Tube thoracostomy is often used to treat pleural effusion, pneumothorax, hemothorax, hemopneumothorax, and empyema. The use of chest tubes has been described as early as the Hippocrates era (460 BCE) when metal chest tubes were used for the treatment of empyema. [1, 2] Playfair is credited as being the first physician to use a water-sealed chest drainage system in 1873 for treating a child with empyema thoracis. Chest tube placement techniques evolved and were perfected during the 1918 flu epidemic in World War I and then during the management of combat injuries in World War II. 
Physiologically, a potential space exists between the parietal pleura (abutting chest wall) and the visceral pleura (abutting lung parenchyma), which normally contains less than 25 mL of pleural fluid. The presence of excess fluid, air, blood, chyle, or pus in this pleural space results in displacement of pulmonary volume, which disrupts gas exchange. Prompt drainage of this abnormal intrapleural collection is required to restore normal pulmonary mechanics. In other scenarios, indwelling chest tubes may be placed for postoperative management of patients after lung resections in order to facilitate creation of space for lung reexpansion. Because chest tubes are used to treat patients with both medical and surgical diagnoses, physicians should be familiar with the appropriate management of patients with these drains. Despite its wide spread use, high-quality, prospective data to guide postplacement management of chest tubes are lacking and current management of patients with chest tubes is driven mainly by anecdotal experience and institutional protocols. [3, 4] Improper management of inserted chest tubes results in premature or delayed removal, both of which may be associated with increased morbidity, hospital stay, and costs. This article discusses the essential and pragmatic concepts of postplacement management of patients with chest tubes. For details on the technique for chest tube placement, please refer to Tube Thoracostomy. 
Indications for chest drains include the following:
Pneumothorax (spontaneous, tension, iatrogenic, traumatic)
Malignant effusions (pleurodesis)
Video-assisted thoracic surgery (VATS)
The need for emergent thoracotomy is an absolute contraindication to tube thoracostomy.
Relative contraindications include the following:
Pulmonary, pleural, or thoracic adhesions
Loculated pleural effusion or empyema
Skin infection at the chest tube insertion site
Following chest tube placement, anesthesia is not required during the management phase.
At the time of tube removal, in an adult, 5 mL of 1% lidocaine hydrochloride is infiltrated with a 24-gauge needle around the emerging tube at the chest wall. Alternatively, premedication with oral or intravenous narcotic medication can be considered prior to chest tube removal.
In current practice, commercial chest tube kits are readily available. However, in resource-limited settings, the following equipment is necessary for optimally managing patients with chest tubes:
Chest drainage bottles (see description of drainage system below)
Adequate length (1.5-2 m) of sterile, transparent, plastic tubing (eg, vinyl/silastic)
Appropriate sterile connectors
Angled clamps (2) for clamping the tube when needed
Distilled water to fill in the drainage bottle
Chest drainage systems work by combining the following three efforts:
Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver)
Gravity helps fluid drain as long as the chest drainage system is placed below the level of the patient’s chest
Suction can improve the speed at which air and fluid are pulled from the chest
The typical drainage system consists of three bottles or chambers, as follows:
Underwater seal chamber
Trap bottle or the reservoir chamber
Suction regulator chamber
Underwater seal bottle
An example is shown below.
The underwater seal chamber is the most important element in pleural drainage. It acts as a low-resistance, one-way valve for the evacuation of pleural contents. When intrapleural pressure rises (eg, expiration, coughing), the free contents of the pleural space are forced out through the chest tube and into the underwater seal drainage chamber.  Hence, a single-chamber system is optimal only for a pneumothorax. The presence of hemopneumothorax or hydropneumothorax necessitates the use of a three-chamber drainage system. Reentry of air into the pleural space when intrapleural pressures become negative (eg, inspiration) is blocked by the underwater seal. The water in this tube is referred to as the "column" of water; its movements reflect the changes in intrathoracic pressure with each inspiration and expiration. The end of the tube in the underwater seal chamber must remain covered with water at all times. When a broad-based bottle (eg, Tudor-Edwards) and a narrow tube are used, elevation of the water column in the tube lowers the level in the reservoir by only a very small amount, keeping the seal intact. The end of the tube must not be kept too far below the surface of water because the resistance to expulsion of air from the chest is equal to the length of tubing that is underwater. The standard recommendation is to keep the tip of the tube 2-3 cm below the surface of water. [7, 8]
An example is shown below.
When excessive fluid drains from the chest, the level of fluid in the underwater seal is raised. This increases resistance to further outflow of fluid from the chest.
To decrease this resistance, a trap chamber is introduced between the chest tube and the underwater seal. The trap chamber collects the fluid draining out of the chest, while the air passes on to the second bottle. This keeps the underwater seal at a constant level. 
Suction regulator bottle
An example is shown below.
A third chamber is introduced to the system to provide suction, which is thought to hasten lung expansion.
The suction regulator chamber has a three-hole stopcock. Short tubes are passed through two of the holes. One short tube connects to the underwater seal bottle’s vent tube, and the other short tube connects to the suction source. An atmospheric vent runs through the third hole, passing below the level of water in this bottle.
When suction is applied, air is drawn down the atmospheric vent in this bottle, equal to the pressure inside the bottle that is decreased by the vacuum. Under stronger vacuum, airflow through the atmospheric vent commences, and air bubbles through the water in the bottle, but the level of suction in the bottle remains the same.
This constant level of low-pressure suction is now transmitted to the underwater seal bottle and then into the pleural cavity, thus aiding evacuation of contents with a uniform pressure. The maximum force of suction is determined by the depth of the atmospheric vent underwater in the suction regulation bottle. 
To obtain a suction of -20 cm of water, set the tip of the tube 20 cm below the surface of the fluid. Then, increase the vacuum gradually until air bubbles gently and constantly through the atmospheric vent in the water during both phases of respiration. A constant pressure of -20 cm of water is now transmitted to the underwater seal and on to the chest drain.
The role of suction is now being debated, with some studies favoring the use of suction versus others not favoring the use of suction in patients with chest tubes, for prevention of postoperative air leak and the development of a pneumothorax. [10, 11]
Multifunction chest drainage system
Contemporary chest tube kits contain a three-chamber system incorporated into one multifunction chest drainage system. The multiple bottles and numerous connections of the typical three-bottle system result in a bulky bedside device, which can be prone to accidental disconnections and blocks in the system. In addition, sterility is difficult to maintain in such a system. These systems, therefore, have been largely replaced by commercially produced, disposable plastic multifunction units (eg, Codman, Pleurovac, Atrium) that fit into a single box and work on the same principles, as shown below.
The kits are designed to incorporate the functions and improve on the safety features of the traditional three-bottle drainage system. They offer patient protection with effective drainage, accurate fluid loss measurement, and assistance in detecting air leaks.
The multifunction systems allow single or multicatheter drainage and are suitable for both gravity-assisted and suction-assisted drainage. The unit has a latex-free patient tube and a filtered water seal to prevent contamination.
Each multifunction chest drainage system contains the following:
A collection chamber: Fluids drain directly into this chamber, which is calibrated in milliliters.
The middle chamber (the water seal): This is a one-way valve, with a U-tube design that can monitor air leaks and changes in intrathoracic pressure.
A suction control chamber: This chamber is also a U-tube; the narrow arm is the atmospheric vent, and the large arm is the fluid reservoir. The water level in this chamber, and not the suction regulator, regulates the amount of suction pressure. Thus, the system is regulated, and controlling negative pressure is relatively easy.  The suction chamber also helps monitor intrathoracic pressure. For gravity drainage without suction, the level of water in the water seal chamber equals the intrathoracic pressure.  For suction-assisted drainage, the level of water in the suction control chamber plus the level of water in the water seal chamber equals the intrathoracic pressure. 
Dry suction systems
Suction systems in present use are dry suction systems incorporating a dry suction regulator with fully calibrated water seal drainage. 
Digital suction systems
These systems are characterized by the following:
The ability to regulate the intrapleural pressure by presetting the device for a required length of time and/or frequency (continuous vs intermittent)
To store information on the pattern and quantity of drainage over time and to be able to retrieve that information in a graphical or numeric manner 
Keep the patient in a semirecumbent position (ie, 45-90°). The semi-Fowler position is useful to evacuate air (pneumothorax).  The high Fowler position is useful to drain fluid (hemothorax).
Adjust tubing to hang in a straight line from the chest tube to the drainage chamber, avoiding excess length and loops.
Drainage system positioning
Regardless of the type of drainage system used, it should always be placed erect and approximately 100 cm below the level of the patient’s chest. This placement aids gravity drainage of chest contents into the drainage system and prevents reentry of fluid into the chest during inspiration. [6, 18, 19]
Chest tube site dressing
Major obtrusive dressings around the chest tube are unnecessary and potentially dangerous. They can potentially kink the tube, thus obstructing the tube and potentially allowing reaccumulation of air or liquid.
The correct taping of the emerging chest tube from the patient is with a "mesentery" fold of adhesive tape that holds the tube to the trunk of the patient. This allows some side-to-side movement of the tube, prevents kinking of the tube as it passes through the chest wall, and is far less painful to the patient than taping the tube directly to the chest wall.
Multifunction chest drainage system setup
Follow the manufacturer’s instructions for adding water to the chambers. This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.
Connect the 6-ft patient tube to the thoracic catheter.
Connect the drain to the vacuum.
Slowly increase vacuum pressure until gentle bubbling appears in the suction control chamber.
Be sure not to allow too much bubbling in the suction control chamber. Vigorous bubbling is loud and disturbing to most patients, and it causes rapid evaporation in the chamber, which lowers the level of suction.
Postprocedure pain control is of vital importance while managing patients with chest tubes. Optimal pain control leads to better patient cooperation for chest exercise and physical therapy. No prospective trials are available in regard to standardizing the pain control regimen for these patients.
Typically, the recommended analgesic options in an alert patient are opioids (eg, morphine—oral, intravenous, or patient-controlled pumps), nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ketorolac—oral, intravenous), and intercostal nerve blocks or epidural analgesia for patients with associated rib fractures or postoperative indwelling chest catheters.
At the time of chest tube removal, adequate analgesia should be considered for patient comfort. A single systemic dose of an opioid or an NSAID and/or infiltration of local anesthetic (egg, lidocaine) around the chest tube entry site usually suffices.
Breathing exercises and chest physiotherapy
Breathing exercise and chest physiotherapy are the mainstays for quick lung expansion and faster recovery.
Incentive spirometry (eg, TriFlo incentive spirometer) provides the patient the impetus to expand the lung quickly.
Upper limb movements, especially at the shoulder, help restore the movements of the chest wall.
Steam inhalations and nebulized bronchodilators may also encourage quick lung expansion.
When caring for and maintaining a patient with a chest tube, the following steps are important:
Keep chest tubes patent
Note the presence of drainage and fluctuations, and observe the patient's vital signs and level of comfort
Ensure that the dressing is occlusive and note whether the chest tube is on negative pressure or is to water seal
Keep the patient in a propped-up position (ie, 45-90°). The semi-Fowler position is useful to evacuate air (pneumothorax).  The high Fowler position is useful to drain fluid (hemothorax). Adjust the tubing to hang in a straight line from the chest tube to the drainage chamber, avoiding excess length and loops.
Check that all connections are secure. All joints must be well-taped with adhesive. A single layer of tape across the long axis of each joint holds better than layers of circular tape over the joint. This prevents disconnection and the subsequent loss of the negative pressure.
Always ensure the correct position of the underwater seal bottle. The bottle should be erect and at least 100 cm below the level of the patient’s chest.
In addition to vital signs, the following items should be monitored routinely:
Swinging or oscillation of the column of water in the water seal chamber
Blowing or air bubbling in drainage chamber with quiet respiration and on coughing (Bubbling of air indicates that the lung is still leaking air. The cessation of bubbling during both quiet respiration and coughing indicates that the air leak in the lung may have closed.)
Type and quantity of drainage (Inform practitioner if drainage is >70mL/h or if quality of the drainage changes to frank blood.)
Never lift the drainage system above the level of the patient’s chest, as fluid from the system may siphon back into the patient’s chest.
Keep two (angled) clamps at the bed side.
Do not clamp a bubbling chest drain.  All nursing procedures, patient movement, and physiotherapy are permitted without clamping the drain, with the drainage system kept below the patient’s chest level at all times. Clamp tubes only for procedures related to the tube or system (eg, changing, emptying, or reconnecting the tubing or the system).
Avoid kinks in the tubing. Teach the patient to look for kinks and to avoid sitting or lying on the tube(s).
"Milk" the tube(s) regularly to avoid blockage by fibrin plugs or clots. If fibrin plugs form, small doses (1 mg to 1 mL sterile solution dilution) of recombinant tissue plasminogen activator (r-tPA) may be used to restore patency. 
Change the connecting tube and drainage system as required, and replace them with sterile equivalents. Wash and disinfect equipment to remove all residue before sterilization.
Connecting two emerging chest tubes to a single drainage unit should be done through a Y-shaped connector (not a T-shaped connector, which causes kinks in the tubes). Additionally, equalizing the length of the emergent tubes before the Y connector is important. This avoids kinking of unequal lengths of tube. 
Traditionally, all chest tubes are connected to wall suction following their placement. However, the evidence supporting this practice is lacking. Conflicting literature exists regarding the use of suction, with studies demonstrating early resolution of air leaks with suction versus studies showing use of suction prolonging the resolution of air leak and hence a delayed chest tube removal. [10, 11, 15, 16, 21] Additionally, only moderate-quality evidence supports that suction reduces the incidence of pneumothorax compared with water seal in the postoperative period. [10, 16]
Regardless, the practice of connecting chest tubes to suction, at least during the initial 1-2 days, is common. Of note, when suction is needed, it should be a constant low-pressure suction to fully remove the pleural contents without causing patient discomfort.
The recommended level of suction is -5 to -20 cm of water. (The measurement of -20 cm of water is based on convention, not research.)
Theoretically, suction can improve the speed at which air and fluid are removed from the chest. Greater negative pressure can increase the flow rate out of the chest, but can also damage lung tissue.
Daily chest radiographs are usually obtained to monitor and confirm the expansion of the lung; however no first-class evidence exists to support this.
Antibiotics are not required during the presence of a chest drain for a simple pneumothorax or hydrothorax.
Cefazolin—a first-generation beta-lactam cephalosporin—can be used prophylactically to prevent the development of an empyema when a chest drain is used in thoracic trauma. 
General recommendations regarding the criteria and timing of chest tube removal exist; however, level 1 studies to guide a uniform chest tube removal practice are lacking. Several studies have presented institution-based protocols or algorithms to drive chest tube removal decisions  ; however, the reliability of these algorithms has not been validated with prospective, randomized controlled trials.
In present practice, chest tube removal guidelines are individualized to institution/surgeon preference. Main considerations include the following  :
The initial indication for chest tube placement
Whether the patient is mechanically ventilated
Daily chest tube output
The presence of an air-leak
Full expansion of lungs on chest radiographs
The timing of tube removal depends on clinical and radiological evidence of complete drainage of all abnormal contents of the pleural cavity, as well as complete expansion of the lung. Minimal drainage should have occurred over the previous 24 hours. Level 1 recommendations state that this should be less than 2 mL/kg/day or less than 200-300 mL over a 24-hour period in adults.  Studies have also suggested that removal of chest tubes with 400-450 mL/day of fluids is also safe. [14, 16] Additionally, no air leak should be present, that is, no bubbling seen in the air-leak chamber during forced expiratory maneuvers (eg, Valsalva maneuver) or cough. The swing in the fluid level in the tube in the underwater seal bottle should be minimal, relating to the normal negative pressures in the chest during the phases of respiration. The evaluation for air leak by this nonobjective method falls prey to interobserver variability. The newer digital drainage systems have the advantage of accurately measuring the presence of air leak and, hence, eradicating interobserver variability. [14, 15] These novel devices are gaining increasing popularity and are the subject of ongoing research on tube thoracostomy management in recent years. [14, 15] Additionally, these devices may also have a value in younger pediatric patients who are unable to perform forceful expiratory maneuvers or cough on demand; however no pediatric studies evaluating this exist currently. The values determining safe chest tube removal in patients who are connected to the newer digital drainage systems are less than 50 mL/min in 12 hours or less than 20 mL/min in 8 hours. 
In adult patients with pneumothorax, a trial period of tube clamping for 6 hours may be performed. A repeat chest radiograph is then obtained. If this shows complete expansion of the lung on the chest radiograph, it confirms that the lung leak has sealed (output <200 mL/day) and proper adhesion between the layers of pleura has occurred (no identifiable air leak). The tube may be safely removed at that time.
In the authors’ pediatric surgery practice, following a 24- to 48-hour period of wall suction, patients may be placed on a 24-hour period of water seal without suction. Following this, if no air leak is present, the chest tube is discontinued and a follow-up chest radiograph is obtained to confirm complete lung expansion and to rule out a recurrent pneumothorax. A residual pneumothorax less than 10% size does not require any intervention; however, a larger pneumothorax may suggest persistent/missed air leak and may require replacement of a chest drainage catheter.
Tube thoracostomy removal is a sterile procedure that requires a practitioner and an assistant. Before removal, the patient should be given a dose of analgesia. In adults, subcutaneous infiltration of 5 mL 1% lidocaine hydrochloride with a 24-gauge needle around the emerging chest drain can increase patient comfort.
Cut loose the securing stitches while the tube is being supported. Free the mattress (sealing) stitch that was inserted and kept long at the time of tube insertion. If this stitch is not in position, consider placing a vertical mattress stitch with a nonabsorbable suture material (eg, silk) across the center of the incision.
Hold the ends of the mattress suture ready to tie a knot. Instruct the patient to hold the breath at either deep inspiration or expiration (incidence of pneumothorax after tube removal is not different).  Gently ease out the tube while simultaneously tying the knot to close the track.
Apply a soft dressing with petrolatum gauze underneath a pad of 4-x-4 gauze pieces. Apply silk or foam tape. If the stitch breaks or cuts through, simply compress the oblique track and apply the occlusive dressing described above.
A chest radiograph is repeated 4 hours after the removal of the tube thoracostomy. The results of this radiograph should confirm that no air has entered the chest and that the lung continues to remain fully expanded.
The underwater seal acts as a one-way valve through which air is expelled and prevented from reentering the pleural space during the next inspiration.
The collection chamber should be kept below the level of the patient’s chest at all times to prevent fluid from being siphoned into the pleural space.
The absence of fluid oscillations may indicate obstruction of the drainage system by clots or kinks, loss of subatmospheric pressure, or complete reexpansion of the lung.
Persistent bubbling may indicate a continuing bronchopleural air leak.
Clamping a pleural drain in the presence of a continuing air leak may result in a tension pneumothorax.
The water seal is a window into the pleural space. It reflects the pressure in the pleural space and exhibits bubbling if air is leaving the chest. In the multifunction chest drainage system, a graduated air leak meter (graduated 1-5) provides a way to measure the leak and monitor it over time. 
|Column is not oscillating||Blocked tubing||Squeeze, milk, or flush the drainage tubing; restoration of patency is confirmed by a respiration-related swing in the draining tube|
|Tubes dislodged/disconnected||Dislodged tube||Check connections and reposition under sterile technique; use new entry site if completely dislodged|
|Leak around the tube||Partial block in the draining system||Remove all blocks from the draining system; if leak persists, place a single nonabsorbable suture to close the leak|
|Underwater seal bottle/drainage system broken||N/A||Clamp chest tube, replace immediately with a fresh bottle/drainage system, and recreate the underwater seal|
|Blocked tube due to poor positioning||Tube gets trapped in the major fissure of the lung||Withdraw tube and reinsert at a different location.|
|Cardiac dysrhythmia||Tube is abutting the mediastinum||Try withdrawing the tube by 1-3 cm; if not helpful, remove the old tube and replace at a new entry site|
|Persistent pneumothorax||Obstructions or leaks in the drainage system||If no leak or obstruction is found, apply suction of up to -20 cm of water|
|Failure of the lung to fully reexpand||
|Infection||Rare; reflects breaks in sterility and incorrect management||Antibiotics|
Frequently Asked Questions
What size chest drains should be used?
Use as large a tube that passes comfortably through the intercostal space. As a general rule, in an adult patient, 24-28F is adequate to drain air, but 32-36F may be necessary to drain fluid.
Can chest drains be clamped?
Never clamp a bubbling drain, as the resultant pneumothorax can cause more problems for the patient. Check that all connections are secure, and then the patient can be subject to all nursing procedures, movement, and physiotherapy with no clamps on the drain. 
When are chest drains clamped?
Drains are clamped only in the following situations:
When the draining tubes and underwater seal bottle are to be changed
Just prior to tube removal, as a trial of clamping for 4-6 hours, to confirm that the air leak has stopped
When reconnecting an accidentally disconnected tube that resulted in loss of the underwater seal
If the drain is clamped, it should be unclamped as soon as possible by the same individual who put the clamp on; clamps are sometimes overlooked when patients are handed over during shift changes of medical personnel; clamps that are not removed lead to deterioration of the patient’s condition
Can a patient with a chest drain inserted be moved?
Yes; patients with chest drains can be moved around as usual. All connections have to be checked for security, and the underwater seal bottle has to be kept erect at a level of about 100 cm below the patient’s chest.
What suction pressure should be applied?
As a general rule, suction pressures need to be between -10 and -20 cm of water (-2 to - 3 kPa). While up to 25 cm of water suction pressure is needed for massive air leaks, 5 cm of suction pressure is sufficient to help drain fluid contents out of the chest.
How long should chest drains be left in?
Apposition of the two layers of the pleura is essential to seal air leaks and reduce the drainage. All air leaks eventually stop if the lung can be kept fully expanded constantly. This usually occurs within a week, but it may take as long as 4-6 weeks.
If the air leak persists, the case needs to be reviewed by a thoracic surgeon. If significant discharge is evident, but the lung seems to be adherent, conversion to open-tube drainage may be needed.
Do alternatives to underwater bottle drainage exist?
Yes; artificially made one-way valve systems may be alternatives to underwater bottle drainage.
The flutter valve (Heimlich) is a one-way system created with a plastic diaphragm, which allows air to escape from the chest and yet maintains expansion of the lung. It is attached to the chest drain and strapped to the patient’s side, allowing greater mobility of the patient. The flutter valve can be used for pneumothorax only.
The intercostal drainage bag: is a plastic bag built around a tube that reaches to the bottom of the bag. The bag is then filled with fluid to the prescribed level, and this acts as the underwater seal. The tube, which is about 1 m long, is connected to the intercostal tube. This bag can now collect up to 200 mL of drainage before the contents have to be drained and fresh fluid poured in to recreate the underwater seal. The bag can be strapped to the thigh of the patient and must always be kept erect. If fluid is draining but air is not leaking, a simple Urosac can be attached to the end of the intercostal tube.