Chest Tube: Clinical Guide to Placement and Management

A chest tube, also known as a thoracostomy tube, is a vital intervention used in respiratory and critical care to remove air, fluid, or blood from the pleural space. Restoring normal negative intrapleural pressure allows the lungs to re-expand and improves ventilation.

Chest tubes are commonly used in conditions such as pneumothorax, hemothorax, and pleural effusions, as well as after thoracic surgery.

Understanding how they function, when they are indicated, and how to manage them is essential for respiratory therapists and healthcare providers involved in patient care.

What Is a Chest Tube?

A chest tube is a flexible catheter inserted through the chest wall into the pleural space. Its primary purpose is to evacuate substances that interfere with normal lung expansion. These substances may include air, blood, pus, lymphatic fluid, or other accumulations.

Under normal conditions, the pleural space maintains a negative pressure that keeps the lungs inflated. When air or fluid enters this space, it disrupts that pressure balance, causing partial or complete lung collapse. A chest tube restores this balance by removing the unwanted material and allowing the lung to re-expand.

Chest tubes are used in a wide range of clinical settings, including emergency departments, intensive care units, and postoperative recovery units. Their placement and management require both technical skill and careful monitoring to ensure effective treatment and prevent complications.

Types of Chest Tubes

Chest tubes can be categorized based on their anatomical placement and clinical purpose. Understanding these types is important for both clinical application and exam preparation.

• Pleural Chest Tube: This is the most common type. It is inserted into the pleural space and is used to remove air or fluid. Indications include pneumothorax, pleural effusion, hemothorax, and empyema.
• Mediastinal Chest Tube: This type is placed in the mediastinum, typically after cardiac or thoracic surgery. Its purpose is to drain fluid and prevent accumulation around the heart and major vessels.
• Pericardial Chest Tube: This tube is placed in the pericardial space surrounding the heart. It is used to remove fluid in conditions such as cardiac tamponade or following open-heart surgery.

Note: Each type serves a specific function, and proper identification is important for ensuring appropriate management and monitoring.

Indications for Chest Tube Placement

Chest tubes are used in both emergency and non-emergency situations. Their placement is indicated when air or fluid in the thoracic cavity compromises lung function or poses a risk to the patient.

Common indications include:

• Pneumothorax, especially when significant or symptomatic
• Tension pneumothorax, which is a life-threatening emergency
• Hemothorax, involving blood accumulation in the pleural space
• Pleural effusion, including transudative or exudative fluid buildup
• Empyema, which is the presence of pus in the pleural space
• Chylothorax, involving lymphatic fluid accumulation
• Pneumopericardium or cardiac tamponade
• Postoperative management following thoracic or cardiac surgery

Note: Among these, tension pneumothorax requires immediate intervention due to its potential to rapidly impair cardiovascular function.

Emergency Management of Tension Pneumothorax

Tension pneumothorax is a critical condition in which air accumulates in the pleural space and cannot escape. This leads to increased intrathoracic pressure, lung collapse, and compression of the heart and great vessels.

Management involves a two-step approach:

1. Immediate Needle Decompression

A large-bore needle is inserted into the second or third intercostal space at the midclavicular line. This allows trapped air to escape and relieves pressure quickly.

2. Definitive Chest Tube Placement

After initial stabilization, a chest tube is inserted to provide continuous evacuation of air and prevent recurrence.

Note: Recognizing this sequence is essential in both clinical practice and exam scenarios.

Chest Tube Size and Selection

Chest tubes vary in size, typically measured in French units, ranging from approximately 7 Fr to 40 Fr. The appropriate size depends on the clinical situation.

• Small-bore tubes are often used for simple pneumothorax
• Larger tubes are preferred for trauma cases or when draining thick fluids such as blood or pus

Note: Larger tubes are more effective at removing viscous substances and preventing obstruction. However, they may also be associated with increased discomfort for the patient. Therefore, clinicians must balance effectiveness with patient tolerance.

Chest Tube Placement and Positioning

Proper placement of a chest tube is critical for effective drainage. The insertion site and direction of the tube depend on whether the goal is to remove air or fluid.

For Air Removal

The tube is typically inserted in the second to fourth intercostal space anteriorly or the fourth to sixth intercostal space at the midaxillary line. It is directed toward the apex of the lung, where air tends to accumulate.

For Fluid Removal

The tube is inserted in the sixth to eighth intercostal space at the midaxillary line and directed toward the posterior base of the lung, where fluid collects due to gravity.

Incorrect positioning can result in ineffective drainage and prolonged respiratory compromise. For this reason, placement is often guided by anatomical landmarks and confirmed with imaging.

Verification of Placement

After insertion, a chest radiograph is obtained to confirm proper placement of the chest tube. This step is essential to ensure that the tube is located in the correct position and functioning effectively.

On imaging:

• The chest tube appears as a radiopaque line
• Pleural tubes extend into the lung fields
• Mediastinal and pericardial tubes are located near the heart and central structures

Note: Radiographic confirmation also helps identify complications such as malposition, incomplete lung re-expansion, or additional pathology.

Chest Drainage Systems

Once inserted, the chest tube is connected to a drainage system that allows removal of air and fluid while preventing backflow into the pleural space.

Two main types of systems are used:

One-Way Valve System

A device such as a Heimlich valve allows air to exit but prevents it from re-entering. This type is often used in ambulatory settings.

Water-Seal Drainage System

This is the most commonly used system in hospital settings. It consists of multiple chambers that serve different functions.

Collection Chamber

This chamber collects fluid drained from the patient. The amount and type of fluid are monitored to assess patient progress.

Water-Seal Chamber

This chamber acts as a one-way valve. It allows air to exit the pleural space while preventing it from re-entering. It also provides visual cues about system function.

Suction Control Chamber

This chamber regulates the amount of suction applied to the system. Suction may be used to enhance drainage when necessary.

Note: Understanding the function of each component is essential for troubleshooting and ensuring proper operation.

Tidaling and System Function

Tidaling refers to the fluctuation of fluid in the water-seal chamber in response to changes in intrathoracic pressure.

• In spontaneous breathing, the fluid level rises during inspiration and falls during expiration
• In patients receiving positive-pressure ventilation, this pattern is reversed

The presence of tidaling indicates that the system is patent and functioning. Absence of tidaling may suggest:

• Lung re-expansion
• Tube obstruction
• Kinking or compression of the tubing
• Improper placement

Note: Careful observation of tidaling helps clinicians assess both the patient’s condition and the functionality of the system.

Air Leaks and Bubbling

Bubbling in the water-seal chamber is another important observation.

• Intermittent bubbling may be normal, especially during coughing
• Continuous bubbling usually indicates an air leak

Air leaks can originate from the patient or the drainage system. Identifying the source is important for determining the appropriate intervention.

Note: If bubbling is observed, clinicians should systematically check connections, tubing, and insertion sites to locate the leak.

Suction Use and Considerations

In many cases, chest tubes are initially placed on a water seal without suction. This allows passive evacuation of air and reduces the risk of complications.

If the lung does not re-expand adequately, suction may be applied to enhance drainage. The amount of suction is controlled by the drainage system and must be carefully regulated.

Excessive suction can cause tissue damage or contribute to complications such as re-expansion pulmonary edema. Therefore, its use should be based on clinical need and monitored closely.

Chest Tube Complications

Although chest tubes are highly effective, complications can occur if they are not properly inserted or managed. Early recognition and prompt intervention are essential to prevent deterioration.

One of the most common complications is tube malposition. If the tube is not located correctly within the pleural space, it may fail to drain air or fluid effectively. This can result in persistent lung collapse or delayed recovery.

Subcutaneous emphysema is another potential issue. This occurs when air leaks into the subcutaneous tissue, producing a characteristic crackling sensation on palpation. While often benign, it may indicate an air leak or improper tube placement.

Obstruction of the chest tube can also impair drainage. Clots, thick secretions, or debris may block the lumen, especially in cases involving hemothorax or empyema. Kinking or dependent loops in the tubing can further reduce flow and should be corrected immediately.

Tube dislodgement or accidental removal is a serious concern. If the tube becomes partially or completely displaced, air or fluid may reaccumulate in the pleural space, potentially leading to respiratory compromise.

Infection is another risk, particularly with prolonged use. Proper sterile technique during insertion and careful site care during maintenance are important to minimize this risk.

Routine Monitoring and Assessment

Effective chest tube management requires continuous monitoring of both the patient and the drainage system. Clinicians should regularly assess the amount, color, and consistency of the drainage. Sudden increases in output may indicate bleeding, while changes in color could suggest infection or other complications.

The insertion site should be inspected for signs of infection, such as redness, swelling, or discharge. The presence of subcutaneous emphysema should also be evaluated.

System integrity is equally important. All connections must be secure, and the tubing should remain free of kinks or loops. The drainage system should be positioned below the level of the patient’s chest to facilitate gravity drainage and prevent backflow.

Respiratory status must be monitored closely. Improvements in breath sounds, oxygenation, and chest expansion suggest effective therapy, while worsening symptoms may indicate complications or treatment failure.

Troubleshooting Chest Tube Systems

Problems with chest tube systems can arise suddenly and require immediate attention. A systematic approach is essential for identifying and resolving issues.

Absence of Tidaling

If tidaling is no longer observed, several possibilities should be considered. The lung may have fully re-expanded, which is a positive sign. However, it could also indicate obstruction, kinking, or malposition of the tube.

The tubing should be inspected for visible problems, and the patient’s clinical condition should be assessed. If obstruction is suspected, further evaluation may be needed.

Continuous Bubbling

Continuous bubbling in the water-seal chamber typically indicates an air leak. The source of the leak must be identified.

Clinicians should check all connections and tubing for leaks. If the system appears intact, the leak may be originating from the patient, such as from a bronchopleural fistula.

Lack of Bubbling in Suction Chamber

If suction is ordered but no bubbling is observed in the suction control chamber, this may indicate insufficient suction, a leak in the system, or an obstruction.

The suction source should be checked, and the system should be evaluated to ensure it is functioning properly.

Disconnection or System Failure

If the chest tube becomes disconnected from the drainage system, immediate action is required. If an air leak is present, the end of the tube should be placed in sterile water to recreate a temporary water seal. This prevents air from re-entering the pleural space.

If no air leak is present, the tube may be briefly clamped to prevent air entry. In all cases, a new drainage system should be connected as soon as possible.

Proper Handling and Safety Considerations

Certain practices are essential for safe chest tube management, while others should be avoided due to potential harm. Clamping the chest tube should be limited to brief situations, such as when changing the drainage system. Prolonged clamping can lead to accumulation of air or fluid and may result in a tension pneumothorax.

Stripping or milking the chest tube is no longer recommended. These techniques can generate excessive negative pressure within the pleural space and may damage lung tissue.

The tubing should be kept free of dependent loops, as these can trap fluid and impede drainage. Proper positioning of the system below chest level is also critical. Maintaining sterile technique during dressing changes and handling of the system helps reduce the risk of infection.

Special Considerations in Trauma Patients

In trauma cases, chest tube management may be more complex due to the presence of both air and fluid in the pleural space. When both pneumothorax and hemothorax are present, clinicians may insert two chest tubes. One tube is directed toward the apex to remove air, while the other is directed toward the base to drain fluid.

This dual-tube approach improves efficiency and ensures that both air and fluid are adequately evacuated. It also reduces the risk of retained collections that could impair lung re-expansion.

Note: Close monitoring is especially important in trauma patients, as rapid changes in condition can occur.

Criteria for Chest Tube Removal

The decision to remove a chest tube is based on clinical and radiographic findings.

Key criteria include:

• Resolution of the underlying condition
• Minimal and stable drainage output
• Absence of significant air leaks
• Evidence of lung re-expansion on imaging

Importantly, chest tube removal should not occur immediately after an air leak resolves. Many clinicians prefer to wait approximately 48 hours to ensure stability and reduce the risk of recurrence.

Note: Premature removal may lead to reaccumulation of air or fluid, requiring reinsertion of the tube.

Chest Tube Removal Procedure

Chest tube removal is typically performed at the bedside using a standardized technique. The patient is often instructed to perform a Valsalva maneuver or hold their breath during removal. This helps prevent air from entering the pleural space.

The tube is then quickly withdrawn, and an occlusive dressing is applied to seal the insertion site.

After removal, the patient should be monitored for signs of recurrence, such as shortness of breath or decreased oxygenation. A follow-up chest radiograph is usually obtained to confirm continued lung expansion.

Role of the Respiratory Therapist

Respiratory therapists play a key role in the management of patients with chest tubes. Their responsibilities include:

• Monitoring respiratory status and oxygenation
• Assessing chest tube function and drainage system integrity
• Identifying complications and reporting abnormalities
• Assisting with troubleshooting and interventions
• Educating patients about the procedure and care

Note: By integrating clinical assessment with system observations, respiratory therapists contribute to safe and effective patient care.

Chest Tube Practice Questions

1. What is the primary purpose of a chest tube?
To remove air, fluid, or blood from the pleural space and allow lung re-expansion.

2. What is another term for a chest tube?
Thoracostomy tube

3. Where is a chest tube inserted?
Into the pleural space through the chest wall.

4. What condition involves air in the pleural space?
Pneumothorax

5. What condition involves blood in the pleural space?
Hemothorax

6. What is the goal of chest tube therapy?
To restore negative intrapleural pressure and re-expand the lung.

7. What is the most commonly used type of chest tube?
A pleural chest tube.

8. What type of chest tube is commonly used after cardiac surgery?
A mediastinal chest tube.

9. What type of chest tube is used to drain fluid around the heart?
A pericardial chest tube.

10. What is a life-threatening indication for chest tube placement?
Tension pneumothorax

11. What is the first step in managing a tension pneumothorax?
Immediate needle decompression.

12. Where is needle decompression typically performed?
In the second or third intercostal space at the midclavicular line or the fourth or fifth intercostal space at the anterior axillary line.

13. What is performed after needle decompression in tension pneumothorax?
Placement of a chest tube.

14. What determines the appropriate size of a chest tube?
The type and viscosity of the substance being drained.

15. What size chest tubes are typically used for pneumothorax?
Small-bore tubes.

16. What size chest tubes are preferred for hemothorax?
Large-bore tubes.

17. Why are large-bore chest tubes used for blood drainage?
To reduce the risk of obstruction from clots.

18. Where should a chest tube be directed for air removal?
Toward the apex of the lung.

19. Where should a chest tube be directed for fluid removal?
Toward the base of the lung.

20. Why does air collect at the apex of the lung?
Because air rises.

21. Why does fluid collect at the base of the lung?
Because gravity causes fluid to settle in dependent areas.

22. What imaging modality is used to confirm chest tube placement?
A chest radiograph.

23. How does a chest tube appear on a chest X-ray?
As a radiopaque line within the thoracic cavity.

24. What is the function of the collection chamber in a chest drainage system?
To collect air, fluid, or blood removed from the pleural space.

25. What is the function of the water-seal chamber?
To act as a one-way valve that prevents air from re-entering the pleural space.

26. What is the function of the suction control chamber?
To regulate the amount of suction applied to the system.

27. What is tidaling in a chest tube system?
The rise and fall of fluid in the tubing or water-seal chamber with respiration.

28. What does tidaling indicate in a chest drainage system?
That the system is patent and functioning.

29. What may the absence of tidaling indicate?
Lung re-expansion or a possible obstruction in the system.

30. What does continuous bubbling in the water-seal chamber indicate?
An air leak in the system or from the patient.

31. What is subcutaneous emphysema in patients with a chest tube?
Air trapped under the skin that produces a crackling sensation on palpation.

32. What can cause subcutaneous emphysema during chest tube therapy?
An air leak or improper tube placement.

33. What is a common cause of chest tube obstruction?
Blood clots or thick secretions.

34. Why should dependent loops be avoided in chest tube tubing?
They can trap fluid and impair drainage.

35. What should be done if the chest tube tubing becomes kinked?
Straighten the tubing immediately to restore flow.

36. Why must the drainage system be kept below the level of the chest?
To promote gravity drainage and prevent backflow into the pleural space.

37. What does intermittent bubbling in the water-seal chamber indicate?
Normal air movement, such as during coughing or exhalation.

38. What should be suspected if continuous bubbling is observed in the water-seal chamber?
An ongoing air leak in the system or from the patient.

39. What is a bronchopleural fistula?
An abnormal connection that allows air to leak from the bronchial tree into the pleural space.

40. What should be checked first when an air leak is suspected?
All tubing connections and the integrity of the system.

41. What may cause a sudden increase in chest tube drainage output?
Active bleeding or a worsening clinical condition.

42. What does cloudy or foul-smelling chest tube drainage suggest?
Infection

43. What signs at the insertion site may indicate infection?
Redness, swelling, warmth, or purulent discharge.

44. Why is sterile technique essential in chest tube care?
To reduce the risk of infection.

45. What is the purpose of suction in chest tube therapy?
To enhance the removal of air or fluid when needed.

46. When is suction typically applied to a chest tube?
When the lung does not fully re-expand with water seal alone.

47. What is a potential risk of excessive suction?
Tissue injury or re-expansion pulmonary edema.

48. What is the purpose of a Heimlich valve?
To allow one-way airflow out of the pleural space.

49. In what setting is a Heimlich valve commonly used?
Ambulatory or outpatient management of pneumothorax.

50. What does absence of bubbling in the suction control chamber suggest?
Insufficient suction or a system malfunction.

51. What should be done if the drainage system disconnects and an air leak is present?
Place the tube end in sterile water to re-establish a water seal.

52. What is the purpose of placing the chest tube in sterile water during disconnection?
To create a temporary one-way valve and prevent air re-entry.

53. What can be done if no air leak is present during system disconnection?
Briefly clamp the chest tube while reconnecting the system.

54. Why should prolonged clamping of a chest tube be avoided?
It can lead to tension pneumothorax.

55. What is chest tube stripping?
Manual compression of the tubing to move contents.

56. Why is routine chest tube stripping not recommended?
It can generate excessive negative pressure and cause harm.

57. What is the role of respiratory therapists in chest tube management?
To monitor system function and assess patient status.

58. What does improved breath sounds after chest tube placement indicate?
Lung re-expansion.

59. What does worsening oxygenation in a patient with a chest tube suggest?
Possible complication or ineffective drainage.

60. Why is continuous patient assessment important during chest tube therapy?
To detect early signs of complications or clinical deterioration.

61. What is the typical size range of chest tubes in French units?
Approximately 7 Fr to 40 Fr.

62. What does the French (Fr) size of a chest tube represent?
The external diameter of the tube.

63. Which intercostal space is commonly used for fluid drainage with a chest tube?
The fifth to eighth intercostal space at the midaxillary line.

64. Which intercostal space is commonly used for air removal in chest tube placement?
The second to fourth intercostal space at the anterior chest.

65. In what direction should a chest tube be advanced for a pneumothorax?
Toward the apex of the lung.

66. In what direction should a chest tube be advanced for a pleural effusion?
Toward the posterior and inferior portion of the thoracic cavity.

67. What is the primary function of the water-seal chamber in a chest drainage system?
To prevent air from re-entering the pleural space.

68. What does fluctuation in the water-seal chamber indicate?
Changes in intrathoracic pressure during respiration.

69. How does tidaling change during positive-pressure ventilation?
It reverses, with fluid rising during expiration and falling during inspiration.

70. What is a possible sign that a chest tube system is obstructed?
A sudden absence of drainage or tidaling.

71. What is the normal pattern of tidaling during spontaneous breathing?
The fluid rises during inspiration and falls during expiration.

72. What complication can result from improper chest tube positioning?
Persistent lung collapse or ineffective drainage.

73. Why is radiographic confirmation required after chest tube insertion?
To verify correct placement and assess lung re-expansion.

74. What should be done if a chest tube is accidentally dislodged?
Apply an occlusive dressing immediately.

75. What is the purpose of an occlusive dressing after chest tube removal?
To prevent air from entering the pleural space.

76. What breathing maneuver is often used during chest tube removal?
The Valsalva maneuver or end-expiratory hold.

77. Why is the Valsalva maneuver used during chest tube removal?
To increase intrathoracic pressure and reduce air entry.

78. What is a key indicator that a chest tube may be ready for removal?
Resolution of the air leak.

79. What additional factor is considered before removing a chest tube?
Stable and minimal drainage output.

80. Why should clinicians wait before removing a chest tube after an air leak resolves?
To reduce the risk of recurrence.

81. What is a typical waiting period after an air leak has resolved?
Approximately 24 to 48 hours, depending on clinical status.

82. What is a chylothorax?
Accumulation of lymphatic fluid in the pleural space.

83. What is empyema?
Accumulation of pus in the pleural space.

84. What is pneumopericardium?
The presence of air within the pericardial sac.

85. What is cardiac tamponade?
Compression of the heart due to fluid accumulation in the pericardial space.

86. What is a key goal of chest tube therapy in hemothorax?
To evacuate blood and prevent clot retention.

87. What can occur if blood clots are not effectively drained?
Obstruction of the chest tube and impaired drainage.

88. Why might two chest tubes be used in trauma patients?
To separately drain air and fluid.

89. Where is the second chest tube typically placed in dual chest tube therapy?
Toward the base of the lung for fluid drainage.

90. What is the primary benefit of using dual chest tubes in trauma?
Improved evacuation of both air and fluid.

91. What is the purpose of securing a chest tube after insertion?
To prevent accidental dislodgement and maintain proper positioning.

92. What type of dressing is typically used at the chest tube insertion site?
A sterile occlusive dressing.

93. What is the significance of monitoring drainage color and consistency?
It helps assess for bleeding, infection, or other complications.

94. What does a sudden decrease in drainage output potentially indicate?
Tube obstruction or resolution of the underlying condition.

95. What complication can occur if a chest tube is inserted too deeply?
Injury to lung tissue or surrounding structures.

96. What is the purpose of marking the insertion depth of a chest tube?
To monitor for tube migration.

97. What is a common sign of effective chest tube therapy in pneumothorax?
Resolution of air leak and improved lung expansion.

98. What should be avoided when handling a chest tube system?
Elevating the drainage system above chest level.

99. What is the role of pain management in patients with chest tubes?
To improve comfort and promote effective breathing.

100. What is the purpose of encouraging deep breathing and coughing in chest tube patients?
To promote lung re-expansion and prevent complications such as atelectasis.

Final Thoughts

Chest tubes are an essential intervention for managing conditions that disrupt normal pleural pressure and lung expansion. Their effectiveness depends on proper selection, accurate placement, and diligent monitoring.

Clinicians must be able to recognize complications, interpret system findings, and respond appropriately to changes in patient status.

Attention to detail and adherence to best practices are critical for ensuring safe outcomes. With a strong understanding of chest tube management principles, healthcare providers can deliver effective care across a wide range of clinical scenarios.