This document provides information on commonly used medical devices seen on chest x-rays in the intensive care unit. It describes the normal positioning and potential malpositions of nasogastric tubes, endotracheal tubes, tracheostomy tubes, central venous lines, chest tubes, pulmonary artery catheters, pacemakers, intra-aortic balloon pumps, and pediatric lines. Malpositions can lead to complications, so the document emphasizes the importance of chest x-rays to evaluate device positioning and detect any issues. Potential complications of each device are also outlined.

1. LINES AND TUBES IN CHEST X RAY
Dr.T.V.S.S.SAI MADHURI

2. • Many medical devices are used in intensive care unit for long durations.
• Each of them is a double edged sword:intended to save life ,but life
threatening if its in wrong place.
• All catheters have the potential risks of coiling, misplacement, knotting,
and fracture.
• So it is essential for a radiologist to know about the normal position and
malpositions of devices and its associated complications.
• 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

3. Commonly used tubes and lines in ICU
Nasogastric tube Pacemaker
Endotracheal tube Pulmonary (swan-ganz)catheter
Tracheostomy tube Intra aortic ballon pump
Central venous line Automated implantable cardioverter
defibrillator
Drainage tube Paediatric lines

4. Nasogastric tube
Indications :1. Feeding purpose
2. Aspiration of contents
The NG tube has multiple side holes.
There are terminal lead balls to
facilitate identification of the tip.
CORRECT POSITION : NG tube tip should be
10 cm distal to gastro esophageal
junction

6. MALPOSITIONS OF NG TUBE AND ITS COMPLICATIONS
• In the oesophagus: If the side holes are positioned within the
esophagus there is increased risk of aspiration
• In the trachea or bronchus: Inadvertent insertion into the
trachea and bronchus can cause pneumonia, pulmonary
contusion, or pulmonary laceration.
• Pharyngeal and esophageal perforations can occur but are
rare.

7. Frontal (A) and lateral (B) radiographs of the neck showigh a NG tube coiled in
the upper esophagus with its tip in
the oropharynx .

8. Frontal radiograph of the chest shows a NG tube forming a
loop in the left bronchus before the tip reaches the right lower lobe bronchus.

9. Tube misplacement in right main bronchus
The tube follows the course of the right main bronchus Its tip is projected over the
lower zone of the right lung The NG tube has been inhaled rather than swallowed .
The tube must be removed and repositioned

11. Endotracheal tube
The endotracheal (ET) tube is inserted for
ventilation of both the lungs and for prevention
of aspiration.
Correct position: ET tube in the neutral position
of the neck is with the tip 5–7 cm above the
carina.
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.

13. Malpositions of ET tube and its complications
• Selective intubation :It can cause collapse of the contralateral lung and
hyperinflation of the ipsilateral lung, or pneumothorax.
• Selective intubation can be clinically occult in about 60% of patients and
only revealed on the CXR,so an immediate CXR after intubation is
warranted as these complications are not uncommon.
• Inadvertent esophageal intubation :It can be detected radiographically by
the presence of an over distended stomach.
• Tracheal stenosis can occur following long-term tube placement.
• Aspiration of tooth can also occur as a complication

14. 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

15. Frontal radiograph of a neonate shows inadvertent placement
of an endotracheal tube in the esophagus with distension of
the esophagus and stomach with air

16. TRACHEOSTOMY TUBE
• Tracheostomy tubes, are inserted
through a stoma post-tracheostomy to
help patients unable to breathe
normally.
INDICATIONS OF TRACHEOSTOMY TUBE
• Prolonged ventilator dependence.
• Prophylactic tracheostomy prior to
head and neck cancer treatment.
• Obstructive sleep apnea refractory to
other treatments.
• Chronic aspiration.
• Neuromuscular disease.
• Subglottic stenosis.

17. CORRECT POSITION:
The tip of the tracheostomy tube should be half way between
the stoma and the carina, at the level of the D3 vertebra.
It should lie parallel to the trachea.

19. COMPLICATIONS OF TRACHEOSTOMY
• Hemorrhage
• Malposition
• False tract
• Tracheal stenosis
• Surgical emphysema
• Pneumo mediastinum
• Pneumothorax

20. Frontal chest radiograph shows complications of tracheostomy:
pneumothorax , pneumo mediastinum , and surgical
emphysema

21. CENTRAL VENOUS LINES
Central venous lines (catheters)
are useful for a variety of
purposes:
• Hemodynamic pressure
monitoring;
• Hemodialysis
• Administration of medications,
nutrition, and fluids.

22. • Correct positioning of a CVC tip depends on the side of entry
and intended use of the catheter
• For most short-term uses, such as fluid administration or
monitoring of central venous pressure -Positioning the tip of
a central venous catheter within the superior vena cava at
or just above the level of the carina is generally considered
• For the purpose of long term chemotherapy –the tip of cvc
may be placed more inferiorly at the cavo-atrial junction -
the junction of the SVC and right atrium .

23. • Superior vena cava (SVC) anatomy
• The internal jugular and subclavian veins join to form the
brachiocephalic veins.
• The brachiocephalic veins join to form the SVC(corresponds
to thethe first anterior intercostal space)
• The SVC is located to the right side of the mediastinum above
and below the level of the carina.
• SVC is not visible on a chest X-ray. As the carina is a visible
structure, it can be used as an anatomical landmark to help
determine the level of a CVC tip within the SVC.
• The cavo-atrial junction is located approximately the height of
two vertebral bodies below the level of the carina

25. VARIOUS APPROACHES FOR CENTRAL
VENOUS LINE
• Right-sided catheters
• CVCs are most commonly inserted via the right
internal jugular vein.
• Right internal jugular catheters are positioned on
the right side of the neck, and pass vertically from
a position above the clavicle.
• This is an ideal position for right-sided catheters
for fluid administration and venous pressure
monitoring, but not for long-term chemotherapy
or dialysis

27. Right subclavian vein catheter
• Catheters inserted into the subclavian vein pass below the clavicle and
then curve into the SVC.

28. Left subclavian vein catheter

30. CV Catheters - Complications
• A chest X-ray taken after central venous catheter placement can
identify immediate complications such as pneumothorax or
pneumomediastinum and to identify incorrect positioning.
• Immediate complications
Complications such as pneumothorax and surgical emphysema may
arise from traumatic placement.
• Incorrect positioning
If catheters are not inserted far enough they may be located in the
jugular, subclavian, or brachiocephalic veins.
Catheters inserted too far may enter the right atrium.

31. IATROGENIC PNEUMOTHORAX

32. CVC IN LEFT BRACHIOCEPHALIC
VEIN
The tip of this catheter
is projected over the
left brachiocephalic
vein rather than the
SVC

33. CATHETER IN RIGHT ATRIUM
This peripherally inserted
central catheter (PICC) was
aimed to be inserted with its tip
at the level of the cavo-atrial
junction (the height of two
vertebral bodies below the
carina)
The PICC has been inserted too
far with its tip in the right atrium
(RA)

34. HORIZONTAL POSITIONING IN
SVC
Catheters placed via a
left-sided approach are
prone to being positioned
nearly horizontally rather
than vertically within the
SVC.
Catheters which contact
the lateral wall of the SVC
in this way may cause
vessel erosion if positioned
long term, and should
therefore be placed so the
tip is orientated vertically.

35. INTERNAL JUGULAR
CATHETER
-MISPLACED
This left internal jugular
catheter has entered
the left subclavian vein.
The catheter needs to
be repositioned.

36. Frontal chest radiograph shows an abnormally medial
course of the catheter in a case of inadvertent carotid
cannulation

37. INTERCOSTAL DRIANAGE TUBES
• The pleural tube, more commonly known as the intercostal
drainage tube (ICD), is inserted through the 4th intercostal
space in the anterior or mid-axillary line.
• It is then directed posteroinferiorly in cases of effusion and
anterosuperiorly in cases of pneumothorax.
• The 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.
• No side holes should lie outside the chest/pleura

38. Chest drain-treatment
for pneumothorax
To drain pneumothorax
the tube is positioned
with its tip pointing
superiorly towards the
apex of the pleural
cavity.

39. CHEST DRAIN - TREATMENT
FOR PLEURAL EFFUSION
To drain pleural effusion
the tube tip is ideally
located towards the
lower part of the
pleural cavity.

40. MALPOSITIONS OF ICD TUBES
An intercostal drainage
tube is noted in situ. One
hole is situated outside the
rib cage, indicating
Malposition, likely
resulting in insufficient
suction.
Pneumothorax noted on
the left side with a
partially collapsed lung

41. PULMONARY ARTERY CATHETER(SWAN-GANZ
CATHETER)
• The pulmonary artery catheter, also called a
Swan-Ganz catheter, is used to monitor
circulatory hemodynamics in critically ill
patients by measuring pulmonary capillary
wedge pressure.
• The catheter is inserted via the subclavian vein
or the internal jugular vein.
• The ideal position of the tip of the catheter is in
the right or left main pulmonary arteries, and
the tip should not extend beyond the proximal
interlobar pulmonary artery (within 2 cm of the
hilum)

42. Swan-Ganz catheter lies in the left pulmonary artery.

43. COMPLICATIONS OF SWAN GANZ CATHETER
• Occlusion of a pulmonary artery branch may occur if the
catheter is too distal, if there is persistent inflation of the
balloon, or if a clot is formed around the distal tip of the
catheter; such occlusion can result in pulmonary infarction. A
chest radiograph may reveal the infarction as a wedge-shaped
pleural-based pulmonary opacity.
• Other potential complications are intracardiac knotting,
pulmonary artery perforation, arrhythmias, cardiac
perforation, and placement in the inferior vena cava

44. Anteroposterior chest radiograph shows that tip of catheter is too distal (i.e.,
> 2 cm lateral to hilum). There is wedged-shaped opacity distal to catheter,
consistent with pulmonary infarction.

45. PACEMAKER
• 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 .
• Sometimes a third lead is placed in the coronary sinus to pace the left
ventricle.

46. 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 . Frontal chest radiograph (B) shows a two-lead pacemaker that has one
electrode in the right atrium and the other at the right ventricular apex

47. COMPLICATIONS OF CARDIAC PACEMAKER
• Malposition,
• Intracardiac knotting,
• Fracture,
• Perforation
• Cardiac tamponade,
• Arrhythmias,
• Infection,
• Hemorrhage.

48. Frontal chest radiograph shows coiling of the lead of a
single-lead pacemaker in the right atrium

49. Frontal chest radiograph shows abnormal course of the
lead with the electrode tip overlying the liver.This was due
to cardiac perforation by the pacemaker lead,with a fatal outcome

50. Frontal chest radiograph shows recoil of the pacemaker lead
with its tip in the superior vena cava . This is called Twiddler’s
syndrome

51. Intra-aortic Balloon Pump
Intra-aortic balloon pump 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.
The catheter is inserted through the femoral artery.
To avoid occlusion of the left subclavian artery and visceral and renal
arteries, its tip should be slightly cephalad to the adjacent carina (2nd–3rd
intercostal space)

52. • The balloon is inflated with
gas during diastole and
deflates during systole,
resulting in increase in
coronary blood flow and
reduction in left ventricular
after load (and hence,
reduction in myocardial
oxygen consumption).

53. Normal positioning of intraaortic counter pulsation balloon pump. Magnified
Anteroposterior chest radiograph obtained during systole shows catheter’s
radiopaque tip within upper descending thoracic aorta indicating proper
positioning.

54. Magnified Anteroposterior chest radiograph obtained during diastole shows
inflated radiolucent balloon as well as radiopaque tip within upper
descending thoracic aorta. Catheter is inflated during diastole to increase
myocardial perfusion and is deflated during systole to decrease left
ventricular after load.

55. MALPOSITIONED INTRAAORTIC COUNTERPULSATION BALLOON PUMP
Anteroposterior chest radiograph during diastole shows inflated radiolucent
balloon. Radiopaque tip of balloon catheter is abnormally located beyond
aortic arch. It is projected over left common carotid artery. This abnormal
positioning can result in cerebral ischemia.

56. Malposition intraaortic counter pulsation balloon pump. Anteroposterior
chest radiograph obtained during diastole shows inflated radiolucent balloon
with its radiopaque tip in mid thoracic aorta. Counter pulsation is less
effective when catheter is too low and may result in obstruction of abdominal
aortic branches, such as renal or mesenteric arteries.

57. Automated Implantable Cardioverter Debrillator
Automated implantable cardioverter
debrillator (AICD) is used in cases of
recurrent refractory ventricular
tachycardia.
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

58. PACEMAKER VS AUTOMATED IMPLANTABLE CARDIOVERTER
DEBRILLATOR

59. • Complications are similar to those with
pacemakers and the incidence of
radiographical abnormalities may approach
20%.

60. Pediatric Lines
• Some catheters are only used in the pediatric
population, for example, the umbilical artery and
venous catheters.
• They are used for vascular access for exchange
transfusion and measurement of blood gases,
pressures, electrolytes, etc.
• The umbilical vein and arteries remain patent for up
to 4–5 days after birth.

61. Umbilical artery line
The catheter should be passed
through the umbilic artery and enter
the aorta via the internal iliac artery.
In order to avoid placement into
aortic branches, the catheter should
be either in a high position above the
celiac, mesenteric and renal arteries
or in a low position below the inferior
mesenteric artery:
High position: T6-T9
Low position: L3-L5
The high position is advisable since it
leads to less vascular complications
(15).

62. Umbilical artery line in a
good high position.
Malposition of umbilical
vein line in right portal
vein.

63. Malposition of umbilical artery line, folded in the
abdominal aorta.

64. Malposition of umbilical artery line in left iliac artery.

65. Umbilical vein
catheter
An umbilical vein catheter
should pass through the
umbilical vein into the left
portal vein.
Then through the ductus
venosus into a hepatic vein
and the inferior caval vein
(IVC)
The tip should be
positioned in the IVC at the
level of the diaphragm.

66. MALPOSITIONS AND ITS COMPLICATIONS
• Low position in the umbilical vein.
• Intrahepatic into the portal venous system, both right and left,
or even into the superior mesenteric or splenic vein.This can
cause thrombosis.
• Perforation of the portal vein can cause haemorrhage or
abscess formation in the liver.
• Position too deep in right atrium or in the left atrium through
a patent foramen ovale or atrial septal defect.
This can lead to cardiac arrhythmias or perforation.

67. Umbilical vein line positioned in the periphery of the liver through the
right portal vein.
Artery line in the left subclavian artery.

68. The umbilical vein line is positioned in the umbilical vein and
not deep enough.

69. The tip of the umbilical vein line is pointed downwards and
probably situated in the mesenteric vein.

70. Frontal radiograph of the chest and abdomen of a neonate shows the tip of an
umbilical venous catheter in the left atrium; it has passed through a patent
foramen ovale. The tip of the umbilical artery catheter is in the arch of the
aorta (which is undesirable as it is near the origin of the carotid artery)

71. Thank you