Before We Start
Pneumothorax — air where it should not be, and how it kills
A pneumothorax is the presence of air in the pleural space — the normally airtight space between the lung and the chest wall. Normally this space has negative pressure that keeps the lungs expanded against the chest wall. When air enters the pleural space, that negative pressure is lost and the lung collapses inward.
The tension pneumothorax is the life-threatening emergency — air continues to enter the pleural space with every breath but cannot escape. Pressure builds, the heart and great vessels are compressed and pushed to the opposite side, and cardiac output collapses. This kills in minutes. Recognition and immediate needle decompression — before X-ray — is the nursing and medical standard.
💡 Why the Pleural Space Normally Has Negative Pressure
The lung's natural tendency is to collapse inward (its elastic recoil). The chest wall's natural tendency is to spring outward. In the intact pleural space, these two opposing forces create a negative pressure (below atmospheric) that keeps the lungs expanded against the chest wall. When air enters this space through a breach in the lung or chest wall, the pressure equalizes with the atmosphere — the lung collapses and the chest wall springs outward.
Types of Pneumothorax
Spontaneous, traumatic, and tension — three very different urgencies
Spontaneous Pneumothorax
The lung blebs that rupture without injury
Primary spontaneous pneumothorax: Occurs in otherwise healthy young people — typically tall, thin males in their 20s. Caused by rupture of small blebs (weak spots) on the lung surface, usually at the apex. No underlying lung disease. Presents with sudden onset sharp chest pain and dyspnea. Often occurs at rest.
Secondary spontaneous pneumothorax: Occurs in patients with underlying lung disease — COPD, cystic fibrosis, tuberculosis, Pneumocystis pneumonia. Much more serious because the remaining lung function is already compromised. A small pneumothorax in a patient with severe COPD can cause respiratory failure.
Treatment based on size:
• Small (<20% of lung): observation, supplemental O2 (accelerates air reabsorption), no intervention
• Large (>20%) or symptomatic: needle aspiration or chest tube insertion
💊 "Tall thin young man with sudden chest pain = spontaneous pneumothorax." This demographic is so characteristic that a tall, thin male (Marfan habitus) presenting with sudden unilateral pleuritic chest pain and decreased breath sounds on one side should immediately trigger consideration of spontaneous pneumothorax before any other diagnosis.
Traumatic Pneumothorax
Penetrating or blunt chest trauma disrupts the chest wall or lung
Trauma — penetrating (stab wound, gunshot) or blunt (rib fractures from MVA, falls) — can breach the chest wall or rupture the lung, allowing air into the pleural space.
Open pneumothorax (sucking chest wound): A chest wall defect large enough for air to move in and out with each breath. A sucking, gurgling sound is audible at the wound. Treatment: occlusive dressing taped on three sides (flutter valve effect — allows air out but not in) while preparing for chest tube.
Iatrogenic pneumothorax: Caused by medical procedures — central line insertion (subclavian or internal jugular approach), thoracentesis, mechanical ventilation (barotrauma). Post-procedure chest X-ray is essential to detect this complication.
Tension Pneumothorax — THE EMERGENCY
Air accumulates with every breath — no escape — pressure builds — heart compressed — death
In tension pneumothorax, a one-way valve mechanism develops — air enters the pleural space with each inspiration but cannot exit. With every breath, more air accumulates and pressure rises.
What happens as pressure builds:
1. Lung on the affected side collapses completely
2. Increasing pressure pushes the mediastinum (heart and great vessels) toward the OPPOSITE side
3. The heart is compressed and the vena cava is kinked — venous return to the heart drops
4. Cardiac output collapses → circulatory failure → cardiac arrest
Classic signs — the tension pneumothorax triad:
• Absent breath sounds on the affected side
• Tracheal deviation AWAY from the affected side — the mediastinum is being pushed
• JVD (jugular vein distension) — venous blood cannot return to the compressed heart
• Plus: severe respiratory distress, hypotension, tachycardia, hypoxia, cyanosis
In mechanically ventilated patients: Sudden rise in peak airway pressures + hemodynamic deterioration = tension pneumothorax until proven otherwise.
Treatment: Immediate needle decompression — do NOT wait for chest X-ray. Second intercostal space, midclavicular line on the AFFECTED side. A large-bore needle (14-gauge) is inserted — a rush of air confirms the diagnosis. Followed immediately by chest tube insertion.
💊 "Tracheal deviation = act now, not after X-ray." Tracheal deviation is a late but definitive sign of tension pneumothorax. By the time it is visible, the patient may have minutes. Needle decompression before imaging is the standard of care. The risk of performing needle decompression on a patient without tension pneumo is far less than the risk of delaying in a patient who has it.
Chest Tube Care
What the drainage system does, what nurses monitor, and what to never do
The Three-Chamber Drainage System
Collection, water seal, and suction — what each chamber does
The chest drainage system (Pleur-Evac or similar) has three interconnected chambers:
Chamber 1 — Collection chamber: Collects fluid draining from the pleural space. The nurse measures and records drainage every shift — amount, color, consistency. Normal: serosanguineous. Alarming: bright red (active hemorrhage), sudden increase, or sudden cessation.
Chamber 2 — Water seal chamber: Contains sterile water to a specific level (usually 2cm). Creates a one-way valve — air from the pleural space can exit (bubbles up through the water) but atmospheric air cannot enter. Tidaling (water level rising and falling with breathing) indicates the tube is patent and functioning. Cessation of tidaling = tube is kinked, clamped, or the lung has fully re-expanded.
Chamber 3 — Suction control chamber: Connected to wall suction. The water level in this chamber (not the suction pressure setting) controls the actual suction applied — typically 20cm H2O. Gentle continuous bubbling in the suction chamber = suction is working correctly. Vigorous bubbling = suction is too high.
💊 "Tidaling = tube working. Bubbling in water seal = air leak. No tidaling + no improvement = tube problem." These three assessments tell you everything about chest tube function. Check them every assessment, every shift.
Chest Tube Nursing Assessment
What to check, what to document, what to report
Assess every shift:
• Drainage amount, color, consistency in collection chamber
• Tidaling in water seal chamber (rises on inspiration, falls on expiration in spontaneous breathing; reverses in mechanically ventilated patients)
• Bubbling in water seal — continuous bubbling = air leak from the pleural space (expected initially, should decrease as lung re-expands). If bubbling persists for days, may indicate persistent air leak.
• Suction chamber — gentle bubbling only
• Insertion site — intact dressing, no subcutaneous emphysema (crackling feeling under the skin = air tracking into tissue)
• Tubing — no kinks, loops, or dependent fluid traps
• Lung sounds bilaterally — are breath sounds returning on the affected side?
Report immediately:
• Sudden increase in drainage (above 100mL/hour for 2+ hours — possible hemorrhage)
• Sudden bright red drainage
• Cessation of drainage with continued respiratory distress (tube may be kinked/clotted)
• Increasing subcutaneous emphysema
• Patient deterioration despite chest tube in place
Critical Chest Tube Rules — What to NEVER Do
The actions that harm or kill chest tube patients
NEVER clamp the chest tube (unless specifically ordered during tube removal or to locate a leak):
Clamping a chest tube in a patient with an air leak or pneumothorax → air accumulates → tension pneumothorax. The only time a chest tube is clamped briefly is during removal or during a provider-ordered diagnostic procedure. Never as a routine measure.
NEVER lift the drainage system above the patient's chest:
The drainage system must always remain BELOW the insertion site. If raised above chest level, fluid flows back into the pleural space by gravity. Maintain below-chest position during transport, repositioning, and ambulation.
NEVER strip or milk the tubing:
Stripping (pinching and sliding fingers down the tube) creates excessive negative pressure in the pleural space — can damage lung tissue and cause bleeding. Modern evidence does not support routine milking. If the tube is clotted, gently squeeze and release — do not strip.
If the tube accidentally disconnects:
Immediately submerge the end of the chest tube in sterile water (creates a water seal) and call for help. Do not clamp — clamping with air leak = tension pneumothorax.
If the tube falls out:
Cover the site immediately with a gloved hand or petrolatum gauze (occlusive dressing). Call for help. Watch for tension pneumothorax.
💊 "Chest tube out of the patient → cover with hand → call for help." The first action is occlusion of the site to prevent air from entering the pleural space through the open wound. Then get help. Then get a new tube. The sequence matters — air entry causes tension pneumothorax faster than you can call for help.
🏥 Clinical Scenario — Tension Pneumothorax in a Mechanically Ventilated Patient
Mr. Santos, 45 years old, is intubated and mechanically ventilated in the ICU after a motor vehicle accident. He has bilateral rib fractures. At 2am, the ventilator begins alarming with high peak airway pressures. His SpO2 drops from 97% to 82% over 3 minutes. BP 72/40. HR 138.
Alarm
Ventilator assessment: Peak inspiratory pressure alarm — was 28, now 52 cmH2O. The ventilator is struggling to push air in. SpO2 falling despite 100% FiO2. BP crashing. This is a respiratory and hemodynamic emergency.
Assess
Rapid physical exam: Breath sounds absent on the right. Trachea deviated to the LEFT (away from the right side). JVD present. No recent procedures. Bilateral rib fractures — one must have punctured the right lung. Tension pneumothorax — RIGHT side. Tracheal deviation away = mediastinum pushed left.
Act
No time for X-ray. Physician called — physician at bedside in 90 seconds. 14-gauge needle inserted at second ICS, right midclavicular line. Rush of air confirms tension pneumothorax. SpO2 begins climbing immediately: 82% → 88% → 94%. BP 72/40 → 98/62. Life saved in under 2 minutes.
Tube
Chest tube inserted: Right-sided chest tube placed in 5th ICS, anterior axillary line. Connected to drainage system at -20cmH2O suction. Tidaling confirmed. 200mL serosanguineous drainage immediately. Breath sounds returning right. Chest X-ray confirms tube position and lung re-expansion. Ventilator pressures normalizing.
📌 NCLEX Application
Pneumothorax and chest tube care are among the most tested critical care nursing topics:
Tension pneumothorax recognition: "A patient with chest trauma develops sudden respiratory distress, absent breath sounds on the left, tracheal deviation to the right, and JVD. What is the priority?" → Notify provider immediately for emergency needle decompression — this is tension pneumothorax. Do not wait for X-ray.
Tracheal deviation direction: Trachea deviates AWAY from the tension pneumothorax. If tension is on the LEFT, trachea goes RIGHT. If on the RIGHT, trachea goes LEFT. Remember: the mediastinum is PUSHED away from the pressure.
Chest tube clamping: "When is it appropriate to clamp a chest tube?" → Only during removal (briefly) or during a provider-ordered diagnostic procedure. NEVER routinely clamp — can cause tension pneumothorax if an air leak is present.
Drainage system position: "Which action by the nurse caring for a patient with a chest tube requires intervention?" → Placing the drainage system on the bed above the patient's chest — it must always remain below chest level to prevent back-flow.
⚠️ The Trap — Clamping the Chest Tube "Just in Case"
A nurse prepares to transport a patient from the ICU to CT scan. To avoid the drainage system getting in the way, she clamps the chest tube during transport — "just to be safe, just for a few minutes."
What happens if the patient has an active air leak: With the tube clamped, air cannot exit the pleural space. Every breath adds more air. Within minutes, a simple pneumothorax becomes a tension pneumothorax. The patient arrests in the CT scanner hallway.
The correct approach during transport: Keep the drainage system patent (not clamped), keep it below the patient's chest at all times, and monitor closely during transport. If the system must be temporarily disconnected, submerge the tube end in sterile water (improvised water seal).
The exception: A provider may order the tube clamped for a specific, time-limited reason (testing for air leak, removal preparation) with close monitoring. This is a deliberate clinical decision — not a nursing convenience measure during transport.
NCLEX version: "A nurse clamps a chest tube before transporting a patient to radiology. Which complication is the nurse putting the patient at risk for?" → Tension pneumothorax — if an air leak is present, clamping allows air to accumulate without any exit route.
✓ Quick Self-Test
Answer before checking:
1. What are the three classic signs of tension pneumothorax?
2. Which direction does the trachea deviate in a right-sided tension pneumothorax?
3. What does "tidaling" in the water seal chamber indicate?
4. Why should chest tube drainage systems NEVER be raised above the patient's chest?
5. A chest tube accidentally falls out. What are the first two nursing actions?
Answers:
1. Absent breath sounds on the affected side · Tracheal deviation AWAY from the affected side · JVD (jugular vein distension). Plus: severe respiratory distress, hypotension, tachycardia.
2. To the LEFT — the mediastinum is pushed away from the pressure (away from the right side where tension is building).
3. Tidaling (water rising and falling with breathing) indicates the chest tube is patent and communicating with the pleural space. It is the normal functioning indicator of a working chest tube.
4. Fluid in the drainage system would flow back into the pleural space by gravity if the system is elevated above the chest. This reintroduces fluid into the space that was just drained and worsens the pneumothorax or effusion.
5. (1) Immediately cover the insertion site with a gloved hand or occlusive petrolatum gauze — prevents air from entering the pleural space through the open wound. (2) Call for help — a new tube will need to be placed. Monitor continuously for signs of tension pneumothorax while waiting.