chest radiology in the icu

Chest radiology in the ICU:

Lines, Tubes, & Drains

Jennifer Lee

Harvard Medical School Year III

Gillian Lieberman, MD

Jennifer Lee, HMSIII


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Objectives

To understand the importance of chest radiograph in the evaluation of commonly used support devices in the ICU setting

To review the normal positions of various indwelling devices and relevant anatomy

To ensure recognition of misplaced devices and common complications



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Our patient: clinical presentation

40 year old female POD#2/1 s/p distal

pancreatectomy and splenectomy for a

mucinous cystic neoplasm, urgent ex-lap

for bleeding, now with persistent hypoxia

You order a portable AP chest film as the

first step in your work-up



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ETT

NGT

Surgical drain below the

diaphragm

But, it’s difficult to assess

the exact location and

course of these devices.

Let’s take a look at the

post-augmentation film.

Image: PACS, BIDMC

Our patient: ETT, NGT, drain on CXR

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ET tube misplaced in the

right mainstem bronchus with

resultant LLL atelectasis

NGT with tip residing in

stomach

Surgical drain residing below

the diaphragm

Image: PACS, BIDMC

Our patient: ETT, NGT, drain on

augmented CXR

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Limitations of CXR in the ICU Standard PA film is rarely taken, usually replaced by AP film

– Magnified views of heart and mediastinum

Supine position alters the physiology of the pulmonary vasculature

– Blood diverted to lung apices

Inspiratory effort is usually limited

– Difficult to assess for atelectasis, pulmonary edema

Comorbid cardiopulmonary disease can obscure the picture

Numerous support devices can add to the confusion



Khan AN, Al-Jadahli H, Al-Ghanem S, Gouda A. Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications

from instrumentation. Annals of Thoracic Medicine. 2009; 4(2): 75-87.

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Role of CXR in the ICU Low sensitivity and specificity

– But, as much as 65% of ICU chest radiographs reveal a significant pathology that may change patient management (Khan et al., 2009)

Current ACR recommendations:

– “CXR should be obtained immediately following placement of indwelling tubes, catheters and other devices to check the position and detect procedure related complications.”

– Of note, “daily chest radiographs should not be obtained on patients with acute cardiopulmonary problems and those receiving mechanical ventilation.” Follow-up radiographs should be obtained only for specific clinical indications.

Study by Bekemeyer et al. found that 27% of newly placed devices were improperly positioned

– 6% resulted in a radiographically visible complication of the intervention



Bekemeyer WB, Crapo RO, Calhoon S, Cannon CY, Clayton PD. Efficacy of chest radiography in a respiratory intensive care unit: A prospective study. Chest. 1985; 88: 691–6. Khan AN, Al-Jadahli H, Al-Ghanem S, Gouda A. Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications from instrumentation. Annals of Thoracic Medicine. 2009; 4(2): 75-87.

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Agenda

Endotracheal tube

Tracheostomy tube

Thoracostomy tube

Nasogastric tube

Central venous line

Pediatric vascular lines

– Umbilical venous catheter

– Umbilical arterial catheter



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Endotracheal Tube (ETT) Used for mechanical ventilation

Correct location with neck in neutral position:

– Tip 5-7 cm above carina

– Tip at the level of T4-5, or roughly, at medial ends of the clavicle above aortic knob

“The hose goes where the nose goes”

– With neck flexion, tube can descend as much as 2 cm

– With neck extension, tube can ascend as much as 2 cm

Inflated cuff should fill, but not bulge tracheal wall

ETT initially misplaced in about 10% patients (Khan et al., 2009)



Image: HiSupplier

http://tenhoo.en.hisupplier.com/product-566303-Oral-

Cuffed-Tracheal-Tube.html

Khan AN, Al-Jadahli H, Al-Ghanem S, Gouda A. Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications from instrumentation. Annals of Thoracic Medicine. 2009; 4(2): 75-87.

10

“The hose goes where the nose goes”

Image: Courtesy of Paul Spirn, MD



Schematic of ETT tip with neck

positioning

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Risk of extubation,

laryngeal injury,

uneven ventilation,

slippage into

pharynx or

esophagus causing

gastric air distention,

reflux of gastric

contents, aspiration

Image: Khan et al.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700481/

Companion #1: High ETT on CXR

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More common than left

mainstem intubation due

to vertical orientation of

right mainstem bronchus

Image: PACS, BIDMC

Companion #2: Right mainstem

intubation with left lung collapse on CXR

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Companion #3: Esophageal intubation with

distention of esophagus and stomach on KUB

Image: Sanjay N. Jain


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Can rarely see

tracheal rupture,

abscess, or hematoma

Image: Khan et al.


Companion #4: Complication of prolonged ETT

with tracheal stenosis on chest CT

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Tracheostomy Tube

Used for long-term mechanical ventilation

Correct location: Tip at the level of T3

Tube should not move with neck flexion or extension unlike ETT

Diameter of tube should be 2/3 that of the trachea

Again, inflated cuff should fill, but not bulge tracheal wall



Image: MDA

http://www.mda.org/publications/breathe/Images/Trach-with-

Passy-Muir.jpg

Jain SN. A Pictoral Essay: Radiology of Lines and Tubes in the Intensive Care Unit. Indian Journal of Radiology and Imaging. 2011; 21(3): 182-90.

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Tracheostomy tube in

appropriate position with

subsequent

pneumothorax,

pneumomediastinum,

subcutaneous emphysema,

deep cervical emphysema



Companion #5: Traumatic tracheostomy tube

placement on CXR

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Thoracostomy tube AKA pleural tube, chest tube, intercostal drainage tube (ICD)

Used to drain air, fluid, or pus

Correct location: In between visceral and parietal pleural surfaces

– For pleural effusion: directed posteroinferiorly

– For pneumothorax: directed anterosuperiorly

Side holes appear as interruption in the radiopaque outline of tube on CXR

– Should not lie outside the pleura or in the lung parenchyma

Tube should not float above the effusion like a “lotus in the pond”

Chest tube malposition occurs in about 10% of patients, rendering the tube malfunctioning or nonfunctioning (Jain, 2011)



Image: St. Joseph’s Hospital

http://krames.sjmctx.com/HealthSheets/3,S,88979


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Companion #6: Right pneumothorax on CXR

Image: PACS, BIDMC

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Image: PACS, BIDMC

Companion #6: Right pneumothorax s/p pigtail

placement on CXR

Re-expansion of right

lung with residual

mid-lung atelectasis

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Companion #7: Low-lying ICD on CXR

Moderate right-sided

pleural effusion and

malfunctioning ICD due to

abnormally low position

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Companion #7: Tip of ICD found within lung

parenchyma on chest CT

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Companion #8: ICD in high position on CXR

Moderate right-sided

pleural effusion

persisting due to

malfunctioning ICD in

high position

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Nasogastric tube (NGT) Used for feeding or aspiration of gastric contents

Correct position: Tip and side holes within gastric antrum

Tip should be at least 10 cm caudal to gastroesphageal junction to lower risk of aspiration

Misplacement into the airway can cause pneumonia and injury to lung parenchyma

Esophageal perforation is rare, but can occur

Do not routinely use chest radiograph to confirm placement, but ACR guidelines say must obtain if prior to first feeding

– Typically push air into NGT while auscultating with stethoscope over stomach to confirm position



Image: NursingFile

http://nursingfile.com/nursing-procedures/demo-video/irrigating-a-

nasogastric-ng-tube.html

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Companion #9: NGT coiled in upper

esophagus on neck films



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Companion #10: NGT coiling in left main

bronchus with tip in RLL bronchus on CXR



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Companion #11: Esophageal perforation

s/p NGT placement on lateral neck film

Image: Khan et al.


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Central venous line (CVL)

Used for hemodynamic pressure monitoring, hemodialysis, administration of meds/nutrition/fluids, long-term venous access

May be inserted peripherally (PICC) or more centrally, in the internal jugular (IJ), subclavian (SC), or femoral veins into the SVC

Correct position:

– Tip should be distal to the junction of the IJ and SCV (level of T1) at the cavoatrial junction, which corresponds to the lower border of the bronchus intermedius

Tip should not enter right atrium due to risk of dysrhythmias and perforation

Tip can enter other vessels with resultant perforation

30% of initial chest radiographs show CVL malposition (Tocino, 1996)

6% risk of pneumothorax, most commonly with subclavian approach (Dunbar, 1984)



Image: StudyBlue

http://www.studyblue.com/notes/note/n/an2-05-

mediastinum/deck/1034591

Tocino I. Chest imaging in the intensive care unit. Eur J Radiol. 1996; 23: 46–57.

Dunbar RD. Radiological appearance of compromised thoracic catheters, tubes and wires. Radiol Clin North Am. 1984; 22: 699–722.

28 Image: Courtesy of Paul Spirn, MD



Relevant anatomy

Image: Gray’s Anatomy for Students

http://pgmcqs.com/2011/05/17/anatomy-thorax/

http://drkamaldeep.files.wordpress.com/2011/05/image30.png

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Companion #12: RIJ CVL in correct position

and left PICC terminating in IVC on

augmented CXR

Image: PACS, BIDMC

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Companion #13: Left-sided pneumothorax

s/p left subclavian CVL insertion on CXR



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Companion #14: CVL extending into SVC

then azygos vein posteriorly on CXR

Image: Khan et al.


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Companion #15: Misplaced CVL coursing

from left to right subclavian vein on CXR

Image: Khan et al.


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Images: PACS, BIDMC

Companion #16: Left-sided CVL descending

into mediastinum on CXR and fluoroscopy

Images: PACS, BIDMC

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Umbilical venous / arterial catheter

Used for transfusion, hyperalimentation, blood gases / pressures / electrolytes exclusively in pediatric population

Umbilical vein and arteries remain patent for up to 4-5 days after birth

Correct location of umbilical vein catheter:

– Tracks anteriorly in midline, with posterior angulation in the liver

– Tip should be at base of right atrium or cephalad portion of IVC (at level of T8-9)

Correct location of umbilical arterial catheter:

– Initially dips into the pelvis to enter the iliac artery before tracking superiorly into the aorta

– Tip can be located high at the level of T6-10 or low at the level of L3-4 to ensure it does not enter vessels supplying vital organs



Image: Education

http://www.education.com/study-help/article/cardiovascular-system-heart/

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Companion #17: Appropriately positioned

umbilical venous and arterial catheters on KUB



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Companion #18: Umbilical venous catheter in

left atrium passing through PFO, arterial catheter

in aortic arch at origin of carotid artery on KUB



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In summary, we have discussed the important

radiologic features associated with these

support devices:



Endotracheal tube

Tracheostomy tube

Thoracostomy tube

Nasogastric tube

Central venous line

Pediatric vascular lines

– Umbilical venous catheter

– Umbilical arterial catheter

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Take-away Points

Chest radiograph plays a critical role in the diagnostic evaluation of cardiopulmonary disease, but is also invaluable for monitoring the various indwelling devices in ICU patients

Support devices are intended to be life-saving, but can be life-threatening if misplaced or if complications are missed

A systematic approach of the radiographic features of the common indwelling lines, tubes, and drains is crucial for all healthcare providers



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Acknowledgements

Special thanks to:


Claire Odom

Javier Perez-Rodriguez, MD

Paul Spirn, MD

Leo Tsai, MD



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References Amorosa JK, Bramwit MP, Mohammed TL, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J, Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD, Expert Panel on Thoracic Imaging. Routine Chest Radiographs in ICU Patients. ACR Appropriateness Criteria. Available from http://www.acr.org. Accessed on 2013 Feb 24.

Bekemeyer WB, Crapo RO, Calhoon S, Cannon CY, Clayton PD. Efficacy of chest radiography in a respiratory intensive care unit: A prospective study. Chest. 1985; 88: 691–6.

Dunbar RD. Radiological appearance of compromised thoracic catheters, tubes and wires. Radiol Clin North Am. 1984; 22: 699–722.

Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. Accuracy and efficacy of chest radiography in the intensive care unit. Radiol Clin North Am. 1996; 34: 21–31.

Hunter TB, Taljanovic ML, Tsau PH, Berger WG, Standen JR. Medical Devices of the Chest. RadioGraphics. 2004; 24: 1725-46.


Khan AN, Al-Jadahli H, Al-Ghanem S, Gouda A. Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications from instrumentation. Annals of Thoracic Medicine. 2009; 4(2): 75-87.

Tocino I. Chest imaging in the intensive care unit. Eur J Radiol. 1996; 23: 46–57.



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chest radiology in the icu

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