So there are many different lines and tubes that can be placed within a patient
for a variety of different reasons.
Let's review what some of these lines and tube can look like
so that you're able to recognize them on a chest x-ray.
We can have an endotracheal tube that's placed for life support.
Patients may have a tracheostomy tube
which is the more permanent version of an endotracheal tube.
They can have feeding tubes which include a nasogastric tube or a Dobhoff tube.
They can have central lines for administration of medications or blood draws.
They can have peripheral lines which are more temporary version of the central line.
They can have Swan-Ganz catheters; they can have chest tubes within the lung.
So these are all a conglomeration of different cardiac lines.
They can have specific cardiac lines actually within the heart as well.
So let's take a look at what each of these look like.
This is an example of an endotracheal tube.
This is again placed for patients who are unable to breathe on their own
and this is used as somewhat of a temporary measure while the patient is in the hospital.
The tip of the endotracheal tube
should be approximately 3 to 5 centimeters above the level of the carina.
Neck flexion and extension can move the tip about 2 centimeters up and down
so it's important to keep that in mind as you take a look at the position
because you want it to remain within that 3 to 5 centimeters above the carina.
Here you can see the carina is pointed out
and it can be sometimes a little bit difficult to visualize
and the endotracheal tube is just above this.
If you can't see the carina, a tip that I sometimes use
is you wanna take a look in the aortic knob
and the bottom portion of the aortic knob is approximately the level of the carina.
So let's take a look at this image here.
This patient has an endotracheal tube in place.
Can you see the location of this endotracheal tube?
So when you're working at a hospital setting,
these tubes an also be very difficult to identify because they can be subtle.
Sometimes what we do is change the window level
or help magnify and that can help us see it a little bit better.
Throughout this lecture feel free to pause and take a good look at these pictures
as we go through them to see if you can see the findings.
So here's a magnified image of the location of the carina.
So you can see the carina here and the endotracheal tube is actually to the right of the carina
so this is actually within the right main stem bronchus and is not in a good position.
This needs to be readjusted right away before it's used any further.
The tracheostomy tube is a more permanent breathing tube
that's placed within a patient and the patient can go out of the hospital with this.
The tip is about 3 centimeters above the carina
and this is not affected by flexion and extension.
Complications of a tracheostomy include tracheal perforation
which happens more acutely right after the placement of the tracheostomy
or you can have stenosis which is more of a long term complication
once the patient has had a tracheostomy in for a while.
This is an example of what a tracheostomy looks like in relation to where the carina is.
So as you can see here, the carina is right around this position
and the tracheostomy is in good position above it.
So there are two major types of feeding tubes.
The most commonly used is the nasogastric tube
and that's used as a short term feeding or medication administration tube.
It's also often used in patients who have bowel obstruction
and it's used to decompress the bowel.
It has a tip and a side port and both should be within the stomach
beyond the level of the gastroesophageal junction.
Complications include placements within the trachea
or having a tube that's not placed far enough
with the tip remaining within the esophagus.
A Dobhoff tube is the more longer term solution for longer term feeding.
The tip is usually placed within the duodenum or the jejunum ideally
although occasionally it can be placed within the stomach as well
and placement assisted guidewire is often helped for positioning.
Placement can be within the trachea
and you can also have perforation with the guidewire
as some of the complications associated with the Dobhoff tube.
So let's take a look at this NG tube.
You can see the NG tube coiled correctly within the region of the stomach.
This entire area here is likely gas within the stomach
so the NG tube is in good position here.
Incidentally, we see this finding here.
Do you know what this is?
So this is actually an EKG lead.
These are very commonly seen on top of patients
especially patients that are within the ICU
so it's important to recognize that this is not located within the patient,
it's just an overlying lead.
So this is an example of a malpositioned nasogastric tube.
Where do you think this tube is?
So tt's actually within the right mainstem bronchus.
You can see here the tube remains within the lung
and it's curving towards the right so before any kind of medication
or feeding is administered through this tube, this immediately needs to be readjusted.
This is an example of a Dobhoff tube.
You can see the difference between a nasogastric tube and a Dobbhoff tube
because the Dobhoff has a thicker tip and this is placed within the duodenum.
So it curves into the stomach beyond the level of the GE junction
and then you can see it takes another curve into the duodenum
crossing the midline here as the duodenum would.
So let's talk a little bit about central lines.
These are usually used for administration of medications
that can't be given through a smaller peripheral line.
These are larger bore lines
and they're inserted through a subclavian or a jugular approach.
The tip should project to the right of the spine
and should remain within the superior vena cava.
So you can see on this image here, a central line that's in place using an IJ approach
because you can see it coming from the neck so through the internal jugular vein
and then coming down and stopping in the region of the superior vena cava right here,
so this is a line that's in good position.
Let's take a look at this line here.
You can see the tip of the line pointed out by the arrow.
So where do you think this is?
It's not to the right of the spine as we would expect.
This line is projecting to the left of midline
and it was actually due to arterial placement of the central line
which really should be within the venous system
so this line needs to be repositioned before it's used.
So complications of central line include a tip that's within the right atrium,
so a line that's just placed a little further than it should be.
The tip could remain within the internal jugular vein
so just a little proximal than it should be
and if it's in within the right atrium it actually can result in arrhythmias.
Pneumothorax is more common with a subclavian approach
and that's because of a puncture of the lung while placing the central line
or you can also cause a perforation of the vein which can lead to hemothorax.
So let's take a look at this line.
What kind of line is this?
So you can see that it's a type of central line.
It ends in the correct location within the superior vena cava
but it has this triangular shaped density associated with it.
So this is a Port-A-Cath, there's a port that's implanted under the skin
and the port is used for drawing blood or injecting medications.
This is usually left in place for long term
and it's often used in patients that are undergoing chemotherapy.