Management of Bubbling in the Water Chamber of a Chest Tube

A bubbling chest tube should never be clamped as this may lead to the potentially fatal complication of tension pneumothorax. 1

Understanding Bubbling in Chest Tubes

Bubbling in the water chamber of a chest tube indicates air in the pleural space (pyopneumothorax) 1
Continuous bubbling suggests a continued visceral pleural air leak 1
Continuous bubbling may also be seen in patients on suction when the drain is partly out of the thorax and one of the tube holes is open to the atmosphere 1
The respiratory swing in the fluid in the chest tube is useful for assessing tube patency and confirms the position of the tube in the pleural cavity 1

Never clamp a bubbling chest drain as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1
Ensure the underwater seal bottle is kept below the level of the patient's chest at all times 1
Verify that the drainage system is functioning properly with unidirectional flow of air or fluid out of the chest 1
Check that the tube is not kinked, blocked, or malpositioned, as these can lead to surgical emphysema 1

If suction is used, it should be applied via the underwater seal at a pressure of 5–10 cm H2O 1
Low pressure suction reduces the likelihood of the drain becoming blocked with debris 1
Suction should be supervised by appropriately trained nursing staff 1
Brief disconnection from suction for procedures such as radiographs is acceptable, provided proper instructions are given regarding keeping the underwater seal bottle below chest level 1

Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 1
Daily reassessment of the amount of drainage/bubbling and respiratory swing is essential 1
Monitor for signs of complications such as surgical emphysema, infection, or respiratory distress 1

In pneumothorax management, a bubbling chest drain indicates an ongoing air leak and should never be clamped 1
In pleural effusion management, the drain may be clamped for specific purposes such as after intrapleural instillation of fibrinolytic agents (e.g., urokinase for 4 hours) 1
If a drain is clamped for any reason, nursing staff should have standing instructions to unclamp it immediately if the patient shows signs of clinical deterioration (breathlessness or chest pain) 1

There is no evidence that large tubes (20–24 F) are better than small tubes (10–14 F) in the management of pneumothoraces 1
Small-bore chest tubes (≤14F) are generally recommended as first-line therapy for spontaneous pneumothorax in non-ventilated patients 2
Larger tubes may be necessary if there is a persistent air leak 1

Clamping a bubbling chest drain can lead to tension pneumothorax 1
Allowing the underwater seal bottle to rise above the level of the patient's chest can lead to fluid backflow into the pleural space 1
Knocking over the underwater seal bottle can disrupt the drainage system 1
Pain, drain blockage, and accidental dislodgment are common complications of small-bore drains 2
More serious complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema 2

Limit initial drainage to 10 ml/kg body weight, then clamp the drain for 1 hour (only if not bubbling) 1
In adults and larger children/adolescents, no more than 1.5 liters should be drained at one time or drainage slowed to about 500 ml/hour 1
Re-expansion pulmonary edema is rare in children but has been reported in cases with malignant lymphoma 1