Checking Invasive Devices Using Chest X-Rays

COMPLICATIONS EXCEPTIONS
PURPOSE
- Pneumothorax - It may be acceptable to leave lines or devices in
This poster identifies acceptable positions on chest X-ray of commonly - New pleural effusion suggesting haemothorax other zones (i.e. in high risk patients and/or those
used devices in Wellington ICU. Please use this to check that any device - Widened mediastinum with difficult vascular access)
has been & remains correctly placed - Subcutaneous emphysema - Exceptions must be approved by medical staff &
- Pneumomediastinum documented in the clinical record
Endotracheal Tube
- Tip about 3-4cm above the carina with the head in neutral position Normal CXR Zones for correct placement

Tracheostomy Tube
- Tip lies between one-half & two-thirds of distance from stoma to carina

Central Venous Catheter

- Line & tip should be parallel to SVC not perpendicular to the wall
- Ideally in lower SVC before the RA = level of carina
- If left IJV or subclavian, tip in either RA or upper SVC as long as not
perpendicular & doesnt impinge on lateral wall of SVC

Dialysis Catheter
- Same as for central venous catheter.
- Line & tip parallel to SVC, not perpendicular to the wall. Tip may be in the RA

Pulmonary Artery Catheter Correct Positioning Incorrect Positioning

- No kinks/coils/ knots in the RA or RV
- No further than left or right main bronchus. Should not extend beyond the
proximal interlobar pulmonary artery (within 2cm of the hilum)

Chest Tube
- Side holes medial to the inner margin of the ribs (within the pleural cavity)
- Ideally apical for pneumothorax, basal for fluid drainage

Intra-Aortic Balloon Pump (IABP)

- Tip should be 2-3cm lower than the left subclavian artery between T2 & T4
- Ideally at the carina or, at the lowest, between carina & left main bronchus
- If tip > 5cm below the aortic arch, it is malpositioned

Nasogastric Tube
Colour Key: Endotracheal tube, central venous catheter, dialysis catheter, PA sheath, pulmonary artery
- Tip within the stomach, beyond the cardia, below the diaphragm, via midline
catheter, chest tube, IABP, nasogastric tube Adapted with permission from original CVICU poster by D Arroyo & A McKee