Lines and tubes to know in thoracic radiology

1. Lines and Tubes
Brian Wells, MD, MS, MPH

2. Fun Facts From This Day:
• 1925 John T. Scopes found guilty of teaching evolution in the “Scopes
monkey trial”, Dayton, Tennessee, fined $100 & costs
• 1969 Neil Armstrong (8/5/1930 – 8/25/2012) becomes the first person
to step on the Moon at 2:56:15 AM (GMT)

3. Overview
•GI Lines and Tubes
•Airways
•Intravascular lines
•Cardiac Devices

6. Did you know?
•Possibly the worst campaign slogan in history belongs to Al
Smith, who was against prohibition. To show his support
for the creation, distribution, and sale of alcohol, he
advertised: “Vote for Al Smith and he’ll make your wet
dreams come true.”
•George Washington blew his entire campaign budget on
160 gallons of liquor to serve to potential voters.
http://www.factretriever.com/us-presidential-elections-facts

8. Introduction
•The American College of Radiology (ACR) recommends a
CXR immediately following placement of indwelling tubes,
catheters and other devices to check the position and
detect procedure related complications.
•Some studies have shown 27% of newly placed catheters
or tubes were improperly positioned and that 6% resulted
in a radiographically visible complication of the
intervention.

9. Nasogastric Tube
• The nasogastric (NG) tube is inserted for either feeding the
patient or for aspiration of gastric contents, and for these
purposes the tip should lie within the stomach.
• The NG tube has multiple side holes. There are terminal lead
balls to facilitate identification of the tip.
• Ideally, the tip of NG tube should lie with its side holes in the
gastric antrum.
• Pushing air into the NG tube while auscultating with a
stethoscope over the stomach is the usual method by which
correct positioning in the stomach is confirmed.

10. Nasogastric Tube
•The tip of the NG tube should be positioned at least 10-cm
caudal to location of the gastroesophageal junction.
•Other naso/oro-enteric tubes are also encountered.
•The tip of a nasoduodenal feeding tube should be inserted
at least 10-12 cm into the small bowel.

11. Nasogastric tube
•Complications
• insertion into trachea or bronchus (pneumonia/pulmonary
contusion/pulmonary laceration)
• pharyngeal or oesophageal perforation

13. •Frontal radiograph
of the chest shows a
NG tube forming a
loop in the left
bronchus (arrow)
before the tip
(arrowhead) reaches
the right lower lobe
bronchus

14. Endotracheal Tube
•The endotracheal (ET) tube is inserted for ventilation of
both the lungs and for prevention of aspiration.
•It has a terminal hole and a cuff.
•The satisfactory position of an ET tube in the neutral
position of the neck is with the tip 5-7 cm above the
carina. The location can vary approximately 2 cm in the
caudal or cephalad directions with neck flexion and
extension, respectively.

15. Endotracheal tube
• When the carina is not visible, the tip of the ET tube should be
approximately at the level of the medial ends of the clavicle.
• It should lie midway between the larynx and carina so that
injury to either structure or complications like inadvertent
extubation or selective main-stem bronchus intubation are
avoided.
• Selective intubation can cause collapse of the contralateral lung
• Tracheal stenosis can occur following long-term tube placement.

17. • Frontal chest radiographs show an endotracheal tube in the right main
bronchus (arrowhead in A), causing hyperinflation of the ipsilateral
lung and partial collapse of the left lung (curved arrow in A). After
withdrawal of the tube into the trachea (arrow in B), the left lung has
inflated

18. Tracheostomy Tube
• The tip of the tracheostomy tube should be half way between
the stoma and the carina, at the level of the D3 vertebra.
• Unlike the ET tube, its position is maintained with neck flexion
and extension.
• The width of the tube (diameter) should be 2/3 of the tracheal
width, and the cuff should not distend the tracheal wall. It
should lie parallel to the trachea.
• Complications: Surgical emphysema, pneumomediastinum,
pneumothorax, hemorrhage, false tract, and tracheal stenosis.
Hematoma causes widening of the superior mediastinum.

19. •Frontal chest
radiograph shows
complications of
tracheostomy:
pneumothorax
(straight arrow),
pneumomediastinum
(curved arrow), and
surgical emphysema
(notched arrow)

21. Endotracheal Tube
•Correct position
• ETT tip 5 cm +/- 2 cm above carina
• i.e. at level of medial ends of clavicles
•Complications
• selective intubation (contralateral lung collapse/hyperinflation of
ipsilateral lung/pneumothorax)
• tooth aspiration

23. Central Venous Catheter
• Correct position
• CV line tip in the superior vena cava or at the cavo-atrial junction
• i.e. at level of 1st anterior intercostal space above carina
• Complications
• insertion into right atrium or ventricle (non-bacterial thrombotic endocarditis
/ dysrhythmias / myocardial perforation)
• mediastinal hematoma secondary to vessel perforation
• Pneumothorax
• hemothorax
• central line-associated bloodstream infection
• deep venous thrombosis

24. • Diagrammatic
representation of the
last valves in the
internal jugular vein
(curved arrow) and
subclavian veins
(notched arrow). The
valves are located near
the inner aspects of the
first ribs. The
brachiocephalic veins
join to form the superior
vena cava (straight
arrow) near the 1st
anterior intercostal
space. The cavoatrial
junction (arrowhead) is
where the superior vena
cava crosses the
bronchus intermedius

25. •Pneumothorax after
central line insertion

26. •Frontal chest
radiograph
following
placement of a
central venous
catheter shows
right paratracheal
soft tissue with a
bulging contour
(arrows), due to
mediastinal
hematoma

27. • Frontal chest radiograph
of a patient who was
receiving fluids through
a right jugular central
venous catheter
(arrows) shows an
opaque right
hemithorax (which was
a fresh finding
compared to earlier
normal radiographs).
This was due to vessel
perforation by the
catheter and resultant
accumulation of fluid in
the pleural space

28. Bronchial Stents
•Bronchial stents are occasionally seen in patients who have
undergone lung transplantation and have developed a
stricture at the anastomosis between the native
tracheobronchial tree and the transplanted one.
•These stents may be metallic and easily recognized, or they
may be composed of various plastic materials and be hard
to recognize, especially if no history of stent placement or
lung transplantation has been given

30. Implantable Loop Recorder
• The implantable loop recorder (ILR) is a subcutaneous, single-
lead, electrocardiographic (ECG) monitoring device used for
diagnosis in patients with recurrent unexplained episodes of
palpitations or syncope, for long-term monitoring in patients at
risk for or with documented atrial fibrillation (AF), and for risk
stratification in patients who have sustained a myocardial
infarction (MI) and those who have certain genetic disorders.
• Contraindicated by the presence of an active infection or a
bleeding diathesis may preclude implantation.

32. Pulmonary Artery (Swan-Ganz) Catheter
• The Swan-Ganz catheter is a flow-directed balloon-tipped
pulmonary artery catheter.
• The balloon is inflated to measure the capillary wedge pressure.
• This catheter is widely used for monitoring circulatory
hemodynamics in the management of a variety of critical
illnesses.
• Initially developed for the management of acute myocardial
infarction (AMI), it gained widespread use in the management
of a variety of critical illnesses and surgical procedures.

33. Pulmonary Artery Catheter
•Data from the Acute Decompensated Heart Failure
Syndromes (ATTEND) Registry involving 4842 patients
showed appropriate PAC use reduced in-hospital mortality
in patients with acute heart failure syndromes, particularly
those with lower systolic blood pressure or who received
inotropic therapy.
•Overall, the literature does not show a positive effect on
patient outcome with PAC use.

34. Pulmonary Artery Catheter
•To measure pulmonary artery pressure and capillary
wedge pressure, the tip of catheter needs to be in the right
or left pulmonary artery.
•To avoid complications, the tip of the Swan-Ganz catheter
must not be more than 1 cm lateral to the mediastinal
margin. The rule of thumb is that the catheter should not
extend beyond the pulmonary hilum on the CXR; else, it
should be retracted.

35. Pulmonary Artery Catheter
• The complication rate of pulmonary infarction is reduced
when the balloon is inflated only during pressure
measurement and insertion.
•Potential complications are intracardiac knotting,
pulmonary infarction, pulmonary artery perforation,
arrhythmias, cardiac perforation, and placement in the
inferior vena cava

38. •Frontal chest
radiograph shows the
tip (curved arrow) of a
Swan-Ganz catheter
(straight arrows) lying
in the descending
branch of the right
pulmonary artery. The
right paracardiac
opacity is due to
pulmonary infarction

39. •Frontal chest
radiograph shows
malposition of a Swan-
Ganz catheter (arrows)
in the inferior vena
cava

41. Intra-aortic Balloon Pump (IABP)
•Intra-aortic balloon pump (IABP) is a long-balloon
temporary circulatory assist device that works on the
principle of cardiac counter-pulsation.
•The IABP is used to support the circulation.
•The balloon, approximately 25-cm long, is mounted on a
catheter. The catheter tip is visible as a 3 x 4-mm
rectangular metallic density while the rest of the catheter
is radiolucent

42. Intra-aortic Balloon Pump (IABP)
• The balloon is radiolucent but the tip has a radio-opaque
marker.
• Device is comprised of a catheter introduced via the femoral
artery, which extends retrogradely to the proximal descending
thoracic aorta.
• The balloon is rapidly inflated at the beginning of diastole and
rapidly deflated at the end of diastole, , resulting in increase in
coronary blood flow and reduction in left ventricular afterload
(and hence, reduction in myocardial oxygen consumption)

44. Intra-aortic Balloon Pump (IABP)
• As the balloon forcibly inflates it displaces blood both forwards
and backwards, known as diastolic augmentation.
• It provides not only additional forward momentum to the blood
in the distal descending aorta but more importantly increases
perfusion to the vessels arising from the arch of the aorta, most
importantly the coronary arteries which are perfused primarily
during diastole.
• This has a dual effect: it firstly decreases left ventricular
afterload through a vacuum effect, decreasing myocardial
oxygen requirements, and secondly increases myocardial
perfusion (during diastole)

45. Intra-aortic Balloon Pump (IABP)
•To avoid occlusion of the left subclavian artery and visceral
and renal arteries, its tip should be slightly cephalad to the
adjacent carina (2 nd -3 rd intercostal space). The balloon
should not occlude more than 85-90% of the aortic
diameter.

46. •Frontal chest
radiograph
demonstrates an
optimally
positioned intra-
aortic balloon
pump catheter. The
catheter tip is
identified by a
rectangular metallic
density (arrow)

47. Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 35640

48. Complications of IABP
• Complications can be divided into those relating to balloon
function and those related to balloon positioning.
• Function
• platelet and red blood cell destruction
• aortic or large vessel arterial dissection during insertion
• distal embolisation (this can be to the brain if positioning is too proximal)
• Positioning
• aortic or large vessel arterial dissection during insertion
• obstruction of the left subclavian artery or renal arteries
• Balloon rupture with air embolization and septicemia are also
rare potential complications.

49. Pacemakers
• Pacemakers are used in cases of severe sinus node dysfunction,
complete heart block, and various arrhythmias.
• They have two main elements: a pulse generator and a lead
wire with electrodes.
• The single-lead pacemaker is the most basic type and is
positioned with its tip in the right ventricular apex.
• An atrioventricular two-lead sequential pacemaker has one
electrode in the right atrium and the other at the right
ventricular apex.

50. • Frontal chest radiograph (A) shows the optimal position of the electrode of a single-lead pacemaker. The
electrode has been placed in the right ventricular apex (straight arrow). Frontal chest radiograph (B) shows a
two-lead pacemaker that has one electrode in the right atrium (arrowhead) and the other at the right
ventricular apex (curved arrow)

53. Pacemakers
• Sometimes a third lead is placed in the coronary sinus to pace
the left ventricle
• It is not feasible to insert an electrode in the left side of the
heart due to the high pressures in these chambers.
• Temporary epicardial wires are sometimes inserted during
cardiac surgery; the tips of these wires resemble a corkscrew.
They can be removed easily.
• A lateral CXR is usually required to confirm the position of the
electrode in the right atrial appendage. The tip points anteriorly
when correctly positioned.

54. Pacemakers
• Correct position
• single chamber: electrode tip in right atrial appendage (atrial pacing) or right
ventricular apex (ventricular pacing)
• dual chamber: electrode tips in right atrium and right ventricular apex
• biventricular: electrode tips in right atrium, right ventricle and coronary sinus
• implantable converter defibrillator: electrode tip in apex of right ventricle
• Complications
• lead malposition (dysrhythmias)
• Pneumothorax
• myocardial perforation
• lead fracture

55. •Frontal chest
radiograph shows
abnormal course of
the lead with the
electrode tip overlying
the liver (arrow due to
cardiac perforation

56. •Frontal chest
radiograph shows
recoil of the
pacemaker lead with
its tip in the superior
vena cava (arrow).
This is called
Twiddler's syndrome.

58. STOP OFFICIAL PRESENTATION

61. Intercostal Tube / Catheter
• Correct position
• intercostal tube tip lies between visceral and parietal pleura
• anterosuperiorly to drain pneumothorax
• posteroinferiorly to drain pleural effusion or haemothorax
• Complications
• placement into lung parenchyma, interlobular fissure or subcutaneous tissue
• mediastinal or abdominal visceral trauma
• re-expansion pulmonary oedema

62. Devices in Thoracic Imaging
• Many devices are regularly seen in radiology on plain film and CT
• Pleural devices such as pigtail catheters, plombage, thoracostomy tubes
• Tracheal/bronchial/esophageal devices such as ET tubes, NG/OG tubes,
stents, pH probes, tracheostomy tubes, endobronchial valves/coils
• Vascular devices such as dialysis catheters, central lines, Swan-Ganz
catheters
• Cardiac devices such as pacemakers, IABP, Impella
• Others: Antibiotic spacer, pericardial drain, diaphragmatic pacemaker

63. Pleural Devices

65. Pleural Devices
•Thoracostomy (chest) tubes are commonly used for
evacuating fluid or air from the pleural space.
•They vary from 10–40 F in size, depending on the viscosity
of the material to be evacuated, and the preferences of
the individual physician involved in the treatment of the
case.
•Usually placed anterosuperiorly to evacuate a
pneumothorax and posteroinferiorly for fluid collections

66. Pleural Devices
•The normally positioned tube lies on the surface of the
expanded lung, between the visceral and parietal pleurae.
•Pigtail catheters may be used in place of standard
thoracostomy tubes, and they are popular for empyema
drainage and for installation of medication for treatment
of an empyema

67. Frontal view of the chest
shows a
pigtail catheter that had been
inserted under
fluoroscopic guidance into a
loculated right
empyema for instillation of
urokinase and
fluid drainage.

69. Plombage
• In the era before antibiotics, a variety of pleural devices were
used in the treatment of tuberculosis.
• These include “ping-pong” ball plombage and wax plombage.
Their appearance is quite dramatic, and they may occasionally
be encountered in an older patient.
• Plombage was a surgical method used prior to the introduction
of anti-tuberculosis drug therapy to treat cavitary tuberculosis
of the upper lobe of the lung.
• The term derives from the Latin word "plumbum" (lead) and
refers to the insertion of an inert substance in the pleural space.

70. Plombage
• The underlying theory of plombage treatment was the belief
that if the diseased lobe of the lung was physically forced to
collapse, it would heal quickly.
• There were positive results in tuberculosis therapy following
plombage in the decades of the 1930s, 1940s and early-1950s.
However, with the introduction of drugs which were effective in
destroying the tuberculosis bacterium (Mycobacterium
tuberculosis), plombage treatment fell into disfavor.
• The technique involved surgically creating a cavity underneath
the ribs in the upper part of the chest wall and filling this space
with some inert material.

72. http://www.nejm.org/doi/full/10.1056/NEJMicm0707466#t=article
Radiographic and computed
tomographic (CT) images of the chest
(Panels A and B, respectively) revealed
the balls, most of which were lucent
(Panel C) and some of which had broken
inside the pleural space. Muddy fluid
was observed inside some of the balls,
which was consistent with the high-
density fluid seen inside the balls on the
CT image (arrows in Panel B).
Pseudomonas aeruginosa was cultured
from both the fluid in the balls and the
patient's blood.

73. Tracheal/Bronchial/Esophageal Devices

76. Tracheal/Bronchial/Esophageal Devices
•Endotracheal intubation is a lifesaving procedure, but it
can also be life threatening if the tube is incorrectly
positioned.
•For adults, the tip of the tube should be situated
approximately 5 cm above the tracheal carina, so that
excursions of 2 cm upward or downward (with neck
extension or flexion) can be safely accommodated.

77. Tracheal/Bronchial/Esophageal Devices
•The carina may not be visible on every image, but the
aortic “knob” usually is.
•The carina is just caudad to the aortic arch, so that if the
tip of the endotracheal tube is just above the aortic arch, it
is in good position, midway between the vocal cords and
the carina.

78. Tracheal/Bronchial/Esophageal Devices
• Most often malpositioned in right mainstem bronchus because
of shallower angle right main bronchus makes with trachea than
does left mainstem bronchus
• Right mainstem bronchus intubation will lead to atelectasis of
entire left lung and hyperinflation right lung
• Bronchus intermedius intubation may lead to atelectasis of
entire left lung and the right upper lobe
• Esophageal intubation may be suspected if tube deviates from
the tracheal air shadow and there is a dilated esophagus and
stomach

79. Tracheal/Bronchial/Esophageal Devices
• Complications
• Aspiration/pneumonia
• Foreign body aspiration
• Broken teeth
• Dentures
• Fillings
• Pneumothorax, pulmonary interstitial emphysema,
pneumomediastinum from barotrauma
• Rupture of alveoli from high pressures with mechanical ventilation
• Sinusitis from prolonged nasotracheal intubation

81. Tracheoesophageal
voice prosthesis
placed in the wall
that separates the
trachea and
esophagus in order
to enable a total
laryngectomy
patient to make
voice.

82. Passy Muir Valve: Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 27899

84. Passy-Muir valve
•Patient has had complete laryngectomy for squamous cell
cancer of larynx. There is a Passy Muir Valve covering the
tracheostomy.
•When you look at trachea the air overlying larynx is wider
than usual. This should clue you into it.
•When placed on the hub of the tracheostomy tube or in-
line with the ventilator circuit, the Passy-Muir Valve
redirects air flow through the vocal folds, mouth and nose
enabling voice and improved communication.

85. Vascular Devices

87. Left Ventricular Assist Device
• The left ventricular assist device, or LVAD, is a mechanical pump
that is implanted inside a person's chest to help a weakened
heart pump blood throughout the body.
• Bleeding is the most common postoperative early complication
after implantation or explantation of LVADs, necessitating
reoperation in up to 60% of recipients.
• One device, the HeartMate XVE, is designed with a biologic
surface derived from fibrin and does not require long term
anticoagulation (except aspirin); unfortunately, this biologic
surface may also predispose the patient to infection through
selective reduction of certain types of leukocytes.

88. Case courtesy of Dr Donna D'Souza, Radiopaedia.org, rID: 18111

89. http://circep.ahajournals.org/content/circae/6/3/648/F1.large.jpg

91. Impella Device
• The Impella device is a catheter-based cardiac-assist device with a small
pump mounted at its tip. The catheter can be introduced percutaneously
via the femoral artery or may be inserted directly into the aorta.
• The pump can be positioned in the left ventricle (or rarely in the right
ventricle) to provide a temporary increase in cardiac output.
• The pump rotates at about 40,000 rpm and can generate a stroke volume
up to 2.5 L/min. Unlike the IABP, the effectiveness of the Impella does not
depend on preexisting cardiac performance. The indications for the Impella
are similar to those for the IABP.
• Impella CP does 3.5 L/min and the Impella 5 does 5 L/min
• The Impella device has also been used in conjunction with the IABP or with
ECMO

93. Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 39058

94. http://eurheartj.oxfordjournals.org/content/35/3/156

97. CardioWest total artificial heart
• Note the four prosthetic valves and the two coil, reinforced
polyurethane tubes carrying pulses of compressed air to the
two artificial ventricles.
• Approved as a bridge to donor heart transplant for patients
dying from end-stage biventricular heart failure.
• A TAH is a "last resort" device. This means only people who have
tried every other type of treatment, except heart transplant, can
get it. TAHs aren’t used for people who may benefit from
medicines or other procedures.
• Issues with blood clots, bleeding, infection, device malfunction

98. http://www.businesswire.com/news/home/20080807005343/en/CardioWest-
TM-Artificial-Heart-Approved-Highest-Reimbursement