Chest drain (chest tube) insertion: why it is needed, what happens and risks

A chest drain is a small tube inserted through the skin that sits in the pleural space, the space between the lung and the inside of the chest wall. Dorset County Hospital explains that it allows air or fluid to be removed so the lung can re-expand, and North Tees and Hartlepool describe it as usually as thin as, or thinner than, a pen.

In clinical language the procedure is sometimes called a tube thoracostomy. Patient leaflets simply call it inserting a chest drain. It is different from a thoracentesis or pleural tap, which uses a needle or thin tube that is removed straight away; a chest drain stays in for a period of time.

The tube is connected to a bottle containing sterile water. North Tees says that an underwater seal prevents air moving back up the tube, while Dorset says this arrangement lets air or fluid drain out.

North Tees lists the most common reasons: a pneumothorax (a collection of air between the lung and the chest wall), a pleural effusion (a build-up of fluid), an empyema (a build-up of infected fluid or pus) and a haemopneumothorax (a build-up of blood and air). Dorset summarises these as air, fluid, blood or pus in the pleural space.

Dorset says that most people find their breathing is much easier after the drain has been inserted. Your doctor will explain the reason in your case, and why a drain rather than a simple needle aspiration has been chosen.

A doctor should explain why a drain is needed and discuss the risks before asking you to consent, as North Tees notes. Dorset says the risks will be discussed in advance and a consent form completed.

Blood thinners matter. Dorset lists general timings for stopping warfarin (usually five days before, with an INR blood test the day before), ticagrelor or prasugrel (usually seven days), apixaban, dabigatran, rivaroxaban or edoxaban (usually two days), and injected heparins (usually not the day before), and says aspirin is normally continued. The leaflet is also dated and your own doctor must give you specific instructions, so do not change any medicine on your own.

North Tees says chest drains are usually inserted on a ward or in the Emergency Department. Depending on the site, you either sit back against pillows with your arm lifted over your head or sit forward resting on a bedside table. Dorset describes sitting on the side of the bed with your arms on a table, or lying with one arm above your head.

Dorset says an ultrasound scan marks a safe site. The skin is cleaned with antiseptic and covered with sterile drapes, local anaesthetic is injected (this can sting temporarily), a small cut is made and the drain is inserted. It is secured with stitches and a special dressing and connected to the drainage bottle. According to Dorset, the procedure usually takes 30 to 45 minutes.

North Tees says a qualified doctor inserts it, often a junior doctor trained in the procedure, and that if a doctor in training is to carry out the procedure they are supervised by a more experienced doctor; you can decline this without it affecting your treatment. Afterwards, a chest X-ray is arranged to check the position of the drain.

Looking after the drain is a shared job. Dorset gives simple rules: carry the drainage bottle with you, always below the level of your waist so fluid cannot flow back into the pleural cavity, do not pull on it or allow it to get tangled, and do not leave the ward unless accompanied by hospital staff. North Tees says extra care is needed when turning, getting in or out of bed, or getting out of a chair.

You may feel some discomfort as the lung expands again, and painkillers can be given. North Tees explains that nurses will check the bottle and record drainage, and that sometimes a senior respiratory doctor asks for suction to be attached to help the problem settle more quickly.

If the tube becomes blocked, North Tees says you may suddenly become short of breath or develop swelling on the chest wall caused by air in the tissues, called surgical emphysema, and you should tell a nurse immediately. Dorset adds that you should tell a nurse if you develop chest pain, feel your drain has moved or may be coming out, or feel more short of breath.

It depends on why the drain was inserted and how quickly the air or fluid drains. Dorset says the drain usually remains between one and seven days, and North Tees says it varies from one day to many days or longer, and that you may have several chest X-rays to check progress.

North Tees describes removal: a nurse or doctor removes the dressing and gently takes out the drain, and you will be asked to hold your breath or breathe out as it comes out, which helps to prevent air being sucked back into the chest. The stitch may be removed or left for a few more days to help the wound heal.

After the drain is removed, North Tees asks you to tell a doctor or nurse immediately if you develop increased pain, difficulty breathing or a temperature higher than 38 degrees Celsius.

North Tees calls insertion a very safe procedure with some risks. Discomfort or pain during insertion is the most common, and the drain can become dislodged, in which case it may need to be re-inserted. It can also be placed in the tissues of the chest wall rather than the pleural cavity, which is sometimes only found on the X-ray and means it needs to be advanced or replaced. Infection is reduced by skin cleaning and sterile equipment and treated with antibiotics if it occurs. Surgical emphysema is more likely when a drain is inserted for pneumothorax or if it becomes blocked.

Much rarer complications include puncture of a major organ such as the lung, stomach, spleen, heart or large blood vessels, and a vasovagal attack, which is a faint caused by a slowing heart rate and fall in blood pressure. Dorset puts serious bleeding from a damaged blood vessel at about one in 500 patients and says ultrasound at the time of insertion greatly reduces the risk of organ puncture.

A chest drain is usually inserted as part of an acute admission, often via the Emergency Department or an acute medical ward, and is part of hospital inpatient care. Where it is planned, your hospital will tell you where it will be done.

Because the need is generally urgent and the drain stays in for days, it is usually done in the hospital where you are being treated. If you have concerns, ask for the plan: why it is needed, how long it is likely to stay in, what will be done if it stops draining and who to tell if you feel worse.