Chest Drains (Intercostal Drains) – overview 
 
1. What is a chest drain? 

A chest drain is a tube inserted into the pleural space to remove air, fluid, blood, pus, or chyle, allowing the lung to re-expand and improving ventilation. 
 
2. Indications for Chest Drain Insertion 
 
A. Air 

Pneumothorax 
Tension pneumothorax (after immediate needle decompression) 
Large primary spontaneous pneumothorax 
Secondary pneumothorax 
Traumatic pneumothorax 
Persistent air leak 

B. Fluid 

Pleural effusion (large or symptomatic) 
Empyema (pus cavities) 
Haemothorax 
Chylothorax 
Malignant pleural effusion (often with indwelling drain) 
 
C. Operative 

During or After thoracic surgery 
During or Following cardiac surgery 
 
3. Types of Chest Drains 
 
Small-bore (8–14 Fr) eg; Seldinger Drain 
Pneumothorax 
Simple pleural effusion 
Less painful 
Pigtail internal fixing 
 
Large-bore (20–36 Fr), eg; thoracic drain 
Trauma 
Haemothorax 
Thick empyema 
Post-surgical drainage 
Surgical drain 
 
4. Chest Drain Insertion Site (Safe Triangle) 
Boundaries: 
Anterior: lateral border of pectoralis major 
Posterior: anterior border of latissimus dorsi 
Inferior: 5th intercostal space (nipple line) 
Superior: base of axilla 
Inserted just above the rib to avoid the neurovascular bundle. 
 
5. Chest Drain Systems 

A. Underwater Seal Drain 
Prevents air re-entering pleural space 
Swinging = tube patent 
Bubbling = air leak (normal initially in pneumothorax) 

B. Suction 
Used if lung does not re-expand 
Commonly −10 to −20 cmH₂O (- 3KPa) – using low thoracic suction device 
 
6. Nursing Care of a Chest Drain 

A. Observations 
Particularly Respiratory rate, oxygen saturations
Pain score 
Drain output (amount, colour, consistency) 
Check swing and bubbling 
Ensure drain is always kept below chest level (below hip height) 
 
B. Drain Site Care 
Dressing clean, dry, occlusive 
Check for: 
Infection 
Subcutaneous emphysema 
Tube dislodgement 
 
C. Drain Management 
Never clamp routinely (only when advised by medical staff) 
Ensure connections are secure 
Keep tubing free of kinks 
Encourage deep breathing and mobilisation (as able) 
 
D. Documentation 
Output volume per shift (hourly in the acute phase) 
Type of drainage (air/fluid/blood/pus) 
Presence of air leak 
Patient tolerance and pain control 
Report high volume drainage immediately (refer to local policy but usually 150mls/hr) 
 
7. Medical Management and Monitoring 

Daily Review 
Chest X-ray after insertion and during treatment as indicated 
Assess lung re-expansion 
Review ongoing indication 

Drain Removal Criteria 
Minimal drainage (e.g. <200 mL/24 hours for fluid; follow local policy) 
No air leak 
Lung fully expanded on X-ray 
Patient clinically stable 
 
8. Chest Drain Removal: 

Performed by trained clinician (for large bore drains this is a two person procedure) 

Patient asked to: 
Exhale fully – then remove the drain 
Occlusive dressing applied immediately (pull purse string suture tight if in situ) 
Observe for respiratory distress post-removal 
Repeat chest X-ray post removal 
 
9. Complications of chest drains 

Early 
Pain 
Bleeding 
Organ injury 
Tube malposition 

Late 
Blockage 
Accidental dislodgement 
Re-expansion pulmonary oedema 
Persistent air leak 
Infection 
 
Emergency Signs 
Sudden respiratory distress or haemodynamic instability 
Large continuous bubbling 
Drain falls out 
Large output on insertion – can cause reperfusion injury therefore often clamped after one litre (as directed by medical staff) 
Massive bleeding (>150 mL immediately or >200 mL/hr) 
 
10. Key Points: 

Swinging = patency 
Bubbling = air leak 

Never clamp a chest drain unless instructed 
Always keep drain below hip height 
Adequate Pain control improves ventilation 
Document output accurately 
Check suction switched on when connected to the drain – always low thoracic suction (connecting and failure to switch on causes a closed system and can lead to tension pneumothorax)