Chest Tubes and Pneumothorax

Medical-Surgical · Respiratory / Pulmonology·Updated 2026-10-27

What it is

A pneumothorax is air in the pleural space that removes the normal negative intrapleural pressure and collapses the lung. In a tension pneumothorax, air enters with each breath but cannot leave, shifting the mediastinum, compressing the heart and great vessels and causing obstructive shock. A chest tube connected to a closed drainage system with a one-way water seal lets air and fluid leave the pleural space without returning, so the lung re-expands.

What the NCLEX focuses on

Pneumothorax: sudden pleuritic pain, dyspnea, tachypnea, decreased or absent breath sounds and hyperresonance on the affected side.
Tension pneumothorax: tracheal deviation away from the affected side, distended neck veins, hypotension and severe distress; needle decompression comes first, then a chest tube.
Tidaling (water seal rising on inspiration and falling on expiration in a spontaneously breathing client) is expected; it stops when the lung re-expands or the tube is kinked or blocked.
Intermittent bubbling in the water-seal chamber with exhalation or coughing is expected with a pneumothorax; continuous bubbling means an air leak.
Gentle continuous bubbling in a wet suction-control chamber is expected.
Routine clamping and vigorous stripping are not done; clamping causes tension pneumothorax.
If the tube disconnects, submerge its end in sterile water to restore the seal; if it is pulled out, cover the site with a sterile dressing and watch for tension pneumothorax.

Priority nursing actions

Assess the client: respiratory rate, SpO2, breath sounds, chest pain and tracheal position.
Check the system from the insertion site to the unit: secure connections, no kinks or dependent loops, unit upright below chest level.
Locate the source of continuous bubbling without leaving the tube clamped.
Measure and mark drainage; report a sudden increase or bright red drainage.
Encourage deep breathing, coughing, incentive spirometry and early ambulation with pain control.

Numbers to know

Item	Standard	Why it matters
Water-seal chamber	2 cm of water	One-way valve that keeps air out
Suction-control setting	Usually -20 cm H2O, as prescribed	Applies gentle negative pressure
Drainage to report	More than 100 mL/hr or bright red	Suggests hemorrhage
Drainage unit position	Below chest level at all times	Prevents backflow into the pleural space
Clamping	Never routine; only briefly as prescribed or per protocol	Trapped air causes tension pneumothorax

Common exam traps

Choosing to clamp the chest tube during transport: wrong because trapped air can cause a tension pneumothorax.
Choosing to strip the tubing every hour: wrong because it creates high negative pressure that damages tissue.
Choosing to raise the drainage unit to the bed level for convenience: wrong because drainage flows back into the chest.
Choosing to treat bubbling in the wet suction chamber as an air leak: wrong because that bubbling is expected; only continuous water-seal bubbling signals a leak.

What to teach

Breathe deeply, cough and use the incentive spirometer every hour while awake.
Keep the drainage unit upright and below the chest; call for help at once with sudden shortness of breath or chest pain.
After removal, report increasing shortness of breath or chest pain.

Try 2 NCLEX-style questions on this topic

From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.

Question 1 · QID 93F98C05

A client with a chest tube for pneumothorax is repositioned in bed. The nurse observes new continuous bubbling in the water-seal chamber, and the client reports mild shortness of breath. What should the nurse do first?

Select the best answer.

A. Temporarily clamp the tubing near the drainage unit to determine whether the bubbling decreases
B. Assess the client and tubing connections for an air leak while keeping the system below chest level
C. Milk the tubing gently toward the drainage system to clear a possible obstruction before reassessing
D. Inspect the drainage unit for correct water levels before assessing the client's respiratory status

Question 2 · QID D1A0092D

For each nursing action, indicate whether it maintains the safety of a client with a chest tube for pneumothorax or is incorrect.

	Correct action	Incorrect action
Keep connections secure and maintain a closed system
Strip the tubing vigorously every hour
Clamp the tube routinely during transport
Maintain tubing free of dependent loops and kinks
Keep the drainage unit below chest level
Assess continuous bubbling in the water-seal chamber as a possible air leak

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Lower Respiratory Problems.
Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021.

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