Faces of Hardware in the Chest

ET Tube

  • Normal – 3- 5cms above the carina (head neutral position)
    • around T5-T7
    • Normal Position of the the ET tube in relation to the Carina
      Normal Position of the the ET tube in relation to the Carina

The position of the ETT is dependent on the position of the head. If the neck is flexed, the tip of the tube descends in the trachea.

If included in the film, the mandible can be used for assessment of whether the neck is in a neutral position. In a neutral position, the lower border of the mandible should be projected over C5/C6. When flexed, the mandible projects around T1 and in extension, over C3/C4.

The carina is usually projected over T5-T7 (it descends with increasing age).

The desired position of an ETT is 5 ± 2 cm above the carina, but markedly varies with neck position and rotation and hence, the inclusion of the mandible is a helpful indicator:

  • flexed: 3 cm (± 2 cm) above carina
  • neutral: 5 cm (± 2 cm) above carina
  • extended: 7 cm (± 2 cm) above carina

Venous Lines

Chest
Venous Line
PICC line
Courtesy Radiopedia

Tunneled Dialysis Catheter

Tunneled dialysis catheter
Courtey Radiopedia
Tunneled dialysis catheter
Courtey Radiopedia

Swan Ganz Line

No further than the right main stem bronchus.  Should not extend beyond the proximal interlobar artery (within 2cms of the hilum)

Swan Ganz line

NG Tubes

Side hole of the NG tube must be 2-3 cms below the GE junction
Dobhoff tube

 

NG Tube needs Advancement

Good Positioning of the ET Tube but NG tube needs to be advanced
CXR
Ashley Davidoff MD
thecommonvein.net
Good Positioning of the ET Tube but NG tube needs to be advanced
CXR
Ashley Davidoff MD
thecommonvein.net

Chest Tubes

Apical for pneumothorax and basilar for pleural effusion

Chest Tube in Good Position with Side holes inside the pleural cavity and position reflection an intra-fissural location
Chest tube in good position for drainage of a right pleural effusion. Modwerate sized left pleural effusion
Ashley Davidoff MD
thecommonvein.net

Pacemakers

Dual Lead Pacemaker

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6411
Posteroanterior and lateral chest radiographs of a pacemaker with normally located leads in the right atrium (white arrow) and right ventricle (black arrowhead), respectively.
Courtesy Stephanie C Torres-Ayala, Guido Santacana-Laffitte, and José Maldonado

Biventricular Leads and Defibrillators

Three leads can be seen in this example of a cardiac resynchronization device: a right atrial lead (solid white arrow), a right ventricular lead (dashed black arrow), and a coronary sinus lead teal arrow). The coronary sinus lead wraps around the outside of the left ventricle, enabling pacing of the left ventricle. Note that the right ventricular lead in this case has 2 thickened aspects that represent conduction coils and that the generator is larger than typical pacemaker generators, demonstrating that this device is both a pacemaker and a cardioverter-defibrillator, capable of delivering electrical shocks for dangerously fast abnormal ventricular rhythms (see separate knol on Implantable Cardioverter-Defibrillators (ICDs).
Gregory Marcus, MD, MAS, FACC
CXR A-P
Dual lead pacemaker with defibrillator, with one electrode in the right atrial appendage and the second in the right ventricle. The thickened portions on the leads reflect the defibrillator component.
Ashley Davidoff MD
thecommonvein.net
CXR Lateral
Dual lead pacemaker with defibrillator, with one electrode in the right atrial appendage and the second in the right ventricle. The thickened portions on the leads reflect the defibrillator component.
Ashley Davidoff MD
thecommonvein.net
CT scan showing dual lead pacemaker with defibrillator, with one electrode in the right atrial appendage and the second heading to the right ventricle.
Ashley Davidoff MD
thecommonvein.net
CT scan showing dual lead pacemaker with defibrillator, with one electrode in the right ventricular septum. The thickened portions on the leads reflect the defibrillator component.
Ashley Davidoff MD
thecommonvein.net

External Defibrillator

CXR – Post Partum Cardiomyopathy
35-year-old female with a 8 year history of post- partum cardiomyopathy presents with of chest pain. Frontal CXR shows global cardiomegaly, blunting of the right costophrenic angle with a suggestion of a subsegmental infiltrate in the right costophrenic angle, and a region of linear atelectasis in the right mid lung field. A small loculated right effusion is present. An external defibrillator is noted. No definite CHF
Ashley Davidoff MD TheCommonVein.net 258Lu 136164
CT – Post Partum Cardiomyopathy with Pulmonary Emboli to Right Lower Lobe
35-year-old female with an 8-year history of post- partum cardiomyopathy presents with a history of chest pain. CT of chest with contrast in an axial projection, at the level of the heart, shows an enlarged left ventricle. The right lower lobe segmental arteries show filling defects and absence of contrast compared to the left lower lobe arteries. An external defibrillator is present.
Ashley Davidoff MD TheCommonVein.net 258Lu 136165

Leadless Pacemaker

Leadless Pacemaker
Case courtesy of Hilary Bowman, Radiopaedia.org, rID: 85742
Leadless Pacemaker
Case courtesy of Hilary Bowman, Radiopaedia.org, rID: 85742
Leadless Pacemaker
Case courtesy of Hilary Bowman, Radiopaedia.org, rID: 85742
2 Leadless Pacemakers
Frontal Chest X-ray in a 75-year-old male shows 2 leadless pacemakers, one in the right atrial appendage and the second in the apex of the right ventricle. Associated findings include bilateral moderate sized effusions
Ashley Davidoff MD TheCommonVein.net 136545

Loop recorder

CXR Pulmonary Hemorrhage Ground Glass Changes and Consolidation
75-year-old man on blood thinners s/p aortic valve replacement s/p trauma, presents with hemoptysis. He was afebrile and without an elevated white count
 A loop recorder is noted overlying the left upper chest.
Ashley Davidoff MD TheCommonVein.net 165Lu 135849

Atrial Appendage Hardware

Watchman Device

Watchman Device
Xray – Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 52875

AtriClip

AtriClip
​Resembles a hair pin
Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 52156

CT – ASD s/p Repair Pulmonary Hypertension CardioMEM Device

CT – ASD s/p Repair Pulmonary Hypertension CardioMEM Device
60-year-old female presents with dyspnea. CT in the axial plane at the level of the heart shows an enlarged right atrium and right ventricle shift of the atrial septum from right to left, and flattening of the interventricular septum indicating significantly elevated right sided pressures.
A high density foreign body is noted in the descending left pulmonary artery and represents CardioMEM that monitors pulmonary artery pressure and enables caregivers to proactively manage heart failure
Ashley Davidoff MD TheCommonVein.net 125H 136212

CT – ASD s/p Repair Pulmonary Hypertension

CardioMEM Device

CT – ASD s/p Repair Pulmonary Hypertension CardioMEM Device
60-year-old female presents with dyspnea. CT in the axial plane at the level of the heart shows an enlarged right atrium and right ventricle shift of the atrial septum from right to left, and flattening of the interventricular septum indicating significantly elevated right sided pressures.
A high density foreign body is noted in the descending left pulmonary artery and represents CardioMEM device (b, red arrowhead) that monitors pulmonary artery pressure and enables caregivers to proactively manage heart failure
Ashley Davidoff MD TheCommonVein.net 125H 136212
CT – ASD s/p Repair Pulmonary Hypertension CardioMEM Device in Place
60-year-old female presents with a dyspnea. CT in the coronal plane at the level of the spine metallic component of the cardioMEM device is noted in the medial segmental left pulmonary artery. The pruning of the pulmonary arteries are again noted
Ashley Davidoff MD TheCommonVein.net 125H 1362217
CT – ASD s/p Repair Pulmonary Hypertension CardioMEM Device in Place
60-year-old female presents with a dyspnea. CT in the coronal plane at the level of the spine The outline of the cardioMEM device (b, red ring) in the medial segmental left pulmonary artery with its distal nitinol stabilizing wire abutting a branch point of the artery . A calcified atherosclerotic plaque lies in the wall of the origin of the LPA from the main pulmonary artery (b red arrow). Image c shows the ex vivo appearance of the device. The pruning of the pulmonary arteries are again noted
Ashley Davidoff MD TheCommonVein.net 125H 1362216
58F with  with history of HTN,  presented with syncopal episode  associated with chest pain proceeded to cardiogenic shock   EKG was consistent with anterolateral STEMI At cath – diffuse RCA and LCx disease with completely occluded proximal LAD. Failed  balloon dilation of  LAD flow. Echo obtained akinesis of the anterior wall, apex and septum with EF was 25%.
Emergent CABG ECMO and Impella Mediastinal Exploration  Endotracheal tube tip projects over the mid intrathoracic trachea, unchanged
* Right IJ venous catheter/introducer sheath, tip projects over the brachiocephalic/SVC junction
* Right IJ Swan Ganz catheter, tip projects over the right main pulmonary artery
* Right and left basilar chest tubes
* 2 mediastinal chest tubes
* Enteric tube tip has been advanced and now lies within the fundus of the stomach in appropriate position.
* Right upper extremity midline, tip projects over the axilla
* Median sternotomy wires are intact (7), similar appearance of mediastinal surgical clips
* Cardiac Impella device and inferior approach ECMO catheter with tip projecting over the right atrium, similar in position compared to recent priors
* Epicardial pacing wires
* Superficial surgical clips project over the right lower neck
,Epicardial temporary pacing wire
Ashley Davidoff MD TheCommonVein.net
b11528

 

Chart with Appropriate Positioning of Lines and Tubes on the CXR
Courtesy Wellington ICU

Links and References

Jain S A pictorial essay: Radiology of lines and tubes in the intensive care unit  2011 Jul-Sep; 21(3): 182–190.