Department of
JOB AID
Developed by:
Critical Care Department
Formulated:
Revised:
September 2005
June 2010
Ref Policy #
PCS # VI-C-5
Policy Link
Page 1 of 2
Task/Process:
Chest Tube Insertion, Management, and Removal
Purpose:
To provide guidelines for assisting physician with safe chest tube insertion and removal,
while providing the nurse with instruction in the management of the patient with a chest
tube(s) and closed drainage system.
Materials:
 Thoracotomy tray/chest tube tray; chest tube of physician’s choice;
chlorohexidine based antiseptic or cleansing solution of physician’s choice; sterile
4x4s and split drain sponges; sterile water; petroleum/Vaseline gauze; tape of
choice; closed chest drainage system; Rubber tipped or “booted” clamps OR large
hemostats without teeth; suture of choice; scalpel; connecting tubing; bedside
suction canister; disposable suction canister.
FOR ALL PATIENT CARE PROCEDURES, BE SURE TO DO THE FOLLOWING:
As appropriate: Verify or secure order, verify informed consent, introduce yourself and identify the
patient per policy, explain procedure, wash your hands and use appropriate PPE as required for the
procedure.
To set up Ocean water seal
suction drainage system

Assemble supplies

Set up closed drainage system

To set up closed drainage system:
 Obtain closed drainage system from supply area
 To fill water seal chamber per manufacturer’s guidelines
 Filling the water seal chamber above 2 cm will increase the
work of breathing and a level less than 2 cm increase risk
of air entering water seal chamber.
o
Attach the funnel to the short tubing on the closed
drainage system, hold funnel lower than the top of
the closed drainage system and fill the entire funnel
to the top. Raise funnel above the top of the closed
drainage system and the water seal chamber will fill
to the 2cm level
 To fill the suction control chamber:
1.
o
Remove vent plug located on top of device
o
Fill suction chamber with sterile water to – 20cm for
the adult; -5 to -10 for the child or as ordered by
physician.
o
Replace vent plug
Cont. from above

Be prepared to connect the drainage system to the patient’s chest

tube as soon as physician inserts chest tube

When the chest tube is inserted, connect the chest drainage
system to chest tube by connecting the long tubing from the
drainage collection chamber to the chest tube. Secure connection with
tape
To set up Oasis dry suction
chest drainage system
Heimlich Flutter Valve
1.

Attach short tubing from chamber to suction source; adjust
suction source until gentle, constant bubbling is observed

Fill water seal chamber to the 2 cm line

Connect patient tube to the patient

Connect suction to chest drainage system

Turn suction source on. Increase suction source vacuum to
80mmHg or higher. Suction regulator on the chest drainage device
is preset to -20cmH2O. Adjust to suction level ordered by
physician.

The flutter valve is a one way valve which allows air to flow out of
the chest cavity when the patient exhales, but prevents air from
entering the chest cavity during inhalation.

The flutter valve is connected to the chest tube and left open to
air or attached to a small drainage bag.

Attach flutter valve to the chest tube on the blue side so that the
other end is open to air.

Leave flutter valve open to air unless there is drainage present or
physician writes orders to place valve to drainage system/bag.

The flutter valve can be connected to a vented drainage system if
necessary.

In the event there is a need or order to switch to a closed
drainage system, clamp chest tube using rubber tipped hemostats,
remove the flutter valve, attach closed drainage system, and then
remove clamp. Secure connections as described above
Insertion
Chest tube insertion is a sterile procedure and should be
performed as such.
A. Verify informed consent.
B. Perform Time Out
C. Pre medicate as ordered.
D. Assist with positioning patient. Typically, for treatment of
pneumothorax the patient remains supine or in Fowler’s position.
For hemothorax, the patient may need to lean over the over
bed table.
E. Open trays and supplies using sterile technique.
F. The patient should be instructed not to cough breath deeply or
move suddenly.
G. When the chest tube is inserted, connect the chest drainage
system to chest tube by connecting the long tubing from the
drainage collection chamber to the chest tube. Secure
connection with tape
H. Attach short tubing from chamber to suction source; adjust
suction source until gentle, constant bubbling is observed
I. Pleural chest tubes should be should be wrapped at insertion
site with petroleum or Vaseline gauze to promote an airtight
seal.
J. Securely tape the junction of the chest tube and chest
drainage system.
K. Stabilize chest drainage system on floor or hang on side of bed.
L. Obtain vital signs every 15 minutes for one hour, then every
hour for 3 hours or as ordered. Assess for signs of worsening
pneumothorax, such as: tachypnea, diminished or absent breath
sounds, respiratory distress, cyanosis, tachycardia, hypotension
and/or tracheal shift.
M. Obtain chest X-ray as ordered.
To apply a dressing to
the chest tube exit site
1.

Once the chest tube is inserted, apply an occlusive dressing using
drain sponges and 4x4s or as ordered. If no order, apply petroleum
(Vaseline) gauze around the tube at the insertion site.

Date and time the dressing

Document in medical record location, size chest tube, date and
time of insertion, type chest drainage system, characteristics of
any drainage, type of suction if any in medical record
Nursing Management
Chest Tube Management
in the Cardiovascular
Surgery Patient

Maintain tight connections between the chest tube and chest
drainage system. Check chest tube, connecting tube and all
connections for leaks.

If chest tube and closed drainage system become disconnected,
reconnect immediately or re-establish underwater seal by
immersing the open end of chest tube in a cup or bottle of water
until system is reconnected.

Prevent dependent loops in the tubing.

If chest tube comes out, seal site quickly with sterile petroleum
gauze. Notify physician.

Chest tubes should not be stripped. If a clot is suspected, the
tube may be gently milked until flow is restored.

If drainage suddenly stops or there is other evidence of
obstruction and patency cannot be restored quickly with gentle
milking, notify the physician.

Clamping of chest tube is contraindicated. However, in the rare
event that clamping is necessary; the tube should be clamped for
no more than 1 minute.

Situations which may necessitate brief clamping are: locate source
of air leak, replace drainage canister, assessing for readiness for
chest tube removal.

If tube is clamped for any reason or becomes obstructed, observe
for signs of pneumothorax such as respiratory distress, cyanosis,
hypotension and/or tracheal shift.

Assess and record chest tube drainage amount hourly x 12 hours
immediately post-op. May record every 2 hours thereafter if chest
drainage is less than 50 ml/hr.

Notify surgeon if any of the following occurs:

Drainage > 200 ml/hr
 Visible clot obstructing flow of drainage. If unable to
manually break up clot with gentle milking of the tubing,
prepare for embolectomy procedure
 Bubbling at chest tube insertion site.
1.
Cont. from above
 Tidaling or fluctuation in tubing or water seal for
mediastinal tube ONLY.
 Chest X-ray showing widened mediastinum
Patient Assessment









Removal
1.
Assess vital signs, including rate and depth of respirations every 4
hours and PRN. Refer to unit specific guidelines for assessment
intervals.
Assess respiratory status, skin color, comfort level. Monitor for
respiratory distress, subcutaneous emphysema, chest pain,
excessive bleeding.
Notify the physician for bloody drainage > 200 ml/hr, sudden
cessation of drainage, and new onset of subcutaneous emphysema
(The presence of air in the subcutaneous tissue is characterized as
a crackling sensation on palpation).
Notify physician for any signs and symptoms of tension
pneumothorax
Monitor amount and character of drainage. Mark the drainage
amount in the collection chamber as ordered or at least every 8
hours and record as output.
Assess for air leaks as indicated by bubbling in the water seal
chamber.
Assess for fluctuation or tidaling in the tubing or in the water seal
chamber.
Document all the above in patient’s electronic medical record.

Organize necessary supplies

Pre-medicate as ordered. Optimal pain relief is provided when
medication is given approximately 30 minutes prior to chest tube
removal.

Position patient in Semi-Fowlers position or on unaffected side as
ordered.

When physician is ready to remove chest tube, have the patient
take a deep breath and hold it.

After removal of chest tube, apply occlusive dressing per MD
order. If no MD order for dressing, immediately place petroleum
gauze over the insertion site and apply occlusive dressing using
sterile 4x4s
Cont. from above
Documentation should
include:

Assess patient after the procedure and compare results to
previous assessment.

Document date and time of chest tube removal in medical record.

Obtain chest X-ray as ordered.

Obtain vital signs as ordered and observe for signs of
pneumothorax, subcutaneous emphysema, pericardial effusion or
cardiac tamponade, etc.

Education of patient and family pre-procedure and postprocedure

Assessment findings pre-procedure and post-procedure.

Date and time of insertion and removal of chest tube(s).

Type dressing applied post-insertions and post-removal.

Date and time of dressing changes.

Size chest tube used.

Amount, color, characteristics of chest tube drainage.

Unexpected outcomes.
REFERENCES
PC Policy VI-C-5
AACN Procedure Manual for Critical Care 5th Ed. 2005
1.