Post-Operative Care for Chest Tube Day 2
On day 2 after chest tube placement, the tube should remain on water seal drainage alone without suction, unless there is documented persistent air leak or failure of lung re-expansion on chest radiograph. 1
Immediate Day 2 Management
Drainage System
- Keep the chest tube on underwater seal (water seal) drainage only – do not apply suction at this early timepoint 1, 2
- The first 48 hours should allow passive drainage without active suction to minimize complications including re-expansion pulmonary edema 2, 1
- High-pressure suction applied too early, particularly in primary pneumothorax present for several days, can precipitate re-expansion pulmonary oedema 2
Clinical Monitoring
- Perform chest radiograph to assess lung re-expansion and residual pneumothorax 1, 2
- Monitor for persistent air leak by observing continuous bubbling in the water seal chamber 1, 2
- Document 24-hour drainage volume – chest tubes producing <100-150 mL per 24 hours may be candidates for early removal 2
- Assess respiratory rate, oxygen saturation, and patient comfort 2
Wound Care
- Inspect the insertion site for signs of infection (erythema, purulent drainage, induration) 2
- Change dressing if soiled or as per institutional protocol 2
- Ensure tube is properly secured but not causing skin pressure necrosis 2
Decision Point at 48 Hours (Day 2)
When to Add Suction
Apply suction (-10 to -20 cm H₂O) only if EITHER condition is present: 1, 2
- Persistent air leak – continuous bubbling through the water seal at 48 hours 1, 2
- Failure of lung re-expansion – incomplete lung expansion visible on chest radiograph despite adequate drainage 1, 2
Suction Specifications (If Indicated)
- Use high volume, low pressure systems only (Vernon-Thompson pump or wall suction with pressure-reducing adaptor) 1, 2
- Set suction at -10 to -20 cm H₂O 1, 2
- System must accommodate air flow volume of 15-20 L/min 1, 2
- Critical: Patients requiring suction must be managed in specialized units with nursing staff experienced in chest drain management 1, 2
If No Air Leak and Lung Expanded
- Continue water seal drainage 1, 2
- Monitor drainage output 2
- Consider tube removal when drainage <100-150 mL per 24 hours and no air leak present 2
Special Populations
Secondary Pneumothorax (Underlying Lung Disease)
- Patients with emphysema or fibrosis typically require longer resolution times (median 19 days vs 8 days without lung disease) 1, 3
- In secondary pneumothorax, only 61% of air leaks resolve by day 7 and 79% by day 14 3
- These patients warrant closer monitoring and lower threshold for specialist consultation 1, 3
Primary Pneumothorax (No Underlying Disease)
- 75% of air leaks cease by day 7 and 100% by day 15 in primary pneumothorax 3
- More favorable prognosis for spontaneous resolution 3
Red Flags Requiring Escalation
Immediate Surgical Consultation
Respiratory Specialist Referral
- Failure to respond within 48 hours of chest tube insertion 1
- For patients WITHOUT underlying lung disease: Persistent air leak at 5-7 days 1, 2
- For patients WITH underlying lung disease, large persistent air leak, or failure of lung re-expansion: Consider earlier referral at 2-4 days 1, 2
Common Pitfalls to Avoid
- Never apply routine suction immediately – this is the most common error and lacks evidence support 1, 2
- Avoid high-pressure, high-volume systems – these can cause air stealing, hypoxemia, or perpetuate air leaks 2
- Do not clamp chest tubes during transport or assessment unless specifically indicated for removal trial 2
- Ensure adequate tube security – but avoid excessive tension that causes skin ischemia 2
- Monitor for subcutaneous emphysema – may indicate tube malposition or inadequate drainage 4, 5
Tube Removal Criteria (When Applicable)
Chest tubes may be removed when ALL criteria are met: 2