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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 tubes 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 a
more permanent version of an
endotracheal tube they can have feeding
tubes which include a nasal gastric tube
or a dhaba tube they can have central
lines for administration of medications
or blood draws they can have peripheral
lines which are a more temporary version
of a 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 three to five centimeters
above the level of the Carina neck
flexion and extension can move the tip
about to two 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 three
to five centimeters above the Carina
here you can see the Quran has 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 want to take a look
at the aortic nob and the bottom portion
of the aortic nob 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 the center tracheal tube
so when you're working in a hospital
setting these tubes can 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 an
magnified image of the location of the
Carina so you can see the Carina here
and the endotracheal tube is actually
toward to the right of the Carina so
this is actually within the right
mainstem bronchus and is not in a good
position this needs to be readjusted
right away before it's used any further
a tracheostomy tube is a more permanent
breathing tube that's placed within a
patient and the patient can go out of
the hospital with these the tip is about
three centimeters above the Carina and
this is not affected by flexion and
extension complications of a
tracheostomy include tracheal
perforation which is 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 a 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 nasal gastric 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 in a side port and both should
be within the stomach beyond the level
of the gastroesophageal Junction
complications include placement within
the trachea or having a tube that's not
placed far enough with the tip remaining
within the esophagus a dhaba tube is a
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 guide wire is often
helped for positioning placement can be
within the trachea and you can also have
perforation with the guide wire as some
of the complications associated with a
job Huff 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 malposition nasal
gastric tube where do you think this
tube is so it's actually within the
Reitman mainstem bronchus so 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 table puff tube you
can see the difference between the
nasogastric tube and a table puff tube
because the table half 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 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
lot 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 so 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
including include a tip that's within
the right atrium so aligned 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 placed me
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
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 if 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
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