Lines and Tubes Flashcards
What are indications for use of Endotracheal tubes?
- need for mechanical ventilation due to inadequate arterial oxygenation, severe airway obstruction, shock and parenchymal diseases that impair gas exchange
- upper airway obstruction
- impending gastric reflux or aspiration
- provisions for tracheobronchial lavage and tracheal suctioning
when are tracheostomies utilized?
for long term use of ETT due to potential to damage the tracheal mucosa
ETT placement
- Once ETT has been inserted, placement is confirmed by a chest radiograph, and is assessed periodically thereafter.
- Properly positioned tube will show the distal tip (5 – 7 cm) superior to the tracheal bifurcation with the neck in neutral position.
- The cuff is inflated with air and positioned at mid trachea; the cuff is not usually radiographically apparent.
What is the most common malposition of the ETT?
intubation into the right main stem bronchus
What are the implications of the ETT being in one of the main stem bronchus?
over ventilation of the one side and potential airway obstruction of the other side
ETT placement radiographically
- When the carina is not visible, the tip of the ET tube should not lie higher than the level of medial ends of the clavicles.
- Higher increases the risk of inadvertent extubation.
where is the Carina located?
between T5 and T7
What are complications associated with ETT?
too distal - bronchial intubation
too proximal - esophageal intubation
- erosion of tracheal mucosa as a result of cuff trauma, causing subcutaneous or mediastinal emphysema
what are the risks associated with esophageal intubation?
- may result in air pumped into stomach resulting in regurgitation which then enters airway resulting on aspiration pneumonia.
- Cuff inflation can damage vocal folds and resulting in inadequate ventilation.
- Greater chance of extubation.
Subcutaneous/Mediastinal Emphysema secondary to intubation
Chest radiograph at admission reveals subcutaneous and mediastinal emphysema, overdistention of the balloon cuff, and distal extension of the balloon toward the endotracheal tube tip.
complications due to endotracheal intubation?
- Pneumothorax (PTX)
- High positive pressures during mechanical ventilation led to pneumothorax
What is a tracheostomy tube?
- Tube is inserted through tracheostomy.
- Required in patients who need long-term ventilation, tracheal suction or where oral or nasal tracheal intubation is not possible (facial trauma).
- Never remove tape or strap holding the tube in place.
Where should the tip of the TT lie?
- The tip of TT should lay halfway between the stoma and the carina, (~ T2 - T3 vertebra).
- Unlike with ETT, chin position does not affect the position of TT and its position is maintained with neck flexion and extension.
What is a thoracostomy tube?
Removes fluid or air accumulated in either the intrapleural space, mediastinum or both.
What are the types of thoracostomy tubes?
- Chest tubes
- Intrapleural tubes
- Intracostal tubes
- Drainage tubes
when are chest tubes used?
to reestablish negative intrapleural [pressure in cases of:
- pneumothorax
- hemothorax
- pus (empyema or pyothorax)
- serous fluid (hydrothorax)
- urine (urinothorax)
Radiographic appearance of pleural effusion?
Pleural fluid accumulation becomes radiographically apparent when enough fluid is present to show costophrenic blunting.
Thoracostomy tube placement
- In the anterior or mid-axillary line, directed posterior-inferiorly in cases of pleural effusion and antero-superiorly in case of pneumothorax.
- Thoracostomy tubes have a terminal hole as well as side holes.
- These side holes can be identified on Chest radiograph by the interruption in the radiopaque outline of the tube. No side holes should lie outside the chest or pleura and the tube should not float above the effusion.
Why is there a need for imaging post thoracostomy tube placement?
- confirm placement/tube position
- assess therapeutic results
radiographic appearance of pneumothorax
- PTX is visualized when the increased density of the collapsed lung is contrasted with a lateral radiolucency that is absent of lung markings.
- During inspiration, the lung expands laterally and meets the lateral rib edge, making small pneumothoraces harder to detect.
- Therefore, expiration AP or PA projections of the chest are often performed to r/o PTX.
What is a central venous catheter (CVC)?
- Catheter that is placed into a large vein (typically, above the heart).
- May be inserted through a vein in the neck, chest or arm.
- Aka central venous line or central line.
- Some catheters have 2 or 3 tubes (called double or triple lumen catheters). This lets you receive more than 1 treatment at once.
- Depending on the type of catheter, it may be left in place for weeks, months or years.
CVC placement
- The goal is to position the end (tip) of the catheter in a large central vein.
- Infusions are less caustic in central veins than in smaller, peripheral veins.
- Superior Vena Cava: tip positioned 2 – 3cm above the right atrial junction
what are the three veins CVC are inserted into?
neck - internal jugular vein
chest - subclavian vein (most common) or axillary vein
groin - femoral vein
Long term CVCs?
- Tend to be tunneled under the skin
- Hickman, Groshong, Raaf, Perm Cath
- PICC
- Port-a-Cath
Short term CVCs?
- internal jugular catheter
- Swan Ganz
what are CVCs available as?
- Percutaneous catheters (subclavian or IJ insertion catheters)
- Peripherally Inserted Central Catheters (PICCs)
- Externally Tunneled Catheters (Hickman, Groshong)
- Totally implanted access ports (Port-a-Cath, Mediport, Infusa Port)
What are CVCs used for?
- measure central venous and cardiac pressures
- administer drugs and fluids
- draw blood
- provide transfusions
- provide TPN (Total Parenteral Nutrition)
- provide dialysis
What are tunneled CVCs?
- A tunneled CVC is a tube that tunnels under the skin of the chest, enters a large vein near the collarbone and threads inside the vein to sit above the right atrium of the heart.
- The other end of the catheter stays outside the body.
- Long term; less infection; more secure.
Dialysis catheter (Perm Cath/Raaf Cath)
- Tunneled under skin – less infection, more secure
- Tip in SVC
- Double lumen for dialysis
- One tip is shorter
Dialysis catheter - radiographic appearance?
Blood is removed through the shorter tip and once processed through the dialysis unit, returned through the longer tip.
Hickman catheter - physical characteristics
- Double or triple lumen
- Tunneled (long term), tip is uneven
- Has clamps
Hickman catheter used for?
Used for hemodialysis, apheresis, administration of I.V. fluids, blood products, drugs, chemotherapy and parenteral nutrition solutions, as well as blood withdrawal.
Groshong - physcial characteristics
- Double or triple lumen
- Long term IV access – not typically used for dialysis
- Tunneled, but tip is even
- Has a valve at the tip, so does not have clamps
what are non-tunnelled CVCs?
- internal jugular catheter
- PICC
What is the internal jugular catheter and when is it used?
- IV access to provide fluids and/or medications
- Shorter term: Post-op, ICU
When can a PICC be used for IV contrast media injection?
if it is power rater
What is a PICC?
- Single, double or tripled lumen
- Vein in arm to distal SVC or cavoatrial junction
- A Groshong catheter may also be used as a PICC
What is a pulmonary arterial line (Swan Ganz Catheter)?
- Single or multi-lumen.
- Tip incorporates a small electrode used to monitor pulmonary artery pressures.
- Measures right sided heart and pulmonary pressure and output. This value is used to extrapolate left sided heart pressure.
Swan Ganz Catheter route?
Internal Jugular V > Brachiocephalic V > SVC > Rt atrium > Rt ventricle > Pulmonary trunk > Rt Pulmonary artery
What are implanted ports?
- Surgically implanted device – usually upper chest
- Completely beneath the skin – appears as a bump under the skin
- When not accessed, they only need an occasional flush but otherwise do not require care. (Low maintenance)
- Can be multilumen.
- Long term use; less prone to infection
what is the physical characteristics of the implanted ports
- Consists of portal and catheter
- Catheter terminates in the SVC or right atrium
When are implanted ports be used?
- May be used to administer medication, chemotherapy drugs and/or IV contrast media, and draw blood sample.
- Oncology patients
Implanted port - radiographic appearance?
- Port-a-Cath, Mediport, Infusa Port
- Nurse required to access port and establish connection for use with power injector (not part of MRT’s authorized acts).
Why are CVCs used?
- Improves and extends quality of life for patients but potential for complications such as dislodgement, occlusions and infections.
- Increased awareness required by radiographer when catheter is present to avoid dislodgement.
- Aseptic practices required to minimize infections.
- Some sites have MRTs trained to insert PICCs.
What are clinical complications of malplaced CVCs?
PTX and hemothorax are potential complications of catheter insertions. Therefore, radiographic confirmation (CXR) of line upon insertion is required and thereafter as needed is common.
- requires thorough knowledge of cardiovascular structures and their branches.
What is a nasogastric (NG) tube?
- A nasogastric (NG) tube is a flexible plastic tube inserted through the nostrils, down the nasopharynx, and into the stomach or the upper portion of the small intestine.
- Placement of NG tubes should always be confirmed with an X-ray prior to use
What are NG tubes used for?
- Short term enteral feeding
- Administer Drugs
- Decompression/Suctioning – prevent vomiting and aspiration
- Lavage
- GI imaging exams
Levin tube
- most common NG tube used for gastric decompression
- small caliber to allow trans nasal passage
- single lumen with several holes at the tip
NG tube - feeding
feeding tubes are narrower
feeding tubes tend to have a radiopaque component, usually at the tip
Nasoenteric (NE) tube
- Tube passes from nose, through stomach, and into small intestine
- Decompress bowel and relieves obstruction
- Provide nutrition
- Single or multilumen
What is the moss esophageal duodenal decompression and feeding tube?
has three chambers
- the first anchors it in the stomach
- the second is for aspiration/suction
- the third is for feeding
What is gastric/gastro-jejunal (GJ) tube?
- Gastrotomy required
- GJ tube for long term feeds
- Patient cannot or may not be allowed to ingest food by mouth; need to bypass stomach
What is a pacemaker?
- Electromechanical devices inserted under the patient’s skin and leads (wires) that are placed in the right atrium and/or right ventricle to regulate heart rhythm and speed.
- Device provides low-level electrical stimuli causing cardiac contraction.
- Patients with arrhythmias are the most likely candidates for permanent pacemakers.
- Temporary pacemakers are usually connected to a pacing electrode, but the pacemaker is external to the patient’s body.
- New magnetic resonance compatible pacemaker system is now in use. (2009 onward)
Implanted Cardioverter Defibrillator (ICD)
- Designed to directly treat sudden cardiac arrests by delivering high energy shock.
- May also pace, using low energy (like pacemaker).
- Inserted under fluoroscopic guidance; CXR to confirm position of tip in the apex of the right ventricle.
- Dual chambered: tips in both the right atrium and ventricle
Working with patients with pacemakers/ICDs
- DO NOT abduct/elevate patient’s left arm (or side pacemaker is placed) for 24 hours post insertion.
- Do not elevate elbow above shoulder height for lateral chest x-ray.
ECG or Cardiac monitors
- DO NOT UNCLIP OR REMOVE!
- Manipulate with care, to not dislodge.
- Lines will show but can move into better location.
- Wires will swivel around electrode to allow MRT to move them out of the way.
Holter Monitors?
- Device used to evaluate patient’s cardiac rhythm over certain amount of time.
- ECG electrodes placed on patient and connected to transmitter (also on patient).
- Same considerations for MRT as with ECG.
Urinary drainage catheters?
Urinary catheterization is the insertion of a tube (plastic, silicone or rubber) via the urethral meatus into the bladder using aseptic technique.
What are the types of urinary drainage catheters?
- Foley catheter (retention balloon)
- Straight catheter
what is an indwelling catheter?
any catheter that remains in place
reasons for catheterization
Empty bladder; Relieve retention of urine or bypass obstruction - post-op patients.
- Irrigate the bladder or introduce drugs
- Obtain specimen
- Accurate measurement of urine output.
- Imaging Procedures that require the introduction of contrast agents
Imagine procedures requiring catheterization
- Fluoroscopic images of the bladder and urethra obtained following introduction of contrast media into the bladder via a catheter.
- Contrast administration usually performed retrograde.
what is atelectasis?
collapsed lung - collapsed alveoli
Cystogram/Voiding Cystourethrogram/CT cystogram
- Can be used to assess filling defects in bladder.
- Images may be obtained under CT.
- Images may be taken while urine flows out (voiding) to assess for reflux (typically, under fluoroscopy).
Retrograde (urethrogram)
- examination of urethra
- almost always on males
- to investigate the cause of poor urinary flow thought to be caused by a narrowing of the urethra
- benign prostatic hypertrophy is the most common cause
What is a stricture?
narrowing
what is benign prostatic hypertrophy?
enlargement of prostate gland
suprapubic catheter?
- Post gynecological surgery
- Urethral injuries
- Prostatic enlargement and obstruction
condom catheter?
- Incontinent male patients
- Must be replaced every 24 to 48 hours for infection control
tissue drainage tubes and devices
- Placed at or near wound or operative sites when drainage is required.
- Fluids can interfere with healing.
- May result in infection or a result in the formation of a fistula
Penrose Drain
- A Penrose drain is a soft, flat, flexible tube.
- It lets blood and other fluids move out of the area of your surgery.
- This keeps fluid from collecting under your incision and causing infection.
- Part of your Penrose drain will be inside your body.
Jackson-Pratt (JP) Drain
- Plastic Drainage Tube
- Maintain constant, low negative pressure by means of a small bulb which is squeezed and slowly expands to create low pressure suction.
Jackson-Pratt (JP) Drain Physical characteristics
- Bulb connected to end of tubing
- Remove plug, squeeze bulb, replace plug
- Suction created from bulb removes fluid
Hemovac
- very common with orthopaedic surgeries
- drain placed under the skin before closing
