Tubes and lines in neonatal chest radiograph

Transcription

1 Tubes and lines in neonatal chest radiograph Poster No.: C-1008 Congress: ECR 2014 Type: Educational Exhibit Authors: R. TUMMA, N. AHMED, V. Prasad ; Hyderabad/IN, HYDERABAD, ANDHRA PRADESH/IN Keywords: Patterns of Care, Catheters, Plain radiographic studies, Thorax, Pediatric DOI: /ecr2014/C-1008 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30

2 Learning objectives In neonatal intensive care units various tubes and lines are placed as required for managing sick neonates. Knowledge about proper location of various tubes and lines on chest radiographs helps in early detection of malpositioning and prevention of complications related to them. Chest radiographs aid in recognizing various causes of respiratory distress and simultaneously provide information regarding tubes and lines. Background Chest radiographs are primary method of investigation to look for position of most of tubes and lines. It is less expensive but involves radiation Routinely chest radiograph is positioned to include regions from neonate chin to umbilicus. In presence of umbilical lines lower abdomen may be included Common tubes and lines found in radiographs are Endotracheal tube (ETT), Nasogastric tube (NGT), Umbilical vein catheter (UVC), Umbilical artery catheter (UAC), Central venous lines(cvl), Peripherally inserted central catheters (PICC), and chest tubes Findings and procedure details Endotracheal intubation is most common procedure in neonates. Tip of endotracheal tube (ETT) should be positioned in mid trachea at the level of D2-D3 vertebra, 1-2cm proximal to carina. Positioning may vary with head movement. High positioning proximal to C7vertebra results in inadequate ventilation of lungs. Low positioning of tip close to carina results in malpositioning into right bronchus. This may lead to hyper aeration of right lung and collapse of left lung. Page 2 of 30

3 Fig. 1: ETT normal in position with tip at D1-D2 vertebra level. Complete opacification of both lungs in Hyaline membrane disease. References: radiology, lotus childrens hospital - Hyderabad/IN Page 3 of 30

4 Fig. 2: ETT is positioned low into right main bronchus, there is complete collapse of left lung and right upper lobe References: radiology, lotus childrens hospital - Hyderabad/IN Page 4 of 30

5 Fig. 3: Congenital diaphragmatic hernia on left.ett positioned high above C6 vertebra level, it needs distal repositioning. NGT is correctly placed. References: radiology, lotus childrens hospital - Hyderabad/IN Umbilical vein catheter tip positioned at base of right atrium near level of diaphragm. If it is further advanced, it may pass through right atrium into left atrium through foramen ovale and may enter pulmonary vein. Malpositioning into liver can cause thrombosis of left portal vien. Page 5 of 30

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7 Fig. 4: Correct positioning of UVC seen along right paraspinal region with tip near diaphragm at D8 vertebra level, tip of NGT is seen left upper quadrant. ETT is positioned high above D1 vertebra, References: radiology, lotus childrens hospital - Hyderabad/IN Umbilical artery courses initially towards pelvis and then curves sharply upwards as it enters internal iliac artery. Tip of umbilical artery catheter should be located in aorta, high at level D7-D10 or low at level of L3-L4 vertebra. Positioning from the level of D12- L2 vertebra should be avoided because it may lead to obstruction to orifices of any major abdominal aorta branch arteries. Page 7 of 30

8 Fig. 7: UAC is seen coursing inferiorly to enter internal iliac artery and positioned in distal aorta. This is low placed UAC at L4 vertebra level. NGT seen in stomach region References: radiology, lotus childrens hospital - Hyderabad/IN Page 8 of 30

9 Fig. 5: Malpositioned UVC into liver, this may lead to portal vien thrombosis. Correct positioned ETT, NGT. Lungs show features of PIE-pulmonary interstitial emphysema References: radiology, lotus childrens hospital - Hyderabad/IN Page 9 of 30

10 Fig. 6: Air lucencies in portal radicles of liver secondary to malpositioning of UVC. ETT, NGT and UAC are also seen References: radiology, lotus childrens hospital - Hyderabad/IN Page 10 of 30

11 Fig. 8: Malposition of UVC in heart. It is probably located in left superior pulmonary vien after entering left atrium through foramen ovale. Pneumomediastenum seen bilaterally with elevated thymus on right side.. Normal position of ETT and NGT. References: radiology, lotus childrens hospital - Hyderabad/IN Central venous line should be positioned at level of SVC,occasionally its placement is associated with complications like pneumothorax or hemothorax Chest tubes may be dislocated sometimes into chest wall, proper positioning is needed for adequate drainage of effusions or pneumthorax Page 11 of 30

12 Fig. 9: Left tension pneumothorax in a neonate with bronchopulmonary dysplasia. Normal position of left chest tube with severe pneumothorax suggests blocked tube. ETT and NGT also seen Page 12 of 30

13 References: radiology, lotus childrens hospital - Hyderabad/IN Fig. 10: Mild right pneumothorax with displaced right chest tube seen into soft tissues References: radiology, lotus childrens hospital - Hyderabad/IN Nasogastric tube tip should be located in stomach at left upper quadrant. Incorrect positoning in esophagus should be avoided. location of NGT sometimes provides evidence of underlying clinical problems. In esophageal atresia recoiling of NGT occurs in upper esophageal pouch Page 13 of 30

14 Fig. 11: Complete collapse of right lung. NGT located in mid esophagus, needs distal repositioning into stomach. Normal postion of ETT, left PICC and right chest tube. Temperature probe in seen in upper abdomen. References: radiology, lotus childrens hospital - Hyderabad/IN Page 14 of 30

15 Fig. 12: Location of NGT guides towards clinical diagnosis.recoiling of NGT in Esophageal atresia. Presence of bowel gases suggests distal trachea-esophageal fistula References: radiology, lotus childrens hospital - Hyderabad/IN Page 15 of 30

16 Fig. 13: Location of NGT in left hemithorax suggests diagnosis of Congenital diaphragmatic hernia with volvulus of stomach. There are no gases in bowels. UVC malpositioned in liver Page 16 of 30

17 References: radiology, lotus childrens hospital - Hyderabad/IN Images for this section: Fig. 1: ETT normal in position with tip at D1-D2 vertebra level. Complete opacification of both lungs in Hyaline membrane disease. Page 17 of 30

18 Fig. 2: ETT is positioned low into right main bronchus, there is complete collapse of left lung and right upper lobe Page 18 of 30

19 Fig. 3: Congenital diaphragmatic hernia on left.ett positioned high above C6 vertebra level, it needs distal repositioning. NGT is correctly placed. Page 19 of 30

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21 Fig. 4: Correct positioning of UVC seen along right paraspinal region with tip near diaphragm at D8 vertebra level, tip of NGT is seen left upper quadrant. ETT is positioned high above D1 vertebra, Fig. 5: Malpositioned UVC into liver, this may lead to portal vien thrombosis. Correct positioned ETT, NGT. Lungs show features of PIE-pulmonary interstitial emphysema Page 21 of 30

22 Fig. 6: Air lucencies in portal radicles of liver secondary to malpositioning of UVC. ETT, NGT and UAC are also seen Page 22 of 30

23 Fig. 7: UAC is seen coursing inferiorly to enter internal iliac artery and positioned in distal aorta. This is low placed UAC at L4 vertebra level. NGT seen in stomach region Page 23 of 30

24 Fig. 8: Malposition of UVC in heart. It is probably located in left superior pulmonary vien after entering left atrium through foramen ovale. Pneumomediastenum seen bilaterally with elevated thymus on right side.. Normal position of ETT and NGT. Page 24 of 30

25 Fig. 9: Left tension pneumothorax in a neonate with bronchopulmonary dysplasia. Normal position of left chest tube with severe pneumothorax suggests blocked tube. ETT and NGT also seen Page 25 of 30

26 Fig. 10: Mild right pneumothorax with displaced right chest tube seen into soft tissues Page 26 of 30

27 Fig. 11: Complete collapse of right lung. NGT located in mid esophagus, needs distal repositioning into stomach. Normal postion of ETT, left PICC and right chest tube. Temperature probe in seen in upper abdomen. Page 27 of 30

28 Fig. 12: Location of NGT guides towards clinical diagnosis.recoiling of NGT in Esophageal atresia. Presence of bowel gases suggests distal trachea-esophageal fistula Page 28 of 30

29 Fig. 13: Location of NGT in left hemithorax suggests diagnosis of Congenital diaphragmatic hernia with volvulus of stomach. There are no gases in bowels. UVC malpositioned in liver Page 29 of 30

30 Conclusion Malpositioning of tubes and lines is associated with increased incidence of complications leading to increased duration of stay in ICU. Knowledge of proper positioning of various tubes, lines and their related complications helps in efficient manegement of neonates Personal information Dr Roja Tumma MD,EDiR, Consultant Radiologist, Department of Radiology, Lotus Childrens Hospital, Hyderabad, India. E mail - rojatumma@gmail.com Dr Nadeem Ahmed, MD,DNB, Consultant Radiologist, Department of Radiology, Lotus Childrens Hospital, Hyderabad, India. Dr VSV Prasad, MDPeds(AIIMS), ABPeds(USA), Chief Consultant Neonatologist and Pediatric Intensivist,Lotus Childrens Hospital, Hyderabad, India. References 1)The neonatal chest. Lobo L Eur J Radiol Nov;60(2): Epub 2006 Aug 22. 2)Confirmation of correct tracheal tube placement in newborn infants. Schmolzwe GM. Resuscitation 2013 Jun:84(6): )Detection and Correction of Endo-tracheal-Tube Position in Premature Neonates. M Lange, S Jonat, and W Nikischin Pediatric Pulmonology : Page 30 of 30