Understanding the common lines and tubes on a chest radiograph in icu setting. Common pathologies encountered in ICU.

1. Chest X-Ray in ICU setting
Presentor- Dr. SourabhArora
DNB Trainee
Moderator- Dr.Aparimita Gogoi
Senior Consultant

2. Lines and Tubes

3. Central Venous Catheters
To measure right atrial pressure
Fluid infusion/ nutrition
Drug/ Contrast administration
Position:- Superior Vena Cava/ Cavoaortal
junction

5. PICC
Tunneled: Hickman

6. Non tunneled: Vascath
Implantable port: Port a Cath

7. Into IJV
Into RV

8. Arterial puncture Via ASD into LA In azygous vein

9. Complications:-
Pneumothorax
Hemothorax
Infusothorax
Arrhythmia
Infection
Arterial placement
Venous perforation

10. Swan- Ganz Catheter
To monitor pulmonary arterial/ capillary wedge
pressure
Right heart pressures
Cardiac Vs Non-cardiac pulmonary edema
Position:- Main or Lobar pulmonary artery
In the pulmonary artery

11. In the left pulmonary artery
In right pulmonary artery

12. Wedge shaped opacity C/L lung collapse

13. Nasogastric Tube
Gastric decompression/ aspiration
Nutrition
Position:- >10cm beyond GE Junction

14. High in oesophagus
Inside Tracheo bronchial tree

15. Nasoenteric Tube
Nutriton
Position:- 2nd part of duodenum
Complete malposition, tube coiling, pulmonary
laceration, pulmonary contusion, pneumothorax and
hydropneumothorax.
Complications:- Pharyngeal, esophageal or gastric
perforation

16. Pneumomediastinum Pneumoperitoneum

17. Intercostal Drainage Tube
To drain- Pneumothorax- Tip pointing apically
Pleural effusion- Tip in posteroinferior
Side holes should be medial to inner margin
Position:- In the pleural space
Not in lung/
fi
ssure/ subcutaneous plane
Inadvertent placement in extra pleural space

18. Complications:- Intra parenchymal positioning
Pulmonary lacerations, hematoma, infarction, bronchopleural
fi
stula
Ineffective drainage: tube kinking, blood clot, pus, debris

19. Malposition of ICDT Kinking

20. Endotracheal tube
Assisted ventilation
Too high- ineffective ventilation
Too low- selective bronchial intubation
Consequently, segmental or complete collapse of C/L lung
Position:-5-7cm above carina
Dynamic
Flexion- 2cm Descent
Extension- 2cm Ascent
Double lumen ETT- ventilate one lung

21. Right main bronchus At carina

22. Complications:-
Esophageal intubation- Right posterior oblique view
Over in
fl
ation unto 1.5x— Rupture/ Tracheomalacia/Tracheal
stenosis
Subcutaneous emphysema, pneumomediastinum, pneumothorax
PPV- Barotrauma
Aspiration pneumonia, nosocomial infection, intratracheal clots/
mucus plugging

23. Esophageal intubation
Tip too high
at the level of thoracic inlet

24. Tracheostomy tube
Assisted ventilation
Long term intubation
Small amount of subcutaneous emphysema,
pneumomediastinum
Tracheal stenosis due to granulation tissue and
fi
brosis

25. Cardiac Pacemaker
Single lead- RV
Double leads- RV + RA
Triple leads- RV+ RA+ LV

26. Fracture of the lead
Correct placement

27. Tip displaced slightly downwards

28. Intra Aortic Balloon Pump
Patients with cariogenic shock
Ejection fraction <20%
Position- metallic tip in AP window
Distal to left subclavian artery
In
fl
ate- diastole
De
fl
ate- systole
Increases coronary
fl
ow
Decreases after load

29. Correct placement

30. Too high position Too low position

31. Automated Implantable Cardiac De
fi
brilator
Monitor and correct an abnormal heart rhythm and
arrhythmia.

33. Perma-cath/ Chemo port

34. Tube/ Line Desired Position
Central Venous catheter/
PICC
Tip in Superior Vena Cava
Swan-Ganz Catheter Tip in proximal R / L Pulmonary artery
Nasogastric Tube 10cm distal to GE Jn / Upto antrum
Nasoenteric Tube Tip in 2nd part of duodenum
ICDT Anterosuperior for PTX; Posteroinferior for effusion
Endotracheal Tube Tip 5+/- 2cm from carina
Tracheostomy Tube 3cm from carina
Pacemaker RA/ RV/ LV
IABP AP window
AICD One lead in SVC; other in R ventricle

35. Lungs Pathology

36. Pneumothorax
Clearly de
fi
ned line.
Upper part of the line is curved at lung
apex.
Absence of lung markings.
Erect xray in full expiration
CT- Best modality

38. Supine:-
Hyperleucent upper quadrant of
abdomen
Lateral costophrenic angle…
Deep Sulcus Sign
Sharply outlined dome of
diaphragm

39. Inspiratory View Complete collapse
Expiratory View

40. (a). Esophageal rupture
(b). Tracheal rupture Measuring size

41. Skin fold/ wrinkle Large bulla

42. Tension Pneumothorax
Total collapse of right lung
Venous return is reduced
Dome of diaphragm is
fl
attened/ depressed
Heart/ mediastinum—? Shift
Urgent cannulation- Triangle of safety

43. Hydro-pneumothorax
Pleural effusion and hydrothorax
After- Thoracocentesis
Bronchopleural
fi
stula
Oesophagopleural
fi
stula
Diffrentials:-
Pyopneumothorax
Hemopneumothorax
Pulmonary abscess
Traumatic pneumatocele
Soft tissue abscess

45. Pneumomediastinum
Causes- Alveolar rupture due to mechanical
ventilation
Thoracic trauma
Tracheal/ Bronchial rupture
Extra thoracic sites:-
Vascular sheath in the neck
Retropharyngeal space
Submandibular space
Retropharyngeal space

46. (a). Continuous diaphragm sign
(b). Halo of air surrounding heart

47. (c). Pneumopericardium
(a). Pneumothorax (b). Pneumomediastinum

48. Surgical Emphysema
Tracheobronchial tree perforation
Pockets of air seen as dark areas

50. Pleural effusion
Large amount of
fl
uid is displaced in supine
No meniscus, only veil like opacity
Types:-
Lamellar- Linear opacity, paralleling lung surface
Encysted- Loculation within a
fi
ssure
Subpulmomary- Pooling within the pleural surface
below the lung

51. Meniscus Sign Subpulmonic effusion

52. Loculated effusion Before drainage After drainage

53. Aspiration pneumonia
Airway plugging
Chemical pneumonitis- Mendelson syndrome
Recumbent Position:-
Posterior segments of upper lobe
Superior segments of lower lobe
Erect position:-
Bilateral basal segments, middle and lingula.
Differential diagnosis, airspace opacity:-
Pulmonary edema
Infectious pneumonia
Primary/ secondary malignancy

54. Posterior segments of upper lobe
Superior segments of lower lobe

55. Pulmonary edema
Abnormal accumulation of
fl
uid in extravascular space
Types:- Cardiogenic and Non-cardiogenic
Peribronchial cuf
fi
ng and parahilar haze
Air space opaci
fi
cation in Batwing distribution
ABCDE
Alveolar opaci
fi
cation
Batwinging
Cardiomegaly
Diffuse interstitial thickening
Effusions

57. Kerley B lines

58. Frontal View Lateral
Stag’s Antler sign

59. Thank You