1. CT diagnosis of malpositioned chest tube
Intern 劉一璋

2. Abstract (1)
Insertion of a chest tube into the pleural space is standard management for various pleural disorders.
Malpositioning of chest tubes in extrathoracic, intraparenchymal and
mediastinal locations and in the fissures is common.
Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality.

3. Abstract (2)
Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph.
CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has
often provided additional valuable information with significant therapeutic impact.

4. Indication for chest tube insertion
pneumothorax,
penetrating chest injuries,
haemothorax,
empyema,
bronchopleural fistula

5. Optimal tube placement
for fluid drainage:
a dependent location at the posterior base
for air evacuation:
a non-dependent position is preferred, apical and anterior

6. Risk of malpositioned chest tube
Malpositioning of chest tubes is common,
especially in traumatic chest injury.
Malpositioning not only results
in inadequate drainage of air and fluid but
also increased morbidity and mortality.
Usually require immediate repositioning or replacement.

7. Diagnosis of a malpositioned tube
is sometimes difficult to establish
because:
(1) clinical manifestations may be absent
(2) a bed-side chest radiograph is usually
unreliable in demonstrating the exact
location of the tube

8. Diagnosis of a malpositioned tubeCT
(1) is extremely accurate in evaluating the
position of a chest tube
(2) often provides additional valuable information
with significant therapeutic impact.
The aim of this pictorial review is to
provide an overview of malpositioned chest tubes
diagnosed on CT.

9. Recognition of malpositioned chest tubes on CT
CT is indicated:
(1) when a chest tube does not drain adequately
(2) the chest radiograph is non-contributory.

10. CT for malpositioned chest tubes
Different window settings are necessary.
pulmonary and pleural lesions may conceal the
course of the tube on a lung window.
A bone window may be of advantage in an extrapleural tube location, where its attenuation may be similar to that of the ribs.
In addition, thin sections in a lung window setting may clarify whether a tube is intrafissural or intraparenchymal.

11. Intraparenchymal tube placement
is most likely to occur with pre-existing pulmonary disease or pleural adhesions.
On CT, the tube is seen traversing the lung.
Probably representing a haematoma due
to lung laceration.
A parenchymal tract may sometimes remain after removal of a tube.
A chronic bronchopleural fistula or lung abscess may also result

12. CT shows the tube is intraparenchymal and does not reach the loculated anterior pneumothorax.

13. CT (mediastinal window) demonstrates
a tube entering through the left anterior chest wall, coursing posteriorly in the apex of the left lung.
Lung window:
Increased attenuation of the lung parenchyma surrounding the tube is probably haematoma

14. Intrafissural tube placement
A chest tube is considered to be intrafissural
(1) when it is outlined by a residual pneumothorax
(2) when it is located in the region of a fssure but
without areas of an intraparenchymal opacity
around it.

15. Chest CT (mediastinal window), contiguous
sections at the lung base show the right tube within
the oblique fissure, crossing the hemithorax, with its
tip very close to the dilated contrast-filled oesophagus.

16. Mediastinal tube placemen
A tube that has been introduced too far into
the thorax may reach the mediastinum.
On CT, the position of the tube can easily be seen
abutting the mediastinum.
Reported complications include:
perforation of the heart, the
pulmonary artery and the esophagus.

17. A 3.5-year-old girl with a right pleural effusion and a lung infiltrate.
A tube was inserted into the right hemithorax.
Chest CT (lung window):
a right hydropneumothorax is present. Part of the tube is seen anteriorly;
its tip cannot be accurately defined.
(b) Chest CT (mediastinal window, same level as (a)):
again the tip of the tube is not well visualized owing to artefacts from a metallic device on the left chest wall, but it probably
abuts the superior vena cava and the ascending aorta.

18. Chest wall tube placement
When a tube tip is positioned outside the
parietal pleura it is considered to be in the chest wall.
Inserting the tube too cranially and too
medially may cause bleeding from the pectoralis
major muscle, especially in men, and
may damage the breast in women.
High insertion in the posterior chest wall has resulted in Horner's syndrome.

19. The tip of a left chest tube lies in the left lateral chest wall (arrow).

20. A gunshot wound at the level of D3 in a29-year-old man.
CT demonstrates bilateral pneumothoraces.
A tube has been inserted anteriorly to drain
the left pneumothorax, causing a haematoma in the
pectoralis major muscle (asterisk).

21. Abdominal placement of a chest tube
When the tube is placed too low it may enter
the peritoneal cavity and can be seen on CT with
the tip below the diaphragm.
The spleen and liver have been injured most commonly in such cases.
Gastric injury from a trocar has also been reported.

22. On CT:
The lower tube is seen entering the lateral aspect of the spleen (arrow).
A tube is seen traversing the left
costophrenic angle (arrow).

23. A 36-year-old woman with bilateral pleural effusions and pneumonia.
CT was performed because of a drastic drop of haemoglobin.
Chest CT (mediastinal window) at level of diaphragm shows:
a right pleural effusion posterior to an atelectatic segment of the right lower lobe.
The lateral aspect of the liver is surrounded by fluid of high density. Air bubbles
within the peritoneal fluid indicate an intra-abdominal placement of the tube.
A left tube had been inserted earlier to drain the left pleural effusion.

24. Thanks for your attention