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