Bubbling and Pneumothorax

Q. Can you please advise whether continuous bubbling should be present in the air leak chamber whilst on continuous wall suction in a patient with a spontaneous pneumothorax who is breathing spontaneously with a dry suction drain? By the way – if the patient was ventilated, what would the difference be?

Wendy Gleeson
Clinical Nurse Specialist Emergency/Clinical Nurse Educator After Hours
Grafton Base Hospital
New South Wales, Australia

A. You’ll see bubbling in the water seal chamber when air enters the system. That is most commonly from the lung, but can also be from a leak somewhere else in the system; for example, if the tube has moved and one of the eyelets of the chest tube is outside the chest.

Negative pressure from suction pulls air from a leak through the drain and positive pressure from the chest — a strong cough, positive pressure ventilation, or a manual resuscitation bag – will push air into the drain. So, if a patient has a pneumothorax or a postoperative leak from the lung, suction will cause continuous bubbling and may make a leak look worse than it is. You’ll see the same pattern caused by PEEP on a ventilator because it is continuous positive pressure pushing air out of the leak. To accurately assess the patient breathing spontaneously with suction, momentarily disconnect the suction tube from the drain, check for bubbling, and then reconnect the tubing. You may be able to pinch the suction tubing closed to accomplish the same thing. I recommend avoiding wall vacuum adjustments for assessment purposes because it is too easy to forget to put it back on.

Otherwise, you would see intermittent bubbling that corresponds to respirations. With a ventilator, you’ll see bubbling on inspiration; if the person is breathing spontaneously, you should see bubbling on exhalation, or with a cough.

A spontaneously breathing person with a spontaneous pneumothorax probably does not need suction. The British Thoracic Society Pleural Disease Guideline 2010 states “suction should not be routinely employed” for managing spontaneous pneumothorax.1 You may also find the Clinical Update for June 2010 useful. While it discusses suction for postoperative patients, the concepts apply to spontaneous pneumothorax as well.

1. British Thoracic Society Pleural Disease Guideline Group. BTS pleural disease guideline 2010. Thorax. 2010;65(suppl 2).