Caring for a Baby With a Chest Tube: What NICU Nurses Need to Know

There are certain pieces of equipment in the NICU that make even experienced nurses pause for a moment — not out of fear, but out of respect. Chest tubes are one of those things. They are small, simple devices in appearance, but they carry enormous responsibility. A chest tube can be the intervention that stabilizes an infant with a life-threatening pneumothorax… and it can also be the piece of equipment that tells you something is changing before the baby ever shows it.

This week, I wanted to bring together everything that helps a NICU nurse move from “I know what a chest tube is” to “I can confidently care for one at the bedside.” The blend of hands-on skills, subtle assessments, and situational awareness is what keeps our patients safe — and what makes this work deeply meaningful.

🫁 Why Babies Need Chest Tubes

A chest tube in the NICU is almost always placed for one of three reasons:

1. Pneumothorax — air trapped in the pleural space causing lung collapse
2. Pleural effusion or chylothorax — fluid compressing the lung
3. Postoperative drainage — preventing fluid accumulation after thoracic surgery

Regardless of cause, the goal is the same:
➡️ remove what doesn’t belong so the lungs can expand.

Because neonates have tiny functional residual capacity and little reserve, even a small amount of trapped air or fluid can significantly impair ventilation. This is why nurses often notice the subtle changes first — asymmetric chest rise, slightly increased work of breathing, or a shift in oxygen needs — long before a dramatic decline.

🔧 Setting Up: The Details That Matter Most

One of the things that makes chest tubes different in the NICU is how precise the setup must be. The systems we use for newborns are designed for gentleness and stability.

Here are the essentials:

• The water seal must be filled to exactly 2 cm — overfilling increases resistance and makes breathing harder.

• The drainage system must remain upright and below the baby at all times.

• The suction bellows should be expanded beyond the marked triangle when suction is applied.

• Tidaling — that tiny rise and fall with each breath — is a primary sign of patency.

Adults rely heavily on output volume and bubbling patterns.
NICU nurses rely on the small, quiet movements in the water seal.

👂 The Assessment That Changes Everything

This week’s longer educational content included a “critical moment” scenario every NICU nurse will eventually face:

You’re caring for a baby with a new or suspected pneumothorax. You notice asymmetric chest rise. You listen longer. You compare sides. The right side is quiet. The baby looks slightly more uncomfortable.

That moment — where your assessment changes — is when your role becomes vital.

Recognizing early signs of lung collapse or reaccumulation allows the team to intervene before the infant becomes unstable. New bubbling, no tidaling, increased distress, frequent desaturations — none of these should ever be brushed off as “normal NICU behavior.”

The chest tube itself is one datapoint.
Your assessment gives meaning to the datapoint.

🚨 When Things Don’t Go as Planned

Chest tube care is not always predictable. Two of the teaching scenarios this week were built around the unexpected — because real NICU care often is.

1. Dislodgement

A prolonged bradycardia pulls you to the bedside. You discover the tube has slipped out.
Your job is simple and immediate:

• Apply petroleum gauze.

• Seal the site.

• Call for help without removing your hand.

This step alone prevents air from re-entering the chest and worsening a pneumothorax.

2. System Changes Before Baby Changes

Sometimes the drainage system is the first thing to signal trouble:

• Loss of tidaling

• Continuous bubbling

• Collapsed bellows

• Fluid that suddenly looks different

• Kinks or dependent loops in the tubing

Tracing from the baby ➝ dressing ➝ tubing ➝ drainage box is one of the most underrated skills in neonatal care.
It can identify problems before the baby crashes.

These “quiet moments of recognition” are often what save lives.

👪 Supporting Families Through the Uncertainty

Chest tubes worry families more than almost any other procedure in the NICU. They see the tube, the dressings, the drainage system, and the bubbling and assume the worst.

Parents need simple, steady reassurance:

• “This tube helps your baby’s lungs expand.”

• “We check it constantly.”

• “If something changes, we see it early.”

• “Your baby may need pain medicine to stay comfortable.”

• “Holding might be delayed, but only until it’s safe.”

Clarity reduces fear.
Consistency builds trust.
Compassion carries them through.

🌱 The Small Wins That Tell the Story

Chest tube care isn’t glamorous. It’s slow, steady progress:

• A softening chest wall

• Improved chest rise

• Lower ventilator pressures

• No air leak on morning assessment

• Clearer X-rays over time

• A baby who finally looks comfortable

And sometimes — the moment the tube is removed — it’s a celebration.
Removal isn’t the end of the story, but it’s often the first sign that a baby is truly turning a corner.

💙 Final Thoughts

Chest tubes require a blend of technical skill, careful observation, and calm responsiveness. They teach us to pay attention to the quiet details — the ones that show up in the water seal before they appear on the monitor. They remind us that newborn physiology is delicate and remarkable. And they reinforce what NICU nurses do best: notice, anticipate, and act with intention.

For anyone caring for these patients — from the brand-new NICU nurse to the seasoned clinician — chest tube care is a powerful reminder that the small things we do consistently make the biggest difference.