Chest Tube Air Leak Assessment Checklist Form
Use this checklist to document and assess the presence of air leaks and key steps in chest tube management. For operational and procedural use only.
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location / Unit
*
Please Select
ICU
Emergency Department
Surgical Ward
Other
Checklist: Pre-Assessment Steps
*
Verify chest tube position and dressing integrity
Ensure drainage system is below chest level
Confirm suction source and settings (if applicable)
Assessment: Presence of Air Leak
*
No air leak detected
Intermittent air leak
Continuous air leak
Air Leak Grading (if present)
Minimal
1
2
3
4
Severe
5
1 is Minimal, 5 is Severe
Bubbling Observed in Water Seal Chamber
*
No bubbling
Bubbling with cough or deep breath
Continuous bubbling
Checklist: Tube & Drainage System Assessment
*
Tube is patent (not kinked or clamped)
No visible blockage or clot
Drainage system connections secure
Fluid Level in Water Seal Chamber (cmHâ‚‚O)
*
Assessment: Chest Tube Drainage Amount (mL)
*
Comments or Additional Observations
Submit Assessment
Should be Empty: