Chest Imaging in ICU - Part 2 - Hardware

One of the reasons that we perform portable AP chest x-rays (CXR) in the ICU is to confirm the correct positioning of hardware: endotracheal tubes, central lines, feeding tubes, pulmonary artery catheters, pacemaker wires and chest tubes. This tutorial discusses the correct position of each of these devices and looks at malplacement and complications.
The ideal location of the tip of the endotracheal tube is 3 to 5cm above the carina, below the clavicles and at the level of the T4 spinous process. If tube is too far in, there is a risk of endobronchial intubation and atelectasis of an entire lung (usually the left lung, but not infrequently the right upper lobe also).
The ideal location of a central line, placed in the SVC distribution (internal jugular, subclavian or PICC) is at the junction of the Superior Vena Cava and the Right Atrium. Although inadvertent arterial puncture is less likely, these days, due to ultrasound guided insertion, the tip of a central line can end up can end up in all kinds of places. The tip placement, for prolonged infusions in critical care (for example - pressors or TPN), needs to be confirmed by chest x ray. The major complication of central lines is pneumothorax due to inadvertent pleural puncture during placement.
The pulmonary artery catheter is floated through the right heart and lodged into a peripheral branch of the pulmonary artery, aided by a balloon. The ideal location of the tip is in the lower zone of the lung, and the appearance of the catheter may be a V - the tip is in the left pulmonary artery or a B - the tip is in the right pulmonary artery. It should not be curled up in the RV or, worse, in the inferior vena cava.
Intra-aortic balloon pumps are inserted in cardiology, to manage cardiogenic shock, and following cardiac surgery. The balloon inflates in diastole to increase diastolic pressure, increasing coronary artery perfusion pressure and improving cardiac performance. The tip of the IABP should be distal to the left subclavian artery as it comes off the thoracic aorta. If the tip is too proximal, there is a risk of ischemia to the left arm, if it is not high enough, then it doesn’t function as required and may injure the kidneys.
Chest drains are typically placed to drain air and fluid from the pleural cavity. The tip of the chest tube needs to be where the “stuff” that you wish to drain is located: in the lung apices for air (if the patient is erect or semi erect), in the bases for fluid. There are two “eyes” on each chest tube - both need to be located inside the pleura or air will leak into the subcutaneous tissues.
Finally you need to be able to identify single lead and dual lead pacemakers, implantable defibrillators (ICD) and loop recorders on chest x-ray.
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Description
00:07 Introduction
00:50 Breathing Tubes
01:55 Correct Placement of Endotracheal Tube
03:50 Incorrect Placement of Endotracheal Tube
04:52 Endobronchial Intubation
05:45 Central Lines - Locations
07:26 Correct Placement of Central Lines
08:26 Incorrect Placement of Central Lines
10:54 Pneumothorax Due to Central Line Placement
11:32 Feeding Tubes - Correct Placement
12:54 Incorrect Placement (endobronchial) of Feeding Tubes
13:26 Aspiration Pneumonitis and Pneumothorax associated with Feeding Tubes
15:15 Cardiovascular Devices - Pulmonary Artery Catheter
17:40 Intra-Aortic Balloon Pump (IABP) Correct and Incorrect Placement
20:20 Stuff in the Pleural Space (pneumothorax and pleural effusions)
21:41 Pneumothorax on CXR
22:58 Location of Chest Drains and the "2 Eyes"
26:04 Review and Preview