Tubes and Drains




Key Point




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    Chest radiography is an invaluable tool for determining the location and potential complications of various tubes and drains.





Endotracheal Tube


Because correct positioning of the endotracheal (ET) tube is of such major clinical importance, there is a radiopaque stripe along the length of the tube to facilitate visualization. The other aspect of the ET tube that is easily visualized is the air cuff, which confers a rounded lucency several centimeters proximal to the tip. The ideal position of the tip of the ET tube is 5 cm proximal to the carina, so that the balloon cuff is safely beyond the vocal chords and the tip is safely away from the carina. The position of the tip of the ET tube is dependent on the position of the chin/neck and varies by about 2 cm, depending on the amount of flexion/extension of the neck, and by up to 1 cm, depending on the rotation of the neck ( Table 25-1 ).



TABLE 25-1

Neck and ET-Tube Tip Positions




















Neck Position Inferior border of mandible Distance from carina (cm)
Extension At or below C4 vertebra 7 ± 2
Neutral At C5 or C6 vertebra 5 ± 2
Flexion At or below T1 vertebra 3 ± 2


Therefore, the tip of the ET tube should be at least 2 cm proximal to the carina. Overinsertion of the ET tube may selectively intubate the right mainstem bronchus with the risk of overinflating the right lung and hypoventilating the left lung.


Complications of Endotracheal Intubation


Complications of intubation ( Figs. 25-1 to 25-10 ) and ventilation that are apparent on a chest radiograph are often potentially life-threatening and should be excluded on every radiograph, both immediately following intubation and with each subsequent radiograph. These possibilities are listed in the following sections.




Figure 25-1


The left image reveals left mainstem intubation, with complete collapse of the left lung. The right image demonstrates reinflation of the left lung following withdrawal of the endotracheal tube (tip) into the trachea.



Figure 25-2


The left anteroposterior chest radiograph is post–aortic valve replacement, showing endotracheal intubation via tracheostomy for chronic respiratory failure. The left lung has collapsed due to bronchial plugging. The right anteroposterior chest radiograph is following chest tube insertion and reexpansion of the left lung.



Figure 25-3


The tip of the endotracheal tube is low, and there has been complete collapse of the left lung. The volume of the right lung is small due to the intubation of the bronchus intermedius to the exclusion of the right upper lobe.



Figure 25-4


The tip of the endotracheal tube is low, and there is partial collapse of the left lung as well as leftward displacement of the heart and mediastinum.



Figure 25-5


The tip of the endotracheal tube is low, and there is nearly complete collapse of the left lung with shift of the heart and great vessels into the left hemithorax.



Figure 25-6


The endotracheal tube is low and at the level of the carina or just into the right mainstem bronchus. The patient is severely rotated, but the positions of the pulmonary artery line and the left internal jugular central venous lines appear to be correct.



Figure 25-7


In the left image, the tip of the endotracheal tube is low and into the right mainstem bronchus, resulting in complete atelectasis of the left lung. In the right image, the left lung is again ventilated and has reexpanded after withdrawal of the endotracheal tube.



Figure 25-8


The endotracheal tube is within the right mainstem bronchus.



Figure 25-9


The endotracheal tube tip is in the left mainstem bronchus, the right lung has collapsed, and the nasogastric tube is too high.



Figure 25-10


Tracheostomy tube, sternotomy wires, implantable cardioverter defibrillator and atrial pacemaker leads, mechanical mitral and aortic valve prostheses, right subclavian central venous line, chest tube, and a nasogastric tube.


Right Mainstem Bronchus Intubation




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    Location of the tip of the ET tube


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    Possible overinflation of the right lung


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    Possible volume loss of the left lung



Bronchus Intermedius Intubation


(This involves deep intubation of the right mainstem bronchus with the tip beyond the take-off of the upper lobe bronchi.)



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    Location of the tip of the ET tube


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    Possible volume loss of the right upper lobe


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    Possible overinflation of the right lower and middle lobes


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    Possible volume loss of the left lung



Barotrauma




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    Pneumothorax


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    Pneumomediastinum


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    Pneumopericardium


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    Subcutaneous emphysema



Hypopharyngeal Tear (Traumatic Intubation)




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    Subcutaneous emphysema of the neck


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    Possible pneumomediastinum


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    Pneumothorax



Esophageal Intubation




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    Distension of esophagus and stomach with air


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    Location of ET tube to the side of the trachea



Cuff Overinflation




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    The walls of the trachea should not be distended outward by the cuff. Distension is overinflation.


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    Width of the ET tube two thirds of the width of the trachea


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Apr 10, 2019 | Posted by in General Surgery | Comments Off on Tubes and Drains

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