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Chest drains

  • Chest drain is a conduit to remove air or fluid from the pleural cavity
  • The fluid can be blood, pus or a pleural effusion
  • Allows re-expansion of the underlying lung
  • Must prevent entry of air or drained fluid back into the chest
  • A chest drain must therefore have three components
    • An unobstructed chest drain
    • A collecting container below chest level
    • A one-way mechanism such as water seal or Heimlich valve

Mechanism of action

  • Drainage occurs during expiration when pleural pressure is positive
  • Fluid within pleural cavity drains into water seal
  • Air bubbles through water seal to outside world
  • The length of drain below fluid level is important
  • If greater than 2-3 cms increases resistance to air drainage

Principles of a chest drain


  • Unless emergency situation then pre-procedure chest x-ray should be performed
  • Drain usually inserted under local anaesthesia using aseptic technique
  • Inserted in 5th intercostal space in mid-axillary line
  • Inserted over upper border of rib to avoid intercostal vessels and nerves
  • Blunt dissection and insertion of finger should ensure that pleural cavity is entered
  • Used to be taught that:
    • To drain fluid it should be inserted to base of pleural cavity
    • To drain air it should be inserted towards apex of lung
  • Probably does not matter provided there is no loculation of fluid within pleural cavity
  • A large drain (28 Fr or above) should be used to drain blood or pus
  • Drain should be anchored and purse-string or Z-stitch inserted in anticipation of removal

chest drain

Does and don'ts of chest drains

  • Avoid clamping of drain as it can result in a tension pneumothorax
  • Drain should only be clamped when changing the bottle
  • Always keep drain below the level of the patient
  • If lifted above chest level contents of drain can siphon back into chest
  • If disconnection occurs reconnect and ask patient to cough
  • If persistent air leak consider low pressure suction
  • Observe for post-expansion pulmonary oedema


  • Remove drain as soon as it has served it purpose
  • For a simple pneumothorax it can often be removed within 24 hours
  • To remove drain ask patient to perform a Valsalva manoeuvre
  • Remove drain at the height of expiration
  • Tie to pre-inserted purse-string or Z-stitch
  • Perform a post-procedure chest x-ray to exclude a pneumothorax


Parry G W,  Morgan W E,  Salama F D.  Management of haemothorax.  Ann R Coll Surg Eng  1996;  78:  325-326.

Tomlinson M A,  Treasure T.  Insertion of a chest drain.  How to do it.  Br J Hosp Med 1997;  58:  248-252.



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