Chest devices are encountered on daily basis by
Chest tubes, central lines, endotracheal tubes and NG
tubes are common
New devices are constantly being introduced
It is important to recognizer the presence of a device
and to have an understanding of its function as well as
complications associated with its use
The proliferation of intensive care units and the
advances in the treatment of the very ill have greatly
increased the numbers of examinations performed at
the patient’s bedside.
Obtaining a daily chest radiograph is standard practice
in most intensive care units
Chest radiograph shows that the tip of the endotracheal tube (black arrow) is
slightly above the aortic arch and well above the carina, in good position. A right
chest tube (white arrow), ECG leads (E), a gown snap (G), and oxygen tubing (O)
are also visible.
Extra thoracic devices
Tubing, clamps, syringes
Ventilator support tubing
other apparatus often lie on or under the patient and
are imaged with the chest during the radiographic
Chest radiograph shows halo apparatus (with emergency
wrench close at hand) for cervical spine stabilization.
chest tubes are commonly used for evacuating fluid or
air from the pleural space
Antero superiorly for pneumothorax
Poster inferiorly for fluid collection
Frontal (a) and lateral (b) views show a thoracostomy(chest) tube in
good position for treatment of a pneumothorax but not for an effusion.
Chest tubes are commonly used for evacuating ﬂuid or air from the pleural space.
The normally positioned tube lies on the surface of the expanded lung, between the visceral
and parietal pleura.
The tube is usually placed anterosuperiorly to evacuate a pneumothorax and
posteroinferiorly for ﬂuid collections.
the normally positioned tube lies on the surface of the
expanded lung, between the visceral and parietal
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
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.
Assess the position of chest tube in both frontal and
lateral view and sometime may required CT scan
May enter the interlobar fissure
Tube may be kinked
58-year-old woman with extrapleural placement of chest
tube. Magnified anteroposterior chest radiograph shows
misplaced chest tube (arrows) within right chest wall.
65-year-old woman with extrapleural placement of chest tube.
A, Magnified anteroposterior chest radiograph shows left chest tube (arrow) in
apparently adequate position. CT scan was requested to further investigate
because of ineffective drainage of left pleural effusion.
Magnified axial CT image shows misplacement of chest
tube within chest wall (arrow).
69-year-old man with intrafissural placement of chest tube.
A, Magnified anteroposterior chest radiograph shows
horizontal course of right chest tube (arrows).
49-year-old man with intraparenchymal placement of
A, Scout image shows chest tube (arrow) projecting
over right mid lung field.
Magnified CT image shows chest tube (thick arrow)
coursing through right upper lobe. There is associated
small pneumothorax (asterisk) and subcutaneous
emphysema (thin arrow).
48-year-old man with chest tube kinking. Magnified
posteroanterior chest radiograph performed after
chest tube placement shows kinking of chest tube
(arrow) precluding adequate pleural drainage.
37-year-old man with mediastinal placement of chest tube.
A, Anteroposterior chest radiograph shows left chest tube (arrows)
in inappropriate position, directed medially and projecting across
mediastinum. There is persistent left pleural effusion.
37-year-old man with mediastinal placement of chest tube.
B, CT image at level of pulmonary artery trunk confirms
that tip of chest tube (arrow) is in anterior mediastinum.
30-year-old male victim of motor vehicle trauma with abdominal placement of
A, Anteroposterior chest radiograph shows horizontally oriented chest tube
(arrow) in left lower hemithorax. There are several left rib
fractures, opacification of left hemithorax, and subcutaneous emphysema.
30-year-old male victim of motor vehicle trauma with abdominal placement of chest tube.
B, CT image shows traumatic left diaphragmatic rupture with migration of abdominal content
to left hemithorax. Chest tube (black arrow) is seen within mesenteric fat abutting small bowel
loops. Note splenic rupture (white arrow) related to trauma.
Tracheal intubation is a life saving procedure but can
be life threatening if placed incorrectly
The tip of the tube should be 5 cm above the carina
The carina is just cauded to the aortic arch
Chest radiograph shows that the tip of the endotracheal tube
(black arrow) is slightly above the aortic arch and well above the
carina, in good position. A right chest tube (white arrow), ECG
leads (E), a gown snap (G), and oxygen tubing (O) are also
When advanced too far, the endotracheal tube usually
enters the right main bronchus, causing various
combinations of hyperinflation and atelectasis of the
two lungs, depending on the positions of the end and
endotracheal tubes can also be placed in the
the soft tissues of the neck.
6-year-old woman with misplaced endotracheal tube. Magnified
anteroposterior chest radiograph shows that tip of endotracheal
tube (thick arrow) is too high, at level of thoracic inlet.
Endotracheal tube cuff (thin arrows) is overdistended. This
abnormal position may cause vocal cord injury.
60-year-old woman with inadvertent right main bronchial
intubation. Anteroposterior chest radiograph shows endotracheal
tube tip (arrow) in right main bronchus, resulting in complete
collapse of left lung and leftward shift of mediastinum.
Frontal view shows a double-lumen endotracheal tube
with selective intubation of the left main bronchus
66-year-old man with left-sided double-lumen endotracheal tube. Magnified
anteroposterior chest radiograph shows double-lumen endotracheal tube with
its left tip (thick arrow) in left main bronchus. Right tip (thin arrow) is noted
within trachea for ventilation of right lung. Double-lumen endotracheal tube
allows control of distribution of ventilation to each lung. It is important to
differentiate between double-lumen endotracheal tubes and inadvertent
selective bronchial intubation with single-lumen catheters.
Nasogastric tubes and feeding tubes are frequently
visualized passing through the mediastinum on their
way to the stomach and intestines.
Esophageal balloons and esophageal stents used to
treat benign and malignant esophageal disease may
manifest themselves at chest radiography.
Routinely used for
Monitoring hemodynamic function
Venous devices are usually inserted, either
percutaneously or surgically, via the
subclavian, internal jugular, or femoral veins. Arterial
devices usually are placed through the femoral artery
central lines typically have one to three lumens
A central venous catheter is ideally positioned in the
superior vena cava for the monitoring of pressure or
infusion of medication and nutrition.
Swan-Ganz is a multilumen catheter used for
measuring hemodynamic pressures and cardiac
output.A better term to use is pulmonary artery
Accurate measurement of pulmonary arterial wedge
chest radiograph shows a right subclavian single-lumen
central venous catheter and a left subcutaneous port
catheter, which enters via the left subclavian vein. Both
catheter tips are in the superior vena cava.
The port is usually connected to a central venous
catheter or to an arterial catheter and can be used for
instillation of fluids, medications, chemotherapeutic
agents, parenteral nutritional solutions, and blood
products. It can also be used for withdrawal of blood
Frontal view of the chest shows a left subclavian Groshong
catheter with its tip in the proximal most portion of the
superior vena cava. (b) Close up view of the catheter tip.
Groshong catheter has closed, rounded tip Near the tip in the side of the
catheter is a three-position valve. The valve is designed to allow fluid to flow in
and out through the valve, but it remains closed when it is not in use. This
catheter does not require routine clamping or heparin solution to keep open. It
does require periodic flushing with 0.9% normal saline.
A good rule of thumb is that the catheter tip
should be within the mediastinal shadow.
Placement more distally increases the chance of
pulmonary infarction or vessel rupture.
Frontal chest radiograph shows a right jugular Swan-
Ganz catheter with its tip (arrow) in the right lower
Frontal chest radiograph shows a Swan-Ganz catheter
(white arrow) in the left pulmonary artery via the inferior
vena cava. Note also the bilateral chest tubes (black arrows)
and ECG leads (E).
Complications of catheter insertion vary with the
catheters used and the sites employed
Pneumothorax is a common complication
Vessel lacerations and perforations can produce
hematomas, hemothorax, and infusion of fluid into
the mediastinum, thorax, or other inappropriate space
Nerve injury is usually a complication of improper
Looping of catheters may lead to knotting.
Malpositioning of pulmonary artery catheter is
exceedingly common, found in approximately 25% of
catheters placed. This may lead to false readings and
an increased risk for complications.
Complications of pulmonary artery catheter
placement include pneumothorax, pulmonary
infarction, cardiac arrhythmias, pulmonary artery
perforation, endocarditis, and sepsis
Cardiac pacemakers, valve prostheses, and artificial
chest radiography is commonly employed in the
assessment of patients with heart disease
recognition of cardiac devices and the problems
associated with them is important for all individuals
involved in the care of these patients.
Mechanical Heart valves most require life-long treatment
Biologic valves are less durable than mechanical
valves, with some deterioration developing, frequently 5–10
years after placement, but they do not usually require
It is not important and often impossible to know the
specific name of a particular prosthetic heart valve, but it is
important to recognize its presence
The mitral and aortic valves are those most commonly
Mechanical heart valve. Lateral view of the chest shows a Hemex
tilting bileaflet mechanical mitral valve prosthesis. Median
sternotomy wires and surgical clips are also evident.
Mechanical heart valve. Lateral view of the chest shows a
Starr-Edwards caged ball mechanical mitral valve prosthesis.
Biologic heart valve. Frontal view of the chest shows a
Hancock porcine mitral valve prosthesis (arrow). A singlelead pacemaker, ECG leads, and median sternotomy wires
are also seen.
Biologic heart valve. Frontal view of the chest shows a
Hancock porcine valve prosthesis in a Rastelli conduit going
from the right ventricle to the pulmonary artery.
Lateral view of the chest in an elderly patient shows a mitral annuloplasty
ring (black arrow) and a dual-lead cardiac pacemaker. Sternal
wires, surgical clips, and ECG leads are also present. The sternal wires are
used to close a sternal dehiscence. The patient has both horizontal sternal
wires and vertical intercostal wires (white arrows).
Lateral view of the chest in a child shows an occlusion
basket (umbrella) for treatment of an atrial septal defect.
common in older adults being treated for abnormal
cardiac rhythms caused by coronary artery disease
Cardiac pacemakers improve cardiac function, reduce
the severity of clinical symptoms, and reduce mortality
A cardiac pacemaker is composed of two main
elements: (a) a pulse generator and (b) lead wires with
electrodes for contact with the endocardium or
Pacemakers range from simple temporary epicardial
electrodes to very complex pacemakers with multiple
atrial and ventricular leads
Frontal (a) and lateral (b) views of the chest show a single electrode epicardial
“corkscrew” subxiphoid pacemaker (arrowhead in a, black arrow in b). There are
also coils (white arrow) occluding a previous right Blalock-Taussig shunt. In
addition, ECG leads and sternal wires are evident.
Frontal (a) and lateral (b) views show an atrioventricular
sequential pacemaker with one electrode in the right atrial
appendage (RA) and the other at the right ventricular apex (RV).
Also shown are ECG leads (E) and the battery-control pack (B)
for the pacemaker.
Because there can be such a wide variation in the
proper positioning of pacemaker leads, it is often
difficult for the to know if a pacemaker is properly
Pacemaker lead fracture is now rarely seen because of
improvements in the flexibility of the metal alloys
used in electrode construction.
Coronary Artery Surgery and Stents
Revascularization techniques include CABG
surgery, coronary artery angioplasty, and coronary
artery stent placement.
Median sternotomy is the usual surgical approach for
CABG surgery, and sternal wires the common method
of fixation of the two sternal segments
At present, almost 90% of coronary interventions
include stent placement
Complications associated with coronary artery stents
are stent thrombosis and restenosis.
Lateral view of the chest shows sternal wires (arrowhead), vascular clips of
a saphenous vein bypass graft to the right coronary artery (curved
arrow), and those of the left internal mammary graft to the left anterior
descending coronary artery (straight arrow).
PA chest radiograph demonstrates bilateral pulmonary artery stents in
a patient with bilateral pulmonary artery stenosis and aneurysmal right
ventricular outflow tract following tetralogy repair.
Circulatory Assist Devices
The high mortality from cardiogenic shock continues
to spur efforts to develop mechanical support for the
Most mechanical support for patients with heart
failure consists of devices that assist the heart without
Mechanical cardiac assist devices can be divided into
(a) temporary cardiac assist devices
(b) permanent cardiac assist devices
(c) heart replacement devices.
short-term cardiac assist devices are the intraaotic
balloon pump and newer left ventricular assist devices
Frontal (a) and lateral (b) views of the chest show a
Thoratec left VAD (arrow).
chest show a CardioWest total artificial heart. the four prosthetic
valves and the two coil, reinforced polyurethane tubes carrying
pulses of compressed air to the two artificial ventricles.
Cropped frontal view (a) and full lateral view (b) of the chest show a
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.
30-year-old man with malpositioned feeding tube. Anteroposterior
chest radiograph shows that feeding tube has entered right main
bronchus, traversed right lower lobe bronchus (white arrows), and has
its tip overlying right upper quadrant of abdomen (black
arrow), raising concern for possible perforation of right
hemidiaphragm. Note associated right pneumothorax (asterisk).
Frontal view of the chest shows “ping-pong ball plombage”
in the right apex, as well as a cardiac pacemaker.
Frontal view of the chest shows a right apical oleothorax
(wax plombage). Extensive pleural calcification includes
the surface of the wax ball (arrows).
A pacemaker is one of the common devices encountered on a chest x-ray. The
usual location for a pacemaker is the anterior left upper chest wall (black arrow).
Pacemakers may have either 1 or 2 leads. The wires connecting the pacemaker to
the intracardiac electrodes must be intact (yellow arrow). The typical position of
the cardiac electrodes is in the right ventricle (red arrow) for a single lead, and
also in the right atrium for a dual-lead pacemaker. It is important to compare the
electrode position to that in previous studies because an electrode may become
a) Frontal view of the chest shows an esophageal stent (black
arrows) that was placed to ameliorate the effects of an esophageal
malignancy. There are also two chest tubes (), a peripherally
inserted central catheter (white arrow), ECG leads (E), a gown snap
(G), and a transjugular intrahepatic portosystemic shunt (T) in the
Frontal view of the chest shows a left jugular Swan-Ganz catheter
(arrows), which passes through a persistent left superior vena cava into the
coronary sinus, through the right atrium and right ventricle, and into the right
pulmonary artery. Also seen are a subcutaneous port (P), an endotracheal tube
(ET), an ECG lead (E), and a nasogastric tube (not labeled).
The electrode is placed in the epidural space adjacent to the spinal cord. The wires are
connected to a stimulating generator implanted subcutaneously. The electrode generates a
weak electrical current that interrupts the transmission of pain at a spinal cord level.
Spinal cord stimulation (SCS) is recommended as a treatment option for adults with chronic
pain of neuropathic origin. Most frequently: Brachial plexopathy, Post-laminectomy
syndrome, Post Chemotherapy Neuropathy, Complex Regional Pain Syndrome (types I and II)
and HIV polyneuropathy.
The implantable loop recorder (ILR) is a subcutaneous electrocardiographic monitoring device that stores ECG data
automatically in response to specific rhythm anomalies or in response to patient activation.
It is mainly used for diagnosis in patients with recurrent unexplained episodes of syncope or palpitations, but is also
useful for long-term monitoring in patients with documented or suspected atrial fibrillation, for risk stratification in
patients who have sustained a myocardial infarction and those who have certain genetic disorders.
48-year-old woman with extravascular placement of double-lumen
A, Anteroposterior chest radiograph shows catheter (arrow) inserted via
right subclavian vein with its tip projecting over right atrium.
48-year-old woman with extravascular placement of double-lumen
B, Because there was clinical suspicion of malpositioning of
catheter, IV contrast medium was injected and was seen to
extravasate into pleural space (arrows).
72-year-old woman with pulmonary infarction as complication of
pulmonary artery catheter placement. Magnified anteroposterior chest
radiograph shows that tip of catheter (black arrow) is too distal (i.e., >
2 cm lateral to hilum). There is wedged-shaped opacity (white arrows)
distal to catheter, consistent with pulmonary infarction.
75-year-old woman with displacement of pacemaker
A, Posteroanterior chest radiograph shows dual-lead
pacemaker. Tip of right ventricular lead (arrow) is
projected at edge cardiac silhouette.
67-year-old man with pacemaker lead fracture. Magnified
anteroposterior chest radiograph shows fracture (arrow) in
pacemaker lead near battery-control pack. Lead fractures most
commonly occur at venous access site, near tip, or near
7-year-old man with normal positioning of intraaortic counterpulsation balloon pump.
B, Magnified anteroposterior chest radiograph obtained during diastole shows inflated
radiolucent balloon (thin arrows) as well as radiopaque tip (thick arrow) within upper
descending thoracic aorta. Catheter is inflated during diastole to increase myocardial perfusion
and is deflated during systole to decrease left ventricular afterload.
misplaced central venous catheters.
6-year-old girl. Posteroanterior chest radiograph shows two misplaced
catheters. Right internal jugular central venous catheter (black arrow)
has its tip in right atrium. Left subclavian central venous catheter
(white arrow) has its tip in right subclavian vein.
Various devices are used to monitor and treat critically
The radiographic evaluation of these devices is
important because the potentially serious
complications arising from their introduction and use
are often not clinically apparent.
Familiarity with normal and abnormal radiographic
findings is critical for the detection of these
The American College of Radiology recommends daily
chest radiography for critically ill patients who have acute
cardiopulmonary disease or are receiving mechanical
ventilation, as well as immediate imaging for all patients
who have undergone placement of endotracheal tubes
(ETTs), feeding tubes, vascular catheters, and chest tubes.
These recommendations are made because the
malpositioning of these devices and the serious
complications that may ensue are often not clinically
apparent. Radiographic evaluation of these devices is
important, albeit challenging, because of the technical
limitations of portable chest radiography and the inability
of patients to cooperate.