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Welcome to Atrium University.
This site, funded by an educational grant from Atrium Medical Corporation, provides professional continuing education for credit in addition to a variety of tools for professional education.

Follow the tabs above to explore our offerings.

CE		Professional continuing education for credit

Tools		Materials for educators; some relate to chest drainage, others are instructional tools that can be used with a variety of content

Learning		Clinical education, not for credit

Clinical Update		Our quarterly newsletter

Evidence Center		Coming soon: resources for evidence-based practice

About		Learn more about Atrium U

Learner Rights		Our commitment to you

Ask the Expert		Ask an expert RN a question about chest drainage

Professional Continuing Education and Self-Quiz

Managing Chest Drainage
A Self-Study Nursing Continuing Education Activity

This continuing education activity is designed to provide registered nurses with information about chest drainage. Our goal is for nurses to better understand the physiology and pathophysiology relating to conditions requiring chest drainage. Learning about the safe and effective use of chest drain systems will allow registered nurses to provide high quality care for their patients.

Target Audience: Nurses who care for patients requiring chest drainage

Learning Objectives:
At the completion of this self-study activity, the learner should be able to…

1. describe the normal anatomy of the chest
2. explain the changes that occur in the thoracic cavity during breathing
3. identify abnormal conditions requiring the use of chest drainage
4. discuss the features of the traditional three-bottle chest drainage system
5. compare and contrast the traditional three-bottle chest drainage system with
the self-contained disposable chest drainage units available today
6. recognize the steps in setting up a chest drain system
7. outline key aspects of caring for a patient requiring chest drainage
8. recognize four signs a chest tube can be removed
9. summarize the use of autotransfusion with chest drain systems

To complete the CE program and self-quiz, follow the steps below

Download the Acrobat PDF of the CE manual.

Print manual and read, or view online.

Return to this site to take the self-quiz.

This activity is funded by an unrestricted educational grant from Atrium Medical Corporation.

This continuing nursing education activity was approved by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

It has been approved for 1.7 contact hours. Contact hours will be awarded until 12/31/2012.

Competency Manual

Chest Drainage Competency Manual
This manual is designed to assist you as you plan your competency assessment
program for nurses caring for patients requiring chest drainage.

The competency manual is currently undergoing revision to provide the most up-to-date quality information, and will be available for download soon.

Additional Drain Readings

If you'd like to learn more about mobile drainage, chest drain usage and pleural drainage in general, the following references are provided by Atrium University for your convenience. Where content is available on the web, links are indicated.

Adrales G, Huynh T, Broering B, et al.: A thoracostomy tube guideline improves management efficiency in trauma patients. Journal of Trauma, Injury, Infection & Critical Care 2002;52:210-216.

Ahrens T, Coleman RH: Ask the Experts: lung volume reduction surgery. Critical Care Nurse 1997;17(1):88-89.

Anderson B, Higgins L, Rozmus C: Critical pathways: application to selected patient outcomes following coronary artery bypass graft. Applied Nursing Research 1999;12(4):168-174.

Antunes G, Neville E, Duffy J, Ali N: BTS guidelines for the management of malignant pleural effusions. Thorax 2003;58(Suppl II):ii29-ii38.

Ayed AK: Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Annals of Thoracic Surgery 2003;75:1593-1596.

Baumann MH: Less is more? Chest 2001;120(1):1-3.

Baumann MH: What size chest tube? What drainage system is ideal? And other chest tube management options. Current Opinions in Pulmonary Medicine 2003;9:276-281.

Baumann MH, Patel PB, Roney CW, Petrini MF: Comparison of function of commercially available pleural drainage units and catheters. Chest 2003;123:1878-1886.

Baumann MH, Strange C, Heffner JE et al.: Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119(2):590-602.

Berger P, Leemans R, Kuiper MA, van der Voort PHJ: Uncommon complications during chest tube placement: a potential role of tube material. Intensive Care Medicine 2003;29:1610-1611.

Broscious SK: Music: an intervention for pain during chest tube removal after open heart surgery. American Journal of Critical Care 1999;8(6):410 415.

Burrows CM, Mathews WC, Colt HG: Predicting survival in patients with recurrent symptomatic malignant pleural effusions. Chest 2000;117(1): 73-78.

Capps JS, Tyler ML, Rusch VW, Pierson DJ: Potential of chest drainage units to evacuate broncho-pleural air leaks. Chest 1985;88S:57S. [classic for discussion of physics]

Carroll P: A guide to mobile chest drains. RN 2002;65(5):56-60,65.

Carroll P: Ask the experts: dry suction chest drainage system. Critical Care Nurse 2003;23(4):73-74.

Carroll P: Chest drainage made easy. RN 1995;58(12):46-56.

Carroll P: Exploring chest drain options. RN 2000;63(10):50-54.

Carroll P: Mobile chest drainage: coming soon to a home near you. Home Healthcare Nurse 2002;20(7):434-441

Carroll PF: Patients with pleural air leaks. Focus on Critical Care 1987;14(3):48-51.

Carroll PL: The principles of vacuum and its use in the hospital environment. 1995. Ohmeda, Inc.; Columbia, MD.

Carson MM, Barton DM, Morrison CC, et al: Managing pain during mediastinal chest tube removal. Heart & Lung 1994;22(4):134-146.

Cerfolio RJ, Bass C, Katholi CR: Prospective randomized trial compared suction versus water seal for air leaks. Annals of Thoracic Surgery 2001;71(5):1613-1617.

Cerfolio RJ, Pickens A, Bass C, Katholi C: Fast-tracking pulmonary resections. Journal of Thoracic and Cardiovascular Surgery 2001; 122(2):318-324.

Cheng, D: Randomized assessment of resource use in fast-track cardiac surgery 1-Year after hospital discharge. Anesthesiology 2003; Mar; 98(3); 651.

Collop NA, Kim S, Sahn SA: Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997;112(3):709-713.

Consorta: Best Practice Models, Implementing CABG Best Practices. 2001.

Cox JE: Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax. Radiology 1999;212(1):165-168.

Crawford BK, Galloway AC, et al: Treatment of AIDS-related bronchopleural fistula by pleurectomy. Annals of Thoracic Surgery 1992;54:212-215.

Crocker HL, Ruffin RE: Patient-induced complications of a Heimlich flutter valve. Chest 1998;113(3), 838-839.

Cunnington J: Spontaneous pneumothorax. Clinical Evidence 2003;10:1738-1746.

Daganou M, Dimopoulou I, Michalopoulos N, et al.: Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting. Chest 1998;113(5):1285-1289.

Davies CWH, Gleeson FV, Davies RJO: BTS guidelines for the management of pleural infection. Thorax 2003;58(Suppl II):ii18-ii28.

Drazen JM, Epstein AM. Guidance concerning surgery for emphysema. Editorial. NEJM 2003;348:2134-2136.

Fox V, Gould D, Davies N, Owen S: Patients’ experiences of having an underwater seal chest drain: a replication study. Journal of Clinical Nursing 1999;8:684-692.

Gift AG, Bolgiano CS, Cunningham J: Sensations during chest tube removal. Heart & Lung 1991;20(2):131-137.

Golden P: Follow up chest radiographs after traumatic pneumothorax or hemothorax in the outpatient setting: a retrospective review. International Journal of Trauma Nursing 1999;5(3):88 94.

Gordon P, Norton JM: Managing chest tubes: what is based on research and what is not? Dimensions of Critical Care Nursing 1995;14(1):14-16.

Gordon P, Norton JM, Merrel R: Refining chest tube management: analysis of the state of practice. Dimensions of Critical Care Nursing 1995;14(1):6-13.

Gordon PA, Norton JM, et al: Positioning of chest tubes: effects on pressure and drainage. American Journal of Critical Care 1997;6(1):33-38.

Gray DT, Veenstra DL: Comparative economic analyses of minimally invasive direct coronary artery bypass surgery. Journal of Thoracic and Cardiovascular Surgery 2003;125:618-624.

Hagl C, Harringer W, Gohrbandt B, Haverich A: Site of pleural drain insertion and early postoperative pulmonary function following coronary artery bypass grafting with internal mammary artery. Chest 1999;115(3):757-761.

Hayes DD: Stemming the tide of pleural effusions. Nursing Management 2001;32(12):30-34.

Heimlich HJ: Heimlich valve for chest drainage. Medical Instrumentation 1983;17(1):29-31.

Heimlich HJ: Valve drainage of the pleural cavity. Diseases of the Chest 1968;53(3):282-287.

Hicks D, Moreno S: Pneumothorax Care Plan Map. Tucson Medical Center. Tucson, AZ 1994. Available through CINAHL.

Henry M, Arnold T, Harvey J: BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl II):ii39-ii52.

Houston S, Jesurum J: The quick relaxation technique: effect on pain associated with chest tube removal. Applied Nursing Research 1999;12(4):196 205.

Hyde J, Sykes T, Graham T: Reducing morbidity from chest drains [editorial]. British Medical Journal 1997;314:914.

Irwin JP, O-Yurvati A, Peska D: Rapid ambulation post-thoracotomy with the Atrium Express Mini-500 system. Available online at: http://www.atriummed.com/PDF/RapidAmbulation.pdf

Jones PM, Hewer RD, Wofenden HD, Thomas PS: Subcutaneous emphysema associated with chest tube drainage. Respirology 2001;6:87-89.

Kam AC, O’Brien M, Kam PCA: Pleural drainage systems. Anaesthesia 1993;48:154-161.

Kinney MR, Kirchhoff KT, Puntillo KA: Chest tube removal practices in critical care units in the United States. American Journal of Critical Care 1995;4(6):419-424.

Kirby TJ, Ginsberg RJ: Management of pneumothorax and barotrauma. Clinics in Chest Medicine 1992;13(1):97-112.

Kirkwood P: Ask the experts: chest tube care and transport. Critical Care Nurse 2002;22(4):70-72.

Kirkwood P: Ask the experts: removing chest tubes and suction bubbling. Critical Care Nurse 2000;20(3):97-98.

Ko JP: Factors influencing pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture contributing factors? Radiology 2001; 218(2), 491-496.

Krishnan JA: High-frequency ventilation for acute lung injury and ARDS. Chest 2000;118(3):795-807.

Lazar HL, Fitzgerald CA, Ahmad T, Bao Y, Colton T, Shapira OM, et al.: Early discharge after coronary artery bypass graft surgery: are patients really going home earlier? Journal of Thoracic and Cardiovascular Surgery 2001;121(5):943-950.

Laws D, Neville E, Duffy K: BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl II):ii53-ii59.

Leavitt BJ, O’Connor GT, Olmstead EM, et al.: Use of the internal mammary artery graft and in-hospital mortality and other adverse outcomes associated with coronary artery bypass surgery. Circulation 2001;103:507-512.

Leonard M: A 21-year-old man with pneumothorax, subcutaneous emphysema, and a persistent air leak after chest tube insertion. Journal of Emergency Nursing 2003;29:5:425-426.

Light RW: Pneumothorax in the ICU: who is at risk and what can be done. Journal of Critical Illness 1997;12(2):77 80,83 84.

Luchette FA, Barrie PS, Oswanski MF et al.: Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: the EAST practice management guidelines work group. Journal of Trauma, Injury, Infection & Critical Care 2000;48(4):753-757.

Marshall MB, Deeb ME et al: Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002;121(3):831-835.

Martino K, Merrit S, Boyakye K et al.: Prospective randomized trial of thoracostomy removal algorithms including commentary with author response. Journal of Trauma, Injury, Infection and Critical Care 1999;46(3):369 373.

Maskell NA, Butland RJA: BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003;58(Suppl II):ii8-ii17.

McKenna RJ, Fischel RJ, Brenner M, Gelb A: Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Annals of Thoracic Surgery 1996;61:1115-1117.

Mimnaugh L, Winegar M, Mabrey Y, Davis, JE: Sensations experienced during removal of tubes in postoperative patients. Applied Nursing Research 1999;12(2):78 85.

Munnell ER: Thoracic drainage. Annals of Thoracic Surgery 1997;63:1497-1502.
National Cancer Institute: Malignant pleural effusion. 1998. Available online at: http://www.meds.com/pdq/effusion_pro.html

National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. NEJM 2003;348:2059-2073.

National Emphysema Treatment Trial Research Group. Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema. NEJM; 2003;348:2092-2102.

National Emphysema Treatment Trial Research Group. Rationale and design of the National Emphysema Treatment Trial: a prospective randomized trial of lung volume reduction surgery. Chest 1999;116:1750-1761.

Obney J, Barnes MJ, Lisagor PG, Cohen DJ: Is bigger better for draining the mediastinum and thorax? [abstract] Chest 2000;118(4):116S.

Owen S, Gould D: Underwater seal chest drains: the patient’s perspective. Journal of Clinical Nursing 1997;6(3):215-225.

Pacanowski JP, Waack ML, Daley BJ: Is routine roentgenography needed after closed tube thoracostomy removal? Journal of Trauma, Injury, Infection & Critical Care 2000;48(4):684-688.

Powner DJ: A review of “chest tubes” during donor care and after transplantation. Progress in Transplantation 2002;12:61-67.

Powner DJ, Cline CD, Rodman GH: Effect of chest-tube suction on gas flow through a bronchopleural fistula. Critical Care Medicine 1985;13(2):99-101. [classic for discussion of physics]

Proehl JA: One-way valve. In: JA Proehl (Ed.), Emergency nursing procedures. WB Saunders Company Philadelphia 1999. pp.137-139.

Puntillo K: Analgesics and chest tube removal pain. American Journal of Critical Care 1994;3(3):245.

Puntillo KA: Effects of interpleural bupivicaine on pleural chest tube removal pain: a randomized, controlled trial. American Journal of Critical Care 1996;5(2):102-108.

Puskas JD, Williams WH, Duke PG, et al. Off pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: A prospective, randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. Journal of Thoracic and Cardiovascular Surgery 2003;125:797-808.
Putnam, JB: Malignant pleural effusions. Surgical Clinics of North America 2002;82(4):867.

Rogers WB, Rogers RM: Understanding LVRS. RT The Journal for Respiratory Care Practitioners 1997;10(2):28,30,32,33,93.

Roman M, Weinstein A, Macaluso S: Primary spontaneous pneumothorax. MedSurg Nursing 2003;12(3):161-16.

Rusch VW, Capps JS, Tyler ML, Pierson DL: The performance of four pleural drainage systems in an animal model of bronchopleural fistula. Chest 1988;93:859-863. [classic for discussion of physics]

Russo L, Wiechmann RJ, Magovern JA et al.: Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Annals of Thoracic Surgery 1998;66:1751-1754

Sahn SA: Malignant pleural effusions. Seminars in Respiratory and Critical Care Medicine 2001;22(6):607-615.

Saji H, Nakamura H, Tsuchida T et al.: The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy. Chest 2002;121(5):1521-1526.

Sandrick K: Fast tracking surgical management improves patient outcomes and reduced hospital length of stay. American College of Surgeons 1999. Available online at: http://www.meds.com/conrad/acs/fasttrack.html

Schlenker, EH: Cardiopulmonary anatomy and physiology. In: Hess, DR, MacIntyre, NR, Mishoe, SC, Galvin, WF, Adams, AB, Saposnick, AB (Eds.), Respiratory care principles and practice. WB Saunders Company Philadelphia 2002. pp.284.

Schmelz JO, Johnson D, Norton JM, Andrews M, Gordon PA: Effects of position of chest drainage tube on volume drained and pressure. American Journal of Critical Care 1999;8(5):319 323.

Schmidt U, Stalp M, Gerich T et al.: Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. Journal of Trauma, Injury, Infection & Critical Care 1998;44(1):98-100.

Scholz JA: Nursing practice issues and answers. Issue: may a registered nurse remove a chest tube? Ohio Nurses Review 1997;72(4):16.

Scott F: Lung volume reduction surgery. Advance for Managers of Respiratory Care 1996;5(6):36-40.

Sittig SE: Ventilation for life. AARCTimes 2002;26(1):18,20-21.

Tang A, Hooper T, Hasan R: A regional survey of chest drains: evidence-based practice. Postgraduate Medical Journal 1999;75:471-474.

Tang ATM, Velissaris TJ, Weeden DF: An evidence-based approach to drainage of the pleural cavity: evaluation of best practice. Journal of Evaluation in Clinical Practice 2002;8(3):333-340.

Tattersall DJ, Traill ZC, Gleeson FV: Chest drains: does size matter? Clinical Radiology 2000;55:415-421.

Thompson SC, Wells S, Maxwell M: Chest tube removal after cardiac surgery. Critical Care Nurse 1997;17(1):34-38.

University of Arkansas for Medical Sciences Medical Center: Procedure for proper usage of the Heimlich valve 1996. Available at: http://www.uams.edu/nursingmanual/Procedures/procedure48.htm (Authorized students only)

Urschel JD, Parrott JCW, et al: Pneumothorax complicating cardiac surgery. Journal of Cardiovascular Surgery 1992;33:492-495.

Vricella LA, Trachiotis GD: Heimlich valve in the management of pneumothorax in patients with advanced AIDS. Chest 2001;120(1):15-18.

Ware JH: The national emphysema treatment trial – how strong is the evidence? NEJM 2003;348:2055-2056.

Weissberg D: Pneumothorax: Experience with 1,199 patients. Chest 2000;117:1279-1285.

Yamagami T, Nakamura T, Iida S, Kate T, Nishimura T: Management of pneumothorax after percutaneous CT-guided lung biopsy. Chest 2002:121:1159-1164.

Suggested Readings About Chest Tube Stripping

Duncan C, Erickson R: Pressures associated with chest tube stripping. Heart & Lung 1992;11(2):166-171.

Duncan CR, Erickson RS, Weigel RM: Effect of chest tube management on drainage after cardiac surgery. Heart & Lung 1987;16(1):1-9.

Gordon P, Norton JM, Merrel R: Refining chest tube management: analysis of the state of practice. Dimensions of Critical Care Nursing 1995;14(1):6-13.

Gordon P, Norton JM: Managing chest tubes: what is based on research and what is not? Dimensions of Critical Care Nursing 1995;14(1):14-16.

Gross, SB: Current challenges, concepts and controversies in chest tube management. AACN Clinical Issues in Critical Care 1993;4(2):260-275.

Isaacson JJ, George LT, Brewer MJ: The effect of chest tube manipulation on mediastinal drainage. Heart & Lung 1986;15(6):601-605.

Lim-Levy F, Babler SA, DeGroot-Kosolcharoen J et al.: Is milking and stripping chest tubes really necessary? Annals of Thoracic Surgery 1986;42(1):77-80.

Oakes LL, Hinds P, Rao B et al.: Chest tube stripping in pediatric oncology patients: an experimental study. American Journal of Critical Care 1993;2(4):293-301.

Pierce JD, Naftel DC: Effects of two chest tube clearance protocols on drainage in patients after myocardial revascularization surgery. Heart & Lung 1991;20(2):125-130.

Teplitz L: Update: Are milking and stripping chest tubes really necessary? Focus on Critical Care 1991;18(6):506-511.

Atrium Interactive Computer-Based Training developed by Patricia Carroll, RN,C, CEN, RRT

Not all learning requires a large time commitment. These activities are shorter than typical continuing education activities to allow busy health care professionals the opportunity to learn in small doses.

Interactive Modules
These free interactive training modules provide a solid foundation in the use of thoracic drainage devices. Each module addresses a key element of knowledge for professionals caring for patients who require chest drainage. All modules use animated graphics and narration and integrate a self-assessment quiz.

Modules will launch right in your browser. Flash Player 8 or higher is required.

Don’t forget to adjust your computer’s volume or use headphones/earphones to listen to the narration.

Note: If you have difficulty viewing any segments of these interactive training modules, you may need to update your Flash Player.

Chest Drainage 101 Chapter 1

Chest Drainage 101 Chapter 2

Chest Drainage 101 Chapter 3

Chest Drainage 101 Chapter 4

Managing Chest Drainage Part 1

Managing Chest Drainage Part 2

Managing Chest Drainage Part 3

Managing Chest Drainage Part 4

Managing Chest Drainage Part 5

Managing Chest Drainage Part 6

Clinical Update

Clinical Update is an award-winning educational newsletter edited by Patricia Carroll, RN,BC, CEN, RRT, MS and celebrating its 14th year of publication in 2011. Each quarterly issue features new information regarding chest drainage, summaries of articles in the nursing literature and helpful web sites.

Clinical Update Library, Current Issue to 1997 (Adobe Acrobat PDF)

	Winter 2012 Patient Satisfaction Also in this issue: The patient as expert, readmission warning signs, and purposeful rounding.
	Fall 2011 Is Thoracic Surgery Evidence-Based? Also in this issue: How nurses redesign healthcare, infection prevention, a new weaning score, and incentive spirometry.
	June 2011 New Rules for Professional Education Also in this issue: Protective equipment, simulation, sepsis nursing care, and work scheduling.
	March 2011 PEEP and CPAP Effects on Chest Drainage Also in this issue: Family presence policy, patient decisions and staffing levels.
	December 2010 Reducing Infection Risk in Chest Surgery Also in this issue: Reevaluating your practice, the TIGER initiative, and patient cost.
	September 2010 Alarm Fatigue Also in this issue: What is an emergency?, evidence-based unit design
	June 2010 Chest Drain Management: Tradition or Evidence-Based? Also in this issue: Curtain of protection, Airway Suction Practice, Lights at Night
	March 2010 DEHP-Free Also in this issue: Stroke assessment, sepsis warning outside the ICU, and the essence of nursing.
	January 2010 H1N1 Special Edition A special edition of Clinical Update dealing with barotrauma complications from H1N1 influenza.
	December 2009 Heparin Induced Thrombocytopenia Also in this issue: Evidence to practice, care decisions, bedside computer disinfection, and discussion of of mental status in determining surgical approach.
	September 2009 Tracking Quality in Cardiac Surgery Also in this issue: Multicultural cardiac care, drawing blood samples, and collaboration.
	June 2009 Chest Tube Positioning and Dependent Loops Also in this issue: Differences in nursing and practice, infection cost, nursing managers
	March 2009 Mediastinitis Also in this issue: Hand hygiene, extending your reach, nonspecialist cancer care.
	December 2008 Update on Chest Tube Insertion Also in this issue: Respiratory research, moral distress, and the value of nursing care.
	September 2008 Mobility in Critical Care Patients Also in this issue: Quality assessment, the health of shift workers, and patient safety
	June 2008 Air Transport for Patients with Chest Tubes Also in this issue: Tradition or science, quality of life after traumatic surgery, blood pressure
	March 2008 Managing Air Leaks Through Chest Tubes Also in this issue: Replicating a study, synergy, "Plug and Play in the ICU"
	December 2007 Identifying Malpositioned Chest Tubes Also in this issue: JCAHO and Magnet, When is the Usual Routine an Error?, Job Satisfaction
	September 2007 Joint Commission's Patient Safety Goals for 2008 Also in this issue: Recognizing stress, factors associated with UTI, reducing MSRA risk
	June 2007 Treating Persistent Air Leak Following Lung Resection Also in this issue: Evidence-Driven or Old Wives’ Tale?, APNs, Chaplains in the Unit
	March 2007 Is Bypass a Factor in Cognitive Decline After CABG? Also in this issue: What Chart Audits Miss, ER to ICU Time
	December 2006Chest Drainage Research in 2006 Also in this issue: Rewarding Staff, Unforgettable Patient Care Events, Nurse/Patient Needs
	September 2006Chest Drainage and Hyperbaric Medicine Also in this issue: Simulation, and the aging nursing workforce
	June 2006Reducing the Pain of Chest Tube Removal Also in this issue: Conciousness assessment, AD to BSN questions, and information dissemination.
	March 2006New Guidelines for CPR and Emergency Cardiac Care Also in this issue: Gastric tube insertion, state of the RN workforce, and "What satisfies nurses?"
	December 2005 Special Year-End Double Issue A review of studies published in 2005 about chest tube management. Full reference list included.
	June 2005 Age Appropriate Competencies: Caring for Children Also in this issue: Alcohol withdrawl, nursing organizations, evidence-based practice Click Here for Bonus Reference Chart
	March 2005 Mobilizing Patients With Chest Drainage Also in this issue: Health Literacy, Patient Safety Alerts, Integrating Research and Practice
	Dec 2004 Toward Evidence-Based Chest Drainage Also in this issue: Blood Conservation in Cardiac Surgery, Titanium Rib, Co-Manager Model
	Sept 2004 Saving Time and Money with Chest Drainage Also in this issue: Cost of Hand Hygiene, Pneumonia Guidelines, Perspectives from Patricia Benner
	June 2004 The Challenges of Different Chest Tubes Part 2 Also in this issue: Staff Retention, Sleep Deprivation, Pelvic Fractures
	March 2004 The Challenges of Different Chest Tubes Also in this issue: Open Chest in the ICU, The Effects of Noise in your Unit
	Dec 2003 Chest Tube Insertion (Part 2) Also in this issue: Reliable Pain Scores, Pain Management, Thumbs Up for Nurses
	Sept 2003 Chest Tube Insertion (Part 1) Also in this issue: Nurse/Physician Relationships, Declining CE Attendance
	June 2003 Does Lung Volume Reduction Surgery Work? Also in this issue: Aging and Shift Work, Family Presence, Decreasing Medication Errors
	March 2003 Chest Trauma Across the Lifespan Also in this issue: Cardiac Surgery Pain, Evidence-Based Pain Management, Lifelong Learning
	Dec 2002 Malignant Pleural Effusions Also in this issue: Violent Situations, Family-Centered Care, Non-Credentialed Assistive Workers
	Sept 2002 Suction or Gravity Drainage? Also in this issue: Degrees, Employee Perception, Responsibility for Error Reporting
	June 2002 Innovations in Chest Drainage—Mobile Chest Drainage Part 2 Also in this issue: Developing a Nursing Portfolio, Preceptors
	March 2002 New Innovations in Chest Drainage —A Mobile Chest Drain Also in this issue: Non-Credentialed Personnel, Ethical Issues and the Nursing Shortage
	Dec 2001 Answers To Your Questions About Chest Drainage Also in this issue: What’s Your Med Error IQ? , What Makes Nurses Stick to a Magnet Hospital?
	Sept 2001 Management of Spontaneous Pneumothorax: Part 2 Also in this issue: Multiple Rib Fractures, Cost of Nursing Interventions, Patient Expectations
	June 2001 Management Of Spontaneous Pneumothorax: Part 1 Also in this issue: Does Absenteeism Make You Sick?, Newbies
	March 2001 Is Your JCAHO Visit Sounding Painful? Also in this issue: Are You Narcophobic?
	Dec 2000 The Nurse's Role In Chest Tube Removal Also in this issue: APRNs Still Practice Nursing, Leading Outside Your Comfort Zone
	Sept 2000 Loculated Pneumothorax: A Special Challenge in Critical Care Also in this issue: Helping nurses use research, Generational Issues
	June 2000 New Technology in Chest Drainage: The Dry Control Drain Also in this issue: Follow up for trauma patients, patients as consumers
	March 2000 Regulating Chest Drainage Suction Also in this issue: Measuring ANCPs Impact, Hospitalists, Pressure Chart
	Sept 1999 A Quick Review Of Lung Surgery Procedures Also in this issue: Ethnicity and Drug Metabolism, Research-Based Practice
	June 1999 The Nurse’s Role In Product Selection Also in this issue: Certification, Leadership Effectiveness
	March 1999 Caring For Pneumonectomy Patients Also in this issue: Raise Morale And Retain Staff, Marketing 101
	Dec 1998 Ambulating Patients With Chest Drainage Also in this issue: Fibrinolytic Therapy for Pleural Effusion, Managing Pleural Efflusions
	Sept 1998 New Developments In Chest Tube Technology Also in this issue: Families and Critical Care, Nurse Educator In The Clinical Setting
	Mar 1998 Latex-Free Chest Drains Also in this issue: Nursing Research at the Bedside, Early Extubation After CABG
	Dec 1997 The Water Seal... a Window Into the Pleural Space Also in this issue: Communicating with Intubated Patients, A Critical Thinking Game

Evidence Center

Coming soon, evidence reviews on topics relating to chest drainage.

The first topic will be managing air leaks.

About Atrium University

Atrium University was established in 1999 to provide nurses with an easy way to identify educational materials provided by Atrium Medical Corporation.

In 2010, to comply with new guidelines regarding commercial support of professional continuing education, Atrium University has been moved to its own Web site dedicated solely to professional education without product-specific information.

Atrium University has partnered with Patricia Carroll, RN,BC, CEN, RRT, MS, a registered nurse and registered respiratory therapist who is a recognized expert in cardiopulmonary care to develop educational materials. Pat published her first article on managing patients with chest tubes in 1986 and since then has written 12 peer-reviewed articles about caring for patients with chest drainage that are indexed in PubMed. She has contributed to nursing textbooks, video and computer-based instruction about chest drainage.

Until she retired from traveling in 2005, Pat spoke at the American Association for Critical-Care Nurses National Teaching Institute for twenty consecutive years. She is also a professional continuing education specialist, board certified in nursing professional development by the American Nurses Credentialing Center. She is a faculty member in the School of Health Sciences at Excelsior College.

Atrium University is funded by an unrestricted educational grant from Atrium Medical Corporation.

Atrium University: Our Promise

We recognize that you are a life-long learner who has chosen to engage in professional continuing education to identify or fill a gap in your knowledge, skill, or performance. As part of our promise to you as a learner, we pledge to provide

Content that:

- promotes improvements or quality in healthcare
- is valid; reliable; and accurate; based on research, evidence, clinical practice guidelines and standards
- offers balanced presentations that are free of commercial bias for or against a particular product or service
- is vetted through a process that resolves any conflicts of interests of planners, teachers, or authors
- is driven and based on identified needs
- addresses the stated objectives
- is evaluated for its effectiveness

A learning environment that:

- supports learners’ ability to meet their personal, individual needs
- respects learners’ diversity
- is free of promotional, commercial, and/or sales activities

Disclosure of:

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Ask the Expert

Do you have a clinical question? Need information about caring for patients with chest tubes that is not already provided on this site? Are you writing or updating evidence-based policies and procedures?

Click here to Ask The Expert!

Note: This is not designed for urgent questions.
If you need an immediate response, call your chest drain manufacturer.

Example questions:

Can you please advise whether continuous bubbling should be present in the air leak chamber whilst on continuous wall suction in a patient with a spontaneous pneumothorax who is breathing spontaneously with a dry suction drain? By the way - if the patient was ventilated, what would the difference be?

Wendy Gleeson
Clinical Nurse Specialist Emergency/Clinical Nurse Educator After Hours
Grafton Base Hospital
New South Wales, Australia

You’ll see bubbling in the water seal chamber when air enters the system. That is most commonly from the lung, but can also be from a leak somewhere else in the system; for example, if the tube has moved and one of the eyelets of the chest tube is outside the chest.

Negative pressure from suction pulls air from a leak through the drain and positive pressure from the chest -- a strong cough, positive pressure ventilation, or a manual resuscitation bag – will push air into the drain. So, if a patient has a pneumothorax or a postoperative leak from the lung, suction will cause continuous bubbling and may make a leak look worse than it is. You’ll see the same pattern caused by PEEP on a ventilator because it is continuous positive pressure pushing air out of the leak. To accurately assess the patient breathing spontaneously with suction, momentarily disconnect the suction tube from the drain, check for bubbling, and then reconnect the tubing. You may be able to pinch the suction tubing closed to accomplish the same thing. I recommend avoiding wall vacuum adjustments for assessment purposes because it is too easy to forget to put it back on.

Otherwise, you would see intermittent bubbling that corresponds to respirations. With a ventilator, you’ll see bubbling on inspiration; if the person is breathing spontaneously, you should see bubbling on exhalation, or with a cough.
A spontaneously breathing person with a spontaneous pneumothorax probably does not need suction. The British Thoracic Society Pleural Disease Guideline 2010 states “suction should not be routinely employed” for managing spontaneous pneumothorax.¹ You may also find the Clinical Update for June 2010 useful. While it discusses suction for postoperative patients, the concepts apply to spontaneous pneumothorax as well.

1.	British Thoracic Society Pleural Disease Guideline Group. BTS pleural disease guideline 2010. Thorax. 2010;65(suppl 2).

Is there any information about how much PEEP or CPAP is transmitted to the pleural space?

The amount of PEEP transmitted to the pleural space is determined by the compliance of the chest wall and the lung. If lung compliance is low (the lung is stiff), but the chest wall compliance is high, meaning it expands freely, very little PEEP is transmitted to the pleural space, resulting in high transpulmonary pressure (the difference between intrapulmonary pressure and pleural pressure).1 If lung compliance is high and the chest wall compliance is low (chest wall expansion is limited due to external factors, such as obesity or skeletal conditions), much more PEEP is transmitted to the pleural space. In this case, pleural pressure can be significantly higher than atmospheric pressure.^1-3

1.	Nunn JF: Positive end-expiratory pressure. International Anesthesiology Clinics 1984;22(4):149-164.
2.	Mason RJ, Broaddus VC, Martin TR, et al., eds: Murray and Nadel's textbook of respiratory medicine. 5th ed. Philadelphia: Saunders Elsevier; 2010; No. 1
3.	Jardin F, Genevray B, Brun-Ney D, Bourdarias J: Influence of lung and chest wall compliances on transmission of airway pressure to the pleural space in critically ill patients. Chest 1985;88(5):653-658.

Is it necessary to clamp a chest tube prior to d/c the chest tube? What is best practice to go from suction to water seal, then clamp and d/c or suction to water seal and then d/c? Can you give me any contact information on references for best practice on clamping chest tubes prior to discontinuation? Thank you.

Theresa Austin, MSN-L ,RN
RN Clinical Education Specialist- Pediatric Service line
Cardon Children's Medical Center at Banner Desert Medical Center

To clamp or not to clamp? That is the question. I was not able to find any research that compared clamping with no clamping. For this response, I am thinking about patients with pleural tubes who are not receiving mechanical ventilation; I’d never clamp a tube if a patient were receiving positive pressure. As for other non-critical patients (typically postoperative) If I were writing the orders, I would prefer to have pleural tubes clamped the night before anticipated removal, and if the patient did fine, pull the tube on morning rounds. The argument in favor of clamping is that if the patient gets breathless or shows other signs of recurring pneumothorax, it is much easier to simply open the clamp rather than face the risk of pulling the tube too soon and having to replace it. I think clamping to simulate removal in order to assess the patient is hard to argue with, but is not evidence-based. Otherwise, I would not clamp a tube -- even to change out a chest drain. I’d be concerned that I might get called from the bedside for an emergency and not open the clamp; it’s the same reason I don’t turn off monitor alarms – I just silence them.

As for the literature, a frequently referenced approach, called “provocative clamping,” is described in a letter to the editor of Annals of Thoracic Surgery as one way to manage patients with prolonged air leak.¹ It’s provocative because it involves clamping a tube in a patient with a known leak from the surface of the lung. But one of the best resources is a letter to the editor of Chest in which a writer is in favor of clamping and provides 8 references to support his position. In response, the author of the original article responds with 5 references that support not clamping the tube². (available online here: http://chestjournal.chestpubs.org/content/119/4/1292.full with links to available full text references)

There has been some good evidence on suction versus gravity drainage after lung surgery. University of Pennsylvania researchers reported their experience randomizing postoperative pulmonary resection patients (not including LVRS) into two groups. One group’s chest drains remained connected to the vacuum regulator with the suction control chamber set for a level of –20 cmH2O; the others were disconnected from the wall vacuum and remained on gravity drainage with the water seal of the chest drain.³ Sixty-eight patients who underwent pulmonary wedge resection were included with 34 in each arm of the study. The two groups were evenly matched; 15 patients in each group had an air leak at the end of the operation. All patients were connected to wall vacuum in the operating room to re-expand the lung at the end of the case. Vacuum was disconnected for transport to the PACU. There, patients were randomized to resume vacuum or to stay on gravity water seal drainage – two days earlier than in a previous study⁴. If a pneumothorax >25% was present on a chest radiograph in the gravity drainage group, the chest drain was reconnected to wall vacuum with a suction level of –10 cmH2O until the pneumothorax was <10%. (Note that none of the patients was symptomatic.) Then, gravity drainage was reestablished. Patients on the wall vacuum protocol had suction control chambers set to –20 cmH2O.

Patients with air leaks in the gravity water seal drainage group had a mean leak duration of 1.50 days. In the wall vacuum group, mean leak duration was 3.27 days. Chest tubes in the gravity water seal patients remained in place a mean of 3.33 days; in the wall vacuum group, the mean duration was 5.47 days. Even when taking the length of staple lines into account, the differences between the two groups remained. The researchers found that the duration of air leaks in the gravity water seal group was about one-half the time of the wall vacuum group. Since many argue that suction is critical to apposition of the pleurae postoperatively, these researchers initially used suction on all patients in the operating room. These researchers note that visually, the bubbling is more vigorous in the water seal chamber when the chest drain is connected to wall vacuum, indicating a greater flow of air out of the lung. They suggest that the benefit of reducing airflow, thereby allowing the suture line to be more closely approximated, aids healing and outweighs any benefit of pleural apposition.

The researchers conclude that placing patients on gravity water seal drainage helps resolve air leaks after pulmonary surgery more quickly than when suction is used. They state that routinely using wall vacuum postoperatively is counterproductive.

Overall, the literature supports using gravity drainage and significantly limiting or avoiding use of suction altogether unless there is a specific indication for suction based on a careful patient assessment^5-12. Based on these findings, I would go to water seal as soon as possible and remove the tube from there. There is no need to clamp the tube unless you wish to simulate chest tube removal to determine patient tolerance.

1.	Kirschner PA: “Provocative clamping” and removal of chest tubes despite persistent air leak. Annals of Thoracic Surgery 1992;53(4):740-741.
2.	Gupta N: Pneumothorax : Is Chest Tube Clamp Necessary Before Removal? Chest 2001;119(4):1292-1293.
3.	Marshall MB, Deeb ME, Bleier JI, et al: Suction vs water seal after pulmonary resection: a randomized prospective study. Chest 2002;121(3):831-835.
4.	Cerfolio RJ, Bass C, Katholi CR: Prospective randomized trial compares suction versus water seal for air leaks. Annals of Thoracic Surgery 2001;71(5):1613-1617.
5.	Merritt RE, Singhal S, Shrager JB. Evidence-based suggestions for management of air leaks. Thorac Surg Clin. Aug 2010;20(3):435-448.
6.	Cerfolio RJ, Bryant AS: The management of chest tubes after pulmonary resection. Thoracic Surgery Clinics 2010;20(3):399-405.
7.	Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA: The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;128(2):816-820.
8.	Powner DJ, Cline CD, Rodman GH: Effect of chest-tube suction on gas flow through a bronchopleural fistula. Critical Care Medicine 1985;13(2):99-101.
9.	Alphonso N, Tan C, Utley M, et al: A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. European Journal of Cardiothorac Surgery 2005;27(3):391-394.
10.	Prokakis C, Koletsis EN, Apostolakis E, et al: Routine suction of intercostal drains is not necessary after lobectomy: a prospective randomized trial. World Journal of Surgery 2008;32(11):2336-2342.
11.	Deng B, Tan Q, Zhao Y, Wang R, Jiang Y: Suction or non-suction to the underwater seal drains following pulmonary operation: meta-analysis of randomised controlled trials. European Journal of Cardio-Thoracic Surgery 2010;38:210-215.
12.	Ayed AK: Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study. Annals of Thoracic Surgery 2003;75(5):1593-1596.

I have been asked to do a chest tube competency for our surgical unit staff and have not had any experience myself. After viewing the video about managing chest drainage and asking others here questions I am still a little confused about the water seal chamber. Bubbling in the chamber can be both good and bad, one indicates an air leak, the other indicates a normal condition. I'm just not sure how to distinguish between good and bad exactly. Also someone here told me that when the water level rises in the water seal chamber that also can be good and bad. Again could you explain this? I am also confused about tidaling as it says you should see this but it can be normal not to occur. Everything about this chamber seems to be a contradiction. How do I know what is good vs bad?

Robert Cole, RN
Nursing Education Department
St Joseph Health Services of RI

Rather than thinking about good vs. bad, it might be easier to think about whether bubbling is expected or unexpected. Bubbling occurs in the water seal chamber when air is entering the chest drain. When you first apply suction, there should be a little bubbling in the water seal as air is pulled through from the collection chamber. If no other air enters the system, the bubbling should soon stop. Bubbling continues when air is entering the system. What is going on with your patient? If the tube has not been in for long and the patient had a pneumothorax or lung resection surgery, you should expect bubbling. What have previous nursing assessments shown? If the patient is 18 hours post-op and has had bubbling in the water seal since leaving the OR, I wouldn’t be worried at all. However, if the patient is 36 hours post op and I am seeing bubbling after 24 hours of no bubbling, I’d want to investigate further. If an air leak is not expected from your patient assessment, there may be a leak in the system – somewhere between the chest tube and the drain itself. An air leak can be “normal” when it is expected and makes sense with the rest of the patient assessment. On the other hand, if you expect bubbling and don’t see it and the patient is short of breath with significantly diminished breath sounds on the side with the chest tube, the tube could be blocked and again, require additional assessment.

Here’s an analogy: let’s say a 32 year old man comes in to the ER with a broken wrist after slipping on an icy sidewalk. You put him on a monitor for sedation for a closed reduction, and you notice he’s in bigeminy. That becomes an incidental finding that doesn’t need treatment. If, however, you see the same rhythm in a patient having an MI with unstable blood pressure, it would need more investigation and probably speedy treatment.

As for the fluid in the water seal chamber, the water seal is a manometer that can measure intrapleural pressures. Pressure changes in the pleural space that occur with breathing will be seen as fluctuations in the level of the water within the tube. These fluctuations, called "tidalling," may be as great as 5 to 10 cmH2O with normal spontaneous breathing. The water level will go up (more negative) during inspiration, and go down (return to baseline) during exhalation. If the patient is receiving positive pressure ventilation, the water level will go down (more positive) during inspiration, and go back up (return to baseline) during exhalation, reflecting the higher positive pressure in the chest with mechanical ventilation. If there is no tidalling, it could mean that:

The tubing is kinked
The tubing is clamped
The patient is lying on the tubing
There is a dependent, fluid-filled loop in the tubing
Lung tissue or adhesions are blocking the catheter eyelets
No air is leaking into the pleural space and the lung has re-expanded

Once again, your complete patient assessment and knowledge of what’s been going on over the past 24 to 48 hours will help you interpret these findings.