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

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 The tip lies too inferiorly, within the right atrium (white arrow) and should be withdrawn to the SVC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

The tip of the pulmonary artery wedge pressure

catheter lies within the right

pulmonary artery

This patient has had recent

cardiac surgery (note sternotomy

wires)

What other lines can you see?

Answer next slide…

Endotracheal tube

2 mediastinal drains

Intraaortic balloon

Don’t worry if you didn’t see all of them - this is a difficult CXR

External monitoring wires

Nasogastric Tubes

• Uses:– Decompression of dilated stomach– Administration of medication /

nutritional support

The tip should lie below the diaphragm with at least 10cm 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

Tip of tube

Note that this patient also has small bilateral

pleural effusions

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 5cm above the carina

Optimum Position of ET tube

In adults, the tip should lie >5cm 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 TubeTip 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 failureDrainage 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

Pacemaker

Pacing leads in left

subclavian vein

Leads in superior vena

cava

Right ventricular

lead

Right atrial 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