6.8 Assisting With Chest Tube Removal

The removal of a chest tube is performed by a health care provider such as a physician, physician’s assistant, or nurse practitioner.

Indications for chest tube removal include the following^[1]:

• Improved respiratory status
• Symmetrical rise and fall of the chest
• Bilateral breath sounds
• Decreased chest tube drainage
• Absence of bubbling in the water seal chamber during expiration
• Improved chest X-ray findings

Nursing Responsibilities

The information below summarizes nursing responsibilities before, during, and after the procedure. Expected outcomes after completing the procedure include re-expansion of the lung, client comfort, and healing of the chest tube insertion site without complications, such as infection.

Pre-Removal

• Prepare the client for removal of the chest tube:
  • Assess the need for analgesia.
  • Obtain required medication orders.
  • Instruct the client about the chest tube removal process and inform them that they may have to take a deep breath and hold when it is removed (Valsalva maneuver) to prevent air from reentering the pleural space.

• Assess the client’s lungs for re-expansion:
  • Report the most recent chest X-ray results to the health care provider.
  • Examine the trend in the water seal fluctuation over the last 24 hours.
  • Note if bubbling is present.
  • Confirm decrease in drainage.

• Assess the client’s understanding of the chest tube removal process.
• Do not clamp the tube before the removal.
• Administer prescribed pain medication 30 minutes before the procedure, if applicable.
• Identify the client using two patient identifiers as part of the “time out” process as the procedure begins.

During the Procedure

• Assess the client’s level of comfort throughout the procedure.
• Perform hand hygiene and apply PPE, including gloves and face shield if needed.
• Assist the client to a seated, supine, or side-lying position (on the side without the chest tube). Apply a protective fluid impermeable pad under the chest tube.
• Provide physical and emotional support to the client during the procedure, especially as the provider removes dressings and sutures.
• After the health care provider removes the chest tube, applies a sterile occlusive dressing, and secures it, assist the client to an upright position supported with pillows.
• Remove equipment and dispose of supplies appropriately.
• Remove gloves and perform hand hygiene.

After the Procedure

• Auscultate lung sounds.
• Inspect and palpate over the area where the tube was inserted to detect any subcutaneous emphysema.
• Evaluate for any signs of respiratory distress immediately after removal and during the first hours after it is removed. Notify the health care provider if respiratory distress occurs.
• Evaluate vital signs, including oxygen saturation, respiratory status, pain assessment, and level of anxiety.
• Review post-removal chest X-ray and report to the health care provider.
• After removal of a chest tube drainage system, assess the client at a minimum of every 15 minutes for at least an hour, according to agency policy. After the client is stable, monitoring may be less frequent.
• Frequently monitor the chest dressing for drainage. Change the dressing as prescribed, identifying any indications of infection or nonhealing at the insertion site.