ICU Tubes and Lines-2012

Tubes and LinesWhat, Where andWhoops

All photos retain the rights of their original owners

Format of Lecture

For each device

What they are and what they do

Where they belong

Whoops – malpositioning andcomplications

Tube or Line

Desired Position

ETT

Tip > 5cm from carina

Tracheostomy tube tip

½way between stoma and carina

Central venous catheter

Tip in SVC

PICC Line

Tip in SVC

Swann-Ganz Catheter

Tip in proximal R or L Pulmonary Artery

Pleural Drainage Tube

Anterosuperior for PTX;posteroinferior for effusion

Pacemaker

Tip at apex of R ventricle; other(s) in RAand/or coronary sinus

AICD

One lead in SVC; other in R ventricle

NG tube

Tip in stomach

Airways

Endotracheal TubesWhat They Are Used For

Indications for

Assisted ventilation

Isolate trachea to permit control of airway

Prevents gastric distension

Direct route for suctioning

Administration of medications via ETT

Endotracheal TubesWhere

Tip should be at least 5cm above carina

Between clavicles and carina

Carina usually at level of T4

Tip may change by 2cm with flexion/extension

Balloon should never distend trachealwalls; if >2.8 cm, suspect laceration

Endotracheal TubesWhoops

Most common malposition: tip in rightmainstem bronchus

Leads to atelectasis, or

Right-sided tension pneumothorax

Tube in larynx or pharynx

Damage vocal chords

Aspiration

Chronic: Sinusitus 2° nasal mucosa edema

Tip of endotracheal tube (yellow arrow) lies well above the carina (green arrow)

TracheostomyWhat

Indications for

Airway obstruction at or above level of larynx

Respiratory failure requiring long-termintubation (>21 days)

Obstruction during sleep apnea

Paralysis of muscles that affect swallowing orrespiration

TracheostomyWhere

Tip half-way between stoma and carina

About T3

Tip placement not affected by flexion/extension

Width of tube about 2/3 width of trachea

TracheostomyWhoops

Immediately after

Subcutaneous emphysema

Pneumomediastinum

Pneumothorax

Cuff should not be >1½ times diameter oflumen

Tracheal stenosis

TracheostomyTracheal Stenosis

Most common late-occurring complication oftracheostomy tube

May occur at stoma, level of cuff or at tip oftube

Most common at stoma

Fibrosis with destruction of cartilage

At cuff site, usually 2° to circumferential scar

Tip of tracheostomy tube (yellow arrow) lies about midwaybetween the stoma (blue arrow) and carina (green arrow)

Intravascular Lines

Central Venous CathetersWhat

Used in critically ill patients

For venous access

Measurement of central venous pressure

Intravascular blood volume

Central Venous CathetersWhere

Subclavian joins brachiocephalic veinbehind medial end of clavicle

Catheter should reach this point beforedescending

Catheter should descend lateral tospine and tip should be in the SVC

Central Venous CathetersWhoops

Most often malpositioned in RA orinternal jugular

Arrythmias in RA; inaccurate CVP readingselsewhere

Occasionally outside blood vessel

Look for sharp bends in catheter

Arterial placement suggested bypulsatile flow

Central Venous CathetersComplications

Air embolism

Pneumothorax (5%)

Hemothorax

Cardiac perforation

Sepsis

Venous perforation

Central Venous CathetersTwo or more attempts

Should initial placement fail, geta chest x-ray before trying otherside to avoid bilateralpneumothoraces

Tip of central venous catheter (yellow arrow) curves gentlydownward into superior vena cava

PICC LinesPercutaneous Intravascular Central Catheters

What

Used for long-term access

Because of small size

Inserted through antecubital vein

Where

Tip should lie within SVC

Whoops

Tips may become malplaced over time

Pulmonary Artery CathetersWhat

Swann-Ganz catheters

Aid in differentiating cardiac fromnon-cardiac pulmonary edema

Pulmonary Artery CathetersWhere

Tip should lie within right or leftpulmonary artery

 2cm from hila

Balloon inflated only whenmeasurements are made

Pulmonary Artery CathetersWhoops

Most common significant complicationis pulmonary infarction

From occlusion by catheter

From embolization off of catheter

Uncommon

Cardiac arrhythmia

Pulmonary artery perforation

Intracardiac knotting

Tip of transabdominal Swan-Ganz catheter (yellow arrow)lies in right pulmonary artery

Pleural Drainage TubesWhat

Used to remove either air in or fluid inthe pleural space

Pleural Drainage TubesWhere

Ideal position is anterosuperior for PTXand posteroinferior for effusion

Usually work well no matter wherepositioned

None of the side holes should lie outsideof the thoracic wall

Pleural Drainage TubesWhoops

Bleeding 2° laceration of intercostal artery

Laceration of liver or spleen on insertion

Insertion into the lung may lead to

Lung laceration

BP fistula

Rapid expansion of lung may lead topulmonary edema

Tip of thoracostomy (pleural) drainage tube (yellow arrow) lies in the apexof the right hemithorax. The side hole (blue arrow) is well within the chest.

Cardiac Devices

Used for cardiac conductionabnormalities

Catheter should have gentle curves

PacemakersWhat

Tip positioned at apex of right ventricle

Tip may have slight bend as it abuts wall ofright ventricle

Not a sharp bend

Some pacers may also have lead(s) inright atrium and/or coronary sinus

PacemakersWhere

Fracture of leads at pacer, tip or site ofvenous access

Leads can perforate heart ➙ cardiactamponade

Look for sharp bends in leads 2° perforation ofblood vessel

Leads may be ectopically placed, e.g.hepatic vein

Pacemaker battery may migrate subcu

PacemakersWhoops

Two-lead pacemaker (red circle) shows one lead in right atrium (greenarrow) and the second in the right ventricle (red arrow).

Implantable DefibrillatorsWhat

Automatic implantable cardiac defibrillators(AICD)

AICDs used to prevent sudden death fromventricular defibrillation

Implantable DefibrillatorsWhere

Usually can be recognized by short,wider electrode on one or both leads

One electrode usually in SVC orbrachiocephalic vein

Other is in right ventricle

Implantable DefibrillatorsWhoops

Leads may fracture or migrate

Two-lead automatic implantable cardiac defibrillator. You can differentiatethis from a pacemaker by the ‘fuzzy leads” (red arrows) on an AICD.

Intraaortic Balloon PumpWhat

Intraaortic counterpulsation balloon pump(IACB or IABP)

Used to improve cardiac output followingsurgery or in patients with cardiogenicshock

Inflated in diastole and deflated in systole

Increases O² to myocardium and decreases LVworkload

Intraaortic Balloon PumpWhere

Tip identified by small, rectangularmetallic marker

 Should lie distal to left subclavian

Metallic marker should point slightly to right inregion of arch

www.CTSnet.org

Tip of intra-aortic balloon pump (red arrow) lies just below top of theaortic arch (green arrow) and heads slightly to the right.

Intraaortic Balloon PumpWhoops

If catheter is too proximal, balloon mayocclude great vessels leads to stroke

If balloon is too distal, leads to decreasedeffectiveness

Aortic dissection may occur

Tip of intra-aortic balloon pump (yellow arrow) lies about2 cm from top of aortic arch (blue arrow)

GI Tubes and Lines

Indications for a NGT

Feeding

Gastric sampling and decompression

Administering medication

Nasogastric TubesWhat

Tip should be in stomach

At least 10 cm of tube should extend intostomach

Many have side holes that extend up to 10cmon tube

Nasogastric TubesWhere

Most commonly malpositioned of all tubesand lines

May enter trachea and bronchi or curl inesophagus

Perforation usually involves cervicalesophagus

Can also perforate stomach

Indwelling tube leads to G-E reflux

May cause esophagitis and stricture

Nasogastric TubesWhoops

Tip of nasogastric tube (yellow arrow) should lieat least 10cm into the EG junction

Feeding TubesWhat, Where and Whoops

What

Used for nutrition

Where

Tip of feeding tube should be in duodenum

Most are in the stomach

Whoops

Perforation by guide wire

Too proximal ➙ aspiration

The tip of the feeding tube (green arrow) lies in theregion of the duodenal bulb. Ideally the tip should be in the duodenum.

Tubes and LinesThat HaveLost Their Way

See if you can tell what’s wrongwith the placement of these tubes and lines

Feeding tube (green arrow) enters right lower lobe bronchus, loops onitself then crosses over to LLL bronchus (red arrow).

Tip of central venous catheter coils back on itself in rightbrachiocephalic vein (red arrow).

Tip of endotracheal tube is in right mainstem bronchus (redarrow) so right upper lobe and entire left lung are atelectaticbecause they are not being aerated.

Swann-Ganz catheter enters left pulmonary artery (red arrow),then loops back on itself with tip in region of right ventricularoutflow tract (green arrow)

Tip of Swan-Ganz catheter lies too peripherally in rightdescending pulmonary artery (red arrow)

Tip of pleural drainage catheter (thoracotomy drainage tube) enterson right and crosses mid-line to the opposite side (red arrow).

Congratulations, You Graduate

I knowmy tubesand lines

To review from the beginning, click here