How do you unclog a chest tube?

How to Unclog a Chest Tube

When a chest tube stops draining, it should be flushed with normal saline to ensure its patency. 1

Assessment of Blocked Chest Tube

When a chest tube abruptly stops draining fluid, the most likely cause is obstruction rather than resolution of the underlying condition. Before attempting to unclog the tube:

1. Check for kinking, especially at the skin exit site (common in small bore drains and mobile patients)
2. Ensure the underwater seal bottle is positioned below the patient's chest level
3. Check for respiratory swing in the fluid level (indicates tube patency)
4. Assess for signs of worsening clinical condition (increasing dyspnea, chest pain)

Unclogging Procedure

For Small Bore Drains (≤14F)

1. Flush with normal saline: Use 10-20 ml of sterile normal saline 1
   • For pediatric patients: 10 ml is usually adequate 1
   • For adults: 20-50 ml may be required 1
2. If unsuccessful, consider repositioning the tube (check for kinks that can be corrected by redressing)

For Large Bore Drains (>14F)

1. Flush with normal saline: Use 20-50 ml of sterile normal saline 1
2. Ensure proper technique when flushing to maintain sterility

Important Cautions

• Never clamp a bubbling chest tube (risk of tension pneumothorax) 1
• If a clamped drain is in place and the patient becomes breathless or develops subcutaneous emphysema, immediately unclamp the drain and seek medical advice 1

Post-Flushing Assessment

After attempting to unclog the chest tube:

1. If drainage resumes: Continue monitoring drainage volume and characteristics
2. If obstruction persists:
   • Obtain imaging (chest X-ray or CT scan) to check tube position and assess for undrained locules 1
   • Consider tube replacement if permanently blocked 1

Alternative Approaches for Persistent Blockage

Fibrinolytic Therapy

For complicated parapneumonic effusions or empyema with thick loculated fluid:

• Intrapleural fibrinolytics may be considered to lyse fibrinous strands 1
  • Urokinase: 100,000 IU once daily for 3 days 1
  • Streptokinase: 250,000 IU twice daily for 3 days 1
  • Alteplase: Can be used at 1 mg/ml concentration (similar to catheter clearance protocols) 2

When to Replace the Tube

• If the tube cannot be unblocked despite attempts at flushing
• If imaging shows significant fluid remaining in the pleural cavity 1
• If the patient's clinical condition is deteriorating

Common Pitfalls and Caveats

1. Failure to recognize blockage: Chest tube blockage occurs in up to 36% of cases and is often underestimated as most clogging occurs in the internal portion of the tube 3
2. Inappropriate clamping: Never clamp a bubbling chest tube as this risks tension pneumothorax 1
3. Inadequate flushing technique: Maintain strict aseptic technique during flushing to prevent pleural infection (empyema rates of 1-6% reported) 1
4. Overlooking tube position: Kinking at the skin exit site is common, especially with smaller tubes 1
5. Excessive initial drainage: When unclogging a tube with a large effusion, limit initial drainage to 10 ml/kg body weight to prevent re-expansion pulmonary edema 4

By following these guidelines, chest tube patency can be maintained effectively while minimizing complications associated with blocked drainage systems.