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C. CXR-TUBES & LINES

C. CXR-TUBES & LINES

1. Endotracheal tube

  • Should be about 4cm above the carina +/- 2cm for neck extension/flexion.
  • Beware: oesophageal intubation, ETT pushed down the right bronchus.

2. Tracheostomy

  • Side walls of the tracheostomy tube should be parallel to the trachea.

3. Intercostal catheter (ICC)

  • Look at the side-holes.
  • For pneumothorax: ICC best placed antero-superiorly. For an effusion - postero-inferiorly.
  • Make sure the catheter is not kinked, particularly at the entrance at the chest wall.

4. Central venous line (CVL)

  • Any line with its tip at the SVC/right atrial or aorto-caval junction (approximates the right 2nd IC).
  • Different approaches: PICC, internal jugular, subclavian, etc.
  • Different lines: permacath, portacath, etc.
  • Beware: the catheter tip may curl up into the IJV, using this may cause thrombosis or embolize into the cerebral circulation; catheter tip situated in the right atrium or ventricle may cause arrhythmias.

5. Swan Ganz Catheter

  • Measures pulmonary capillary wedge pressure.
  • The tip should be no further than 2cm beyond the right medistinal silhouette.

6. Nasogastric tube (NG)

  • The tip should be >10cm beyond the gastro-oesophageal junction.
  • Beware: NG tubes in the bronchi; or coiled in a dilated oesophagus (such as in oesophageal achalasia; look at previous imaging or order lateral imaging).

7. Nasoenteric (feeding) tube

  • Thin plastic catheter with a radio-opaque tip.
  • Placed distal to the pyloric sphincter.

8. Pacemakers

  • Single chamber (used to manage atrial/ventricular arrhmythias), dual chamber (synchronizes atrial + ventricular chambers), biventricular pacing (3 electrodes for the right atrium, ventricle and coronary sinus).
  • The atrial electrode should be in the right atrium (atrial appendage) + ventricular electrode should be in the myocardium of the right ventriclular apex.
  • In biventricular pacing, the additional lead is in the coronary sinus.
  • The leads should have a direct course through the veins, should not be taught, redundant or fractured.
  • Beware complications: pneumothorax, pleural effusion, myocardial perforation.

9. Implanted cardac defibrillators (ICD)

  • Single lead with 2 electrodes at the right atrium + right ventricle.


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REFERENCES

1. Goodman, L. and Felson, B. (2015). Felson's principles of chest roentgenology. 3rd ed. Philadelphia, PA: Elsevier, Saunders.
2. Dähnert W. Radiology Review Manual. LWW. (2011) ISBN:1609139437. Read it at Google Books - Find it at Amazon
3. Elizabeth Puddy, Catherine Hill; Interpretation of the chest radiograph, Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 3, 1 June 2007, Pages 71–75, https://doi.org/10.1093/bjaceaccp/mkm014

Ⓒ A. Manickam 2018

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