sterile technique.
3. What are the three chambers of a chest tube drainage system?
The three chambers are the drainage chamber, water seal chamber, and suction control chamber. The drainage chamber collects output. The water seal prevents air from going back into the chest, while the suction chamber controls suction if ordered.
4. What does tidaling mean in a chest tube?
Tidaling means the water in the water seal chamber moves up and down with breathing. It usually shows that the tube is patent and responding to pressure changes. If tidaling stops, the lung may have re-expanded or the tube may be blocked, so the patient must be assessed.
5. Is bubbling normal in the water seal chamber?
Intermittent bubbling may be normal if air is leaving the pleural space, especially with pneumothorax. Continuous bubbling is abnormal and often suggests an air leak. The nurse should check connections, insertion site, and notify the provider if the leak continues.
6. What is the difference between wet suction and dry suction?
Wet suction is controlled by the height of water in the suction control chamber. Dry suction is controlled by a suction control dial. Both systems still have a collection chamber and water seal chamber.
7. Why should the chest drainage system stay below the chest?
The system should stay below the chest tube insertion site to promote gravity drainage. This also helps prevent fluid from flowing backward toward the patient. Raising the system above chest level can increase infection and respiratory risk.
8. What should you do if a chest tube falls out?
Stay with the patient, call for help, and cover the insertion site with sterile gauze or an occlusive dressing according to facility policy. Assess breathing and oxygen saturation immediately. Notify the provider and prepare for possible reinsertion.
9. What should you do if the chest tube system disconnects?
Place the end of the tube into sterile water or sterile saline to create a temporary water seal. Call for help and reconnect the patient to a new sterile drainage system. Assess the patient and notify the provider.
10. When should the provider be notified about chest tube drainage?
Notify the provider if drainage becomes suddenly bright red, increases rapidly, stops suddenly soon after insertion, or exceeds the facility’s reporting limit. Also notify the provider for respiratory distress, continuous bubbling, subcutaneous emphysema, tube dislodgement, fever, or signs of infection.
