Chest Xray Tubes/Lines

Question 1

What can be immediate complications of incorrect CVC placement?

Answer 1

• Pneumothorax
• Surgical Emphysema

Question 2

Where is the ‘corrent’ endotracheal position and what do we need to remember about it’s fixation point?

Answer 2

5-7cm above the carina is acceptable.

This is to account for displacement of the tube that occurs with flexion/extension of the neck as there is a fixation point at the teeth.

Question 3

Where is the correct position for a tracheostomy tube and why are we less worried about neck movement with these?

Answer 3

Tip should be positioned so the tip is at the mid point between the tube and the carina.

Tracheostomy tubes are fixed at the skin and is less susceptible to change in position on neck flexion/ extension as an ET tube is.

Question 4

What are the complications if an ET tube is inserted too far??

Answer 4

It can enter one of the main bronchi (probably right) and only ventilate one lung, causing collapse in the contralateral lung or a lobe of the intubated lung

Accidental intubation of a bronchus is more common on the right because the right main bronchus is more vertically orientated than the left main bronchus.

Question 5

What is surgical emphysema?

Answer 5

Trapped air in the subcutaneous tissue beneath the skin.

Easiest to see inthe neck and upper chest.

Surgical emphysema may result from incorrect tube positioning such that the end is located within soft tissues of the chest wall. This may also occur if the tube becomes displaced following correct tube placement.

Question 6

Where does the oesohpagus lie anatomically? (important for correct placement of NG tube)

Answer 6

Passes posteriorally and slightly left to the left side of the trachea.

Immediately right to the aortic knuckle.

Then passes midline to the level of the gastro-oesophageal junction at the level of the diaphragm.

Question 7

keeping the anatomy of the oesophagus in mind, where is the correct position for an NG tube?

Answer 7

Passes vertically in the midline (or just to the left of) to at least 10cm through the gastro-oesophageal junction.

Below the level of the carina should NOT follow either main bronchi.

If it passes below the level of the diaphragm but its tip is not visible, a second image may be neccassary!

Question 8

What is the concern re NG tube misplacement?

Answer 8

This carries a high ris of food/medication aspiration into the airways, which carries a high mortality rate.

*either from looping or misplacement down trachea!*

Question 9

Ideally a CVC tip would be positioned……?

Answer 9

Short term: In the SVC at or just above the level of the carina

Long term (chemo): placed more inferiorally at the cavo-atrial junction (junction of the SVC and RA)

Haemodialysis: placed at the cavo-atrial junction or even the RA

Question 10

Most common insertion site of a right CVC?

Answer 10

The right IJV and pass vertically from a position above the clavicle

You can also have right subclavian vein catheter

Question 11

Left-sided catheters are commonly inserted into

Answer 11

left SVC

Question 12

What is a PICC line and where is it best positioned?

Answer 12

Peripherally Inserted Central Catheter

Tip at the level of the cavo-atrial junction.

Approx heigh of two vertebral bodies below the level of the carina

Question 13

Where do you position a chest drain?

Answer 13

Pneumothorax: Is positioned with its tip pointing superiorly within the pleural cavity

Pleural Effusion: Chest drain tip ideally located towards the lower part of the pleural cavity