Chest Tube Management for Respiratory Therapists
The RT's role in chest tube care — drainage system assessment, air leaks, transport safety, and clinical escalation.
For educational reference only. Procedural and clinical management information on this page is intended for educational context only. Procedures must be performed by qualified, credentialed professionals following physician orders, institutional protocols, and competency requirements.
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The RT's Role in Chest Tube Care
Respiratory therapists frequently encounter chest tubes as part of managing ventilated or critically ill patients. While thoracic surgeons and critical care physicians place and manage chest tubes, RTs must be able to assess the drainage system, recognize complications, safely transport patients with tubes in place, and escalate concerning findings promptly.
In some institutions and under specific protocols, experienced RTs may participate more actively in chest tube management — including monitoring drainage system integrity, troubleshooting air leaks, and assisting with tube assessment during spontaneous breathing trials or weaning. Know your facility's specific scope.
Common scenarios where RTs interact with chest tubes: mechanically ventilated patients with pneumothorax or hemopneumothorax, post-operative thoracic surgery patients, patients with large pleural effusions requiring drainage, and transport of ICU patients with active chest drainage.
Indications for Chest Tubes
Understanding why a chest tube is present provides context for what to expect from the drainage system and what changes in drainage would be clinically significant.
Pneumothorax
Air in the pleural space. Large pneumothoraces, tension pneumothorax (emergency), or smaller pneumothoraces in patients on positive pressure ventilation (who are at high risk of progression) typically require tube placement. The drainage system will show air bubbling.
Hemothorax
Blood in the pleural space — trauma, post-surgical bleeding, or spontaneous in coagulopathic patients. Output is bloody initially, transitioning to serous as the collection resolves. Monitor output volume closely.
Pleural effusion
Large effusions causing respiratory compromise, empyema, or malignant effusions may require drainage. Output appears straw-colored (transudative), cloudy (exudative or infected), or frank pus (empyema).
Post-thoracic surgery
After lobectomy, pneumonectomy, or other thoracic procedures, chest tubes drain residual blood, fluid, and air while the pleural space heals.
Three-Chamber Drainage System
Modern disposable chest drainage units (CDUs) — such as the Pleur-evac — incorporate three functional chambers in a single device:
Water Seal vs. Suction
Chest tubes can be placed on either suction (active negative pressure) or water seal (passive drainage with no applied suction). The choice is physician-directed and depends on the indication, the rate of air or fluid output, and the phase of treatment.
Suction (typically –20 cmH₂O): Used when faster drainage is needed, when the lung is not fully expanded, or when air leak is significant and the pleural space needs active evacuation. Higher negative pressure risks injuring the lung parenchyma if applied when the lung is already fully expanded.
Water seal only: Passive drainage — used when the air leak has resolved or drainage is minimal, as a trial before tube removal, or when the patient is being assessed for tube discontinuation. The lung's elastic recoil drives passive drainage.
A patient's clinical status may change with a transition from suction to water seal. Be prepared to assess breath sounds, respiratory effort, and oxygenation closely around suction-to-water-seal transitions.
Tidaling and Air Leaks
Tidaling refers to the movement of the water level in the water seal chamber with the respiratory cycle. During inspiration, intrathoracic pressure decreases, pulling the water level up. During expiration, pressure increases and the water falls. Tidaling of 5–10 cm with normal breathing is expected.
Loss of tidaling can indicate: tube occlusion or kinking, the lung has fully re-expanded (no longer a space for fluid to fluctuate), the tube is no longer in the pleural space, or that the tube has been inadvertently clamped.
Air leak assessment is performed by observing bubbling in the water seal chamber:
- Bubbling only during coughing or forced exhalation: small, resolving air leak — expected early after pneumothorax drainage.
- Continuous bubbling: ongoing air leak from the pleural space, a bronchopleural fistula, or (importantly) a leak in the external drainage circuit itself.
- No bubbling: air leak has resolved, or the tube is occluded.
To differentiate a patient-side air leak from a circuit leak: temporarily clamp the tube close to the patient. If bubbling stops immediately, the leak is from the patient side. If bubbling continues, the leak is in the external circuit (connection, CDU).
Transport Considerations
Patients with chest tubes require careful preparation for transport. The drainage system must remain functional and below chest level throughout transport to maintain effective drainage and prevent backflow.
- Never clamp a chest tube during transport unless specifically ordered and in a monitored setting — a clamped tube in a patient with an active air leak risks tension pneumothorax.
- Keep the CDU below chest level at all times to prevent backflow of drainage fluid into the pleural space.
- Ensure all connections are secure before leaving the unit.
- Know the current drainage output, air leak status, and tidaling before transport.
- Have suction available at the transport destination if the patient requires active suction.
- Monitor SpO₂, respiratory effort, and breath sounds continuously during transport.
Escalation Red Flags
Contact the physician or rapid response team immediately if any of the following occur:
Reviewed by RTB2 Editorial Team
Last updated April 2026