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A chest drain, or intercostal catheter, is a tube placed between the ribs into the space around the lung to let out air, fluid, blood or pus that should not be there. Once that space is emptied, the lung can expand again. The tube runs into a container beside the bed with a one-way water seal, so what comes out cannot go back in. Having a drain is uncomfortable but it is not a reason to stay in bed — sitting up, walking and breathing deeply are part of the treatment, and physiotherapists are usually the people who get that started. This page explains how the system works and what is safe to do with one in place.
Why a drain is inserted
The pleural space is a potential space holding only a few millilitres of lubricating fluid. Anything that fills it — air, fluid, blood or pus — compresses lung tissue and causes compressive collapse. A drain restores the space so the lung can re-expand.
| Indication | What is drained | Note |
|---|---|---|
| Pneumothorax | Air | Not all need drainage — conservative management is now supported in selected stable patients |
| Pleural effusion | Fluid | Drain volume is limited by symptoms and re-expansion oedema risk |
| Empyema / complex parapneumonic effusion | Pus | Often needs intrapleural tPA and DNase, or surgery |
| Haemothorax | Blood | Trauma or post-surgical; large-bore tube, watch output volume |
| Post-thoracic surgery | Air and fluid | Routine after lung resection; removal is protocol-driven |
| Malignant effusion | Fluid | Increasingly an indwelling pleural catheter managed at home |
How the system works
The classic underwater seal drain has three functional parts, whether they are three separate chambers or a single moulded unit:
- Collection chamber — where drained fluid accumulates and is measured.
- Water seal — a one-way valve. Air escapes out through the water on expiration and cannot be drawn back in on inspiration.
- Suction control — where low-pressure wall suction is applied, typically around −20 cmH2O, if prescribed.
Digital drainage systems are now common after thoracic surgery. They quantify air leak numerically rather than by eye, are portable and battery-powered, and remove much of the guesswork from removal decisions.
Reading the bottle
| Observation | What it means | Action |
|---|---|---|
| Swinging (fluid level moves with breathing) | Drain is patent and communicating with the pleural space | Normal — expect it; loss of swing may mean the lung has re-expanded, or the tube is blocked or kinked |
| Bubbling on expiration or cough | Air leak — expected in pneumothorax and after lung resection | Note and hand over; treat and mobilise as normal |
| Continuous bubbling | Large leak, or air entering through a loose connection or the insertion site | Check connections and dressing; report |
| New or increasing bubbling | New or worsening leak | Stop treatment, escalate |
| No swing, no bubbling, no drainage | Re-expanded lung or a blocked/kinked tube | Check the tubing; do not assume resolution — report |
| Sudden brisk blood loss | Bleeding | Emergency — escalate immediately |
Physiotherapy with a drain in situ
Mobilise — that is the intervention
Early mobilisation with a drain is safe and is recommended in thoracic enhanced-recovery guidance; the evidence supports getting patients up rather than waiting for removal.1,2 Keep the drainage system upright and below the level of the insertion site so drained fluid cannot track back, carry or wheel it at that level, disconnect suction for the walk if the medical team permits, and make sure a second person or a suitable trolley is available if the patient is unsteady.
Restore the hemithorax
A drain hurts, and pain produces splinting, shallow breathing, a dropped shoulder and a rotated trunk. Left alone this becomes reduced expansion, basal atelectasis and a stiff shoulder that outlasts the admission. Treat all of it: thoracic expansion exercises with an end-inspiratory hold on the drain side, side-flexion and rotation, full active shoulder range, and posture correction in sitting and standing.
Get the analgesia right first
Splinted, shallow breathing is almost always inadequate pain relief rather than unwillingness. Time treatment to peak analgesia, and escalate to the medical team rather than working around the pain — the analgesia is part of the respiratory treatment.
Airway clearance — only if indicated
A drain is not itself an indication for clearance. Treat retained secretions where they genuinely exist — coexisting suppurative lung disease, post-operative retention, a weak cough — and support the wound with a hand or pillow for huffing and coughing. Avoid percussion and vibration over the insertion site.
- Never clamp a bubbling drain. Clamping a drain with an air leak can produce a tension pneumothorax. Brief clamping is a medical decision, not a physiotherapy one.
- Keep the system below the insertion site and upright at all times, including during transfers.
- Do not milk or strip the tubing routinely — it generates high negative pressures and is not supported by evidence.
- Positive-pressure therapy needs a medical decision where there is an undrained pneumothorax or a large air leak — check before applying IPPB, NIV or cough assist.
- If the drain falls out: cover the site with an occlusive dressing sealed on three sides, sit the patient up, call for help immediately.
When to stop and escalate
- Sudden breathlessness, chest pain, tracheal deviation or hypotension — suspect tension pneumothorax.
- New, increasing or continuous bubbling during or after treatment.
- Rapidly expanding surgical emphysema (crackling under the skin of the chest, neck or face).
- Brisk or increasing blood in the drain, or a large sudden increase in output.
- Cough with pink frothy sputum during or shortly after large-volume drainage — possible re-expansion pulmonary oedema.
- The drain becomes dislodged, disconnected, or the dressing is soaked or lifted.
- Fever, increasing pain or purulent discharge at the site.
Removal and afterwards
Removal follows unit protocol — typically no air leak, drainage below a defined volume, and a satisfactory chest X-ray. It is briefly painful, needs analgesia, and is usually performed at end-expiration or during a held breath. Afterwards the priorities are unchanged: deep breathing, mobility, shoulder range and posture. Expect discomfort at the site for some weeks, and warn patients that chest-wall and shoulder stiffness will persist if they do not keep moving. Persistent numbness or burning at the scar is common and usually settles. New breathlessness or pain after removal warrants review for recurrence.
Indwelling pleural catheters
A tunnelled indwelling pleural catheter is a different device with a different purpose: long-term, usually home-based drainage of recurrent malignant effusion. There is no underwater seal — drainage is intermittent into vacuum bottles by the patient or a carer. Physiotherapy here is about normal activity with the catheter in place, showering and dressing advice from the treating team, maintaining shoulder range on the catheter side, and breathlessness management where the lung is trapped and will not fully re-expand.3
Role of the physiotherapist
The physiotherapist's job with a chest drain is almost entirely about function and mechanics rather than the drainage itself. It means getting the patient upright and walking on day one rather than waiting, restoring expansion and shoulder movement on the affected side before splinting becomes fixed, ensuring analgesia is adequate enough for a deep breath, and treating secretion retention only where it genuinely exists. It also means being the clinician in the room who reads the system competently — who notices a new air leak, a loss of swing, or expanding surgical emphysema, and escalates rather than continuing. Done well, a drain is a reason to treat a patient more actively, not less.
Evidence summary
Framing. Chest drain management is protocolised medical and nursing care, but the functional consequences — splinting, hypoventilation, basal collapse, shoulder restriction and immobility — are physiotherapy problems, and they are where the avoidable morbidity sits. Contemporary thoracic enhanced-recovery guidance is explicit that drains should not delay mobilisation, that routine prophylactic respiratory physiotherapy is not indicated in the uncomplicated patient, and that early drain removal shortens stay.1
Drain management evidence- Smaller-bore tubes hurt less with comparable efficacy: 12F tubes produced significantly lower pain scores than 24F for talc pleurodesis in the randomised TIME1 trial, though pleurodesis failure was marginally higher.4
- Ultrasound guidance for pleural procedures reduces pneumothorax and organ injury and is mandated in current guidance.3
- Suction is not routinely superior to water seal alone after pulmonary resection; meta-analysis shows no consistent advantage, and water seal may shorten air-leak duration — relevant because it is what frees the patient to walk.5
- Digital drainage systems reduce chest tube duration and hospital stay compared with traditional analogue systems by objectifying air-leak assessment.6
- In pleural infection, intrapleural tPA plus DNase improved drainage and reduced surgical referral (MIST2); no physiotherapy technique drains pus, and attempts to do so waste the session.7
- Early mobilisation with drains in situ is safe and is a core ERAS recommendation after lung surgery; delayed mobilisation is associated with more pulmonary complications and longer stay.1,2
- No lung-expansion modality is superior — deep breathing with an inspiratory hold, incentive spirometry, PEP and CPAP perform comparably, so choose on pain, tolerance and cost rather than device.8
- Prophylactic physiotherapy reduces postoperative pulmonary complications in major surgery, with a single preoperative education session halving them in LIPPSMAck-POP.9
- Regional analgesia improves pain scores and respiratory mechanics compared with systemic opioid alone in chest-wall pain, and is the enabling intervention for effective breathing and mobility.10
- Treat the drain as a logistical problem, not a contraindication. Plan the walk — system upright and below insertion level, suction disconnected if permitted, a second person if unsteady.1
- Never clamp a bubbling drain, and do not routinely milk or strip tubing; both risk harm and neither is evidence-supported.
- Withhold positive-pressure therapy (IPPB, NIV, CPAP, mechanical insufflation–exsufflation) where there is an undrained pneumothorax or a significant unresolved air leak until the medical team sanctions it.
- Escalate rather than persist on new or increasing air leak, expanding surgical emphysema, brisk bleeding, dislodgement, or sudden haemodynamic change.
- Document the drain state each session — swing, bubbling, output, suction, site — because serial physiotherapy observations frequently detect change before the next medical round.
- Treat shoulder and thoracic mechanics from day one; restriction on the drain side is common, preventable and frequently unaddressed after discharge.
- Loss of swing means either re-expansion or obstruction — never assume the favourable one without checking tubing and correlating clinically.
- A patient who cannot take a deep breath has an analgesia problem, a mechanical problem or fatigue; the response differs for each, and only the first is solved by asking the medical team.
- Persistent air leak beyond the expected window is a surgical question, not a reason to intensify respiratory technique.
- Breathlessness that does not improve after adequate drainage suggests trapped lung, parenchymal disease, embolism or cardiac cause — report it rather than increasing exercise load.3
- No trial has evaluated physiotherapy interventions specifically in patients with chest drains; all practice is extrapolated from thoracic surgery and pneumonia populations.8,9
- Optimal timing, dose and content of thoracic mobility and shoulder work during drainage are unknown.
- Whether early rehabilitation reduces residual pleural thickening, restriction or chronic chest-wall pain has not been studied.
- Long-term shoulder and chest-wall outcomes after prolonged drainage are poorly described.
References & evidence base
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- Kaneda H, Saito Y, Okamoto M, Maniwa T, Minami K, Imamura H. Early postoperative mobilization with walking at 4 hours after lobectomy in lung cancer patients. Gen Thorac Cardiovasc Surg 2007;55(12):493–498.
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42.
- Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion (TIME1): a randomized clinical trial. JAMA 2015;314(24):2641–2653.
- Coughlin SM, Emmerton-Coughlin HMA, Malthaner R. Management of chest tubes after pulmonary resection: a systematic review and meta-analysis. Can J Surg 2012;55(4):264–270.
- Pompili C, Detterbeck F, Papagiannopoulos K, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg 2014;98(2):490–496.
- Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection (MIST2). N Engl J Med 2011;365(6):518–526.
- Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care 2011;56(10):1600–1604.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
- Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2019;45(4):597–622.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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