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 clavicle
igures 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should be withdrawn to the SVC (green arrow)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
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
What other lines can
you see?
Answer next slide…
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
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
Note that this patient
also has small bilateral
pleural effusions
Tip of tube
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 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)
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 failure
Drainage 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
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
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