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HOW TO ASSESS LINES AND TUBES ON CXR
Surface Anatomy
Before you look at an xray for line and tube placement, you have to know your surface anatomy
The important things to know and identify are:
- The SVC enters the RA at the bottom of the right mainstem bronchus.
- The SVC is always to the right of the spine
- The Aorta is always to the left of the spine
- The esophagus is always to the left of the spine
- You have to be able to identify the carina
From now on, whenever you look at an xray after a procedure
Think about all the ways you can harm people and prove to yourself that you have not done something heinous
TUBES THAT BELONG IN THE NOSE
Principles
First, the proper xray for placement
- xray must provide a full view of the trachea and both mainstem bronchi ie a CXR
- sometimes you have to ask the techs do an extended view if you want to see the tip. You can simply write this on the req
- The projection of the tube should be anatomical and logical ie should travel to the left of the spine into the stomach
Complications to look for on CXR
- endobronchial insertion and perforation of the lung is the most major complication and so you are specifically looking for a pneumothorax if this happens
- Remember that no healthy patient has a feeding tube. Patients have feeding tubes often times because they have poor airway reflexes from stroke, weakness, altered LOC, or are intubated in ICU etc.
- Do not expect them to always cough or gag if a feeding tube enters the airway
- Feeding tubes and NGs can easily enter an airway on an awake or intubated patient, perforate the lung, and cause a pneumothorax . DO NOT push if there is resistance.
- ETTs and Tracheostomies are not protective against insertion into the airway - if you push - it will go.
- You have to develop a "feel" for putting them in. There should be no resistance beyond the nasal cavity and they should slide easily
- ALWAYS LISTEN FOR BORBORYGMI OVER THE STOMACH WITH A STETHOSCOPE WHILE YOU GIVE AN AIR BOLUS WITH A 20CC SYRINGE TO CONFIRM PLACEMENT
- Starting feeds with a feeding tube in an airway or after it has perforated the lung can be disastrous and result in effusions, infections/empyema, ARDS, and death. We have all seen this happen
- And while we are on topic, posterior nose bleeds especially in anticoagulated or coagulopathic patients are also a dreaded complication. We have all admitted patients from the ward who've bled so much that they've aspirated blood and developed respiratory failure and/or have formed a clot in the oropharynx resulting in a complete airway obstruction
HOW THEY LOOK EX-VIVO
Feeding tubes
- have at least 2 access ports
- They are small bore
- They are extremely supple and collapsable which is an essential feature to avoid erosions of the nasal mucosa
- The are not ever used for suctioning and collapse when connected to suction
- They can remain in situ for prolonged periods of time
Nasogastric Tubes
- One port to connect to suction (although you can use an adapter for enteral nutrition if need be for the short term)
- They are large bore
- They are not supple or collapsable which is a essential feature because they are designed for suctioning gastric contents and blood
- They can rub against the gastric mucosa and cause bleeding, especially when on suction (usually minor bleeding)
HOW THEY LOOK ON CXR
Feeding Tubes
- feeding tubes are fat and easy to see on CXR
- FEEDING TUBES CAN NEVER BE TOO DEEP, YOU NEVER HAVE TO PULL THEM BACK. If you have managed to get them into the small bowel that is a wonderful bonus.
Nasogastric Tubes
- NGs are more difficult to see on CXR. They are translucent except for the tiny skinny longitudinal opaque line that runs its full length
- NGs are designed to suck out the stomach and therefor they CAN be too deep if they are in the small bowel where the drainage will never end
LINES THAT BELONG IN THE VEINS
Principles
It is important to realize that you are looking at the CXR specifically to
- Make sure the you have not caused a complication
- Ensure the line hasn't taken an unusual course (subclavian insertion but the line has gone up the Internal Jugular)
- Take an opportunity to re-look at ALL the existing lines and tubes to ensure they remain in good position
If you manage to diagnose an arterial insertion of a central line on an xray , something more than just the arterial insertion has gone terribly wrong.
Click below for more information
HOW THEY LOOK EX-VIVO
Its important to know what you are looking for and where you should be looking when looking at a CXR for line placement
Triple lumens
- These are small bore long lines (up to 20cm)
- They are used in the ICU when a patient requires multiple infusions of IV medications and when IV access is difficult (ICU patient are often edematous)
- the approach will always be Internal Jugular or Subclavian
Hemodialysis lines (or Vasc Caths)
- These are large bore long lines (up to 20cm)
- They are of course used for Hemodialysis and Slow Low Efficiency Dialysis (SLED) but they can also be used as IV access when you have no other IV access.
- The approach will always be Internal Jugular or Subclavian
Introducer (or Cordis or Sheath)
- These are large bore short lines
- These are our best central resuscitation lines due to their width and length. They also serve as an introducer for swan ganz catheters and pacemaker wires
- The approach will always be Internal Jugular or Subclavian
Peripherally Inserted Central Catheter (PICC Line)
- These are very small bore long lines
- These come in single and double lumens. We will always require a double lumen PICC in the ICU if we are requesting one and indicate this on the requisition
- These lines are good for IV access and blood draws. They are not the best resuscitation lines but they will do in a pinch
- They are placed through the basilic, brachial, cephalic, or medial cubital vein of the arm. The approach is in the vicinity of the antecubital fossa
HOW THEY LOOK ON CXR
Picture 1 (top left)
- This is a right internal jugular triple lumen which you will recognize by its diameter and long length.
- This one has a perfect trajectory and has landed at the cavoatrial junction as indicated by its position around the right mainstem bronchus
Picture 2 (top right)
- This a right subclavian dialysis line which you will recognize by its diameter and long length.
- This one has a perfect trajectory and has landed at the cavoatrial junction as indicated by its position around the right mainstem bronchus
Picture 3 (bottom left)
- This is a right internal jugular Introducer which you will recognize by its diameter and short length.
- Introducers are the only exception to the the rule of location. They are short, large bore lines that do not reach the cavoatrial junction
- The reason you are looking at this xray is to make sure you have not caused a pneumothorax.
- If the line was in an artery you should have known that at the time of insertion
Picture 4 (bottom right)
- This is a left PICC which you will recognize by its ultra-thin diameter and length.
- When you are looking for PICC placement its often helpful to start in the axilla or upper arm and trace it from there
- This one has a perfect trajectory and has landed at the cavoatrial junction as indicated by its position around the right mainstem bronchus
A WORD ON CENTRAL LINE INSERTIONS
DON'T FORGET TO ALWAYS LANDMARK
DEEP TRENDELEBERG IS YOUR BEST FRIEND
DEEP TRENDELEBERG IS YOUR BEST FRIEND
Back in the days when dinosaurs roamed the earth we put central lines in using only our landmarks and our knowledge of anatomy
It is essential that you still landmark even if using ultrasound in order to ensure you are putting your needle in the safest position. It is tempting to poke low because the vessel is wider but it increases the risk of pneumothorax and arterial puncture/insertions.
Your best insertion site is at the apex of the sternal and clavicular head of the sternocleidomastoid muscle and aimed towards the ipsilateral nipple
That said, we all know you often cannot see or feel this on patients with thick necks. and so another way is to palpate the sternal notch and the mastoid process and go half way between the two (try it on the picture above. It works.
DEEP TRENDELEBERG IS YOUR BEST FRIEND
DEEP TRENDELEBERG IS YOUR BEST FRIEND
DEEP TRENDELEBERG IS YOUR BEST FRIEND
The deeper the Trendelenberg the fatter the vein. Period.
The fatter the vein, the easier it is to cannulate. Period
The fatter the vein, the less likely you are to puncture the artery. Period.
USE THE BLUE AND WHITE CAPS IN THE KITS
THE TRANSDUCER CATHETER IS ALSO A GOOD FRIEND
THE TRANSDUCER CATHETER IS ALSO A GOOD FRIEND
The lines have to be secured in 4 places because the patients are constantly being moved and lines can snag and come out
This is risky. Some of those lines will have life support running through them (pressors and inotropes) and/or sedatives to keep the patient asleep and keep them from extubating themselves.
The blue and white caps in the kit work as follows:
- Wrap the white cap around the line and suture it down. It will not secure the line until the blue cap is snaapped on top and so it will pop off while you are suturing it but that's ok. do not suture the blue cap
- The blue cap is designed to snap over top of the white cap that is sutured down securely in place and tightens it around the central line
- The reason you do not suture the blue cap is because it was designed so that you can pop it off and pull your line back if its too deep, then simply pop it back on and redress the line (ie no sutures have to be cut to adjust your line and you do not have re-suture when you're finished
THE TRANSDUCER CATHETER IS ALSO A GOOD FRIEND
THE TRANSDUCER CATHETER IS ALSO A GOOD FRIEND
THE TRANSDUCER CATHETER IS ALSO A GOOD FRIEND
To repeat (because this is important)
The diagnosis of an arterial puncture happens when you take the syringe off your needle and see bright red pulsatile flow.
In fact, the syringe will often fill by itself when you are in an artery due to the pressures
Do not aim for "bloodless" procedures. It is IMPORTANT that you see the blood and if you are not sure whether you are in an artery or a vein, STOP. DO NOT DILATE.
Your options are to
- Start again
- Place the transducer catheter over the guide wire, pull out the guide wire, re-examine your blood flow, draw a sample off it for a blood gas, and transduce it to see if there is an arterial waveform.
- If it is venous, you can safely re-insert the guide wire, pull out the transducer, and proceed with your line insertion
Having said all of this, arterial pokes are rarely subtle. For more information click below
TUBES THAT BELONG IN THE AIRWAYS
Principles
First, the proper xray for placement
- CXRs are for placement of Entdotracheal Tubes. Tracheostomies are confirmed only by bronchoscopy
- a plane old cxr that has the carina and both mainstem bronchi in view and includes the clavicles is required
- The projection of the tube should be anatomical and logical and within the trachea
Complications to look for on CXR
Tube is too high
- a tube that is too high is at risk of falling out
- can cause vocal cord necrosis from pressure from the cuff of the ETT
Tube is too low (touching the carina)
- tubes that touch the carina can cause endless irritation and coughing
- can also cause erosions from constantly rubbing with coughing and head movement
Tube is way too low (in one of the mainstems (usually right)
- Hypoxia and lunch collapse of the opposite side where there is no ventilation
- High airway pressures/difficult to bag
- Lung injury from over ventilation of the intubated lunch +/- pneumothorax
- This goes without saying but no imaging modality can or should tell you if you are in the esophagus. That is a clinical diagnosis that you need to recognize immediately through direct visualization, end tidal CO2, chest rise (as opposed to abdominal distention) and auscultation over the stomach and chest.
HOW THEY LOOK EX-VIVO
A picture says a thousand words here.
- both have a pilot for cuff inflation
- both have a cuff (although trachs have cuffless options)
- ETTs are longer and have more resistance (less comfortable to breath through)
- Trachs are shorter and therefore there is less airway resistance and they are more comfortable
HOW THEY LOOK ON CXR
Endotracheal Tubes
- Proper positioning is 2-3 cm above the carina
Tracheostomies
- inserted by creation of a stoma under direct guidance of bronchoscopy
- positioning is confirmed by bronchoscopy
- as you can imagine, a CXR of a tracheostomy would like identical if the trach was in the airway, sitting in the subcutaneous tissues (as can happen), or sitting outside ex-vivo with the ties still attached
TUBES THAT BELONG IN THE CHEST
Principles
First, the proper xray for placement
- CXRs are for placement of all pigtails and chest tubes
- Positioning should be between the 4th and 5th ribs
- Pigtails can also be placed anteriorly and posteriorly under ultrasound guidance by VERY EXPERIENCED HANDS
Complications to look for on CXR
Chest tubes and Pigtails
- New effusion (hemothorax from disruption of intercostal vasculature)
- Malpositioning (subcutaneous, lung intraparenchymal, subdiaphragmatic, kinked)
Pigtails Alone
- inadvertent placement into major nearby organs (spleen, liver, heart)
HOW THEY LOOK EX-VIVO
Chest Tubes
- large bore (good for drainage of blood and puss)
- multiple drainage holes so that if one becomes occluded the system will still function
- They are radiolucent but the ingenious creators of chest tubes designed a radio-opaque longitudinal line with a breach in it where the last hole that enters the chest is located. This hole MUST be between the ribs within the chest cavity or the chest tube with entrain air
Pigtails
- Pigtail on the end with multiple holes that curls up within the chest cavity
HOW THEY LOOK ON CXR
Chest Tubes
- Skinny line on CXR
- direction doesn't matter as long as it is draining
- kinks do not matter as long as they are draining
- the last hole MUCH be beyond the ribs (within the chest cavity)
Pigtails
- The pigtail portion simply must be beyond the ribs (within the chest cavity
The Case of the Isolated Gastroesophageal Situs Inversus
The Case of the Isolated Gastroesophageal Situs Inversus
The Case of the Isolated Gastroesophageal Situs Inversus
- 80 year old woman with history of severe bipolar disorder admitted to ICU with right MCA stroke and associated seizures.
- Extubated and transferred to ward. Pulled out feeding tube however remained unable to swallow due to stroke
- Feeding tube reinserted and confirmed to be in good position based on the above xray
- Enteral nutrition started
- 1 hour later developed severe respiratory distress and hypotension
- RACE called and she was admitted to the ICU
The Case of the Isolated Gastroesophageal Situs Inversus
The Case of the Isolated Gastroesophageal Situs Inversus
- Repeat xray performed in ICU due to suspicion of feeding tube malpositioning
- 48 hours later
- New right sided pleural effusion
- Ongoing respiratory distress and new hemoptysis
- Pigtail catheter inserted for drainage
- Bronchoscopy revealed edematous and friable right middle lobar bronchus covered in clot (presumed trauma from feeding tube)
- Ultimately resulted in a 3 week ICU admission
The Case of the Feeding Tube Fugitive
The Case of the Feeding Tube Fugitive
The Case of the Feeding Tube Fugitive
- 65 year old woman with history of DM2, CKD, CAD, CABG, admitted to AMA for Hyperosmolar Coma.
- Pulled out her feeding tube.
- Feeding tube inserted by nurse, xray performed to confirm new feeding tube placement
- The feeding tube has entered the trachea, descended the right mainstem, perforated the lung, hit resistance at a dead end, turned a corner, and is now heading straight for the mediastinum
- Feeding tube removed
The Case of the Feeding Tube Fugitive
The Case of the Feeding Tube Fugitive
- Feeding tube reinserted by resident
- The feeding tube is on the run again. It has entered the trachea, descended the right mainstem, perforated the lung, hit resistance at a dead end, turned a corner, headed towards the mediastinum, hit resistance again at another dead end, turned another corner, shimmied up the mediastinum, and is now attempting an escape past the hilum
- Feeding tube was once again removed
- Patient developed severe respiratory distress, tachycardia, and hypotension. RACE called
- RACE arrived – patient was peri-arrest from her tension pneumothorax
- Needle decompression performed followed by insertion of a chest tube
- Patient now intubated
- Feeding tube is in the correct position having followed the correct trajectory
The Case of the Traveling Triple Lumen
- 68 year old woman, previously well, slipped on ice, unstable C-spine fracture of C5 with central cord syndrome and neurogenic shock
- Taken to the OR for C4-C7 stabilization (decompression and fusion)
- CXR upon admission to ICU to confirm central lines and ETT placement
- Triple Lumen placed in the OR under ultrasound guidance into the right subclavian artery, takes a quick jaunt into the common carotid, then descends the brachiocephalic artery and lands in the aorta
A Case of the Invisible Complication
- 32 year old woman, first presentation of type 1 DM with DKA and a pH of 6.9.
- Very agitated and requiring multiple IV infusions for insulin, electrolyte replacement, and vasoactive support therefore central line inserted
- A right subclavian was placed under ultrasound guidance
- Do you see the pneumothorax? It's there.
WHAT IF I HIT AN ARTERY
The diagnosis of an arterial puncture happens when you take the syringe off your needle and see bright red pulsatile flow.
If you manage to diagnose an arterial insertion of a central line on an xray , something more than just the arterial insertion has gone terribly wrong
In fact, the syringe will often fill by itself when you are in an artery due to the pressures
Do not aim for "bloodless" procedures. It is IMPORTANT that you see the blood and if you are not sure whether you are in an artery or a vein, STOP. DO NOT DILATE.
Your options are to
- Start again
- Place the transducer catheter that comes in the central line kit (yes - it is there,. It is the additional catheter that come in the kit that no one ever knows why its there), over the guide wire, pull out the guide wire, re-examine your blood flow, draw a sample off it for a blood gas, and transduce it to see if there is an arterial waveform.
- If it is venous, you can safely re-insert the guide wire, pull out the transducer, and proceed with your line insertion
Having said all of this, arterial pokes are rarely subtle.