1. Lines and Tubes

2. What are the common lines?
Central venous catheters
Nasogastric tubes
Endotracheal tubes
Intercostal chest drains
Cardiac Pacemaker

3. Why the CXR is useful in Tubes and Lines
To check it is in the right position
To check for complications of placement of the tube/line

4. Central Venous Catheters
Uses:
Rapid fluid replacement
Monitoring of central venous pressure
Administration of some drugs
May be inserted from either subclavian or internal jugular vein
The tip should lie within the superior vena cava

5. Where is the Superior Vena Cava?
Lateral to thoracic spine, inferior to medial end of right clavicle
Figures copyright Primal Pictures 1993

6. Lateral to thoracic spine, inferior to medial end of right clavicle
Optimum Position
Lateral to thoracic spine, inferior to medial end of right clavicle

7. Right internal jugular venous line in good position (red arrow)
The tip of this left internal jugular venous line lies at the origin of the SVC (green arrow)

8. What can go wrong with central venous catheters?
Complications are rare (<8%)
Tip misplaced
Advanced too far into right atrium
Passes into wrong vein
Arterial puncture instead of venous puncture
Pneumothorax
Haemothorax
Air embolism
Infection
Always think about complications

9. Incorrect placement of central line 1
A central venous line inserted into the right subclavian vein has passed up into the right internal jugular vein

10. Incorrect placement of central line 2
Left internal jugular venous line. The tip lies too inferiorly, within the right atrium (white arrow) and should be withdrawn to the SVC (green arrow)

11. Pulmonary Artery Wedge Pressure Measurement
This may be performed following cardiac surgery and in patients with severe cardiac / pulmonary dysfunction
The approach is usually via the right internal jugular vein
The catheter passes through the SVC, the right atrium, the right ventricle and the tip lies within a pulmonary artery

12. This patient has had recent cardiac surgery (note sternotomy wires)
The tip of the pulmonary artery wedge pressure catheter lies within the right pulmonary artery

13. What other lines can you see?
Answer next slide…

14. Don’t worry if you didn’t see all of them - this is a difficult CXR
External monitoring wires
Endotracheal tube
Intraaortic balloon
2 mediastinal drains
Don’t worry if you didn’t see all of them - this is a difficult CXR

15. Nasogastric Tubes Uses: Decompression of dilated stomach
Administration of medication / nutritional support
The tip should lie below the diaphragm with at least 10cm lying within the stomach

16. Optimum Position of NG tube
The tip should lie below the diaphragm coiled within the stomach

17. Satisfactory Position of NG tube
Note that this patient also has small bilateral pleural effusions
Tip of tube

18. What can go wrong with NG Tubes?
Commonest (and most dangerous) is placement within bronchial tree
This can be FATAL if NG feeding occurs into the lung
Perforation of oesophagus is rare
Be suspicious of a misplaced NG tube if the patient is extremely uncomfortable during tube insertion with severe coughing

19. Incorrect placement of NG tube
The tip of this NG tube lies in the right lower lobe bronchus and should be urgently replaced

20. Tracheostomy Tube
Did you notice that this patient also has a tracheostomy tube?
Look at all of an X-Ray – not just at an obvious abnormality

21. Endotracheal Tube Uses: Assisted ventilation To secure airway
The tip should lie between the clavicles, at least 5cm above the carina

22. Optimum Position of ET tube
In adults, the tip should lie >5cm above the bifurcation of the trachea (carina)

23. Good position of Endotracheal Tube
Tip of tube (red arrow) lies in good position, above the carina (green arrow)

24. What can go wrong with ET Tubes?
Tube too far advanced
Typically, within right main stem bronchus
Placement within oesophagus
Tracheal perforation

25. Misplaced ET Tube

26. Note abnormal enlarged left hilum (lung cancer)
Misplaced ET Tube
Tip of ET tube in right main stem bronchus. The patient is at risk of left lung collapse
Note abnormal enlarged left hilum (lung cancer)

27. Intercostal Chest Drains
These are used to remove fluid or air within the pleural space
Main indications for insertion
Pneumothorax
Tension
Simple pneumothorax unresponsive to aspiration
Pnemothorax in a patient with chronic lung disease
Drainage of pleural fluid
Pleural effusion
Haemothorax

28. Optimum position of drain
This depends on why the drain is being inserted:
Pneumothorax
Towards lung apex (superiorly)
Pleural fluid drainage
Towards cardiophrenic border (inferiorly)

29. Bilateral chest drains
This patient has bilateral chest drains, inserted following pneumothoraces secondary to rib fractures.
Note surgical emphysema. Both drains lie towards the apex, but the left drain is coiled and should be withdrawn a little.
The pneumothoraces are not visible on this film.

30. Problems with Chest Drains
These mostly occur with drain placement
Pain, damage to neurovascular bundle
Trauma to liver, spleen, lung
Drainage ports
These must lie within the
chest or there is a risk of
surgical emphysema and
drain failure
Drainage hole correctly sited within chest

31. Cardiac Pacemakers Used to treat conduction abnormalities
Pacemakers may be single chamber (pacing lead embedded in right ventricular wall) or dual chamber (second lead embedded in right atrial wall)
They are usually inserted via subclavian veins

32. Dual Chamber Cardiac Pacemaker
Pacing leads in left subclavian vein
Leads in superior vena cava
Pacemaker
Right atrial lead
Right ventricular lead
Note that there are no sharp bends in the leads

33. Problems with Pacemakers
At insertion:
Pneumothorax
Vascular trauma
Cardiac wall puncture
Delayed
Lead migration
Lead fracture

34. Pacing Problem
This patient had a single chamber pacemaker inserted several years ago, but the pacemaker no longer works. Can you tell why?

35. Misplaced pacing lead
The ventricular lead has become detached and now lies coiled within the right atrium. It should lie in the region of the red circle

36. Take Home Points
A CXR can be used to identify the position of drains, tubes and lines
A CXR is also used to check for complications of these devices, which may occur at the time of insertion or later