Various lines and tubes on xray, their normal position, identification and abnormal positions

1. Dr Mudit Singhal
DNB Primary
Radio-diagnosis

2. NG TUBE
IDENTIFICATION-
multiple side holes
terminal lead balls
Ideally, the tip of NG tube should
lie with its side holes in the
gastric antrum.
The tip of the NG tube should be
positioned at least 10 cm caudal
to location of the gastro
esophageal junction

3. 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
WRONG POSITIONING –
•Insertion in trachea or
bronchus can cause
pneumonia, pulmonary
contusion, or pulmonary
laceration.
•Pharyngeal and
esophageal perforations
can also occur

4. ET TUBE
ET tube position in the neutral
position of the neck is with the tip
5+/- 2cm above the carina (5th –
7th T vertebrae) for neck flexion
and extension.
OR
Tip should be at the level of
medial ends of clavicle

5. ET tube misplaced at carina
Misplaced ET tube with lung collapse

6. OESOPHAGEAL TEMP
PROBE
have its tip in the lower third of
the oesophageal tract at the
mid-level of the heart
Malposition:
•traversing either bronchus or
more distally into the lung
•coiling in the upper airway

7. 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
The tube diameter should be
2/3rd of the tracheal width, and
the cuff should not distend the
tracheal wall
COMPLICATIONS:
•Surgical emphysema
•Pneumomediastinum
•Pneumothorax

8. DRAINAGE
TUBE
IDENTIFICATION
ICD tube has a terminal hole as
well as side holes
The side holes can be identified
on a CXR by the interruption in
the radio-opaque outline of the
tube
ICD Tube is directed postero-
inferiorly in cases of effusion and
antero-superiorly in cases of
pneumothorax

9. Surgical emphysema
Surgical emphysema may
result from incorrect tube
positioning such that the
end is located within soft
tissues of the chest wall.
This may also occur if the
tube becomes displaced
following correct tube
placement.

10. CENTRAL VENOUS
LINES
Central venous lines are inserted
through major veins such as the
subclavian, internal jugular into the
superior vena cava
On the CXR, the first anterior
intercostal space corresponds to
the approximate site of the junction
of the brachiocephalic veins to form
the superior vena cava
POSITIONING
CV line tip should be in the superior
venacava or just above the level of
carina.Distal end of a CVC should
be orientated vertically within the
SVC
Right internal jugular
vein catheter

11.  PICC placed for the purpose
of long term chemotherapy
may be placed more
inferiorly at the cavo-atrial
junction - the junction of the
SVC and right atrium (RA)
Position of Cavo Atrial Junction-
 2 vertebral body below level
of carina
 intersection of bronchus
intermedius with the
right heart border
PICC LINE

12. 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.
Placement
To avoid complications, the tip of the
Swan-Ganz catheter should not
extend beyond the pulmonary hilum
on the CXR
COMPLICATION-
•Pulmonary infarction
•Pulmonary artery perforation
•IVC placement
•Arrhythmias

13. INTRA-AORTIC
BALLOON PUMP
The catheter tip is visible as a
3 x 4-mm rectangular metallic
density while the rest of the
catheter is radiolucent
Correct position
Tip at the level of the AP window
Complications
•aortic dissection
•obstruction of the left subclavian
artery (too high)
•obstruction of the splanchnic
arteries (too low)
Intra-aortic balloon pump catheter.
The catheter tip is identified by a
rectangular metallic density

14. PACEMAKER
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
Temporary epicardial wires are
sometimes inserted during cardiac
surgery; the tips of these wires
resemble a corkscrew.
Dual Chamber Pacemaker

15. Automated Implantable
Cardioverter Debrillator
It has two electrodes (one electrode
in the right atrium and the other in
the right ventricle).
The lead is wider compared to the
pacemaker lead and has a ‘coiled-
spring’ appearance
Frontal chest radiograph of a patient with automated
implantable cardioverter debrillator. Dense bands
(arrows) along the electrode are characteristic of this
device

16. UMBILICAL ARTERY
CATHETER
The catheter should pass through
the umbilicus -> umbilical artery
then in the anterior division of
the internal iliac artery ->common
iliac artery and then into the aorta
The tip of the catheter should thus
be placed in one of two locations:
high position: at T6 to T10 level
low position: at L3 to L5 level

17. UMBILICAL VENOUS
CATHETER
Passes through
umbilicus, umbilical vein, left
portal vein, ductus venosus,
middle or left hepatic vein, and
into the inferior vena c
Tip should lie at the junction of
the inferior vena cava with
the right atrium