Nursing care
Chest Tube Management: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Chest tube nursing management centres on reading the water seal chamber correctly: gentle rise and fall with breathing, called tidaling, is expected, while continuous bubbling means an air leak in the system. Clamping the tube to troubleshoot is almost always wrong, because it can trap air or blood and cause a tension pneumothorax.
When it is done and why
Chest tubes drain air, blood, or fluid from the pleural space to re-expand the lung and restore negative intrapleural pressure. Indications include pneumothorax, haemothorax, pleural effusion, and post-thoracic or cardiac surgery, where the tube prevents accumulation while the pleura heals.
The size and position of the tube depend on what's being drained: air rises, so a pneumothorax tube is placed higher and anteriorly, while fluid or blood pools, so a haemothorax or effusion tube sits lower and posteriorly. Knowing which condition is being treated tells you what to expect in the drainage chamber and what a sudden change means.
Preparing the patient
Confirm consent, verify the insertion site with imaging or the provider's marking, and gather the chest drainage system, sterile dressing supplies, and local anaesthetic before the provider begins. Position the patient supine or slightly elevated with the arm on the affected side raised above the head to widen the intercostal space.
Explain that they'll feel pressure and a pinching sensation despite local anaesthesia, and that a chest x-ray will follow to confirm tube placement. Pain control matters here: unmanaged pain after insertion leads to shallow breathing and poor cough effort, which raises the risk of atelectasis and retained secretions.
The steps that matter for safety
Once the system is running, tidaling in the water seal chamber, the fluid level rising with inspiration and falling with expiration in a spontaneously breathing patient, confirms the tube is patent and the system is connected to the pleural space. Continuous bubbling in that same chamber is different: it signals an air leak somewhere in the system, from the pleural space itself, a loose connection, or an insertion site that isn't sealed, and it needs tracing back to source rather than ignoring.
Keep the drainage system below the level of the patient's chest at all times to prevent fluid siphoning back into the pleural space, and keep tubing free of dependent loops that trap fluid and impede drainage. Clamping the tube is almost always the wrong response to a problem: it can convert an open pneumothorax into a tension pneumothorax by trapping air with nowhere to escape. The only situations where brief clamping is appropriate are locating a leak, changing the drainage unit, or on specific provider order, and never to 'wean' the tube.
During the procedure — the nurse's role
Assist the provider by maintaining sterile technique, positioning the patient, and monitoring vital signs and oxygen saturation throughout insertion. Once the tube is secured, connect it to the drainage system and check suction is set to the ordered level, usually -20 cmH2O, evidenced by gentle continuous bubbling in the suction control chamber, not the water seal chamber.
Secure the tube to the chest wall to prevent dislodgement and apply an occlusive dressing over the insertion site. Confirm a portable chest x-ray is ordered to verify placement, and keep a clamp and sterile petroleum gauze at the bedside in case the tube is accidentally removed, since an open chest wound needs immediate three-sided occlusive dressing, not clamping.
After: monitoring and complications
Monitor drainage amount, colour, and consistency hourly initially, marking the level and time on the collection chamber. Notify the provider if drainage exceeds 100 mL/hr or turns suddenly bright red, which can indicate active bleeding, and if drainage abruptly stops in a patient who was previously draining well, since this can mean a kink, clot, or the tube pulling out of position rather than resolution.
Watch for subcutaneous emphysema around the insertion site, felt as a crackling sensation under the skin, which suggests air leaking into the tissue rather than draining through the tube. Auscultate breath sounds regularly to detect re-expansion or a worsening pneumothorax, and reassess respiratory rate, effort, and SpO2 with every set of vitals.
Documentation and teaching
Document drainage volume and characteristics at each check, the presence or absence of tidaling, any bubbling and where it occurs, suction level, and the condition of the insertion site and dressing. Record deep breathing and incentive spirometry use, since these support lung re-expansion around the tube.
Teach the patient not to lie on the tubing, to keep the drainage unit upright and below chest level even when walking, and to report sudden chest pain or breathlessness immediately. Before removal, they should know to perform a Valsalva manoeuvre or exhale fully as instructed, since the timing of the breath during removal affects the risk of air re-entering the pleural space.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our respiratory practice questions are the closest set to what this page covers.
Common questions
What does continuous bubbling in the water seal chamber mean?
Continuous bubbling in the water seal chamber indicates an air leak somewhere in the system, either from the patient's pleural space or from a loose connection along the tubing. It should prompt you to check every connection and the insertion site dressing before assuming the leak is coming from inside the chest.
Is tidaling in the water seal chamber normal?
Yes. Gentle rise and fall of the fluid level with the patient's breathing, rising on inspiration and falling on expiration in a spontaneously breathing patient, confirms the tube is patent and connected to the pleural space. Absence of tidaling can mean the lung has fully re-expanded or that the tube is obstructed or kinked.
When is it appropriate to clamp a chest tube?
Rarely. Clamping is reserved for briefly locating an air leak, changing the drainage unit, or by specific provider order, and it should never be used routinely to manage drainage. Clamping a tube draining an active air leak can cause a tension pneumothorax, so it's not a default troubleshooting step.
What drainage amount should be reported to the provider?
Report drainage exceeding 100 mL/hr, a sudden change to bright red output, or drainage that stops abruptly after previously flowing well. Each of these can signal active bleeding, a new complication, or a mechanical problem such as a kinked or dislodged tube rather than genuine improvement.
What should a nurse do if a chest tube falls out?
Immediately cover the insertion site with a sterile occlusive dressing taped on three sides, leaving one side open to allow air to escape and prevent a tension pneumothorax, then call for help and monitor respiratory status closely. Do not attempt to reinsert the tube.