CHEST TUBES AND LINES

• Central venous catheters

• Pulmonary artery catheter – Swartz Ganz catheter
• Nasogastric Tube
• Nasoenteric Tube
• Intercostal drain
• Endotracheal tube
• Tracheostomy tube
• Oesophageal Doppler tube

COMMON LINES SEEN ON CXR

Function
• To monitor right atrial pressure
• Fluid infusion/ nutrition
• Drug administration

Position
• SVC or Brachiocephalic vein

CENTRAL VENOUS CATHETER

• Optimal position is in lower third of SVC to cavoatrial junction

– Tip location for all centrally located vascular access devices:

• Optimal tip location: Lower superior vena cava/upper right atrium
• Acceptable tip location: Mid-superior vena cava.
• Unacceptable tip location: Brachiocephalic, upper
superior vena cava, innominate vein.

Normally placed CVC

Abnormal positions
• Tip too High- Inaccurate right atrium monitoring
pressures
• Tip too low – In Right Atrium can cause arrhythmia and
Cardiac Tamponade
• Vessel wall perforation
• Infusion of fluid into mediastinum/pleural space
• Pneumothorax

Misplaced lines causes…

• Also known as pulmonary arterial line commonly
• To assess left atrial pressure and cardiac output
• Very important in ICU patients to distinguish between
cardiac and non cardiac pulmonary edema
• Now a days not much in use in regard with patient
outcome

Swartz Ganz Catheter

• Distally placed tip will cause Pulmonary infarction
• Proximallly placed in right ventricle -- Arrythmia

Misplaced lines causes…

• Side holes of the tube in the NG tube extend around 5
cm so the tube should be atleast 10 cm beyond the OG
junction
• Uses:
1. Gastric decompression
2. Gastric aspiration
3. Nutrition

NASOGASTRIC TUBE
Dobhoff tube is a special type of
nasogastric tube (NGT), which is a small-bore
and flexible so it is more comfortable for the
patient than the usual NGT. The tube is
inserted by the use of a guide wire called the
stylet , which removed after the tube correct
placement is confirmed.

• Optimal position depends on

intended use
– Feeding tube – distal
stomach or duodenum
– Decompression – both tip
and side port below GE
junction
• If it enters trachea – ARDS
• If still in oesophagus – Can cause regurgitation

Misplaced Tubes causes..

• These feeding tubes are thin plastic catheters with a
mercury / tungsten filled tip.
• The optimum position for the tip is distal to the
pyloric sphincter.

Nasoenteric Tube
• The tube is very thin so caution should be taken
while
inserting the tube
• It may coil itself pharynx , Oesophagus or stomach
• It may enter trachea or right main bronchus

Misplaced tube causes..

• USE: Assisted ventilation
• The tip of an ETT will be in a satisfactory position if
it approximates to the level of the medial ends of the
clavicles
• Ideal position is 5–7 cm above an adult’s carina when
the head is held in the neutral position.
• And if carina is not visible in 95% people it is situated
at T5-T7 vertebra

Endotracheal tube
• The ETT can move up or down
• Flex the neck and the tip can move 1.9 cm I,e ~2cm
downwards.
• Extend the neck and it can move 1.9 cm I,e
~2cm upwards.
• Rotate the neck and it can move 0.7 cm upwards.

Position changes
• Tip of right main bronchus:
1. Left lung collapse
2. Right upper lobe collapse
3. Right lung overdistension/pneumothorax
• Tip in Oesophagus:
1. ETT lateral to tracheal air shadow
2. Oesophagus distended with air
3. Stomach distended with air

Malposition
• Tracheostomy tube lies parallel to the long axis of the
trachea
• The tip lies several centimeters well above carina
• The inflated cuff should not extend lateral walls of
trachea

Tracheostomy tube
• Mediastinum widening
• air in the mediastinum – leak is occurring

Misplaced position
• Position: Mid esophagus
• Use: To monitor cardiac output via measurement of blood
velocity in the descending aorta

Oesophageal Doppler probe

• Used in pneumothorax
• Position:
1. if its placed superiorly I,e towards apex – Pneumothorax
2. If tis placed inferiorly I,e towards cardiophrenic border
– Pleural drainage
• Correct position:
On entering the pleural cavity - gush of air is felt
• Misplacement - On connecting it with the bag – if bubble
is present then its in the lung parenchyma

Intercostal Drain
 SINGLE OR DUAL CHAMBER
Single chamber –nowadays used less frequently
• used for atrial or ventricular dysarrythmia
• Atrial – positioned in right atrial appendage
• Ventricular – Electrode placed against myocardium at
apex of right ventricle

Pacemaker
Dual pacemaker
• Attempts to synchronize atrial and ventricular
system
• One electrode @ Right atrium
•Other electrode @ apex of right ventricle
Sometimes a third lead is also noted
• Third –coronary sinus <Biventricular
pacing>

Pacemaker
Misplaced Leads
• Myocardial penetration – if electrode tip is within
3mm of epicardial fat
• Myocardial perforation – if tip is in epicardial fat
• Pneumothorax
• Pleural effusion

Complications
• Twiddlers
• Subclavian crush

Syndrome
• Position – Approximately 2cm away from left
subclavian artery and counter pulsates
USES:
• Unstable angina
• Myocardial infarction
• Cardiopulmonary bypass

IABP