Chest X-Ray Tubes & Lines

Correct & incorrect position & its complications

• Complications:

cause surgical emphysema.

placement into lung parenchyma, interlobar fissure or subcutaneous tissue.

mediastinal or abdominal visceral trauma

re-expansion pulmonary oedema

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• Identification of the tip of the ETT and awareness of secondary signs of the endobronchial intubation is pivotal in making the diagnosis. 
• Carina (T5-T7) (it descends with increasing age).
• Ideally, ETT tip position should be just below the interclavicular line and approximately 5 cm +/- 2 cm above the carina (neutral position) /// 3 cm +/- 2 cm ( flexed position ) /// 7 cm +/-2 cm ( extended position). This allows for tube tip movement when the neck is moved ²: when the chin is depressed, the tube tip will move downwards and when the chin is lifted, the tube tip will move upwards.
• In children, the trachea is shorter, and the optimum position for the tip of the ETT is 1.5 cm above the carina.

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• In circumstances where the carina cannot be visualized, the ideal position of ET is the middle third of the trachea at T2 to T4 level(neck neutral position).
• The right main bronchus has a more vertical orientation than the left. Thus, if endobronchial intubation occurs too far, it is (more often than not) the right main bronchus that is intubated. 
• If the tube is inserted deep into the right main bronchus, the right upper lobe bronchus can be obstructed. This results in collapse of the left lung and the right upper lobe. (In some patients, an anomalous right upper lobe bronchus may be obstructed by a normally sited tube.)
• Secondary signs of endobronchial intubation on chest radiograph include collapse of lobe / segments obstructed.
• Complications
• selective intubation (contralateral lung collapse/hyperinflation of ipsilateral lung/pneumothorax)
• tooth aspiration
• Gastric hyperinflation due to esophageal intubation.

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CV lines

Central venous line/catheter (CVL/CVC)

Correct position

CV line tip in the superior vena cava or at the cavo-atrial junction

i.e. at level of 1^st anterior intercostal space above the carina

Complications

insertion into right atrium or ventricle (non-bacterial thrombotic endocarditis / dysrhythmias / myocardial perforation)

mediastinal haematoma secondary to vessel perforation

pneumothorax

haemothorax

central line-associated bloodstream infection

deep venous thrombosis

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NG tube

50 yrs old female patent , with CA of the tongue operated upon recently . While she is in the post operative care , she complains from fever , rigor & cough

A 55 yrs. old patient presented with traumatic fracture of the mandible . After admission, he complain suddenly from sever dyspnea.

60 yrs old unconscious female in RCU , now she has sudden onset of decreased SPO2.

15 yrs Patient had RTA , with sever dyspnea , how can you manage him?

46 yrs old patient in the RCU , complains from sever epigastric pain

45 yrs old male patient , with ca colon receiving chemotherapy , now presented with fever & DVT.

25 yrs. tall male patient ,presented with sudden onset of sever dyspnea , presented to the ER , after management , he still complain of dyspnea & soft tissue swelling.

60 yrs. old patient with congestive heart failure , presented with plural effusion. The patient after intervention complain from worsening of the dyspnea & tachypnea.

Multinodular goitre : �thyroid gland is increased in size with multiple different size nodules seen

Abnormal LN which have increased echogenicity with foci of calcification �with no hilum seen

Abnormal lymph node which is cystic and some hilum is seen deviated to one side ,no calcification seen

Thank you