Chest tubes and water-seal drainage: what is normal and what to do

What the system is doing

A chest tube lets air and fluid leave the pleural space so the lung can re-expand. A closed drainage unit has three chambers: one that collects drainage, one that acts as a one-way water seal, and one that controls suction. The water seal lets air out of the chest and stops it from coming back in.

Most exam questions are about reading the water-seal chamber and deciding what to do about what you see in it.

Reading each chamber

1. 01

   Collection chamber

   Note the amount, color and consistency of drainage and mark the level and time. Drainage is usually bloody at first and becomes thinner and straw colored. Report a sudden increase, especially bright red blood, according to the provider's parameters.

2. 02

   Water-seal chamber

   Tidaling, the water level moving up and down with breathing, is expected. Occasional bubbling when the client coughs or exhales can be expected early after a pneumothorax. Continuous bubbling means air is entering the system and needs a response. Loss of tidaling can mean the lung has re-expanded, or that the tubing is kinked, blocked or dependent.

3. 03

   Suction-control chamber

   When suction is applied, gentle continuous bubbling here is expected. The suction level is set by the amount of water in this chamber or on the dial, as the provider orders. Vigorous bubbling is not the goal.

Continuous bubbling in the water seal: what to do

Think of it as finding where air is getting in.

1. 01

   Look at the client

   Check respiratory rate, effort, oxygen saturation and the chest. A client in respiratory distress is an emergency: call for help and treat as one.

2. 02

   Trace the tubing

   Follow the tubing from the client's chest to the drainage unit, checking each connection and the insertion site dressing. Tighten loose connections and make sure the tubing is not kinked.

3. 03

   Do not clamp it

   Do not clamp the tube close to the chest to try to stop the bubbling. Air that cannot escape builds up in the pleural space and can cause a tension pneumothorax. Clamping is only done briefly and on a provider order, for example when locating a leak or changing the unit.

4. 04

   Escalate

   If you cannot find and fix the leak, notify the provider with your findings.

Care points that appear again and again

• ·Keep the unit below the level of the chest and upright so drainage cannot flow back toward the client.
• ·Do not strip or milk the tubing unless it is the facility's order or protocol.
• ·Report subcutaneous emphysema, a crackling feeling under the skin around the site, along with any new or worsening distress.
• ·If the system is accidentally disconnected or the unit breaks, follow your facility's protocol and notify the provider right away.
• ·Assess and document respiratory status, tidaling, bubbling and drainage at the intervals ordered.