The tubes keeping them alive, and the six ways they fail

☐ Tidaling in the water seal Fluid rises and falls with respiration. This is expected and it means the system is patent and connected to the pleural space. Absence of tidaling means the lung has re-expanded, or the tube is obstructed or kinked. Assess the patient before assuming good news.

☐ Bubbling in the water seal Intermittent bubbling while a pneumothorax is evacuating is expected. New continuous bubbling means an air leak. Work from the patient outward: inspect the dressing and insertion site first, then every connection, then the tubing, then the unit.

☐ The system disconnects or breaks Submerge the distal end of the chest tube in a container of sterile water to restore a water seal, then obtain and connect a replacement system. Do not clamp the tube while you hunt for the problem, because a clamped tube in a patient with an air leak builds a tension pneumothorax.

☐ The tube comes out of the chest Cover the site immediately with a sterile occlusive dressing taped on three sides so trapped air can still escape. Stay with the patient. Call. A four-sided seal creates a one-way valve that can convert an open pneumothorax into a tension pneumothorax within minutes.

☐ Tracheostomy obstructed Increasing work of breathing, high airway pressures on the ventilator, a patient who suddenly cannot be ventilated, and a suction catheter that will not pass. Suction, humidify, and remove the inner cannula. If suction will not pass, stop treating it as a secretion problem and treat it as a blocked or displaced tube emergency.

☐ Tracheostomy dislodged Within roughly the first week the tract is immature and blind reinsertion can create a false passage into the tissues of the neck. Ventilate over the stoma, or orally with a bag-valve-mask while occluding the stoma, call for help, and use the obturator and the two spare tubes kept at the bedside. A mature, well-healed stoma may be recannulated according to institutional protocol.

Memory hook: TIDAL · BUBBLE · BELOW. Three seconds at every chest tube: is it tidaling, is it bubbling, is the unit below the chest.

Watch outNever clamp a chest tube routinely, and never strip or milk the tubing. Stripping generates high negative pressure that damages pleural tissue.

Margin notethe answer is almost never "clamp it."

Suction pressure settings and cuff pressure ranges are described here in clinical sentences only: → BOOK 07 · P7. Dressing and site infection prevention is → BOOK 04 · P6. Clamping and dressing protocols vary by institution and by device; the manufacturer's current instructions for the specific system in use govern.

TakeawayEvery tube emergency has one correct immediate action, and in four of these six that action is performed before anyone is called.