PROCEDURE
24 Chest Tube Removal (Assist)
Peggy Kirkwood
PURPO SE: Chest tube removal is performed to discontinue a chest tube when it
is no longer needed for the removal or drainage of air, blood, or fluid from the
intrapleural or mediastinal space.
PREREQUISITE NURSING
KNOWLEDGE
• Chest tubes are placed in the pleural or mediastinal space
to evacuate an abnormal collection of air or fluid or both.
• For interpleural chest tubes, the air leak detector should
bubble gently immediately on insertion of the chest tube
during expiration and with coughing. Continuous bub-
bling in the air leak detector indicates a leak in the patient
or the chest-drainage system. Fluctuations in the water
level (also known as tidaling) in the water-seal chamber
of 5 to 10 cm, rising during inhalation and falling during
expiration, should be observed with spontaneous respira-
tions. If the patient is on mechanical ventilation, the
pattern of fluctuation is just the opposite. Any suction
applied must be disconnected temporarily to assess cor-
rectly for fluctuations in the water-seal chamber.
• Flexible Silastic (Blake; Ethicon, Inc, Somerville, NJ)
drains may be used in place of large-bore chest tubes in
the mediastinal and pleural spaces after cardiac surgery.
These tubes provide more efficient drainage and improved
patient mobility with minimized tissue trauma and pain
with removal.3,16
• Chest radiographs are done periodically to determine
whether the lung has reexpanded. Daily chest radiographs
have been found to be unnecessary while the tube is in
place.5,7,16,19,21 Reexpanded lungs, along with respiratory
assessments that show improvement in the patient’s respi-
ratory status, are the basis for the decision to remove the
chest tube.
• While the tubes are in place, patients may have related
discomfort. Prompt removal of chest tubes encourages
patients to increase ambulation and respiratory measures
to improve lung expansion after surgery (e.g., coughing,
deep breathing). However, removal of the chest tube may
also be a painful procedure for the patient.4,9,12–14
• The types of sutures used to secure chest tubes vary
according to the preference of the physician, the physician
assistant, or the advanced practice nurse. One common
type is the horizontal mattress or purse-string suture,
which is threaded around and through the wound edges in
190
a U shape with the ends left unknotted until the chest tube
is removed. Usually, one or two anchor stitches accom-
pany the purse-string suture (Fig. 23-1).
• A primary goal of chest tube removal is removal of tubes
without introduction of air or contaminants into the pleural
space.
• Available data indicate there is no consensus as to the rate
of drainage that should be used as a threshold for tube
removal and no evidence to suggest that it is unsafe to
remove tubes that still have a relatively high rate of fluid
drainage.5,20 Research has shown that, depending on the
reason for the chest tube, volumes of 200 to 450 mL/day
do not adversely affect length of stay or overall costs
compared with lower threshold volumes, nor does the risk
of pleural fluid reaccumulation increase.5,22 However,
some suggested guidelines include the following:
❖ Drainage has decreased to 50 to 200 mL in the prior
24 hours if tube was placed for hemothorax, empyema,
or pleural effusion.
❖ If tube was placed after cardiac surgery, drainage has
changed from bloody to serosanguineous, no air leak
is present, and amount is less than 100 mL in the past
8 hours.1,10
❖ Pleural tubes are placed after cardiac surgery if the
pleural cavity has been entered. They typically are
removed within 24 to 48 hours after surgery.1,10
❖ Mediastinal chest tubes most often are removed 24 to
36 hours after cardiac surgery.1
❖ Lungs are reexpanded (as shown on chest radiographic
results).
❖ Respiratory status has improved (i.e., nonlabored res-
pirations, equal bilateral breath sounds, absence of
shortness of breath, decreased use of accessory muscles,
symmetrical respiratory excursion, and respiratory rate
less than 24 breaths/min).
❖ Fluctuations are minimal or absent in the water-seal
chamber of the collection device, and the level of solu-
tion rises in the chamber.
❖ For interpleural chest tubes, air leaks have resolved for
at least 24 hours (the absence of continuous bubbling
in the water-seal chamber or absence of air bubbles

from right to left in the air leak detector), and the lung
is fully reinflated on chest radiographic results.
EQUIPMENT
• Suture-removal set
• Antiseptic swabs (povidone-iodine, chlorhexidine gluco-
nate with alcohol, etc.)
• Petrolatum gauze, as per hospital protocol
• Rubber-tipped Kelly clamps or disposable umbilical
clamps
• Wide occlusive tape (2 inches)
• Elastic closure device, such as Steri-Strips (3M, St. Paul,
MN)
• Dry 4 × 4 gauze sponges (two to four)
• Waterproof pad
• Personal protective equipment (goggles, sterile and non-
sterile gloves, mask, gown)
Additional equipment, to have available as needed, includes
the following:
• Specimen collection cup (if catheter tip is to be sent to the
laboratory for analysis)
• Scissors
PATIENT AND FAMILY EDUCATION
• Assess the patient’s and family’s level of understanding
about the condition and rationale for the procedure. Ratio-
nale: This assessment identifies the patient’s and family’s
knowledge deficits concerning the patient’s condition, the
procedure, the expected benefits, and the potential risks.
It also allows time for questions to clarify information and
voice concerns. Explanations decrease patient anxiety and
enhance cooperation.
• Explain the procedure, reason for removal, and sensations
to be expected.15,19 The most commonly reported sensa-
tions are pulling, pain or hurting, and burning.14 Ratio-
nale: This explanation prepares the patient and enhances
cooperation.
• Explain the patient’s role in assisting with removal.
Explain that the patient should perform the Valsalva
maneuver on the count of three. Have the patient practice
the maneuver before the procedure. Rationale: This
explanation elicits patient cooperation and facilitates
removal.
• Instruct the patient to turn and reposition every 2 hours
after the chest tube has been removed. Rationale: This
action prevents complications related to immobility and
retained secretions.
• Instruct the patient to cough and breathe deeply after the
chest tube has been removed, with splinting of the affected
side or sternum (with mediastinal tubes). Rationale: This
action prevents respiratory complications associated with
retained secretions. The application of firm pressure over
the insertion site (i.e., splinting) decreases pain and
discomfort.
• Instruct the patient about the availability of prescribed
analgesic medication after the chest tube is removed.
Rationale: Analgesics alleviate pain and facilitate cough-
ing, deep breathing, and repositioning.9,13,19
24 Chest Tube Removal (Assist) 191
• Instruct the patient and family to report signs and symp-
toms of respiratory distress or infection immediately.
Rationale: Immediate reporting facilitates prompt inter-
vention to relieve a recurrent pneumothorax or to treat an
infection.
PATIENT ASSESSMENT AND
PREPARATION
Patient Assessment
• Assess respiratory status. Rationale: Assessment of respi-
ratory status verifies the patient’s readiness for chest tube
removal.
❖ Oxygen saturation within normal limits
❖ Nonlabored respirations
❖ Absence of shortness of breath
❖ Decreased use of accessory muscles
❖ Respiratory rate of less than 24 breaths/min
❖ Equal bilateral breath sounds
• Assess chest tube drainage (less than 200 mL in 24 hours
or less than 100 mL in 8 hours after cardiac surgery).1,5,10
Rationale: Assessment of drainage verifies patient readi-
ness for chest tube removal.
• For interpleural chest tubes, assess for minimal or no air
leak in the air leak detector zone or indicator. Rationale:
This assessment indicates whether the lung is reexpanded
and whether or not air leak is present.
• Obtain chest radiographic results. Rationale: Lung reex-
pansion indicates that need for chest tube is resolved.
• Assess vital signs. Rationale: Vital sign assessment
indicates whether the patient can tolerate chest tube
removal.
• Assess laboratory results for clotting capability and medi-
cations that may affect clotting. Rationale: Low platelet
levels or thrombolytic medications may precipitate exces-
sive bleeding.17
Patient Preparation
• Verify correct patient with two identifiers. Rationale:
Prior to performing a procedure, the nurse should ensure
the correct identification of the patient for the intended
intervention.
• Ensure that the patient understands preprocedural teach-
ings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication
evaluates and reinforces understanding of previously
taught information. Anticipatory preparation may prepare
patients for a better experience.12,18
• Administer premedication of adequate analgesics at least
20 minutes before the procedure. Alternatively, subfascial
lidocaine may be injected into the chest tube tract. In
addition to opioids, adjunct methods shown to decrease
pain during chest tube removal include slow deep-
breathing relaxation exercises and application of cold
packs.8,9 Rationale: Intravenous 4-mg morphine 20
minutes before or 30-mg ketorolac 60 minutes before the
procedure have been shown to have substantial relief of
pain without excessive analgesia.12 Pain medication,
relaxation exercises, and application of cold reduces the
192 Unit I Pulmonary System
discomfort and anxiety experienced, which facilitates
patient cooperation.8,9,12,13
• Time the removal procedure to occur at peak analgesic
effect. Rationale: This timing increases patient coopera-
tion and decreases anxiety.13
Procedure for Assisting with Chest Tube Removal
Steps
1. HH
2. PE
3. Assist with opening the sterile suture
removal set and preparing petrolatum
gauze dressing and two to four 4 × 4
gauze sponges, as per hospital
protocol.
4. Perform a preprocedure verification
and time out, if nonemergent.
5. Assist with discontinuing suction
from chest-drainage system and
check for air leakage in air leak
detector zone or indicator. Observe
the air leak detector zone or indicator
while the patient coughs.
6. Assist with removing existing tape,
and clean area around tubes with
antiseptic swab. (Level D*)
7. Assist with covering the pleural
insertion sites with petrolatum gauze
dressing and mediastinal insertion
site with 4 × 4 gauze pads, as per
hospital protocol.
8. Assist with clamping each tube to be
removed with two Kelly clamps or
umbilical clamps.11 (Level E*)
9. The tube is removed while the
patient is performing a Valsalva
maneuver at either end inspiration or
end expiration.2 (Level E)
A. End inspiration: Instruct patient
to take a deep breath and hold it
while performing the Valsalva
maneuver for each tube removed.
If the patient is receiving
ventilator support and is unable
to follow instructions, remove the
tube during peak inspiration.
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to
support recommendations.
• Place the patient in the semi-Fowler ’s position. Alterna-
tively, place the patient on the unaffected side with the
waterproof pad underneath the site. Rationale: This posi-
tion enhances accessibility to the insertion site of the chest
tube and protects the bed from drainage.
Rationale Special Considerations
Aseptic technique is maintained to
prevent contamination of the
wound.
Ensures patient safety.
Bubbling in the air leak detector is If an air leak is present, the tube
associated with an air leak. When should not be removed. Consult
an air leak is present, removal of with the physician, physician
the chest tube may cause assistant, or advanced practice
development of a pneumothorax. nurse to determine appropriate
Ensures a recurrent action.
pneumothorax has not occurred.
Allows access to the chest tube at Antiseptic swabs remove a broad
the skin level and prepares the spectrum of microbes quickly and
sutures for removal. provide high-level antimicrobial
action for up to 6 hours after use.6
Avoids the influx of air.
Possibly prevents air from being
introduced into the pleural space,
although controversy is found in
the literature.11
Valsalva maneuver is needed to
provide positive pressure in the
pleural cavity and decrease the
incidence of an involuntary gasp
by the patient when the tube is
removed.2
Removal of pleural chest tubes
should be accomplished rapidly
with the simultaneous application
of an occlusive dressing or
closure with purse-string sutures
to decrease possibility of air from
entering the pleural space.
 24 Chest Tube Removal (Assist) 193

Procedure for Assisting with Chest Tube Removal—Continued

Steps
B. End expiration: Instruct patient to
forcibly exhale and perform the
Valsalva maneuver at end
expiration.
C. If possible, patients may need to
hold their breath until sutures are
tied.
10. Assist with securing the dressing
with tape.
11. Assess the patient’s condition after
the procedure, and compare the
results with preprocedure assessment
as noted previously.
12. Ensure a chest radiograph is
obtained, if ordered (generally 1–24
hours after removal) only as
clinically indicated.7,16,19,21 (Level B*)
13. Dispose of used supplies and
equipment and remove PE .
14. HH
Rationale Special Considerations
Creates a firm closure of the chest This action is easier with a second
tube site. person to place the tape while
holding pressure over the site.
Ensures stable respiratory status Increased work of breathing,
after the procedure. decreased oxygen saturation,
increased restlessness, symptoms
of chest discomfort, and
diminished breath sounds on the
affected side are warning signs to
be observed.
Assesses that the lung has remained Low incidence of complication.
expanded. Recommended to perform chest
radiograph only if patient is
clinically deteriorating.7,16,19,21

*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.

Expected Outcomes Unexpected Outcomes

• Patient is comfortable and has no respiratory distress • Pneumothorax
• Lung remains expanded after chest tube removal • Bleeding
• Site remains free of infection • Skin necrosis
• Retained chest tube
• Infected chest tube insertion site

Patient Monitoring and Care

Steps
1. Assess respiratory status,
including oxygen saturation, work
of breathing, breath sounds, and
symptoms of chest discomfort.
Obtain chest radiograph if
significant changes are found.
Rationale
Diminished respiratory status could
indicate a pneumothorax.
Pneumothorax could be from
removal of the chest tube before
all the air, fluid, or blood in the
pleural space had been drained,
or it may recur after removal of
the chest tube if air is introduced
accidentally into the pleural space
through the chest tube tract.
Reportable Conditions
These conditions should be reported
if they persist despite nursing
interventions.
• Decreased oxygen saturation on
pulse oximetry
• Increased work of breathing
• Diminished breath sounds on
affected side
• Increased restlessness and
symptoms of chest discomfort
Procedure continues on following page
194 Unit I Pulmonary System

Patient Monitoring and Care —Continued

Steps
2. Monitor insertion site for bleeding.
If bleeding is found, apply
pressure and place a tight
occlusive dressing over site, which
may be removed after 48 hours.
3. Monitor purse-string suture site
for signs of skin necrosis.
4. Monitor site for signs of infection.
5. Monitor insertion area for
development of subcutaneous
emphysema.
6. Monitor for signs and symptoms
of pericardial effusion or cardiac
tamponade.
7. Follow institution standard for
assessing pain. Administer
analgesia as prescribed.
Rationale
Persistent bleeding from insertion
site could mean chest tube was
against a vein or artery of chest
wall before removal.
If purse-string suture was pulled too
tightly closed when chest tube
was removed, skin necrosis may
be seen.
Prolonged insertion of a chest tube
increases the risk that the tract
created by the chest tube may
become infected, or infection may
occur after removal of the chest
tube if the opening created by the
removal becomes contaminated.
Air may leak into the surrounding
tissues and cause crepitus.
Removal of chest tubes may cause
increased bleeding into
pericardium.
Pericardial bleeding may continue
after chest tubes are removed.
Identifies need for pain
interventions.
Reportable Conditions
• Persistent bleeding
• Dark or inflamed skin with
necrotic areas visible
• Purulent drainage
• Increased body temperature
• Inflammation
• Tenderness
• Warmth at site
• Crepitus
• Distant heart tones
• Decreased blood pressure,
tachycardia
• Pulsus paradoxus
• Narrowed pulse pressure
• Equalized pulmonary artery
pressures
• Continued pain despite pain
interventions

Documentation
Documentation should include the following:
• Patient and family education
• Respiratory and vital signs assessments before and
after procedure
• Date and time of procedure and who performed the
procedure
• Amount, color, and consistency of any drainage
• Application of a sterile occlusive dressing
• Patient’s tolerance of the procedure
• Completion and results of chest radiograph
• Specimens sent to laboratory (if applicable)
• Unexpected outcomes
• Nursing interventions
• Pain assessment, interventions, and effectiveness

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.