Ch.10 - Recognizing the Correct Placement of Lines and Tubes: Critical Care Radiology

Question 1

Tracheostomy tube tip - Desired position:

Answer 1

Halfway between stoma and carina.

Question 2

Central venous catheter - Desired position:

Answer 2

Tip in the SVC.

Question 3

Peripherally inserted central catheters (PICC) - Desired position:

Answer 3

Tip in the superior vena cava.

Question 4

Swan-Ganz Catheter - Desired position:

Answer 4

Tip in proximal right or left pulmonary artery, within 2cm from hilum.

Question 5

Double-lumen (Quinton) catheters - Desired position:

Answer 5

Tips in either superior vena cava or right atrium (or both) depending on the type of the catheter.

Question 6

Pleural drainage tube - Desired position:

Answer 6

Anterosuperior for pneumothorax - Posteroinferior for pleural effusion.

Question 7

Pacemaker - Desired position:

Answer 7

Tip at the apex of right ventricle - Other lead(s) in right atrium and/or coronary sinus.

Question 8

Automatic implantable cardiac defibrillator (AICD) - Desired position:

Answer 8

One lead in SVC - Other lead(s) in RV and/or coronary sinus.

Question 9

Intraaortic balloon pump (IABP) - Desired position:

Answer 9

Tip about 2cm from top of aortic arch in descending thoracic aorta.

Question 10

Nasogastric (Levin) tube (NGT) - Desired position:

Answer 10

Tip in stomach 10cm from esophagogastric junction.

Question 11

Feeding (Dobbhoff) tube (DHT) - Desired position:

Answer 11

Tip ideally in the duodenum but more frequently in stomach.

Question 12

Endotracheal tubes - General features:

Answer 12

1. Tip should be about 3-5cm ABOVE the carina.
2. Inflated cuff should NOT distend the trachea.
3. MC malpositioned in the right main or right lower lobe bronchi.
4. If positioned with their tip in the neck, damage to vocal cords can occur.

Question 13

Tracheostomy tubes - General features:

Answer 13

1. The tip should be halfway between the entrance stoma and the carina.
2. If so equipped, the cuff is generally not inflated to a size greater than the tracheal lumen.
3. Short-term complications may include perforation of trachea.
4. Tracheal stenosis is the MC long-term complication, usually at the site of the entrance stoma.

Question 14

Central venous catheters - General features:

Answer 14

1. Tip should lie in the superior vena cava.
2. All bends in the catheter should be smooth curves, not sharp kinks.
3. MC malpositions are in the right atrium and internal jugular vein (for subclavian inserted catheters).
4. Always check for pneumothorax after successful or unsuccessful insertion attempt.

Question 15

Peripherally inserted central catheters (PICC) - General features:

Answer 15

1. Tip should lie in the SVC or axillary vein.
2. May be difficult to visualize because of their small size.
3. Thrombosis of the line may occur over time.

Question 16

Pulmonary artery catheters (Swan-Ganz Catheters) - General features:

Answer 16

1. Tip should be about 2cm from the hilum in either the right or left pulmonary artery.
2. Balloon should be inflated only when pressure measurements are performed.
3. The tip of the catheter should NOT lie within a peripheral pulmonary artery.

Question 17

Double lumen catheters - General features:

Answer 17

1. Tip should be either in the SVC or RA.
2. Right internal jugular vein has the lowest incidence of clotting so it is the preferred access route.
3. Complications: Pneumothorax, thrombosis, infection.

Question 18

Pleural drainage tubes (Chest tubes) - General features:

Answer 18

1. Work well no matter where they are positioned, but malpositioning can result in inadequate drainage.
2. For pleural effusions, they work best with their tip placed posteriorly and inferiorly.
3. For pneumothorax, they work best with their tip placed anteriorly and superiorly.
4. Rapid drainage of a large pleural effusion or large pneumothorax can produce RE-EXPANSION pulmonary edema in the underlying lung.

Question 19

Pacemakers - General features:

Answer 19

1. Usually placed in the left anterior chest wall with at least one lead in the right ventricular apex.
2. Remember that the right ventricle projects to the left of the spine on the frontal view and anteriorly on the lateral view of the chest.
3. Complications are infrequent but include fractures in the lead wires and pneumothorax.
4. Ectopically placed leads may result in failure of the pacemaker to function properly.

Question 20

AICD - General features:

Answer 20

1. Can be differentiated from pacemakers by the presence of a thicker electrode on at least one lead.
2. May have one (RV), 2( RA/RV), or 3 leads (RA/RV/Coronary sinus).
3. Bends in the leads should be smooth curves, not sharp kinks.
4. Visible complications can include lead breakage and dislodgment.

Question 21

Intraaortic balloon pumps - General features:

Answer 21

1. Tip has a metallic marker which should lie distal to the origin of the left subclavian artery.
2. When inflated, the balloon will be visible as an air-containing “sausage” in thoracic aorta.
3. Catheters placed too proximally may occlude the great vessels.
4. Catheters placed too distally may be ineffective.

Question 22

NGT (Levin tube) - General features:

Answer 22

1. Tip of the NGT should extend into the stomach about 10cm past the EG junction.
2. NG tubes are the MC malpositioned of all tubes - always check their positioning with a radiograph.
3. When malpositioned, they most frequently coil in the esophagus.
4. If inserted in the trachea, they can extend into a bronchus to periphery of lung, more often on the right side.

Question 23

Feeding tubes - Dobbhoff - General features:

Answer 23

1. Tip should ideally be in the duodenum, although most lie in the stomach.
2. Tip is recognizable by a metallic marker.
3. If inadvertently inserted into the trachea, the tip may extend into the lung.
4. Always obtain a confirmatory radiograph before using the tube for feedings.

Question 24

EET (endotracheal tube) - Desired position:

Answer 24

Tip 3-5cm from carina.