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Underwater seal chest drainage in the highly dependent or critically ill infant or child: nurse role: ongoing chest drain management

What's New

This single guidance document replaces two nursing procedures: chest drain ongoing management & unplanned chest drain events. 


Chest drains and chest drainage systems are used frequently in the paediatric critical care unit. There are many reasons for chest drain insertion but primarily they are used whenever there are specific conditions that interfere with the normal mechanism of lung expansion and altered intrathoracic pressures.

Pleural chest tubes are inserted to evacuate blood, pus, air and fluid, from the thoracic cavity, to re-establish negative pressure in the intra pleural space and thereby expand the lungs following collapse resulting from surgery or trauma. 

Mediastinal chest tubes are placed in the mediastinum following open heart surgery, via a medial sternotomy in order to prevent accumulation of blood and clots around the heart, which could cause cardiac tamponade – a life threatening situation. 

There are many different types of chest drains available including one-way flutter valve drains such as the Heimlich device or portable drains. However, for the majority of patients in the paediatric critical care unit an underwater seal chest drainage system will be used. These systems provide an underwater seal, fluid collection chamber and suction chamber. 

In paediatric intensive care it is normally the physician or Advanced Nurse Practitioner who inserts chest drains. However, the bed side nurses’ role is pivotal in ensuring the patient is cared for safely throughout the insertion procedure.

This guideline is intended as a resource for staff involved in caring for children in Paediatric Critical Care 1D (PICU) that require chest drain insertion. The guideline has been constructed after literature search and review of sourced textbooks, national guidelines & recommendations British Thoracic Society, Medline and CINHAL, and external nurse expert peer review and opinion.

Further information on chest drainage in: ‘Tutorial Notes-Chest Drainage’ Maxwell (2018) and additional chest drain system resource at: See also recommendations and precautions.


This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring underwater seal chest drainage within the Paediatric Critical Care Unit 1D (PICU) at the Royal Hospital for Children, Glasgow. 


All nursing staff involved in caring for infants or children requiring underwater seal chest drainage in Paediatric Critical Care (PICU) should be familiar with this nursing procedural guideline.

Equipment: Ongoing chest drain management

Equipment: Available for ongoing management or in case of any untoward event

Fig. 1. Bed side equipment for ongoing chest drain management

Available at bed side:

  • Clamps (x1 each drain)                              
  • Suction tubing-if required                          
  • Suitable dressing (for ongoing site care)  
  • Sterile gloves
  • Sterile water
  • Sterile scissors                        
  • Disposable apron                                      
  • Disposable gloves                          
  • Wall suction gauge-if required (low flow * Fig. 2)


  • Chest drain site occlusive dressing (E.g. Duoderm®)  
  • Steri-strips                                          
  • Chlorhexidine 2% & 70% alcohol (swab suitable for urgent event-Clinell)

On chest drain trolley:

  • Chest drain system

Fig. 2. *Low flow suction unit 


Procedure: Ongoing chest drain management

PROCEDURE: Ongoing chest drain management


Vital signs & patient observations: The infant or child with a chest drain(s) in situ must have the following observations monitored frequently &  documented:

  •  Respiratory rate, effort & work of breathing
  • Air entries
  • Heart rate & pulse
  • Oxygen saturations (SpO2)
  • Blood pressure
  • Temperature

If a suitable invasive monitoring line is in situ then regular arterial or venous blood gases should be done.

Frequent monitoring of vital signs is important in detecting any alterations from previously documented normal values as these may indicate problems such as haemorrhage, unresolved pneumothorax, tension pneumothorax, sepsis, infection and ventilation-perfusion mismatch.

Suggestions for monitoring vital signs ranges from ¼ hourly immediately post drain insertion/admission, to ½ hourly to hourly whilst drain is in situ.   

The frequency of monitoring specific vital signs and blood gas analysis will be determined by the child’s clinical status with any deterioration in the child’s vital signs being reported to the nurse-in-charge and medical team immediately.   

Chest drain site care: the nurse must ensure the drain site is checked regularly for the following:

  • Drain is properly anchored with appropriate suture(s) and secured to child’s chest wall

  • Drain site is dry, clean & covered with dry non-adherent dressing

  • Drain site dressing should be inspected for signs of leakage or odour

  • Area around drain site inspected for signs of leakage, inflammation, infection or subcutaneous emphysema

The drain must be well secured after insertion to prevent it becoming dislodged, slipping or falling out.

Large amounts of tape and padding may restrict chest movement and prevent regular inspection of the drain site for complications. A dry non-adherent dressing, non-occlusive is most suitable.  

The drain site and dressing should be reviewed daily and the dressing should not need redressed for 2-3 days unless leakage apparent.

Any signs of complications such as infection should be documented and reported and appropriate action taken. E.g. wound swab or medical team review.

Chest drainage unit (CDU) care: the nurse must check the under water seal chest drainage system frequently to ensure it is working correctly and to avoid potential problems:  *see (Fig. 3)

Keep chest drainage system and tubing below the level of the patients chest


Perform initial inspection of connections & tubing.

Thereafter inspect CDU tubing & drain connections regularly (suggested hourly) and keep tubing free from bedsides/cot-sides

Ensure tubing & drain(s) are secure but not ‘pulling’. Try not to secure tubing to child’s bed, linen or loose clothing (Fig. 4)

Aim to lay tubing horizontally across bed before dropping it vertically into drainage system to facilitate drainage – avoid dependent ‘loops’ or kinking of tubing (Fig. 5)

Ensure chest drainage unit is secured upright on floor beside or at the end of the bed/cot.



The chest drainage system must always be kept below the level of the child’s chest to prevent fluid re-entering the pleural space – syphonage.  


Regular inspection of the drain and tubing is vital to ensure that the system is still intact the drain has not slipped, connections have not come loose or tubing has become kinked.

Securing tubing to clothing or bedding is not advised as sudden movements by the child or change of bed-linen could dislodge the drain.

Dependent loops or kinking of tubing can impede drainage, block tubing and cause high pressures at chest tube and drainage tube connections, potentially resulting in clinical complications such as tension pneumothorax.   

Securing the drainage system to the floor with tape may be necessary to prevent tipping of system.    

Check water seal chamber (B) (Fig. 3) maintained at 2cm level  

Monitor and record any ‘bubbling’ or ‘swinging’ in the water seal chamber of the CDU. Report any changes to nurse-in-charge.  

If chest drain in pleural cavity, observe and record any fluctuations in water seal level of CDU with respiratory effort/ventilation – ‘tidalling’  

Ensure suction chamber (A) (Fig. 3) filled to -20cmH2O level in CDU.

If suction required - Check suction tubing connected to low flow regulated suction & suction control stopcock at CDU switched on.  

Check negative pressure on suction is set low enough to give gentle bubbling in the suction chamber – no excessive bubbling

Ensure suction filter attached – changed when indicated

Check fluid collection chamber (D) (Fig.3) frequently (*15 min. intervals to 30min., then hourly) and document volume, type and colour of drainage. E.g. fresh blood, serous, cloudy.

Always label chest drain(s) and drainage units clearly. E.g. Left (L) pleural 1 or Right (R) mediastinal 2.


Water in the water seal chamber (B) (Fig. 3) can evaporate and under water seal will be lost. The level must be checked regularly and ‘topped-up’ as per manufacturers instructions.

Persistent bubbling may suggest visceral pleural air leak, a drain on suction that has one of the drain eyelets open to air or with mediastinal drains patient with ‘open’ chest. ‘Swinging’ of the water seal level with respirations indicates drain patency and confirms drain position in pleural cavity.


If suction is required, a low pressure system must be used as excessive negative pressures may cause perpetuation of air leaks. If suction is required for more than one chest drain then a separate suction unit is advised for each chest drain.

Turbulent bubbling is unnecessary, will not improve fluid drainage and will result in increased evaporation of water in the chamber.


Frequent assessing and documenting of fluid volume and type drained and from what site is essential, as this may help the nurse determine if the child has any of the following:

  •  Persistent or fresh bleeding
  • Infection
  • Chylothorax
  • Tamponade

*Frequency of checking tubing and drainage will range from every 15 minutes initially (for first 6 hours) post admission from cardiac or thoracic surgery, to 30 minutes (6 hours) then hourly once child stabilised. This is provided there is no other evidence or suspicion of bleeding or tamponade present.

Specific nursing care issues:  

  • The nurse should assess the child’s level of pain or discomfort regularly and administer analgesia as prescribed
  • Reposition the child regularly as tolerated ensuring drain and tubing secure throughout – a two nurse procedure.
  • Avoid excessive chest tube handling/manipulation such as ‘milking’ or ‘stripping’ unless specifically instructed.  (see Chest Drainage tutorial book for more details)






  • Avoid routine clamping of chest drain tube unless specifically instructed by senior physician (see Chest Drainage tutorial book for more details)

Pain from having a chest drain in situ can inhibit the child’s movement and breathing which can slow their recovery. Therefore, regular pain assessment is vital to ensure the child receives adequate analgesia while the drain is in situ.

Repositioning and improving mobility can facilitate drainage, aid breathing and lung expansion and reduce complications associated with immobility.

Repositioning the infant/child with a chest drain in situ should involve at least two nurses in order to prevent accidental disconnection or kinking of drain and/or tubing.  

Routine manipulation of chest drain tubing by ‘milking’ or ‘stripping’ the tubing has been common practice in the past in an attempt to prevent mediastinal drains from blocking with clots and causing cardiac tamponade. However, this type of tubing manipulation is thought to cause significant increases in negative intrathoracic pressures, may not be of proven benefit and may cause tissue damage.  

Routine clamping of chest drains is not recommended especially if bubbling, as it prevents the escape of air or fluid from the chest or mediastinum, leading to an increased risk of tension pnuemothorax or cardiac tamponade.


Fig.3. Underwater seal chest drainage unit

Fig.4 Tubing secure


Fig.5 Avoid dependent loops 

(Elevation of cot/bed –as above - should also aid drainage)

Equipment: Management of unplanned chest drain events

Available for ongoing management or in case of any untoward event. (Equipment available at bed side or on *chest drain trolley)

  • Gloves (for all contact with chest drains)
  • Apron (for all contact with chest drains)
  • 70% alcohol & 2% Chlorhexidine swabs (E.g. Clinell® swabs)
  • Chest drain clamps
  • Sterile scissors
  • Stethoscope
  • Spare connector – correct size (attached to back of chest drainage system) Occlusive dressing:
  • Occlusive dressing: e.g. Duoderm®
  • Steri-strips
  • New underwater seal system*
  • Sterile water* 

A. Occlusive Seal Dressing (Fig 6)

To be kept in bed side trolley & attached to back of chest drain system of every child with chest drain insitu. Occlusive seal dressing example: Duoderm® & steristrips

Fig 6.

B. Chest Drain Safety Pack

To be attached to the back of the chest drain collecting chamber of every child with chest drain insitu (Fig. 7 & 8). To include – appropriately sized chest drain connector, scissors, Clinell® swabs (Fig.1, 7 & 8)

Fig. 7

Fig 8. 


Procedure: Accidental removal of chest drain - child WITH air leak (e.g. pneumothorax)

CHILD WITH AIR LEAK (E.g. Pneumothorax)



Quickly cover chest drain site/wound with an occlusive seal dressing - Duoderm®*

(*Occlusive dressing for accidental removal of chest drain)   (Fig.6)

This will provide an occlusive seal and help prevent air being introduced into pleural space during respiration.


Notify medical & senior nursing staff  immediately

To formulate a plan for ongoing management

Prepare for reinsertion of chest drain

Equipment required at bedside, to aid prompt chest drain re-insertion

Careful observation of child’s respiratory and cardiovascular status

To monitor for symptoms of increasing pneumothorax and / or tension pneumothorax

Fig. 6

Procedure: Accidental removal of chest drain - child WITHOUT air leak (e.g. pleural effusion)

CHILD WITHOUT AIR LEAK (E.g. Pleural effusion)



Tie staying suture if present and cover site with A. Occlusive seal dressing-Duoderm®*

(*Occlusive dressings for accidental removal of chest drain) (Fig.6) 

If no staying suture present, then use steri-strips to close chest drain wound site.

Then cover site with Duoderm® (Fig. 6)

This will provide an occlusive seal and help prevent air being introduced into pleural space during respiration.


Notify medical and senior nursing staff immediately

To formulate a plan for ongoing management

Careful monitoring of child’s respiratory status

To monitor for symptoms of increasing pleural effusion.

Procedure: Accidental disconnection / damage to drainage system - child WITH air leak (e.g. pneumothorax)



Clamp chest drain

To prevent air being introduced into pleural space during respiration


It is generally contraindicated to clamp a chest drain with an air leak, however in this emergency the chest drain MUST be clamped, to prevent air being drawn into the chest, but for the shortest time possible

Call for help


Using equipment from B. Chest drain safety pack (Fig. 7 & Fig. 8)

Clean chest drainage system tubing approximately 10-15cm below tubing disconnection site with Clinell® swab.

Using sterile scissors cut the tubing at the cleaned area.

Insert sterile (appropriately sized) chest drain connector to the cut and clean tubing.

Clean end of chest drain with Clinell® swab.

Reconnect chest drain to cleaned tubing and connector and remove clamp



 To reduce potential of infection

To remove portion of tubing contaminated during disconnection

To reduce potential of infection and ensure good seal

To reduce potential of infection

To re-establish underwater drainage system

Prepare new drainage system

Ensure connections are secure

Secure drainage container to the floor

To prevent infection


Inform medical and senior nursing staff

To formulate a plan for ongoing management

Procedure: Accidental disconnection / damage to drainage system - child WITHOUT air leak (e.g. pleural effusion)



Clamp chest drain

To prevent air being introduced into pleural space during respiration

Place drain end on sterile drape

To prevent infection

Call for help


Prepare new drainage system

To prevent infection

Clean drain end with Clinell® swab

Connect to drainage system, remove clamps

Ensure connections are secure

Secure drainage container to the floor

To prevent infection

To re-establish underwater drainage system

Inform medical and senior nursing staff

To formulate a plan for ongoing management

Procedure: Chest drain site infection / chest wall injury



Regular assessment of chest drain site

To recognise signs of skin deterioration or infection

(exudate, odour, redness, swelling)

If infection suspected -

  • Remove dressing
  • Obtain wound swab
  • Send to microbiology for culture & sensitivity

To ascertain if infection is present

Apply dressing to chest drain site according to hospital wound chart or contact Tissue Viability Nurse for wound assessment

To provide evidence based wound care and promote healing

Document wound management plan, by completing wound chart

To provide continuity of wound care

Re-assessment of wound as documented in wound chart

To evaluate effectiveness of treatment

Utilise sterile technique when dressing / manipulating chest drain

To prevent infection

Procedure: Infection of chest drain tract



Monitor chest drain losses for signs of infection

To recognise infection

Obtain sample of chest drain loss

Sampling of patient drainage must be in accordance with approved hospital infection control standards.

Wash hands, don apron and gloves before either procedure.

Sample Collection Procedure  - (needle-free)

Sample to be taken from drainage system tubing, not collecting chamber

  1. Clean sample port with Clinell® swab.
  2. Attach luer-lock syringe (E.g. 5ml) to sample port (Fig. 9)
  3. Manipulate chest drain system tubing to manoeuvre chest drain exudate towards sampling port (Fig. 10)
  4. Aspirate sample into syringe.
  5. Insert aspirated chest drain exudate into universal container.
  6. Send to microbiology for culture & sensitivity and / or investigations requested by medical staff











Sample Collection Procedure – (with needle)

In chest drain systems without a sampling port (E.g. Atrium 2002), sample must be aspirated from drainage system tubing using a needle.


  1. Manipulate drainage tubing to form a temporary dependent loop.
  2. Clean tubing area with Clinell® swab.
  3. Insert sterile needle (*20g or less) & attached syringe into tubing at an oblique angle.
  4. Aspirate sample (Fig. 11) & then remove needle and syringe

Then follow steps v. & vi. above.

To ascertain if infection is present




Selected models of chest drain systems (E.g. Atrium 2012) include a needleless luer port on the patient tube connector for sampling patient drainage. (Fig. 9 & Fig 10)

Fig. 9                                                                             

Fig. 10

ALL CHEST DRAIN SYSTEMS SHOULD BE NEEDLE-FREE. However, if you have a system  that is not, use the following procedure:

*Do not puncture chest drain system tubing with an 18g or larger needle.

Fig. 11

Monitor child for signs of systemic sepsis


To ascertain if localised infection has become systemic infection.

To formulate a management plan

Procedure: Chest drain tubing blockage



Monitor chest drain losses at regular intervals. E.g.

  • Post cardiac surgery
    • 15mins for 1st 6 hours
    • 30mins for following 6 hours
    • hourly
  • Pleural drains
    • hourly

Or as required by child’s clinical condition

To ascertain sudden cessation in drainage




Position chest drain tubing to prevent dependant loops and coiling by laying tubing along bed dropping vertically into drainage chamber (Fig. 12)

To prevent clot formation and blockage of  tubing

Monitor chest drain and tubing for clot formation and blockage

Position tubing over bed covers to allow constant observation


Blockage of chest drains can lead life-threatening complications

  • Post cardiac surgery
    • unrecognised bleeding
    • cardiac tamponade
  • Pleural drains
    • tension pneumothorax
    • undrained pleural effusion

leading to haemodynamic and respiratory compromise

Inform medical & senior nursing staff of clot formation or blockage of chest drain and tubing


To formulate a plan for ongoing management

Stripping of chest drains with mechanical rollers is a technique used to clear the tubing of clots and blockages, by generating short bursts of negative pressure to the drain.

This is a controversial technique and should only be undertaken under senior nurse & medical staff supervision.

Fig. 12

Precautions and further information

Practical chest drainage system issues: When there is no air leak, the water level in the water seal chamber should rise and fall with the patient's respirations, reflecting normal pressure changes in the pleural cavity during respiration. During spontaneous respirations, the water level should rise during inhalation and fall during exhalation. If the patient is receiving positive pressure ventilation, the oscillation will be just the opposite. Oscillations may be absent if the lung is fully expanded and suction has drawn the lung up against the holes in the chest tubes.

A patient with mediastinal chest tubes (and a ‘closed’ chest) should have no bubbling or fluctuations in the water seal chamber. As one of the risks of accumulation of fluid, blood or clots around the heart is cardiac tamponade, it is particularly important for nurses caring for patients with mediastinal chest tubes to be watchful for signs of cardiac tamponade with special attention paid to the volume and consistency of drainage in the collection chamber (D) (Fig. 3).

APPENDIX 1: Quick guide flowchart: chest drainage – ongoing management

APPENDIX 2: Quick guide flowchart: chest drainage – managing unplanned events

  1. Allibone, L (2003) Nursing Management of chest drains. Nursing Standard, Vol.12 (17), pp. 45-54.

  2. Allibone, L (2005) Principles for inserting and managing chest drains. Nursing Times, Vol. 101 (42), pp. 45-48.

  3. Atrium (2016) A personal guide to managing chest drainage. Atrium teaching resource accessed at:  and

  4. Balfour-Lynn, IM Abrahamson, E Cohen, G Hartley, J King, S Parikh, D Spencer, D Thomson, AH Urquhart, D (2005) BTS guidelines for the management of pleural infection in children. Thorax, Vol. 60, Suppl. I, pp. i1-i21.

  5. Bar-El, Y Ross, A Kablawi, A Egenburg, S (2001) Potentially dangerous negative pressures generated by ordinary pleural drainage systems. Chest, Vol. 119 (2), pp 511-514

  6. Briggs, D (2010) Nursing care and management of patients with intrapleural drains. Nursing Standard, Vol. 24 (21), pp. 47-55.

  7. Coughlin, AM Parchinsky, C (2006) Go with the flow of chest tube therapy. Nursing, Vol. 36 (3), pp 36-41.

  8. Crawford, D (2011) Care and management of a child with a chest drain. Nursing Children and Young People, Vol.23 (10), pp.27-33.

  9. Day, TG Perring, RR Gofton, K (2008) Is manipulation of mediastinal chest drains useful or harmful after cardiac surgery? Interactive Cardiovascular and Thoracic Surgery, Vil. 7, pp 888-890.

  10. Duncan, C Erikson R (1982) Pressures associated with chest tube stripping. Heart and Lung, Vol. 11 (2), pp. 166-171.

  11. GOSH (2016) Chest drain management.  Great Ormond Street Hospital: Clinical Guidelines, London. 

  12. Halm. MA (2007) To strip or not to strip? Physiological effects of chest tube manipulation. American Journal of Critical Care, Vol. 16 (6), pp. 609-612.

  13. Havelock, T Teoh, R Laws,D Gleeson,F (2010) on behalf of the BTS Pleural Disease Guideline group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010, Thorax, Vol. 65 (Suppl.2), pp 61-76. 

  14. Horrox, F (2002) Chest drain management. In: Manual of Neonatal & Paediatric Heart Disease, Whurr, London.

  15. Kwiatt, M  Tarbox, A  Seamon, MJ et al (2014) Thoracostomy tubes: A comprehensive review of complications and related topics. International Journal of Critical Illness and Injury Science, Vol. 4 92), pp. 143-155.

  16. Lazzara, D (2002) Eliminate the air of mystery from chest tubes. Nursing, Vol.32 (6), pp 3643.

  17. Maxwell, S (2015) Chest Drain Tutorial Notes. Paediatric Critical Care , Royal Hospital for Children, Glasgow

  18. NHS Greater Glasgow & Clyde (2016) Infection Prevention and Control: Core prevention policies: Decontamination of Equipment and the Environment; Standard Precautions. NHS Greater Glasgow & Clyde Control of Infection Committee Policy. NHSGGC.

  19. Scmelz, JO Johnson, D Norton, JM Andrews, M Gordon, PA (1999) Effects of position of chest drainage tube on volume drained and pressure. American Journal of Critical Care, Vol. 8 (5), pp. 319-323.

  20. Shalli, S., Saeed, D., Fukamachi, K., Gillinov, M., Cohn, W.E., Perrault, L.P. & Boyle, E.D. (2009) “ Chest tube selection in cardiac and thoracic surgery: A survey of chest tube-related complications and their management”, Journal of Cardiac Surgery, Vol.24, pp.503-509

  21. Sullivan, B (2008) Nursing management of patients with a chest drain. British Journal of Nursing, Vol. 17 (6), pp 388-393.

  22. Thorn, M (2006) Chest drains: A practical guide. British Journal of Cardiac Nursing, Vol. 1 (4), pp 180-185.

  23. Tooley, C (2002) The management and care of chest drains. Nursing Times, Vol. 98 (26), pp 48-50.

  24. Wallen, M Morrison, A Gillies, D O’Riordan, E Bridge, C Stoddart, F (2007) Mediastinal chest drain clearance for cardiac surgery. The Cochrane Database of Systematic Reviews, Vol. 2, 2007.

Editorial Information

Last reviewed: 30 September 2018

Next review: 30 September 2021

Author(s): Jeanette Grady

Approved By: PICU Clinical Guideline Group