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Lines and Tubes.

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Presentation on theme: "Lines and Tubes."— Presentation transcript:

1 Lines and Tubes

2 What are the common lines?
Central venous catheters Nasogastric tubes Endotracheal tubes Intercostal chest drains Cardiac Pacemaker

3 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

4 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

5 Where is the Superior Vena Cava?
Lateral to thoracic spine, inferior to medial end of right clavicle Figures copyright Primal Pictures 1993

6 Lateral to thoracic spine, inferior to medial end of right clavicle
Optimum Position Lateral to thoracic spine, inferior to medial end of right clavicle

7 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)

8 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

9 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

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 The tip lies too inferiorly, within the right atrium (white arrow) and should be withdrawn to the SVC (green arrow)

11 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

12 This patient has had recent cardiac surgery (note sternotomy wires)
The tip of the pulmonary artery wedge pressure catheter lies within the right pulmonary artery

13 What other lines can you see?
Answer next slide…

14 Don’t worry if you didn’t see all of them - this is a difficult CXR
External monitoring wires Endotracheal tube Intraaortic balloon 2 mediastinal drains Don’t worry if you didn’t see all of them - this is a difficult CXR

15 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

16 Optimum Position of NG tube
The tip should lie below the diaphragm coiled within the stomach

17 Satisfactory Position of NG tube
Note that this patient also has small bilateral pleural effusions Tip of tube

18 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

19 Incorrect placement of NG tube
The tip of this NG tube lies in the right lower lobe bronchus and should be urgently replaced

20 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

21 Endotracheal Tube Uses: Assisted ventilation To secure airway
The tip should lie between the clavicles, at least 5cm above the carina

22 Optimum Position of ET tube
In adults, the tip should lie >5cm above the bifurcation of the trachea (carina)

23 Good position of Endotracheal Tube
Tip of tube (red arrow) lies in good position, above the carina (green arrow)

24 What can go wrong with ET Tubes?
Tube too far advanced Typically, within right main stem bronchus Placement within oesophagus Tracheal perforation

25 Misplaced ET Tube

26 Note abnormal enlarged left hilum (lung cancer)
Misplaced ET Tube Tip of ET tube in right main stem bronchus. The patient is at risk of left lung collapse Note abnormal enlarged left hilum (lung cancer)

27 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

28 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)

29 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.

30 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 failure Drainage hole correctly sited within chest

31 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

32 Dual Chamber Cardiac Pacemaker
Pacing leads in left subclavian vein Leads in superior vena cava Pacemaker Right atrial lead Right ventricular lead Note that there are no sharp bends in the leads

33 Problems with Pacemakers
At insertion: Pneumothorax Vascular trauma Cardiac wall puncture Delayed Lead migration Lead fracture

34 Pacing Problem This patient had a single chamber pacemaker inserted several years ago, but the pacemaker no longer works. Can you tell why?

35 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

36 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

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