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Introduction ⬇

Chest tube removal should occur as soon as the chest tube is no longer clinically indicated, to prevent infection along the tube tract, reduce hospital length of stay, and prevent complications related to hospitalization.1 The timing of chest tube removal is based on individualized assessment of the patient. Chest tube removal occurs when drainage has diminished, an air leak no longer exists, fluctuations in the water seal chamber are minimal or absent, the patient’s respiratory status has improved, breath sounds are equal and at baseline for the patient, or a chest X-ray shows the lung is reexpanded.1,2 After lung reexpansion and drainage control have occurred, the practitioner may order tube clamping for several hours to simulate chest tube removal and assess the patient’s response.1 This approach allows time to observe the patient for signs and symptoms of respiratory distress, an indication that air or fluid remains trapped in the pleural space.

Chest tube removal is the responsibility of a physician, a nurse practitioner, an advanced practice nurse, or a physician’s assistant, according to the scope of practice. A nurse assists with removal, as needed.

Equipment ⬆ ⬇

Equipment

Gloves ▪ sterile gloves ▪ goggles and masks or masks with face shield ▪ gowns ▪ prescribed premedication ▪ suture removal kit ▪ fluid-impermeable pad ▪ 4′× 4′ (10 cm × 10 cm) sterile gauze dressing ▪ tape ▪ antiseptic swabs ▪ disinfectant pad ▪ vital signs monitoring equipment ▪ stethoscope ▪ pulse oximeter ▪ Optional: sterile petroleum gauze, prescribed pain medication, chest tube clamps.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order for chest tube removal.
  • Gather and prepare the necessary equipment and supplies.
  • Perform hand hygiene.3,4,5,6,7,8
  • Confirm the patient’s identity using at least two patient identifiers.9
  • Provide privacy.10,11,12,13
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.14
  • Premedicate the patient, as ordered, following safe medication administration practices to reduce the patients discomfort.15,16,17,18
  • Obtain vital signs and perform a respiratory assessment to determine readiness for chest tube removal.1
  • Raise the bed to waist level before performing patient care to prevent caregiver back strain.19
  • Perform hand hygiene3,4,5,6,7,8 and put on a mask and goggles or mask with face shield, a gown, and gloves.20
  • Place the patient in the semi-Fowler position or on the unaffected side to enhance access to the insertion site.1
  • Place a fluid-impermeable pad under the affected side to protect the linens from drainage and to provide a place to put the chest tube after removal.
  • Prepare the suture removal kit and a sterile occlusive dressing with a 4′× 4′ (10 cm × 10 cm) sterile gauze dressings and tape so that the practitioner can cover the insertion site with it immediately after removing the chest tube.1 Note that some practitioners use petroleum gauze in addition to the sterile gauze, based on patient assessment.1,2
  • The practitioner performs hand hygiene and puts on goggles and a mask or a mask with a face shield, a gown, and sterile gloves.21
  • If instructed by the practitioner, remove the existing chest tube dressing and discard it appropriately.22 Be careful not to dislodge the chest tube prematurely.
  • Assist the practitioner, as needed, with cleaning the area around the tubes with an antiseptic swab and removing the sutures.1
  • Trace the chest tube from the point of origin to the patient to ensure removal of the proper tube.23 Clamp the chest tube catheter (if not already clamped) following the manufacturer’s instructions to minimize dead space and stop air from entering or exiting the catheter.1
  • Assist the practitioner as necessary. The practitioner will instruct the patient to perform the Valsalva maneuver by exhaling and bearing down to increase intrathoracic pressure and prevent air from entering the pleural space while the practitioner removes the chest tube and covers the insertion site with the airtight dressing. If the patient can’t follow instructions, the practitioner will remove the tube during peak inspiration.1
  • Help secure the dressing with tape. Make it as airtight as possible to seal the insertion site from air entry.1
  • Instruct the patient to breathe normally.
  • Return the bed to the lowest position to prevent falls and maintain patient safety.24
  • Discard equipment and waste in appropriate receptacles.22
  • Remove and discard your gloves and other personal protective equipment20,21 and perform hand hygiene.3,4,5,6,7,8
  • Closely monitor the patient after the procedure to determine the patients response to and tolerance of the procedure.1 Monitor vital signs; oxygen saturation; respiratory rate, pattern, and effort; breath sounds; and symptoms of chest discomfort.1
  • Obtain a chest X-ray, if ordered, to verify lung expansion.1 Keep in mind that a chest X-ray might not be indicated after chest tube removal unless the patient’s condition changes.1

NURSING ALERT Notify the practitioner immediately if the patient develops acute respiratory distress, which may indicate the need for a new chest tube.

  • Position the patient for comfort.
  • Encourage coughing and performance of deep breathing exercises to help prevent pneumonia and promote lung expansion. (See Instructions for coughing and deep breathing.)
  • Regularly assess the chest tube site for bleeding, skin necrosis, infection, and subcutaneous emphysema (air leakage into surrounding tissue).1 Screen for and assess the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand.25
  • Treat the patient’s pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination of approaches. Base the treatment plan on evidence-based practices and on the patient’s clinical condition, past medical history, and pain management goals.25
  • Perform hand hygiene.3,4,5,6,7,8
  • Clean and disinfect your stethoscope using a disinfectant pad.26,27
  • Perform hand hygiene.3,4,5,6,7,8
  • Document the procedure.28,29,30,31

Special Considerations ⬆ ⬇

Special considerations
  • If the patient is receiving mechanical ventilation therapy, the practitioner should remove the chest tube at peak inspiration.1

Complications ⬆ ⬇

Complications

Potential complications of chest tube removal include infection at the site, tension pneumothorax, bleeding, skin necrosis, retained chest tube, pericardial effusion, and cardiac tamponade.1

Documentation ⬆ ⬇

Documentation

Record the date and time of chest tube removal; nursing preparation procedures; the patient’s vital signs and respiratory status; and the patient’s tolerance of the procedure. Also document the medications you administered, including the medication strength, dose, route of administration, date and time of administration, and effectiveness.32 Document the condition of the insertion site and any complications that occurred, including the name of the practitioner notified, the date and time of notification, interventions performed, and the patient’s response to those interventions. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. WiegandD. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (6th ed.). St: Louis, MO: Elsevier.
  2. CarrollP. (2019) Chest tube drainage and management. https://www.rn.org/courses/coursematerial-98.pdf
  3. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  4. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  5. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  6. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  7. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  8. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  9. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  10. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(c)(1)

    .
  11. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  12. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  13. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  14. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  15. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Nursing services. 42 C.F.R. § 482.23(c)

    .
  16. The Joint Commission. (2021). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  17. Accreditation Association for Hospitals and Health Systems. (2020). Standard 16.01.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  18. DNV GL-Healthcare USA, Inc. (2020). MM.1.SR.2. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  19. WatersT. R., et al. (2009). Safe patient handling training for schools of nursing. https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)
  20. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  21. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  22. Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  23. U.S. Food and Drug Administration. (2017). Examples of medical device misconnections. https://www.fda.gov/medical-devices/medical-device-connectors/examples-medical-device-misconnections
  24. GanzD. A., et al. (2013, reviewed 2021). Preventing falls in hospitals:

    A toolkit for improving quality of care

    (AHRQ Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html (Level VII)
  25. The Joint Commission. (2021). Standard PC.01.02.07. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  26. RutalaW. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf (Level I)
  27. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  28. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  29. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  30. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  31. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  32. The Joint Commission. (2021). Standard RC.02.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)