Troubleshooting a Chest Drain 

Always prioritise patient safety. If the patient is acutely unwell (respiratory distress, hypoxia, hypotension), treat this as an emergency and escalate immediately. 

1. Quick safety check (first 30–60 seconds) 
Before focusing on the drain, assess the patient. 

Airway & breathing: respiratory rate, oxygen saturation, work of breathing 
Circulation: heart rate, blood pressure, capillary refill 
Pain: chest pain or discomfort at the insertion site 
Drain position: is the tube still in place and secured? 
If unstable/unwell → call for senior help immediately. 

2. Understand the basics of the system 

A chest drain usually has: 
Chest tube (in pleural space) 
Tubing (connecting to bottle/device) 
Drainage system (underwater seal or digital system) 

Normal findings may include: 

Swinging (tidalling) with respiration 
Intermittent bubbling (for pneumothorax) 
Gradual fluid drainage 

3. Common problems and how to troubleshoot 

A. No swinging / tidalling 

Possible causes 
Lung fully re-expanded 
Tube kinked or clamped 
Blocked tube (clot, debris) 
Tube displaced or against lung/chest wall 

What to do 
Check tubing for kinks, clamps, compression 
Ask patient to take a deep breath or cough 
Ensure the bottle is below hip height 
Escalate if unsure or if clinical concern persists 

B. Continuous bubbling in the underwater seal 

Possible causes 
Air leak from the lung (common early in pneumothorax) 
Loose connections 
Crack in tubing or bottle 

What to do 
Check and tighten all connections 
Briefly clamp the drain close to the chest wall (only if trained and local policy allows): 
If bubbling stops → air leak likely from patient 
If bubbling continues → system leak 
Report persistent air leaks to senior staff 

C. Sudden cessation of bubbling in pneumothorax 

Possible causes 
Resolution of pneumothorax 
Tube blockage 
Tube displacement 

What to do 
Assess the patient clinically 
Check for swinging and tube patency 
Review recent imaging and escalate for review 

D. Drain not draining fluid 
Possible causes 
Tube blockage (clot/fibrin) 
Kinked tubing 
Bottle positioned too high 
Loculated effusion 

What to do 
Inspect tubing carefully 
Ensure bottle is below chest level 
Do not routinely flush unless prescribed (and trained to do so)
Escalate for medical review 

E. Sudden increase in drainage 

Possible causes 
Active bleeding (especially post-op or trauma) 
Rapid drainage of large effusion 

Red flags 
200 mL/hour (or per local policy) 
Bright red blood 
Associated hypotension or tachycardia 

What to do 
Urgently escalate to senior/consultant 
Monitor observations closely 
Prepare for potential transfusion or imaging 

F. Drain falls out 

What to do 
Immediately cover site with an occlusive dressing (e.g. tegaderm with pad/gauze) 
Monitor patient closely 
Call for urgent medical review 

G. Drain disconnects from bottle 

What to do 

Clamp the drain briefly
Clean the end if possible and reconnect using aseptic technique 
If contamination suspected, replace tubing system and bottle 
Escalate and document 

4. Infection and site problems 

Signs 
Redness, swelling, discharge 
Fever or rising inflammatory markers 
Increasing pain at insertion site 

Actions 
Maintain sterile handling 
Change dressings as per protocol 
Escalate concerns early 

5. Pain and comfort 

Chest drains are painful and can impair breathing 
Ensure adequate analgesia 
Encourage deep breathing and physiotherapy if appropriate 

6. Documentation and communication 
Always document: 
Drain output (amount, colour, consistency) 
Presence or absence of swinging/bubbling 
Patient symptoms and observations 
Any interventions and escalation 
Clear handover is essential. 

7. When to escalate immediately 
Respiratory distress or hypoxia 
Suspected tension pneumothorax 
Large or ongoing bleeding 
Drain displacement or accidental removal 
Uncertainty about drain function 

Key reminder 
Treat the patient, not the drain. Escalate concerns immediately. 
If the clinical picture and the drain findings do not match, seek senior advice.