1. Tubes & LinesTubes & Lines Radiographic Evaluation of the Placement ofRadiographic Evaluation of the Placement of Monitoring and Support DevicesMonitoring and Support Devices Tula TopTula Top February 20, 2004February 20, 2004

2. Central Venous CathetersCentral Venous Catheters 3. Central Venous CathetersCentral Venous Catheters PurposePurpose Central venous catheters, also known as central venous pressure (CVP)Central venous catheters, also known as central venous pressure (CVP) lines, are used to monitor central venous pressure in the ICU and alsolines, are used to monitor central venous pressure in the ICU and also allow for intravenous fluid or medication administration.allow for intravenous fluid or medication administration. 4. Central Venous CathetersCentral Venous Catheters Access and PlacementAccess and Placement CVP lines are typically inserted throughCVP lines are typically inserted through the internal jugular,the internal jugular, subclavian, orsubclavian, or femoral veins, and offer more consistentfemoral veins, and offer more consistent venous blood flow than morevenous blood flow than more peripherally inserted catheters, whichperipherally inserted catheters, which may be subject to compression viamay be subject to compression via vasoconstriction during times ofvasoconstriction during times of cardiovascular collapse. The CVP linecardiovascular collapse. The CVP line should ideally be positioned central toshould ideally be positioned central to the venous valves at the origin of thethe venous valves at the origin of the superior vena cava. The SVC is formedsuperior vena cava. The SVC is formed by the junction of the right and leftby the junction of the right and left brachiocephalic veins and lies to thebrachiocephalic veins and lies to the right of midline at the level of the firstright of midline at the level of the first intercostal space.intercostal space. The following radiograph demonstratesThe following radiograph demonstrates a CVP line in the proper position.a CVP line in the proper position. 5. Central Venous CathetersCentral Venous Catheters 6. Central Venous CathetersCentral Venous Catheters Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 7. Click for a hint.Click for a hint. 8. The CVP line is in the left Subclavian Artery. Click for another hint.Click for another hint. 9. The CVP line is in the left Subclavian Artery. We expect the line to end up here Click for another hint.Click for another hint. 10. We expect the line to end up here The CVP line is in the left Subclavian Artery. Then, where is the tip located? Click for the answer.Click for the answer. 11. Central Venous CathetersCentral Venous Catheters Answer:Answer: The tipThe tip is in Descending Thoracic Aorta.is in Descending Thoracic Aorta. When the line extendsWhen the line extends above the clavicleabove the clavicle, it is very likely that it lies in, it is very likely that it lies in the subclavian artery. The subclavian vein normally liesthe subclavian artery. The subclavian vein normally lies behind thebehind the clavicleclavicle.. Differential Location (if in vein):Differential Location (if in vein): A left-sided SVC is a normal anatomic variant in 0.3% of individuals, ofA left-sided SVC is a normal anatomic variant in 0.3% of individuals, of whom some two-thirds will also have a right-sided SVC. A largewhom some two-thirds will also have a right-sided SVC. A large proportion of these individuals also will have the left BCV connecting toproportion of these individuals also will have the left BCV connecting to both the right and left SVCs. When the SVC is duplicated, the vesselsboth the right and left SVCs. When the SVC is duplicated, the vessels typically are relatively smaller in caliber than those in patients with singletypically are relatively smaller in caliber than those in patients with single SVCs. The left SVC drains through the oblique vein of the left atrium, theSVCs. The left SVC drains through the oblique vein of the left atrium, the great cardiac vein, and the coronary sinus into the right atrium.great cardiac vein, and the coronary sinus into the right atrium. Biffi M., et al. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-Biffi M., et al. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter- defibrillator implantation: a 10-year experience.defibrillator implantation: a 10-year experience. ChestChest. 120(1):139-44, 2001 Jul.. 120(1):139-44, 2001 Jul. 12. Which Line Did you Put in?Which Line Did you Put in? The Right or Left Subclavian?The Right or Left Subclavian? 13. Which Line Did you Put in?Which Line Did you Put in? The Right or Left Subclavian?The Right or Left Subclavian? Right Subclavian Artery Left Subclavian Vein 14. Central Venous CathetersCentral Venous Catheters Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 15. Click for a hint.Click for a hint. 16. Is the CVP line in the right place? Click for another hint.Click for another hint. 17. Is the CVP line in the right place? Yes, it is. But whatand whereis this lucency? Click for the answer.Click for the answer. 18. Central Venous CathetersCentral Venous Catheters ComplicationsComplications Air embolization is a potentially fatal complication of venipuncture andAir embolization is a potentially fatal complication of venipuncture and line placement and may be detected on CXR or CT with concomitantline placement and may be detected on CXR or CT with concomitant intravenous contrast injection.intravenous contrast injection. 19. Central Venous CathetersCentral Venous Catheters ComplicationsComplications Catheters placed in the left brachiocephalic vein should demonstrate anCatheters placed in the left brachiocephalic vein should demonstrate an anterior curve on the lateral chest radiograph as the left BCV coursesanterior curve on the lateral chest radiograph as the left BCV courses anteriorly to join the right BCV. A posterior projection of the catheter tipanteriorly to join the right BCV. A posterior projection of the catheter tip suggests placement into the azygos vein, which joins the SCV posteriorlysuggests placement into the azygos vein, which joins the SCV posteriorly prior to entering the pericardium. Such malpositioning may be missed ifprior to entering the pericardium. Such malpositioning may be missed if evaluated solely by a PA radiograph. Suspect placement of the catheterevaluated solely by a PA radiograph. Suspect placement of the catheter tip merits orthogonal views to confirm its location.tip merits orthogonal views to confirm its location. 20. Central Venous CathetersCentral Venous Catheters ComplicationsComplications The vasculature in close proximity to the heart offers a number of aberrantThe vasculature in close proximity to the heart offers a number of aberrant routes for an inserted CVP line to follow. Among the most common areroutes for an inserted CVP line to follow. Among the most common are the:the: Internal jugular veinInternal jugular vein Right atrium (with risk of perforation or dysrhythmias if placed near theRight atrium (with risk of perforation or dysrhythmias if placed near the tricuspid valve)tricuspid valve) Right ventricleRight ventricle Opposite subclavian veinOpposite subclavian vein Corresponding arteryCorresponding artery Numerous extrathoracic locations (with potential of ectopically infusingNumerous extrathoracic locations (with potential of ectopically infusing toxic substances in the vicinity of the liver or heart instead of into thetoxic substances in the vicinity of the liver or heart instead of into the central venous system where rapid dilution can occur; look forcentral venous system where rapid dilution can occur; look for widening and opacification of the mediastinum or pleural space due towidening and opacification of the mediastinum or pleural space due to rapid accumulation of fluid.)rapid accumulation of fluid.) Venous perforation may also occur if a catheter tip abutting the lateralVenous perforation may also occur if a catheter tip abutting the lateral wall of the SVC places excessive focal pressure on the wall.wall of the SVC places excessive focal pressure on the wall. 21. Central Venous CathetersCentral Venous Catheters ComplicationsComplications Every chest radiograph that features a CVP catheter should be evaluatedEvery chest radiograph that features a CVP catheter should be evaluated carefully for pneumothorax, which occurs with 6% of line placements andcarefully for pneumothorax, which occurs with 6% of line placements and can manifest several days after the procedure. Moreover, there is ancan manifest several days after the procedure. Moreover, there is an increased potential for bilateral PTX given that a PTX on one side mayincreased potential for bilateral PTX given that a PTX on one side may have gone undetected following an initial failed attempt at line insertionhave gone undetected following an initial failed attempt at line insertion before success was finally achieved on the other side.before success was finally achieved on the other side. Catheter embolization can occur as a result of laceration of the catheterCatheter embolization can occur as a result of laceration of the catheter by the insertion needle, catheter fracture at a point of stress, orby the insertion needle, catheter fracture at a point of stress, or detachment of the catheter from its hub. The freed apparatus may lodgedetachment of the catheter from its hub. The freed apparatus may lodge in the SVC, inferior vena cava, right heart, or pulmonary artery, causingin the SVC, inferior vena cava, right heart, or pulmonary artery, causing thrombosis, infection, or perforation.thrombosis, infection, or perforation. 22. Central Venous CathetersCentral Venous Catheters ComplicationsComplications The catheter tip may serve as a nidus for clot formation, impairing itsThe catheter tip may serve as a nidus for clot formation, impairing its ability to measure central venous pressure accurately or to deliver fluidsability to measure central venous pressure accurately or to deliver fluids to the venous system.to the venous system. Extension of the clot may result in venous thrombus or pulmonaryExtension of the clot may result in venous thrombus or pulmonary embolus.embolus. The pinch-off syndrome refers to impingement of the catheter betweenThe pinch-off syndrome refers to impingement of the catheter between the clavicle and the first rib. This can result in fracture of the catheter orthe clavicle and the first rib. This can result in fracture of the catheter or fragmentation.fragmentation. 23. Central Venous CathetersCentral Venous Catheters Summary of complicationsSummary of complications MalpositionMalposition Corresponding arterytip heads toward aortaCorresponding arterytip heads toward aorta Right atriumcardiac perforationRight atriumcardiac perforation Right ventriclearrhythmia or cardiac perforationRight ventriclearrhythmia or cardiac perforation Inaccurate central venous pressure measurementInaccurate central venous pressure measurement Pneumothoraxusually immediate, may be delayedPneumothoraxusually immediate, may be delayed Ectopic infusion of fluid into mediastinum or pleural spaceEctopic infusion of fluid into mediastinum or pleural space Catheter breakage and embolizationCatheter breakage and embolization Inadvertent puncture of subclavian arteryInadvertent puncture of subclavian artery Local bleedingsmall apical extrapleural opacityLocal bleedingsmall apical extrapleural opacity More significant bleedinglarger extrapleural opacityMore significant bleedinglarger extrapleural opacity Air embolizationair seen in main pulmonary artery on CXR/CTAir embolizationair seen in main pulmonary artery on CXR/CT Clot formationClot formation Pinch-off syndrome between clavicle and first ribPinch-off syndrome between clavicle and first rib Difficult infusion with arms downDifficult infusion with arms down ThrombosisThrombosis Fracture/embolization of catheter fragmentFracture/embolization of catheter fragment 24. Swan-Ganz CathetersSwan-Ganz Catheters 25. Swan-Ganz CathetersSwan-Ganz Catheters PurposePurpose Swan-Ganz (pulmonary artery flotation) catheters are placed to aid in theSwan-Ganz (pulmonary artery flotation) catheters are placed to aid in the differentiation of cardiogenic from noncardiogenic pulmonary edema bydifferentiation of cardiogenic from noncardiogenic pulmonary edema by allowing the clinician to monitor pulmonary capillary wedge pressure,allowing the clinician to monitor pulmonary capillary wedge pressure, reflecting left atrial pressure and left end-diastolic volume, via a centralreflecting left atrial pressure and left end-diastolic volume, via a central channel. Another channel allows assessment of central venouschannel. Another channel allows assessment of central venous pressure and cardiac output. A third channel connects to an inflatablepressure and cardiac output. A third channel connects to an inflatable balloon at the catheter tip, which when inflated causes the tip to floatballoon at the catheter tip, which when inflated causes the tip to float distally through the arterial system and when deflated causes it todistally through the arterial system and when deflated causes it to resume a more central position.resume a more central position. 26. Swan-Ganz CathetersSwan-Ganz Catheters A CaveatA Caveat Despite research indicating that radiographic findings allow a moreDespite research indicating that radiographic findings allow a more accurate means of distinguishing between cardiogenic versusaccurate means of distinguishing between cardiogenic versus noncardiogenic edema, SG catheters are still in widespread usenoncardiogenic edema, SG catheters are still in widespread use throughout all medical centers.throughout all medical centers. Milne E.N., et al. The radiologic distinction of cardiogenic and noncardiogenic edema.Milne E.N., et al. The radiologic distinction of cardiogenic and noncardiogenic edema. American Journal ofAmerican Journal of RoentgenologyRoentgenology. 144(5):879-94, 1985 May.. 144(5):879-94, 1985 May. 27. Swan-Ganz CathetersSwan-Ganz Catheters Access and PlacementAccess and Placement Access is usually gained via theAccess is usually gained via the subclavian vein, but jugular andsubclavian vein, but jugular and femoral vein approaches are alsofemoral vein approaches are also employed via use of a sheathemployed via use of a sheath called a cordis that facilitatescalled a cordis that facilitates advancement and withdrawal ofadvancement and withdrawal of the catheter and can providethe catheter and can provide short-term venous access onceshort-term venous access once the SG is removed. The catheterthe SG is removed. The catheter tip is ideally positioned within thetip is ideally positioned within the left pulmonary artery or theleft pulmonary artery or the proximal interlobar artery.proximal interlobar artery. The following radiographThe following radiograph demonstrates a SG catheter indemonstrates a SG catheter in the proper position.the proper position. 28. Click to locate the NGT.Click to locate the NGT. 29. NGTNGT Click to locate the ETT.Click to locate the ETT. 30. Tip of ETTTip of ETT NGTNGT Click to locate the SGC.Click to locate the SGC. 31. SGCSGC NGTNGT Tip of ETTTip of ETT Click to proceed.Click to proceed. 32. Swan-Ganz CathetersSwan-Ganz Catheters Whats the diagnosis in the following chest radiograph?Whats the diagnosis in the following chest radiograph? 33. Click for a hint.Click for a hint. 34. Is the SGT in the right place? Click for another hint.Click for another hint. 35. Is the SGT in the right place? No, in factits inserted too distally. And complicating things even more is this lucency, which is? Click for the answer.Click for the answer. 36. Swan-Ganz CathetersSwan-Ganz Catheters Complications:Complications: Pulmonary infarction can also arise as a result of a persistently inflatedPulmonary infarction can also arise as a result of a persistently inflated balloon obstructing a major pulmonary artery. The inflated balloonballoon obstructing a major pulmonary artery. The inflated balloon appears as a 1-cm rounded radiolucency at the catheter tip. It should beappears as a 1-cm rounded radiolucency at the catheter tip. It should be inflatedinflated onlyonly when pressure measurements are being taken, andwhen pressure measurements are being taken, and nevernever while chest radiography is being performed. Dr. Gosselinwhile chest radiography is being performed. Dr. Gosselin willwill hunt youhunt you down if you do this!down if you do this! 37. Swan-Ganz CathetersSwan-Ganz Catheters Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 38. Click for a hint.Click for a hint. 39. Click for the answer.Click for the answer. 40. Swan-Ganz CathetersSwan-Ganz Catheters ComplicationsComplications Aberrant insertion of the SG catheter can also result in pulmonary arteryAberrant insertion of the SG catheter can also result in pulmonary artery rupture, pulmonary artery pseudoaneurysm, pulmonary artery to bronchialrupture, pulmonary artery pseudoaneurysm, pulmonary artery to bronchial tree fistula, balloon rupture, and intracardiac knotting of the catheter.tree fistula, balloon rupture, and intracardiac knotting of the catheter. Other complications of SG catheters are similar to those that can occurOther complications of SG catheters are similar to those that can occur with CVP lines. Also, redundancy or coiling of the SG catheter in the rightwith CVP lines. Also, redundancy or coiling of the SG catheter in the right heart can irritate the conduction bundle and induce dysrhythmias.heart can irritate the conduction bundle and induce dysrhythmias. 41. Swan-Ganz CathetersSwan-Ganz Catheters ComplicationsComplications The risk of pulmonary infarction increases the more distally the catheterThe risk of pulmonary infarction increases the more distally the catheter tip is advanced, as the vessel diameters approach that diameter of the tip.tip is advanced, as the vessel diameters approach that diameter of the tip. Likewise, clot formation about the tip can lead to occlusion of the vesselLikewise, clot formation about the tip can lead to occlusion of the vessel in which it resides. Infarctions can be recognized on CXR by thein which it resides. Infarctions can be recognized on CXR by the appearance of patchy airspace opacification that is often wedge-shapedappearance of patchy airspace opacification that is often wedge-shaped and subpleural in location.and subpleural in location. 42. Swan-Ganz CathetersSwan-Ganz Catheters Summary of ComplicationsSummary of Complications Complications associated with central venous pressure catheter placementComplications associated with central venous pressure catheter placement Pulmonary infarctionPulmonary infarction Distal placement of catheter tipDistal placement of catheter tip Failure to deflate balloonFailure to deflate balloon ArrhythmiaArrhythmia Catheter tip in right atrium or right ventricleCatheter tip in right atrium or right ventricle Excessive coiling or redundancy of catheter tubing in right heartExcessive coiling or redundancy of catheter tubing in right heart Pulmonary artery pseudoaneurysmPulmonary artery pseudoaneurysm Pulmonary artery rupturePulmonary artery rupture Pulmonary artery to bronchial tree fistulaPulmonary artery to bronchial tree fistula Intracardiac knotting of catheterIntracardiac knotting of catheter Balloon ruptureBalloon rupture 43. Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps 44. Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps PurposePurpose The intra-aortic balloon pump consists of a long inflatable balloon 26-The intra-aortic balloon pump consists of a long inflatable balloon 26- 28cm in length surrounding the distal end of a centrally placed catheter.28cm in length surrounding the distal end of a centrally placed catheter. It is used in the setting of cardiogenic shock to enhance cardiac function.It is used in the setting of cardiogenic shock to enhance cardiac function. 45. Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps Access and PlacementAccess and Placement The balloon pump is introduced via the femoral artery and advancedThe balloon pump is introduced via the femoral artery and advanced retrograde into the thoracic aorta. The balloon is ideally situated with theretrograde into the thoracic aorta. The balloon is ideally situated with the tip located just distal to the left subclavian artery at the level of the aortictip located just distal to the left subclavian artery at the level of the aortic arch. Such placement ensures maximal augmentation of diastolicarch. Such placement ensures maximal augmentation of diastolic pressures in the proximal aorta. Inflation of the balloon during diastolepressures in the proximal aorta. Inflation of the balloon during diastole increases diastolic pressure, enhancing perfusion of the coronaryincreases diastolic pressure, enhancing perfusion of the coronary arteries and oxygen delivery to the myocardium. Deflation of the balloonarteries and oxygen delivery to the myocardium. Deflation of the balloon during systole creates a vacuum within the vessel lumen, decreasingduring systole creates a vacuum within the vessel lumen, decreasing ventricular afterload and enhancing forward blood flow.ventricular afterload and enhancing forward blood flow. The following radiograph demonstrates an IABP in the proper position.The following radiograph demonstrates an IABP in the proper position. 46. Click to locate the SGC.Click to locate the SGC. 47. SGCSGC Click to locate the IABP tip.Click to locate the IABP tip. 48. SGCSGC Tip of IABPTip of IABP Click to locate the IABP proper.Click to locate the IABP proper. 49. SGCSGC Tip of IABPTip of IABP IABPIABP Click to proceed.Click to proceed. 50. Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps ComplicationsComplications Even with ideal positioning, the long lumen of the IABP traverses the ostiaEven with ideal positioning, the long lumen of the IABP traverses the ostia of the celiac trunk, superior mesenteric artery, inferior mesenteric artery,of the celiac trunk, superior mesenteric artery, inferior mesenteric artery, and renal arteries and can lead to occlusion of these vessels (mesentericand renal arteries and can lead to occlusion of these vessels (mesenteric ischemia, renal failure).ischemia, renal failure). Too proximal a placement of the IABP can lead to obstruction of the leftToo proximal a placement of the IABP can lead to obstruction of the left subclavian artery or cerebral embolus.subclavian artery or cerebral embolus. Too distal a placement of the IABP results in suboptimal counterpulsationToo distal a placement of the IABP results in suboptimal counterpulsation during diastole.during diastole. Aortic dissection and death can rarely occur with advancement of theAortic dissection and death can rarely occur with advancement of the catheter during IABP placement.catheter during IABP placement. Potential complications also include traumatic platelet and red blood cellPotential complications also include traumatic platelet and red blood cell destruction, peripheral emboli, balloon rupture with resultant gasdestruction, peripheral emboli, balloon rupture with resultant gas embolus, and vascular insufficiency of the catheterized limb.embolus, and vascular insufficiency of the catheterized limb. 51. Intra-Aortic Balloon PumpsIntra-Aortic Balloon Pumps Summary of ComplicationsSummary of Complications Balloon advanced too farBalloon advanced too far Obstruction of left subclavian arteryObstruction of left subclavian artery Cerebral embolusCerebral embolus Balloon not advanced far enoughBalloon not advanced far enough Inadequate counterpulsation during diastoleInadequate counterpulsation during diastole Aortic dissectionAortic dissection Reduction of plateletsReduction of platelets Red blood cell destructionRed blood cell destruction EmboliEmboli Balloon rupture with gas embolusBalloon rupture with gas embolus Renal failure (balloon occlusion of renal artery)Renal failure (balloon occlusion of renal artery) Vascular insufficiency of catheterized limbVascular insufficiency of catheterized limb 52. Endotracheal TubesEndotracheal Tubes 53. Endotracheal TubesEndotracheal Tubes PurposePurpose Intubation of the airway by oral or nasal ETT (or alternatively byIntubation of the airway by oral or nasal ETT (or alternatively by cricothyroidotomy or tracheostomy) and mechanical ventilation may becricothyroidotomy or tracheostomy) and mechanical ventilation may be required in situations involving airway obstruction, disorders of gasrequired in situations involving airway obstruction, disorders of gas exchange, or failure of the airways protective mechanisms. ETTs helpexchange, or failure of the airways protective mechanisms. ETTs help prevent large aspirations, but small aspirations still occur continuously.prevent large aspirations, but small aspirations still occur continuously. 54. Endotracheal TubesEndotracheal Tubes Access and PlacementAccess and Placement Most ETTs are radiopaque or feature anMost ETTs are radiopaque or feature an opaque tip to facilitate evaluation ofopaque tip to facilitate evaluation of placement by chest radiography. The tipplacement by chest radiography. The tip should be located at least 3 to 4 cm aboveshould be located at least 3 to 4 cm above the carina (roughly at the level of T6 onthe carina (roughly at the level of T6 on portable CXR)ideally at the level of T4portable CXR)ideally at the level of T4 and at least 3 to 4 cm below the vocal cordsand at least 3 to 4 cm below the vocal cords (roughly C6) in adults. The ETT moves with(roughly C6) in adults. The ETT moves with the chin: With extension of the neck fromthe chin: With extension of the neck from the neutral position, the tip recedesthe neutral position, the tip recedes cephalad up to 2 cm; with flexion, the tipcephalad up to 2 cm; with flexion, the tip advances caudad up to 2 cm. It is thusadvances caudad up to 2 cm. It is thus imperative to determine the patients headimperative to determine the patients head position before making anyposition before making any recommendations to reposition the ETT.recommendations to reposition the ETT. The following radiograph demonstrates anThe following radiograph demonstrates an ETT in the proper position.ETT in the proper position. 55. Click to locate the ETT.Click to locate the ETT. 56. Tip of ETTTip of ETT Click to locate a helpful landmark.Click to locate a helpful landmark. 57. Tip of ETTTip of ETT CarinaCarina Click to locate more landmarks.Click to locate more landmarks. 58. Tip of ETTTip of ETT CarinaCarina T1 T2 T3 T4 Click to proceed.Click to proceed. 59. Endotracheal TubesEndotracheal Tubes Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 60. Click for a hint.Click for a hint. 61. Click for the answer.Click for the answer. 62. Endotracheal TubesEndotracheal Tubes ComplicationsComplications The cuff (balloon) of the ETT should be inflated to fill the lateral trachealThe cuff (balloon) of the ETT should be inflated to fill the lateral tracheal walls (i.e., equal to or slightly greater than the diameter of the trachea towalls (i.e., equal to or slightly greater than the diameter of the trachea to provide a secure seal), but it should not be bulging, as in the precedingprovide a secure seal), but it should not be bulging, as in the preceding radiograph. Also, in the preceding radiograph the ETT has not beenradiograph. Also, in the preceding radiograph the ETT has not been advanced far enough into the trachea before the cuff, residing in theadvanced far enough into the trachea before the cuff, residing in the hypopharynx, was inflated. Placement of the ETT too near the vocal cordshypopharynx, was inflated. Placement of the ETT too near the vocal cords may lead to vocal cord injury when the cuff is inflated.may lead to vocal cord injury when the cuff is inflated. 63. Endotracheal TubesEndotracheal Tubes Whats the diagnosis in the following chest radiograph?Whats the diagnosis in the following chest radiograph? 64. Click for a hint.Click for a hint. 65. What does this lucent tract represent? Click for another hint.Click for another hint. 66. What does this lucent tract represent? Whats happened to the left lung, and why? Click for the answer.Click for the answer. 67. Endotracheal TubesEndotracheal Tubes ComplicationComplication Advancement of the ETT into the right mainstem bronchus is one of theAdvancement of the ETT into the right mainstem bronchus is one of the most common errors encountered during intubation. The left lungmost common errors encountered during intubation. The left lung typically collapses when this occurs. The left mainstem bronchus istypically collapses when this occurs. The left mainstem bronchus is clearly visible, as indicated by the first hint.clearly visible, as indicated by the first hint. 68. Endotracheal TubesEndotracheal Tubes ComplicationsComplications Insertion of the ETT into the esophagus is a life-threateningInsertion of the ETT into the esophagus is a life-threatening complication. On CXR, the ETT will be situated just lateral to thecomplication. On CXR, the ETT will be situated just lateral to the trachea. As with pharyngeal placement, the stomach becomestrachea. As with pharyngeal placement, the stomach becomes markedly distended, though aspiration does not occur due to occlusionmarkedly distended, though aspiration does not occur due to occlusion of the esophagus by the ETT cuff.of the esophagus by the ETT cuff. Pharyngeal placement of the ETT results in disrupted mechanicalPharyngeal placement of the ETT results in disrupted mechanical ventilation and may distend the stomach with air, with aspiration ofventilation and may distend the stomach with air, with aspiration of gastric contents.gastric contents. Intubation can result in tracheal laceration with an overinflated cuffIntubation can result in tracheal laceration with an overinflated cuff herniating through the tear on CXR. A concomitant pneumothorax orherniating through the tear on CXR. A concomitant pneumothorax or pneumomediastinum may also be observed.pneumomediastinum may also be observed. Overinflation of the cuff may occur with inadvertent hyperinflation,Overinflation of the cuff may occur with inadvertent hyperinflation, intraesophageal placement, chronic intubation, or tracheomegaly.intraesophageal placement, chronic intubation, or tracheomegaly. ETT placement is associated with an increased incidence of sinusitisETT placement is associated with an increased incidence of sinusitis due to mucosal edema and obstruction of sinus drainage.due to mucosal edema and obstruction of sinus drainage. 69. Tracheostomy TubesTracheostomy Tubes 70. Tracheostomy TubesTracheostomy Tubes PurposePurpose Tracheostomy tubes are usually placed one to three weeks following ETTTracheostomy tubes are usually placed one to three weeks following ETT placement in patients requiring ongoing mechanical ventilation or trachealplacement in patients requiring ongoing mechanical ventilation or tracheal suctioning.suctioning. 71. Tracheostomy TubesTracheostomy Tubes Placement and Positioning:Placement and Positioning: A stoma is created at the level of the thirdA stoma is created at the level of the third tracheal cartilage, though which thetracheal cartilage, though which the tracheostomy tube is inserted. Like ETTs,tracheostomy tube is inserted. Like ETTs, the tip should be situated severalthe tip should be situated several centimeters above the carina; unlike ETTs,centimeters above the carina; unlike ETTs, however, the position of the tip does not varyhowever, the position of the tip does not vary considerably with head flexion or extension,considerably with head flexion or extension, and the cuff should not extend to theand the cuff should not extend to the tracheal wall.tracheal wall. The following radiograph demonstrates anThe following radiograph demonstrates an NGT in the proper position.NGT in the proper position. 72. Note that there is slight rotation in this view. Click to proceed.Note that there is slight rotation in this view. Click to proceed. 73. Tracheostomy TubesTracheostomy Tubes NoteNote It is not uncommon to observe slight subcutaneous emphysema in theIt is not uncommon to observe slight subcutaneous emphysema in the neck and upper mediastinum following surgical placement of theneck and upper mediastinum following surgical placement of the tracheostomy tube. It is usually mild and self-limited, and patients andtracheostomy tube. It is usually mild and self-limited, and patients and their families should be reassured accordingly.their families should be reassured accordingly. http://www.perspectivesinnursing.org/v1n1/Dixon.htmlhttp://www.perspectivesinnursing.org/v1n1/Dixon.html 74. Tracheostomy TubesTracheostomy Tubes Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 75. Click for a hint.Click for a hint. 76. Whats the expected orientation of a properly placed ETT? Click for the answer.Click for the answer. 77. Tracheostomy TubesTracheostomy Tubes ComplicationsComplications Massive, clinically significant subcutaneous emphysema can occur as aMassive, clinically significant subcutaneous emphysema can occur as a result of paratracheal insertion or tracheal perforation (the latter depictedresult of paratracheal insertion or tracheal perforation (the latter depicted in the preceding radiograph). Pneumothorax can occur if the apicalin the preceding radiograph). Pneumothorax can occur if the apical pleural space is breached during surgery but can also arise in the settingpleural space is breached during surgery but can also arise in the setting of tracheal perforation. Subsequent radiographs of the preceding patientof tracheal perforation. Subsequent radiographs of the preceding patient should be meticulously checked for all of the above sequelae followingshould be meticulously checked for all of the above sequelae following surgical revision of the tracheostomy tube placement.surgical revision of the tracheostomy tube placement. 78. Tracheostomy TubesTracheostomy Tubes ComplicationsComplications Some degree of mucosal injury occurs in every patient undergoingSome degree of mucosal injury occurs in every patient undergoing placement of a tracheostomy tube due to mucosal irritation and bacterialplacement of a tracheostomy tube due to mucosal irritation and bacterial colonization. A few cases may progress to ulceration and, potentially,colonization. A few cases may progress to ulceration and, potentially, cartilage necrosis.cartilage necrosis. Mucosal edema, erythema, and superficial ulcerations following extubationMucosal edema, erythema, and superficial ulcerations following extubation usually heal of their own accord. Deep ulcerations, however, can lead tousually heal of their own accord. Deep ulcerations, however, can lead to permanent laryngeal scarring, tracheal stenosis, and tracheomalacia.permanent laryngeal scarring, tracheal stenosis, and tracheomalacia. These may not fully manifest for several weeks to months followingThese may not fully manifest for several weeks to months following extubation, and all subsequent CXRs should be evaluated for anyextubation, and all subsequent CXRs should be evaluated for any laryngeal or tracheal narrowing.laryngeal or tracheal narrowing. 79. Tracheostomy TubesTracheostomy Tubes ComplicationsComplications Barotrauma and air leak can occur in up to 50% of patients, and thoseBarotrauma and air leak can occur in up to 50% of patients, and those with adult respiratory distress syndrome are at increased risk. Airwith adult respiratory distress syndrome are at increased risk. Air escapes from the ruptured alveoli and dissects medially along theescapes from the ruptured alveoli and dissects medially along the bronchovascular connective tissue towards the mediastinum. If thebronchovascular connective tissue towards the mediastinum. If the pressure increases, air can track cephalad into the neck or follow thepressure increases, air can track cephalad into the neck or follow the esophagus caudad to the retroperitoneum, continuing along the anterioresophagus caudad to the retroperitoneum, continuing along the anterior and posterior perirenal space and properitoneal fat. In men, if this doesand posterior perirenal space and properitoneal fat. In men, if this does not sufficiently decompress the mediastinum, air can dissect along thenot sufficiently decompress the mediastinum, air can dissect along the anterior abdominal and chest wall and into the scrotum. Ultimately, airanterior abdominal and chest wall and into the scrotum. Ultimately, air can rupture into the peritoneum and the into the pleural space by way ofcan rupture into the peritoneum and the into the pleural space by way of the mediastinal parietal pleura.the mediastinal parietal pleura. 80. Tracheostomy TubesTracheostomy Tubes Summary of ComplicationsSummary of Complications MalpositionMalposition Right mainstem ETT intubation leads to hypoventilation or collapse of left lungRight mainstem ETT intubation leads to hypoventilation or collapse of left lung Dislodgment from trachea interrupts mechanical ventilationDislodgment from trachea interrupts mechanical ventilation Placement just beyond vocal cords leads to vocal cord injury when cuff is inflatedPlacement just beyond vocal cords leads to vocal cord injury when cuff is inflated Placement within esophaguslook for:Placement within esophaguslook for: Gastric dilatationGastric dilatation Overinflated cuff lung hypoventilationOverinflated cuff lung hypoventilation Lateral placement of tubeLateral placement of tube Tracheal or laryngeal lacerationlook for:Tracheal or laryngeal lacerationlook for: PneumothoraxPneumothorax PneumomediastinumPneumomediastinum TracheostenosisTracheostenosis TracheomalaciaTracheomalacia 81. Chest TubesChest Tubes PurposePurpose Chest tubes may be required to evacuate the pleural space of air, blood,Chest tubes may be required to evacuate the pleural space of air, blood, pus, or other pleural fluid.pus, or other pleural fluid. 82. Chest TubesChest Tubes Placement and PositioningPlacement and Positioning The side hole of the chest tube is marked by an interruption in theThe side hole of the chest tube is marked by an interruption in the radiopaque strip that runs the length of the tube. This hole should beradiopaque strip that runs the length of the tube. This hole should be located medial to the inner margin of the ribs.located medial to the inner margin of the ribs. The following radiograph demonstrates a chest tube in the properThe following radiograph demonstrates a chest tube in the proper position.position. 83. Click to locate the chest tube.Click to locate the chest tube. 84. Click to proceed.Click to proceed. 85. Chest TubesChest Tubes Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 86. Click for a hint.Click for a hint. 87. Note the smooth curvature of the chest tube. Click for the answer.Click for the answer. 88. Chest TubesChest Tubes ComplicationsComplications The chest tube is likely located within a fissure when it reproduces theThe chest tube is likely located within a fissure when it reproduces the anatomy of the major or minor fissure as in the preceding radiographanatomy of the major or minor fissure as in the preceding radiograph (tube resides within the right major fissure). Frontal CXR ideally should(tube resides within the right major fissure). Frontal CXR ideally should demonstrate a vertically oriented radiopacity; a more horizontal coursedemonstrate a vertically oriented radiopacity; a more horizontal course with gentle curvature of the chest tube (red arrow) suggests locationwith gentle curvature of the chest tube (red arrow) suggests location within a fissure. Such location may result in occlusion of the tube by thewithin a fissure. Such location may result in occlusion of the tube by the surrounding lung parenchyma, rendering suctioning ineffective.surrounding lung parenchyma, rendering suctioning ineffective. 89. Chest TubesChest Tubes Whats the finding in the following chest radiograph?Whats the finding in the following chest radiograph? 90. Click for a hint.Click for a hint. 91. What does this lucency represent? Click for the answer.Click for the answer. 92. Chest TubesChest Tubes ComplicationComplication Other errors of placement include placement of the chest tube within theOther errors of placement include placement of the chest tube within the subcutaneous tissues, advancement into the mediastinum, within the lungsubcutaneous tissues, advancement into the mediastinum, within the lung parenchyma, or through the liver, spleen, or diaphragm (as in theparenchyma, or through the liver, spleen, or diaphragm (as in the preceding radiographnote the area of lucency representing colonic air),preceding radiographnote the area of lucency representing colonic air), resulting in a bronchopleural fistula, hemorrhage, or infection. Followingresulting in a bronchopleural fistula, hemorrhage, or infection. Following removal of the chest tube there may be a residual pleural or parenchymalremoval of the chest tube there may be a residual pleural or parenchymal line on CXR representing the tubes prior course. This should not beline on CXR representing the tubes prior course. This should not be mistaken for the visceral pleural edge of a pneumothorax. Rapid lungmistaken for the visceral pleural edge of a pneumothorax. Rapid lung reexpansion may result in pulmonary edema when the amount of pleuralreexpansion may result in pulmonary edema when the amount of pleural fluid removed is large (>1.5L).fluid removed is large (>1.5L). 93. Nasograstric TubesNasograstric Tubes 94. Nasogastric TubesNasogastric Tubes PurposePurpose NG tubes are used for suctioning gastric contents (as in treatment ofNG tubes are used for suctioning gastric contents (as in treatment of small-bowel obstruction).small-bowel obstruction). 95. Nasograstric TubesNasograstric Tubes Access and PositioningAccess and Positioning The tip of the NG tubeThe tip of the NG tube should reside within theshould reside within the stomach, with the side portstomach, with the side port lying beyond thelying beyond the gastroesophageal junction.gastroesophageal junction. The NG tube appears as aThe NG tube appears as a 1-cm diameter tubing with1-cm diameter tubing with a single thick radiopaquea single thick radiopaque stripe and a break in thestripe and a break in the stripe 6 cm from the tipstripe 6 cm from the tip representing the side port.representing the side port. The following radiographThe following radiograph demonstrates an NGT indemonstrates an NGT in the proper position.the proper position. 96. Click to locate the ETT.Click to locate the ETT. 97. Click to locate the SGC.Click to locate the SGC. Tip of ETTTip of ETT 98. Click to locate the NGT.Click to locate the NGT. Tip of ETTTip of ETT SGCSGC 99. Click to proceed.Click to proceed. Tip of ETTTip of ETT SGCSGC NGTNGT 100. Nasogastric TubesNasogastric Tubes ComplicationsComplications Most relate to malpositioning, such as incomplete insertion and/or tubeMost relate to malpositioning, such as incomplete insertion and/or tube coiling within the esophagus, which predisposes the patient to aspiration.coiling within the esophagus, which predisposes the patient to aspiration. 101. Dobhoff Feeding TubesDobhoff Feeding Tubes 102. Dobhoff Feeding TubesDobhoff Feeding Tubes PurposePurpose Infusion of enteral nutritional support or medications.Infusion of enteral nutritional support or medications. 103. Dobhoff Feeding TubesDobhoff Feeding Tubes Access andAccess and PositioningPositioning Dobhoff tubes are insertedDobhoff tubes are inserted orally or nasally and areorally or nasally and are ideally situated within theideally situated within the third part of the duodenum,third part of the duodenum, almost to the ligament ofalmost to the ligament of Treitz, although placementTreitz, although placement within the proximalwithin the proximal duodenum is adequate. Itduodenum is adequate. It appears as a thin 3-mm tubeappears as a thin 3-mm tube with a weighted radiopaquewith a weighted radiopaque distal tip. The side port liesdistal tip. The side port lies just proximal to the weightedjust proximal to the weighted tip.tip. The following radiographThe following radiograph demonstrates a Dobhoff indemonstrates a Dobhoff in the proper position.the proper position. 104. Click to locate a helpful landmark.Click to locate a helpful landmark. 105. Click to locate the ETT.Click to locate the ETT. EsophagusEsophagus 106. Click to locate the Dobhoff tube.Click to locate the Dobhoff tube. EsophagusEsophagus ETTETT 107. Click to proceed.Click to proceed. DobhoffDobhoff EsophagusEsophagus ETTETT 108. Dobhoff Feeding TubesDobhoff Feeding Tubes ComplicationsComplications Dobhoff tubes may inadvertently be introduced into the lungs (with tubeDobhoff tubes may inadvertently be introduced into the lungs (with tube feeds leading to overwhelming pneumonia), pleural space, or evenfeeds leading to overwhelming pneumonia), pleural space, or even through the diaphragm, or the tip may be placed in the hypopharynx orthrough the diaphragm, or the tip may be placed in the hypopharynx or esophagus, which may perforate during insertion. Esophageal perforationesophagus, which may perforate during insertion. Esophageal perforation may manifest as pleural effusion, pneumomediastinum, extraesophagealmay manifest as pleural effusion, pneumomediastinum, extraesophageal location of the tube, mediastinal widening, and mediastinal air-fluid levelslocation of the tube, mediastinal widening, and mediastinal air-fluid levels that can be detected radiographically.that can be detected radiographically. 109. ReferencesReferences Amorosa, J.K.Amorosa, J.K. Essentials of RadiologyEssentials of Radiology. CD-ROM 1999.. CD-ROM 1999. Collins, J., and Stern, E.J.Collins, J., and Stern, E.J. Chest Radiology: The EssentialsChest Radiology: The Essentials. Lippincott Williams & Wilkins:. Lippincott Williams & Wilkins: Philadelphia 1999.Philadelphia 1999. Dixon, L. Tracheostomy: Postoperative Recovery.Dixon, L. Tracheostomy: Postoperative Recovery. Perspectives: Recovery Strategies from the OR to HomePerspectives: Recovery Strategies from the OR to Home.. LINKLINK Milne E.N., et al. The radiologic distinction of cardiogenic and noncardiogenic edema.Milne E.N., et al. The radiologic distinction of cardiogenic and noncardiogenic edema. AmericanAmerican Journal of RoentgenologyJournal of Roentgenology. 144(5):879-94, 1985 May.. 144(5):879-94, 1985 May. Mullan, B. Positions of Tubes and Lines on Chest Films.Mullan, B. Positions of Tubes and Lines on Chest Films. Virtual HospitalVirtual Hospital.. LINKLINK Biffi M., et al. Left superior vena cava persistence in patients undergoing pacemaker orBiffi M., et al. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: a 10-year experience.cardioverter-defibrillator implantation: a 10-year experience. ChestChest. 120(1):139-44, 2001 Jul.. 120(1):139-44, 2001 Jul.