Chest Tube Air Leaks

nurseprnRN, BSN, RN · Jan 6, 2014

Chest tubes, pneumothorax, and tension pneumos made clear: Everything you wanted to know about chest tubes and a little bit more. I promise this will answer your question. :)

This little tutorial started out with a few sample NCLEX questions someone posted. I answered this one....

1. Place the client in Trendelenburg position

2. Hold the insertion site open with a Kelly clamp.

3. Obtain sterile Vaseline gauze to cover the opening.

4. Cover the opening with the cleanest material available.>>

As always in NCLEX-land (and in real life), you're looking for the answer that keeps the patient safest. I know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax (which certainly will)?

And while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space). To understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo.

Respiratory mechanics first ! When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you aren't so lucky).

Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.

How does the air get in the pleural space where it doesn't belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.

The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again, including a WEDGE RESECTION, which leaves holes that can't be sealed until they heal by themselves). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.

So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.

However, the other guy, with the ruptured blebs or wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole(s) in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has "an air leak." What happens to him if his chest tube gets disconnected?

Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.

Esme12, ASN, BSN, RN · Jan 6, 2014

Hey everyone
I'm having some trouble finding a complete answer to this question: What are the steps that I need to take when I find a new, intermittent, small air-leak in the chest-tube of a post-surgical patient? I'm a newer nurse, so please bear with me.
I had a patient who had a VATS with a RUL wedge resection the other day. He came back from the OR on PM shift, and I started at 2300. I found a new, small, intermittent air-leak in his chest-tube. It was to wall-suction. The patient was completely stable. I communicated this to our intensivist (a chief resident who covers all of the surgicals overnight) who told me to just "monitor" it. Nothing (of course) was documented in the chart about chest tube position, previous air leak, etc. The leak didn't get bigger, and the patient had a chest x-ray at 0600 as is the norm for all POD surgical patients. When the surgeon came in before I left, he just kept staring at the chest tube, as if there was something wrong with it. I told him what happened, but he didn't say anything (in retrospect, I wish I would have had the confidence to ask him this question).
Should I have requested that the patient get a chest x-ray as soon as I found the leak? Should I have immediately called the surgeon even though the patient was stable?
What should I be expecting out of the chest tubes with the different types of surgeries (ie. VATS, CABG, etc.)?
Any additional resources would be helpful as well.
Thank you!

With some surgeries that are expected air leaks. A gentle intermittent bubble indicating that there is air leaking would be expected in this kind of surgery and in a pneumothorax...which is trapped air in the pleural space. As long as the patient is not in distress and subq emphysema isn't present everything is fine.

In the case of open hearts it might be different. Air leaks aren't expected as the lung was not operated on so no leak should be there. The pleural chest tubes are placed for drainage if the internal mammary was used and if the lung was deflated during the operation. The mediastinal chest tubes will also not have air leaks, if the do they will be minor and brief because of course there is mediastinal air when the opened the pericardial sac to perform the bypass

This may help you understand.....Troubleshooting Chest Tubes on ADVANCE for Nurses

Editorial Team / Admin · Jan 7, 2014

Another reason an air leak may be "new": many surgeons will fill the chest cavity with warmed irrigation fluid to check for a major air leak that requires a repair rather than allowing natural healing. Because the lung is inflated with the fluid in the cavity, suctioning all of it out is essentially impossible. Depending on how recently the patient arrived to the unit and whether they had more than one chest tube, it may simply have been that the fluid drained before enough air came out with it be noticeable- air still would have come out but just wasn't as obvious. When I have these patients in the OR, we may only see the air leak every third or fourth breath because the leftover fluid is just pouring out and so much more noticeable.

weirdscience · Jan 7, 2014

This oughta be a sticky. Great info.

gigglestarsRN · Jan 7, 2014

Chest tubes, pneumothorax, and tension pneumos made clear: Everything you wanted to know about chest tubes and a little bit more. I promise this will answer your question. :)
This little tutorial started out with a few sample NCLEX questions someone posted. I answered this one....
1. Place the client in Trendelenburg position
2. Hold the insertion site open with a Kelly clamp.
3. Obtain sterile Vaseline gauze to cover the opening.
4. Cover the opening with the cleanest material available.>>
As always in NCLEX-land (and in real life), you're looking for the answer that keeps the patient safest. I know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax (which certainly will)?
And while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space). To understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo.
Respiratory mechanics first ! When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you arent so lucky).
Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.
How does the air get in the pleural space where it doesnt belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.
The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again, including a WEDGE RESECTION, which leaves holes that can't be sealed until they heal by themselves). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.
So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.
However, the other guy, with the ruptured blebs or wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole(s) in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has an air leak. What happens to him if his chest tube gets disconnected?
Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.

This is so helpful- once again, thank you GrnTea!

Home Health Columnist / Guide · Jan 7, 2014

More info:

Chest Tubes - Notes on ICU Nursing

bebbercorn · Jan 7, 2014

@ GrnTea... Wow.

Guests · Jan 7, 2014

Chest tubes, pneumothorax, and tension pneumos made clear: Everything you wanted to know about chest tubes and a little bit more. I promise this will answer your question. :)

This little tutorial started out with a few sample NCLEX questions someone posted. I answered this one....

1. Place the client in Trendelenburg position

2. Hold the insertion site open with a Kelly clamp.

3. Obtain sterile Vaseline gauze to cover the opening.

4. Cover the opening with the cleanest material available.>>

As always in NCLEX-land (and in real life), you're looking for the answer that keeps the patient safest. I know you'd rather cover that hole with something sterile, but what is a greater immediate danger to this unfortunate fellow, an infection (which may not even develop) or a great honking pneumothorax (which certainly will)?

And while we're at it, let's talk about how you know whether to clamp or not to clamp a chest tube that has been disconnected from its drainage device (but is still in the pleural space). To understand this, let's look at the differences between a tension pneumo and a pneumo that isn't a tension pneumo.

Respiratory mechanics first ! When you breathe in, you're not actually pulling air into your lungs with your muscles. You're actually making a suction inside your chest with them (I know this may seem like a distinction without a difference, but stay with me), and the air enters the lungs thru the route provided for it to do so-- your trachea, via your nose or mouth (or trach tube, if you aren't so lucky).

Your lungs are covered with a slippery membrane called the visceral pleura. The inside of your chest wall has one too, the parietal pleura. They allow the lungs to slip around with chest wall motion, like you can slip two wet glass plates around that are stuck together. Like the two glass plates, they're hard to pry apart due to the surface tension of the wet between them, and that's why the lungs fill the chest cavity and stay there. But just as you can easily pop those glass plates apart if you get a teeny bit of air between them, you can pop the bond between the two pleural layers with air, and if you do, the natural elasticity of the lung will cause it to collapse down to about the size of a goodish grapefruit.

How does the air get in the pleural space where it doesn't belong? Well, you can do it two ways. One is to play rough with the bad boys (or have surgery, which is, after all, only expensive trauma) and have a sharp object puncture your chest wall and admit air into the pleural space. How does it get in there? Well, you make suction in your chest when you breathe in, and now air has TWO routes to get inside your chest-- down the trachea into the lungs, and thru the hole in the chest wall into the pleural space. This is called a pneumothorax, air in the chest that is outside of the lung. The lung will tend to collapse because the surface tension between the wet layers is now interrupted (remember how the pieces of wet glass can be separated by introducing air between them?) and the lungs are naturally elastic.

The other way to get air into your pleural space is from having blebs/bullae on your lung surfaces, and pop one (or more), or have some other hole in your lung (sharp things again, including a WEDGE RESECTION, which leaves holes that can't be sealed until they heal by themselves). Then air gets out of your lungs thru the hole(s) and disrupts that pleural side-to-side thing, and there you go again, a pneumothorax. This, however, is called a TENSION pneumothorax, because that air increases with every exhalation (the lung now having two routes to exhale air out of, the trachea and the hole in the lung itself). This allows the lung to collapse on that side, and soon enough pressure (tension) will develop in that half of the chest to push the chest contents over to the other side, compromising blood flow and air exchange in the other lung & heart when it does so. (This is when you see the "tracheal shift.") This is also a bad thing.

So: now both of these fine folks have bought themselves chest tubes. The guy with the chest wall trauma has had his trauma hole sewed up, so when he takes a deep breath air enters his trachea only. He has a water seal on his chest tube so he can't pull air into his chest thru the tube-- the water seal acts like the bend in your sink drain and prevents continuity of the inside and outside places. The suction on the chest tube setup has done its job of removing the air from the pleural space where it didn't belong--it was seen bubbling out thru the water seal and then couldn't get back in. (When all the air is gone from his pleural space, there will be no more airleak in the water seal compartment.) Now, if he disconnects his Pleurevac (or other copyrighted device), he can again take a deep breath and pull air thru the open tube into his pleural space, where it doesn't belong, collapse his lung, and start all over again. THEREFORE, when this guy disconnects his tube, you clamp it IMMEDIATELY, to prevent air from entering the pleural space. He should ALWAYS have those two big old chest tube clamps taped to his Pleurevac (so they go with him to xray and all), just in case he does this.

However, the other guy, with the ruptured blebs or wedge resection and the intact chest wall? Well, his chest tube is pulling air out of the pleural space, but more is still getting in there since he still has a hole(s) in his lung. The idea of the CT is to pull it out faster than he can put it in, and allow the hole to heal up, at which point he will no longer collect air in his pleural space and be all better. Meanwhile, though, you see air bubbling in the waterseal chamber, showing you that there is still air being pulled out of his pleural space. He has "an air leak." What happens to him if his chest tube gets disconnected?

Well, remember, he still puts air into his pleural space, because there's still a hole in his lung. You put a tube in there to take it out, remember? OK, so what happens if you clamp his tube? Bingo, air reaccumulates in the pleural space all over again, his lung collapses, and things go to hell in a handbasket. This guy should NEVER have clamps at his bedside, because some fool may be tempted to clamp his tube before his airleak seals, and he'll get in trouble all over again. If he pulls his tubing setup apart, have him breathe slowly and shallowly (to minimize the air leaving the hole in his lung and getting trapped in his pleural space) while you quick-like-a-bunny hook him up again to a shiny new sterile setup. But do NOT clamp his tube while your assistant gets it set up for you.

GrnTea, this was so well written (meaning informative and humorous) that I actually scrolled all the way back up your post to hit the "Kudos" face. If you knew just how lazy I am in the middle of my 8 days off, you'd realize just what a compliment I've paid you.

Site management, the placement of the "Kudo" face at the top of the posts really sucks...

wooh, BSN, RN · Jan 7, 2014

GrnTea, this was so well written (meaning informative and humorous) that I actually scrolled all the way back up your post to hit the "Kudos" face. If you knew just how lazy I am in the middle of my 8 days off, you'd realize just what a compliment I've paid you.
Site management, the placement of the "Kudo" face at the top of the posts really sucks...

I scrolled to the top to like your post because I like your complaint of the location of the like. :yes:

Home Health Columnist / Guide · Jan 8, 2014

Admin note:
Re Kudos LIKE face icon: Joe IT Admin working on relocation ...

Another stellar GnTea post... crank up the LIKES---juct click on blue smilie face at top of post to give kudos.

classicdame, MSN, EdD · Jan 8, 2014

Google the manufacturer's website for your type of chest tubes. If you cannot locate it, you can get excellent info on this site:

www.atriummed.com/en/chest_drainage/education.asp. I keep their slides on my internal website at work so nurses have a quick reference.