Haemothorax (blood in the chest cavity): causes, symptoms and chest drain treatment

The lungs sit inside the chest cavity, and each is wrapped in a thin membrane, the pleura. North Bristol NHS Trust explains that a narrow space, lined on both sides by the pleura and known as the pleural cavity, sits between the lung and the chest wall. A haemothorax is blood collecting in that space.

North Tees describes the normal arrangement: the lung closely follows the inside of the chest wall but is not stuck to it, with a tiny amount of fluid allowing the two to slide easily. When fluid, whatever its type, builds up in this space it is called a pleural effusion. A haemothorax is the form where the fluid is blood, which, according to North Tees, can follow an injury to the chest wall that causes bleeding into the chest cavity.

Blood in this space matters because it takes up room the lung needs. North Bristol says that collections of blood, air, fluid or pus can cause problems with breathing and can stop the lungs from working properly.

The most common cause is injury. North Tees names injury to the chest wall as the cause of haemothorax, and the same leaflet places it among several other causes of fluid around the lung, including pneumonia, cancer or growths within the chest, heart or kidney failure, and conditions with an overactive immune system. Other kinds of fluid are named separately: pus in an infected effusion is an empyema, and leakage of fat-containing fluid from an injured lymphatic duct is a chylothorax.

Chest injuries include road traffic collisions, falls, sporting injuries and penetrating wounds, as well as medical procedures. These examples are general and are not listed in the sources read for this page. A person taking blood-thinning medicines may bleed more readily after a chest injury, which is why it is important to tell staff about anticoagulants.

North Tees says the most common symptom of fluid around the lung is breathlessness that worsens over time, with a dry cough and pain on the affected side of the chest, and that other symptoms such as fever or coughing up blood are usually related to whatever has caused the fluid. After injury a haemothorax may come with chest wall pain, bruising, and signs of shock if blood loss is large; these latter features are general clinical points rather than quotes from the pages read.

NHS guidance on pleurisy, which is inflammation of the lung lining and a related but different problem, notes sharp chest pain on breathing in that may be worse with coughing, sneezing or moving, which shows how chest pain linked to breathing is a signal that needs to be checked.

A suspected haemothorax is an emergency. After any significant chest injury, call 999 or go to A&E, particularly if there is difficulty breathing or worsening chest pain. The NHS pleurisy page lists difficulty breathing, sudden chest pain lasting 15 minutes or more, sudden chest pain spreading to the arms, back, neck or jaw, and coughing up more than just a few spots of blood as reasons to call 999 or go to A&E, and says not to drive yourself to A&E.

For less urgent symptoms, such as sharp chest pain that comes and goes or has not improved after a few days, or regularly feeling short of breath, the NHS says to ask for an urgent GP appointment or get help from NHS 111.

North Tees says the most important initial test is a chest X-ray, which is usually enough to show the fluid. A CT scan gives a detailed three-dimensional picture that shows how much fluid is present and what may have caused it, and a chest ultrasound, usually done at the bedside or in clinic, locates the fluid more precisely and shows where arteries, veins and other organs lie in relation to it before a procedure.

In an injured patient the emergency team will examine the whole body for other injuries, and scans may be performed quickly. A sample of fluid can be taken, a procedure called pleural aspiration, to test what the fluid is; for a haemothorax, the nature of the fluid is often obvious from the drain.

North Bristol NHS Trust explains that a chest drain allows blood, fluid or air to leave the body so the lung can re-expand. Before it is inserted the doctor will discuss the procedure and you will sign a consent form. Blood tests may be needed, and if you take blood-thinning medication it may need to be stopped beforehand to reduce the risk of bleeding, with a plan made with you. You may be offered painkillers first, an ultrasound may be done to choose the site, the skin is cleaned and local anaesthetic is injected, a small cut of approximately 2 to 3 mm is made and the tube is passed into the pleural cavity, then held with stitches under a waterproof dressing and connected to a bottle. A chest X-ray checks the drain's position.

About half of people with a chest drain have some discomfort that is usually controlled with simple painkillers, and some develop coughing or chest discomfort as the lung re-expands, which usually settles quickly. While the drain is in you can move and walk but must carry the bottle below waist level, keep it on the floor in bed and avoid pulling or tangling the tube. Tell your nurse about increasing pain or breathlessness, a tube that has moved, or leaking.

How long the drain stays depends on the condition and the response. Removing it is described as a simple procedure: the dressings are removed, the stitch is cut and the drain gently pulled out. Afterwards a gauze dressing is applied, steristrips can be removed after 5 days and a stitch is removed by the practice nurse after 7 to 10 days. In some injuries, such as heavy bleeding that does not stop, an operation may be needed; that is decided by the hospital team and is not covered by the leaflets read for this page.

Recovery depends on the cause and the extent of the injury. Many people recover well once the blood has been drained and the lung has re-expanded, but pain control, breathing exercises and follow-up are important. Your hospital team will explain what to expect and when to return to work or sport.

In the NHS this is emergency care delivered through the ambulance service, emergency department, trauma services and respiratory or thoracic teams. A suspected haemothorax is dealt with through emergency pathways.