Lines and Tubes What are the common lines

Lines and Tubes

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

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

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

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

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

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)

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

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

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 The tip lies too inferiorly, within the right atrium (white arrow) and should be withdrawn to the SVC (green arrow)

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

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

What other lines can you see? Answer next slide…

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

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

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

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

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

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

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

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

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

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

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

Misplaced ET Tube

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)

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

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)

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.

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

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

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

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

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

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

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