While not all prehospital folks place chest tubes, nearly all of us manage them after placement and in transport. There’s some variation in how these tubes are managed, especially when we consider austere settings, but only a handful of underlaying principles. The hope is that this quick primer will help clinicians feel a bit more at ease when transporting patients with chest tubes. Just know that some of the things we discuss here are contrary to how folks are typically taught. Be sure to practice per the rules and guidelines where you work and recognize that the following information is for educational purposes.
First, let’s just do a quick review of the thing. Chest tubes are placed into the pleural space when it is filled with stuff that shouldn’t be there. This might be air (pneumothorax), blood (hemothorax), a mix of both (hemo-pneumothorax), or other gunk entirely (pleural effusion or empyema). A chest tube is placed to help get whatever stuff is there and shouldn’t be out.
Stuff in the pleural space is problematic because it can impair breathing and exert pressure on the other things that live in the thoracic cavity. Both of which are problematic. Hopefully that’s a review, but if not the fine folks at Ninja Nerd have both a video and a podcast on the subjects of chest tubes and pneumothoraces, respectively:
Now not all cases of stuff in the pleural space warrant a chest tube. Sometimes we can fix the problem with a needle (needle decompression) or just by cutting into the space and venting it with a finger (finger thoracostomy) or by placing some other type of smaller-gauge pleural drain (pigtail or the like). No need to dive deeper for now, but look here for more information on those other techniques: LITFL “Own the Chest Tube”
The things that generally warrant a chest tube are those that cause hypoxia or threaten hemodynamic stability. In the transport setting these tend to be large pneumothoraces and/ or hemothoraces. They can be acute, as in a hemothorax caused by a ballistic injury to the chest, or may develop more slowly over time, as in a pneumothorax that evolves in a patient being mechanically ventilated with high pressures. In any event, we place a tube in the pleural space, get it secured, and then need to figure out how best to deal with the thing now that it’s in there.
There are two strategies we can use to manage a chest tube once it’s in place: application of suction or passive drainage. Let’s take a look at each, in turn.
Suction is generally applied after placement of a chest tube to facilitate re-inflation of a collapsed lung. Said another way, suction allows for the maintenance of a slight negative pressure in the pleural space (similar to physiologic normal or baseline) to help recruit alveoli that may have collapsed within the lung tissue itself. Suction can also facilitate the removal of fluid, as in the case of a hemothorax, although much of that drainage will happen passively. And lastly, suction is also used when there is a continuous leak of air from the airways or lung tissue into the pleural space (more on this idea shortly).
Now when we apply suction to a chest tube, we don’t typically do so by attaching the tube itself via suction tubing to a suction machine, rather we use a contraption that attenuates the suction to a specific goal (an atrium or similar device). If we look at the dial on our bedside or portable suction, the numbers are often in the range of 0-500mmHg with the optimal section notated in the neighborhood of 100-150mmHg.
But with a chest tube we often use 20cmH2O (which is about 15mmHg) and sometimes we go up to 40cmH2O (which is about 30mmHg). These pressures are much weaker than what we’d achieve with normal suction devices. This is important to note, because in the event that we don’t have an atrium on hand (which, as we mentioned, attenuates the pressure to a specific goal), we might be tempted to simply hook up the suction and let it suck all the bad stuff out. This is dangerous because we can injure lung tissue and cause further damage if we use excess suction. Also, it isn’t necessary because, as we already said, whatever fluid has accumulated in the pleural space will likely make its way out via the chest tube passively.
More on the subject of injury related to excessive pressure applied to a chest tube in this archaic 1997 paper from the Annals of Thoracic Surgery: “Thoracic Drainage”
Let’s recap this bit. We often see chest tubes with suction applied at 20-40cmH20 via a chest tube atrium. This low level of suction helps facilitate alveolar recruitment to re-inflate a collapsed lung. Suction should only be applied using an atrium or similar device, it should not take the form of our normal suction machine simply connected, in-line to the chest tube. And if we do we decide, against the aforementioned advice, to attach the chest tube to suction directly, be absolutely sure to keep it the number dialed way down.
So that’s suction. Easy enough. Let’s look at the passive drainage concept now. In this setup we simply allow whatever is in the pleural space to follow gravity and exit from the body via the chest tube. But there’s one extra step: we add in some sort of mechanism that allows stuff out but prevents air from getting back in - a one-way valve.
We need a one-way valve in the system because if we allow air to go back into the pleural space via the chest tube, which will happen every time a spontaneously breathing patient takes a negative-pressure breath, we basically create a sucking chest wound. Which we would all agree is counter to what we are trying to do for our patient.
One-way valves in chest tube systems can take either of two forms. The first is a mechanical one-way valve that we add to the end of the chest tube:
That photo is from an article titled “Heimlich Valve and Pneumothorax” that provides quite a bit of detail on the little device and how to use it.
A one-way valve can also be improvised with a glove or a bag:
For a text-based explanation and the above photo, read: “Improvised Chest Tube Valve for Intra-Hospital Transport”
And this second example which shows how we might do the thing with a glove and a rubber band is from the show notes of an episode of The Dustoff Medic podcast which, sadly, is no longer available: “Tube Thoracostomy (Part 2)”
The other way to do this one-way valve thing is to use a water seal. To make this happen, we simply run tubing from the chest tube into a container of water or saline. As the patient exhales, air that might be in the pleural space escapes from the chest tube via the tubing and it travel up through the fluid into the atmosphere. Then as the patient inhales, the water prevents air from being sucked back into the tubing via the chest tube. A simple setup of this looks like so:
It’s also worth noting that in both systems, either the mechanical valve or a water seal, fluid can also escape. This movement of fluid, however, is largely dependent on gravity, so be sure to keep the system below the level of where the chest tube enters the body. This also prevents whatever has drained into the collection chamber from accidentally making its way back into the pleural space if the container is too full and tips.
Recap number two. Chest tubes can either be placed to suction or be allowed to drain passively. If draining passively, there needs to be some sort of one-way valve in the system to prevent air from traveling the wrong way back into the pleural space. This one-way can be either a mechanical valve or a water seal.
In practice in the modern healthcare system, we pretty much always use an atrium system. This was noted above when we explained that the atrium allows us, among other things, to dial down or attenuate the suction to a specific goal. The atrium serves as a collecting vessel (so we can measure output), a water seal, and a suction device - all in one! Here is a labeled example of one such device:
The above image and the next one are borrowed from Deranged Physiology. For links to pages that have all you need to know about setting up these types of devices, look at the references section at the bottom of their writeup: “Underwater Chest Drain System”
We can also improvise this setup with buckets and tubing we likely have laying around:
Note that the water level in which the tubing is submerged in the third (right-most) bottle correlates to suction applied, regardless of what the suction device or machine is set to. A 10cm column of water means we end up with 10cmH2O (8ish mmHg) of negative pressure in the system.
And then final thing on this whole process is that the typical strategy after placement of the chest tube starts with application of suction, transition to water seal, then removal of the tube. Sometimes there is an intermediate step of clamping the tube for a certain amount of time in between the water seal and removal steps - this allows us to see if a pneumothorax re-develops. If it does, simply unclamp and consider reapplying suction.
To read more on this idea: Clamping of Thoracostomy Tubes: A Heretical Notion?
And then the transition to water seal step happens when we think the lung has re-inflated and there is no longer air in the pleural space. We make this determination based on imaging (CXR, not POCUS since lung sliding may not return for many days) and/ or resolution of an air leak and cessation of tidaling. For a review of these concepts (air leak and tidaling), as well as bedside management of chest tube in the hospital setting, listen to this excellent podcast overview: Straight Nursing Podcast “Build Your Confidence Working with Chest Tubes”
And here’s a one-page cheat sheet to summarize or review those things: ICU One-Pager “Chest Tubes”
As a quick side note: there are many places around the world that don’t use suction at all and simply manage chest tubes by water seal alone. It’s just that the lung re-inflates slower without the extra assistance of applied suction. We showed one example already, but here’s another:
Next let’s talk about problems that can happen along the way. Problems basically come in two flavors - either the system is broken open in some way or it inadvertently gets occluded. There are also issues related to increases and decreases in output, but that’s a bit beyond the scope of this discussion. Suffice it to say we should receive in our patient report or handoff what is to be expected, in terms of output, and what it might indicate if we are significantly above or below that goal.
Back to the two main issues: disconnection and obstruction. It’s worth mentioning that there is a bit of a difference in what can go wrong based on whether the patient is spontaneously breathing or mechanically ventilated. As we already discussed, spontaneous ventilation occurs via a negative pressure mechanism. Contraction of the diaphragm and expansion of the chest wall cause an increase in intrathoracic space, a decrease in pressure, and movement of air into the lungs. If there is a hole in the chest, either a sucking chest wound caused by an injury or a tube put in place by a clinician, this can result in a pneumothorax that can then tension as more air is sucked into the pleural space with each breath exacerbating the pathophysiologic process. This is why the one-way system is important.
In the mechanically ventilated patient, the situation is a bit different. Imagine the following: totally normal and healthy patient with a chest tube in place, the tube goes from the outside world through the chest wall into the pleural space, the patient is paralyzed and ventilated with positive-pressure ventilation, the chest tube is unclamped and not connected to any sort of drainage or one-way system. In this hypothetical situation, the risk if a pneumothorax developing is quite low, as any air that may make its way via the chest tube into the pleural space on exhalation will be pushed back out with inhalation when a positive-pressure breath is given and the lungs expand.
That said, this situation rarely happens. More often a chest tube is placed in response to some sort of trauma that penetrates deeper than the pleural space and its linings and goes into the lung tissue itself. In these sorts of injuries air can get into the pleural space as we deliver positive-pressure breaths from the airways themselves - air simply escapes from the site of injury at the lung tissue and gets into the pleural space from the inside. A chest tube gives that air in the pleural space a place to escape to, so long as it is patent and open. Think of it as pneumothorax occurring from the inside out rather than the outside in:
Versus how we often think of it (shown below). And this how we think of it situation may be specific to EMS because we seem to focus a lot on traumatic injuries and chest seals and the like.
This idea of a continuum between pneumothorax and bronchopleural fistula is mentioned here, along with a general overview of the ICU management of both issues: IBCC Chapter on “Pneumothorax and Bronchopleural Fistula (BPF)”
In the inside out pneumothorax situation, a kink in the tube or clamping it intentionally would inhibit this escape of air. This problem is amplified if the patient is being ventilated mechanically or via positive pressure, as we are pushing air out of that injury site with each breath. For that reason, we often advise clinicians not to clamp chest tubes. This general stance against chest tube clamping is very common in many places.
In other places, however, it is common practice to clamp the tube during transitions. This might be while moving a patient from a bed to a stretcher, while in CT scan, while getting out of bed, etc. The reason for this is that there are also risks of a disconnect occurring in the system. For example, maybe the tubing to the atrium gets snagged and pulls off. In the spontaneously breathing patient, as we talked about earlier, this could result in a new or worsening pneumothorax. In the mechanically ventilated patient, however, clamping itself may pose a greater risk.
One way to conceptualize this is by way of a matrix. Clamping and disconnection have different likelihoods of poor outcome (i.e., a pneumothorax, new or worsening) depending on whether the patient is breathing spontaneously or mechanically ventilated:
There’s also a time component, as these risks of complication decrease with resolution of the pneumothorax:
If we agree on these two matrices, which may actually be up for interpretation (and do reach out with thoughts on this!), the only risky scenario that is consistently risky would be spontaneously breathing patient with an accidental disconnect. So we could make the case to clamp the chest tube for spontaneously breathing patients and then either apply that rule across the board or have an alternate “leave unclamped” rule for vented patients.
In practice, however, it probably makes the most sense to leave the system intact and unclamped but have clamps or hemostats on hand to troubleshoot if needed. This idea of having all the things needed to troubleshoot a chest tube issue is mentioned in this open-source textbook chapter: Clinical Procedures for Safer Patient Care “Chest Tube Drainage Systems”
This decision, however, could arguably vary depending on what sort of system we have attached to the tube. If we are using a simple water seal of the variety that is just a bottle with tubing partially submerged, we may opt to clamp the thing to avoid fluid spilling back from the bottle into the tubing and into the pleural space as the patient is packaged. Especially if the patient needs to be carried or the maneuvered into any position other than supine.
In the scenario shown below, a patient has been packaged for transport with a water seal system placed between his legs. There is a risk that the bucket could spill or tip and that fluid could make its way back into the pleural space. Or even that the distal end of the suction tube gets released to air and therefore the water seal is broken. For this reason, some may advocate to clamp the tube during movement.
And then what about suction? Totally AOK to stop suction, transition to water seal, then reattach to suction later on. Suction is used to facilitate re-inflation, but stopping or pausing it doesn’t mean that the lung will automatically deflate again. The water seal is our one-way valve to keep things stable and maintain progress until we get suction up and running again.
One caveat here is that in cases where there is significant leak of air from the lung tissue itself or the lower airways, similar to a bronchopleural fistula, cessation of suction can make a pneumothorax worse. In these cases, be sure to keep any interruption in suction to the absolute minimum needed to do whatever it is we need to do. It probably isn’t ever necessary, except in rare cases, to maintain suction with a portable machine during movements, just focus instead on being efficient.
Now on to troubleshooting!
First rule is to try not to dislodge the tube. Seems obvious enough. In general, these tubes are fairly well secured with sutures, but we know how these things can happen. And if you have a tube that doesn’t seem secure, make it so.
Video demonstration of one technique that can be used to secure a chest tube with towel clamps (i.e., if no sutures are available or if the sutures have failed somehow): “Towel Clamp Temporary Chest Tube Securing Method”
And here’s a screenshot of the procedure halfway through that shows one of two clamps in place to give the gist of the thing:
We could also use copious amount of whatever super-sticky tape happens to be on hand, so long as we keep the tube in place and don’t inhibit normal chest wall movement in the process.
Worst case with pulling the tube out completely is that we cause another one of those sucking chest wound scenarios and have to apply a seal as we would in any other setting with that sort of injury. We are more likely to need a chest seal the further away in time we are from initial placement. For example, if we put a hole through the chest wall and then let it go immediately, as in performing a finger thoracostomy, the hole will likely get sealed up as the tissue of the chest wall falls back in to place. But if we stick a tube in the space for a week or two, some healing takes place, and we are more likely to have a hole remaining when the tube is removed. For this reason, some folks say to not worry about an occlusive dressing after finger thoracostomy, but it is generally expected and encouraged with chest tube removal.
This idea is discussed in passing here: Foamfrat Podcast “Finger Thoracostomy w/ Dr. Cynthia Griffin”
In any case, let’s try not to dislodge the chest tube. And if it does get removed accidentally, go ahead and place an occlusive dressing for good measure and monitor for the need to decompress or vent just as we would with any other use of an occlusive dressing to the chest.
For a thorough discussion on chest seals, consider listening to this episode of The EURMED Podcast: “To Chest Seal or Not to Chest Seal”
If the tube dislodges only partly, we need to determine if it’s still useful or not. There are a few ways to do this. If we have a water seal in place that is also to suction, worsening or new bubbling indicates a leak (i.e., the system is no longer useful or not as useful as it was before). If we are to water seal only, we can attach to suction as a diagnostic tool. This involves clamping the tube and seeing if the leak resolves. If we clamp at the chest tube itself and the leak resolves, we know the issue is in the lungs or in the tube itself; if the leak persists, the leak is somewhere downstream. This concept of clamping to diagnose a leak is discussed in the Straight Nursing Podcast “Build Your Confidence Working with Chest Tubes” which we have mentioned already.
If we have a chest tube to an improvised water seal or to a one-way valve in which we can’t apply suction, we may be able to hear or feel a leak instead. We can also look at the thing directly, which will require taking the dressing down to visualize where the tube enters the skin, and see if it’s still where it should be - if we see holes (aka fenestrations), then we have a problem.
Image showing fenestrations in chest tubes borrowed from “Managing Chest Tubes: Air Leaks and Unplanned Removal”
There is the case that no fenestrations protrude outside of the body, but rather rest in the chest wall tissue itself. In this case we may see new or worsening subcutaneous emphysema. Be sure to do the normal patient assessment things and get professional hands on the patient’s body to look for this sort of thing.
If we have a dislodgment and are sure it’s not a leak elsewhere in the system (because we clamped the tube itself and saw the leak go away or because we took the dressing down and got eyes on the insertion site and saw fenestrations showing or found evidence of new subcutaneous air, all as mentioned above), there are a few options that may come to mind: re-insert the tube, seal the holes, remove the tube.
Typically, only one of these options, remove the tube, is endorsed for a partially dislodged tube, but let’s work through the other options just for good measure to explore why that is the case.
Reinsertion of the same tube is generally discouraged due to concerns for sterility. This take, however, is based on the assumption that we have the capability to repeat the procedure at a new site on the chest wall in a safe and clean manner. That assumption may not always be true. For this reason, re-insertion or repositioning of a displaced tube may need to be considered if the tube is for sure needed and there is no possibility of placing a new one or decompressing the pleural space by some other means.
Alternatively, we could, theoretically, leave the thing as is and cover with a chest seal or air-tight tape or occlusive dressing - basically try to reseal the device and hope that the tip of the tube remains in the pleural space. We aren’t actually aware of any case studies or documentation of salvaging a chest tube in this way by using a chest seal or the like, but if anyone out there has anything on the idea get in touch and we’ll look into it. It seems unlikely and would generally be discouraged, as we’d likely end up with lots of subcutaneous air - if we can see holes or fenestrations outside the body, there are more on the inside and they may track into the tissue of the chest wall. So resealing a partially dislodged tube is probably not a good idea. And this would matter more (as in be a more significant problem) with a mechanically ventilated patient.
And if we do decide to reinsert or salvage a partially dislodged chest tube that was previously to water seal, it may make sense to apply suction once we get the thing working again. Applying suction alone will not fix the problem of a dislodged tube with a leak but can help mitigate the development of a pneumothorax or the spread of subcutaneous emphysema after the primary fix is in place.
Chest tube removal, our other option, is the pathway that is generally recommended. Again, this assumes our ability to place a new tube if needed, so if that isn’t the case, we may need to explore alternatives. Chest tube removal is typically done with a bit of forethought and while having the patient hold their breath or while performing an inspiratory pause if ventilated. In the case of a partially dislodged tube in which air may have already made its way into the pleural space, it could theoretically help to do these things as soon as the issue is identified, but probably not a big deal if we don’t recall this step in the moment. The bigger deal would be leaving the air leak in place and allowing even more air to get inside and worsen the pneumothorax. Note that this one matters more with the spontaneously breathing patient.
Video demonstration of a simulated chest tube removal: HealthPartnersMedEd “Chest Tube Removal”
If the chest tube remains in place and has not dislodged, rather it is simply the case that the tubing extending from it has disconnected somehow, this too can also cause problems.
For the spontaneously breathing patient, this situation can cause the development of a pneumothorax. First step, then, is to clamp the tube to prevent that pneumothorax from developing, then get your system and one-way valve back in action. For the ventilated patient the need to clamp the thing right away may be less important, so just get the system set back up.
If there are time and resources, recall that this circuit of atrium, tubing, chest tube runs inside the patient’s body. This means that a break in the system and tubing dragging across the clinic or ambulance floor puts the patient at risk for infection. One more reason to always try and keep the system intact. Also consider swapping tubing if indicated or cleaning contaminated components.
Now it may have become apparent that there’s a bit of nuance to this discussion depending on whether the patient is ventilated or not. If we can remember those specifics, great. If not, fine. We can also manage chest tube issues with a systematic process that is the same regardless of what is going on with the patient. The reason we can do this, despite all the differences discussed, is that all of the bad outcome scenarios take time to develop. So if we have a system in place to correct an issue in a timely manner, it doesn’t really impact the patient in an adverse way overall.
Let’s play it out step by step to make this idea clear. Imagine we are loading a patient with a chest tube into our ambulance or aircraft. The chest tube snags on something, gets tugged, and the tubing to the atrium disconnects. Clamp the tube, reconnect to the atrium, and reassess. Specifically, reassess to make sure the chest tube is still in place and working as intended.
Even if this patient is mechanically ventilated early in the course of a penetrating chest injury and we know for sure that there is a risk for worsening a pneumothorax with a clamped chest tube, it’s fine to have the thing clamped for a few moments while we fix the system. Just don’t forget to unclamp it as soon as you can.
And what if during this shuffle we drop the atrium and it breaks and now we’ve lost our water seal? No big deal. Clamp the tube and make a new one-way valve. Use a commercial device, improvise one with a glove and tape, or reattach tubing to the end of the chest tube and submerge the other end in some sort of sterile fluid. And then once that’s done, unclamp the tube and reassess.
The idea here is that while it may be fun and nerdy to discuss the nuances and it’s worth knowing the “why” behind these things, in reality when there’s a problem to be solved, we need a simple, actionable plan that can be utilized in all situations without having to think too hard.
One final subject: accidental occlusion in the system. We’ve covered already why it can be problematic to clamp the system in different scenarios, but let’s consider what to do if this happens unintentionally. First is to identify the problem. Indications could include loss of tidaling and/ or bubbling, decrease in output, and/ or development of a pneumothorax (and therefore any of the associated signs and symptoms that go with that).
Obviously, it’s fine and encouraged to remove a physical obstruction if the chest tube or tubing got pinched somehow from the outside. For internal obstructions, such as a clot of blood or tissue, there are some considerations. First is that most of these blockages will resolve without intervention or with suction (low and continuous, as described previously). If we are worried, it is OK to roll the tube or tubing between the fingers to try and break up a clot, but stripping the tube is problematic because that can generate significant negative pressure which (as discussed way earlier) can cause injury or further complication. If we’re just to water seal and have a presumed clot, apply to suction, and give it time.
There are some other interventions that we can employ to make a clotted chest tube patent again, but these are not often utilized for tubes placed in the pleural space. This is because we can generally fix the complication of an occluded tube if it does occur (i.e., decompress a pneumothorax) and also because many cases of clotted chest tubes resolve on their own.
If there is a blockage that results in the worsening of a pneumothorax with signs of tension and we can’t get the chest tube or the system cleared, treat as any other pneumothorax with needle decompression, finger thoracostomy, or placement of a new tube. We don’t need to take the occluded chest tube out in the moment, as this can be deferred until later or it may even clear with time.
More on all of this and other fun things here: “Thoracostomy Tubes: A Comprehensive Review of Complications and Related Topics”
And actual very last thing is what to use to clamp the tube. Whatever is on hand. Some atriums have little plastic slider clamps that can be used along the tubing itself:
You can also pinch the tube or tubing with fingers, fold it over on itself and tape it, use clamps, etc. Doesn’t much matter which type of clamp, but if we have access to big ones with no teeth, that’d be preferred. And if not, even the small ones with teeth work just fine. Chest tubes and suction tubing are thick and fairly difficult to chew apart. The more important thing is to work through troubleshooting systematically and remove the clamp once the system is working again as it should.
Let’s summarize all of this and then we’ll call it a day.
Chest tubes are used to fix issues caused by unwanted stuff in the pleural space. At a minimum, chest tubes drain passively with a one-way valve system in place. We may also apply a low level of suction to facilitate lung re-inflation.
Clamping the chest tube is fine for short periods of time and some people and places do that routinely during transitions or movement of the patient. That said, many places advocate to avoid clamping unless necessary and to focus, instead, on safe movement practices and not breaking the system in the first place. As for suction, it’s OK to discontinue during transitions and then reapply afterwards.
Troubleshooting emergencies is largely dependent on having the stuff you might need on hand or close by and approaching issues in a systematic manner. Breaks in the system, accidental dislodgment/ removal and inadvertent occlusion can all be identified and treated quickly to prevent acute deterioration in patient status.
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