Dr Aftab Qadir

Chest devices are encountered on daily basis by

radiologists Chest tubes, central lines, endotracheal tubes and NG tubes are common New devices are constantly being introduced

 It is important to recognizer the presence of a device

and to have an understanding of its function as well as complications associated with its use

 The proliferation of intensive care units and the

advances in the treatment of the very ill have greatly increased the numbers of examinations performed at the patients bedside. Obtaining a daily chest radiograph is standard practice in most intensive care units

 Chest radiograph shows that the tip of the endotracheal tube (black arrow) is slightly above the aortic arch and well above the carina, in good position. A right chest tube (white arrow), ECG leads (E), a gown snap (G), and oxygen tubing (O)

are also visible.

Medical devices
Extra thoracic devices
Pleural devices Tracheal

Esophageal
Vascular Cardiac Circulatory assist devices

Extra thoracic devices

Tubing, clamps, syringes
Ventilator support tubing ECG electrodes

Breast prostheses
other apparatus often lie on or under the patient and

are imaged with the chest during the radiographic examination

 Chest radiograph shows halo apparatus (with emergency

wrench close at hand) for cervical spine stabilization.

 ECG leads

Pleural Devices
chest tubes are commonly used for evacuating fluid or

air from the pleural space Antero superiorly for pneumothorax Poster inferiorly for fluid collection

 Frontal (a) and lateral (b) views show a thoracostomy(chest) tube in

good position for treatment of a pneumothorax but not for an effusion.

 Chest tubes are commonly used for evacuating uid or air from the pleural space. The normally positioned tube lies on the surface of the expanded lung, between the visceral and parietal pleura. The tube is usually placed anterosuperiorly to evacuate a pneumothorax and posteroinferiorly for uid collections.

 the normally positioned tube lies on the surface of the

expanded lung, between the visceral and parietal pleurae. Pigtail catheters may be used in place of standard thoracostomy tubes, and they are popular for empyema drainage and for installation of medication for treatment of an empyema

 Frontal view of the chest shows a pigtail catheter that had been

inserted under fluoroscopic guidance into a loculated right empyema for instillation of urokinase and fluid drainage.

 Assess the position of chest tube in both frontal and

lateral view and sometime may required CT scan

Complication Malposition
May enter the interlobar fissure Lung parenchyma Subcutaneous tissue Tube may be kinked

 58-year-old woman with extrapleural placement of chest

tube. Magnified anteroposterior chest radiograph shows misplaced chest tube (arrows) within right chest wall.

 65-year-old woman with extrapleural placement of chest tube. A, Magnified anteroposterior chest radiograph shows left chest tube (arrow) in apparently adequate position. CT scan was requested to further investigate because of ineffective drainage of left pleural effusion.

 Magnified axial CT image shows misplacement of chest

tube within chest wall (arrow).

 69-year-old man with intrafissural placement of chest tube. A, Magnified anteroposterior chest radiograph shows

horizontal course of right chest tube (arrows).

 49-year-old man with intraparenchymal placement of

chest tube. A, Scout image shows chest tube (arrow) projecting over right mid lung field.

 Magnified CT image shows chest tube (thick arrow)

coursing through right upper lobe. There is associated small pneumothorax (asterisk) and subcutaneous emphysema (thin arrow).

 48-year-old man with chest tube kinking. Magnified

posteroanterior chest radiograph performed after chest tube placement shows kinking of chest tube (arrow) precluding adequate pleural drainage.

 37-year-old man with mediastinal placement of chest tube. A, Anteroposterior chest radiograph shows left chest tube (arrows)

in inappropriate position, directed medially and projecting across mediastinum. There is persistent left pleural effusion.

 37-year-old man with mediastinal placement of chest tube.

B, CT image at level of pulmonary artery trunk confirms

that tip of chest tube (arrow) is in anterior mediastinum.

 30-year-old male victim of motor vehicle trauma with abdominal placement of chest tube. A, Anteroposterior chest radiograph shows horizontally oriented chest tube (arrow) in left lower hemithorax. There are several left rib fractures, opacification of left hemithorax, and subcutaneous emphysema.

 30-year-old male victim of motor vehicle trauma with abdominal placement of chest tube. B, CT image shows traumatic left diaphragmatic rupture with migration of abdominal content to left hemithorax. Chest tube (black arrow) is seen within mesenteric fat abutting small bowel loops. Note splenic rupture (white arrow) related to trauma.

Tracheal Device
Tracheal intubation is a life saving procedure but can

be life threatening if placed incorrectly The tip of the tube should be 5 cm above the carina

 The carina is just cauded to the aortic arch

 Chest radiograph shows that the tip of the endotracheal tube

(black arrow) is slightly above the aortic arch and well above the carina, in good position. A right chest tube (white arrow), ECG leads (E), a gown snap (G), and oxygen tubing (O) are also visible.

Complications
When advanced too far, the endotracheal tube usually

enters the right main bronchus, causing various combinations of hyperinflation and atelectasis of the two lungs, depending on the positions of the end and side holes. endotracheal tubes can also be placed in the esophagus the soft tissues of the neck.

 6-year-old woman with misplaced endotracheal tube. Magnified

anteroposterior chest radiograph shows that tip of endotracheal tube (thick arrow) is too high, at level of thoracic inlet. Endotracheal tube cuff (thin arrows) is overdistended. This abnormal position may cause vocal cord injury.

 60-year-old woman with inadvertent right main bronchial

intubation. Anteroposterior chest radiograph shows endotracheal tube tip (arrow) in right main bronchus, resulting in complete collapse of left lung and leftward shift of mediastinum.

 Frontal view shows a double-lumen endotracheal tube

with selective intubation of the left main bronchus (arrow).

 66-year-old man with left-sided double-lumen endotracheal tube. Magnified anteroposterior chest radiograph shows double-lumen endotracheal tube with its left tip (thick arrow) in left main bronchus. Right tip (thin arrow) is noted within trachea for ventilation of right lung. Double-lumen endotracheal tube allows control of distribution of ventilation to each lung. It is important to differentiate between double-lumen endotracheal tubes and inadvertent selective bronchial intubation with single-lumen catheters.

Esophageal devices
NG tubes
Esophageal balloons Esophageal stents

PH probe

NG tubes
Nasogastric tubes and feeding tubes are frequently

visualized passing through the mediastinum on their way to the stomach and intestines. Esophageal balloons and esophageal stents used to treat benign and malignant esophageal disease may manifest themselves at chest radiography.

Vascular devices
Routinely used for Monitoring hemodynamic function Hemodialysis Administrating fluids Medication Nutrition

 Venous devices are usually inserted, either

percutaneously or surgically, via the subclavian, internal jugular, or femoral veins. Arterial devices usually are placed through the femoral artery central lines typically have one to three lumens A central venous catheter is ideally positioned in the superior vena cava for the monitoring of pressure or infusion of medication and nutrition.

 Swan-Ganz is a multilumen catheter used for

measuring hemodynamic pressures and cardiac output.A better term to use is pulmonary artery catheter. Accurate measurement of pulmonary arterial wedge pressure

 chest radiograph shows a right subclavian single-lumen

central venous catheter and a left subcutaneous port catheter, which enters via the left subclavian vein. Both catheter tips are in the superior vena cava.

 The port is usually connected to a central venous

catheter or to an arterial catheter and can be used for instillation of fluids, medications, chemotherapeutic agents, parenteral nutritional solutions, and blood products. It can also be used for withdrawal of blood samples.

 Frontal view of the chest shows a left subclavian Groshong

catheter with its tip in the proximal most portion of the superior vena cava. (b) Close up view of the catheter tip.

 Groshong catheter has closed, rounded tip Near the tip in the side of the catheter is a three-position valve. The valve is designed to allow fluid to flow in and out through the valve, but it remains closed when it is not in use. This catheter does not require routine clamping or heparin solution to keep open. It

does require periodic flushing with 0.9% normal saline.

 A good rule of thumb is that the catheter tip

should be within the mediastinal shadow. Placement more distally increases the chance of pulmonary infarction or vessel rupture.

 Frontal chest radiograph shows a right jugular Swan-

Ganz catheter with its tip (arrow) in the right lower pulmonary artery.

 Frontal chest radiograph shows a Swan-Ganz catheter

(white arrow) in the left pulmonary artery via the inferior vena cava. Note also the bilateral chest tubes (black arrows) and ECG leads (E).

 Complications of catheter insertion vary with the

catheters used and the sites employed Pneumothorax is a common complication Vessel lacerations and perforations can produce hematomas, hemothorax, and infusion of fluid into the mediastinum, thorax, or other inappropriate space Nerve injury is usually a complication of improper puncture technique Looping of catheters may lead to knotting.

 Malpositioning of pulmonary artery catheter is

exceedingly common, found in approximately 25% of catheters placed. This may lead to false readings and an increased risk for complications. Complications of pulmonary artery catheter placement include pneumothorax, pulmonary infarction, cardiac arrhythmias, pulmonary artery perforation, endocarditis, and sepsis

Cardiac Devices
Cardiac pacemakers, valve prostheses, and artificial

hearts chest radiography is commonly employed in the assessment of patients with heart disease recognition of cardiac devices and the problems associated with them is important for all individuals involved in the care of these patients.

Heart valves
Mechanical Biologic Mechanical Heart valves most require life-long treatment

with anticoagulants. Biologic valves are less durable than mechanical valves, with some deterioration developing, frequently 510 years after placement, but they do not usually require anticoagulant treatment. It is not important and often impossible to know the specific name of a particular prosthetic heart valve, but it is important to recognize its presence The mitral and aortic valves are those most commonly replaced

 Mechanical heart valve. Lateral view of the chest shows a Hemex

tilting bileaflet mechanical mitral valve prosthesis. Median sternotomy wires and surgical clips are also evident.

 Mechanical heart valve. Lateral view of the chest shows a

Starr-Edwards caged ball mechanical mitral valve prosthesis.

 Biologic heart valve. Frontal view of the chest shows a

Hancock porcine mitral valve prosthesis (arrow). A singlelead pacemaker, ECG leads, and median sternotomy wires are also seen.

 Biologic heart valve. Frontal view of the chest shows a

Hancock porcine valve prosthesis in a Rastelli conduit going from the right ventricle to the pulmonary artery.

 Lateral view of the chest in an elderly patient shows a mitral annuloplasty

ring (black arrow) and a dual-lead cardiac pacemaker. Sternal wires, surgical clips, and ECG leads are also present. The sternal wires are used to close a sternal dehiscence. The patient has both horizontal sternal wires and vertical intercostal wires (white arrows).

 Lateral view of the chest in a child shows an occlusion

basket (umbrella) for treatment of an atrial septal defect.

Cardiac Pacemakers
common in older adults being treated for abnormal

cardiac rhythms caused by coronary artery disease Cardiac pacemakers improve cardiac function, reduce the severity of clinical symptoms, and reduce mortality and morbidity. A cardiac pacemaker is composed of two main elements: (a) a pulse generator and (b) lead wires with electrodes for contact with the endocardium or myocardium

 Pacemakers range from simple temporary epicardial

electrodes to very complex pacemakers with multiple atrial and ventricular leads

 Frontal (a) and lateral (b) views of the chest show a single electrode epicardial corkscrew subxiphoid pacemaker (arrowhead in a, black arrow in b). There are also coils (white arrow) occluding a previous right Blalock-Taussig shunt. In addition, ECG leads and sternal wires are evident.

 Frontal (a) and lateral (b) views show an atrioventricular

sequential pacemaker with one electrode in the right atrial appendage (RA) and the other at the right ventricular apex (RV). Also shown are ECG leads (E) and the battery-control pack (B) for the pacemaker.

 Biventricular devices (CRT)

 Because there can be such a wide variation in the

proper positioning of pacemaker leads, it is often difficult for the to know if a pacemaker is properly positioned. Pacemaker lead fracture is now rarely seen because of improvements in the flexibility of the metal alloys used in electrode construction.

Coronary Artery Surgery and Stents

Revascularization techniques include CABG surgery,

coronary artery angioplasty, and coronary artery stent placement. Median sternotomy is the usual surgical approach for CABG surgery, and sternal wires the common method of fixation of the two sternal segments At present, almost 90% of coronary interventions include stent placement Complications associated with coronary artery stents are stent thrombosis and restenosis.

 Lateral view of the chest shows sternal wires (arrowhead), vascular clips of

a saphenous vein bypass graft to the right coronary artery (curved arrow), and those of the left internal mammary graft to the left anterior descending coronary artery (straight arrow).

 PA chest radiograph demonstrates bilateral pulmonary artery stents in

a patient with bilateral pulmonary artery stenosis and aneurysmal right ventricular outflow tract following tetralogy repair.

Circulatory Assist Devices

The high mortality from cardiogenic shock continues

to spur efforts to develop mechanical support for the circulatory system Most mechanical support for patients with heart failure consists of devices that assist the heart without replacing it.

Mechanical cardiac assist devices can be divided into three groups: (a) temporary cardiac assist devices (b) permanent cardiac assist devices (c) heart replacement devices. short-term cardiac assist devices are the intraaotic balloon pump and newer left ventricular assist devices (VADs)

 Frontal (a) and lateral (b) views of the chest show a

Thoratec left VAD (arrow).

 Abdominal image shows a HeartMate VAD.

 Abdominal image shows a Novacor VAD.

 chest show a CardioWest total artificial heart. the four prosthetic

valves and the two coil, reinforced polyurethane tubes carrying pulses of compressed air to the two artificial ventricles.

 Cropped frontal view (a) and full lateral view (b) of the chest show a CardioWest total artificial heart. Note the four prosthetic valves and the two coil, reinforced polyurethane tubes carrying pulses of compressed air to the two artificial ventricles.

 More x rays for interactive session

 30-year-old man with malpositioned feeding tube. Anteroposterior

chest radiograph shows that feeding tube has entered right main bronchus, traversed right lower lobe bronchus (white arrows), and has its tip overlying right upper quadrant of abdomen (black arrow), raising concern for possible perforation of right hemidiaphragm. Note associated right pneumothorax (asterisk).

 Frontal view of the chest shows ping-pong ball plombage

in the right apex, as well as a cardiac pacemaker.

 Frontal view of the chest shows a right apical oleothorax

(wax plombage). Extensive pleural calcification includes the surface of the wax ball (arrows).

 Implanted bilateral brain stimulators

 A pacemaker is one of the common devices encountered on a chest x-ray. The usual location for a pacemaker is the anterior left upper chest wall (black arrow). Pacemakers may have either 1 or 2 leads. The wires connecting the pacemaker to the intracardiac electrodes must be intact (yellow arrow). The typical position of the cardiac electrodes is in the right ventricle (red arrow) for a single lead, and also in the right atrium for a dual-lead pacemaker. It is important to compare the electrode position to that in previous studies because an electrode may become dislodged.

 a) Frontal view of the chest shows an esophageal stent (black

arrows) that was placed to ameliorate the effects of an esophageal malignancy. There are also two chest tubes (), a peripherally inserted central catheter (white arrow), ECG leads (E), a gown snap (G), and a transjugular intrahepatic portosystemic shunt (T) in the liver.

 Frontal view of the chest shows a left jugular Swan-Ganz catheter (arrows), which passes through a persistent left superior vena cava into the coronary sinus, through the right atrium and right ventricle, and into the right pulmonary artery. Also seen are a subcutaneous port (P), an endotracheal tube (ET), an ECG lead (E), and a nasogastric tube (not labeled).

 The electrode is placed in the epidural space adjacent to the spinal cord. The wires are connected to a stimulating generator implanted subcutaneously. The electrode generates a weak electrical current that interrupts the transmission of pain at a spinal cord level.
Spinal cord stimulation (SCS) is recommended as a treatment option for adults with chronic pain of neuropathic origin. Most frequently: Brachial plexopathy, Post-laminectomy syndrome, Post Chemotherapy Neuropathy, Complex Regional Pain Syndrome (types I and II) and HIV polyneuropathy.

The implantable loop recorder (ILR) is a subcutaneous electrocardiographic monitoring device that stores ECG data automatically in response to specific rhythm anomalies or in response to patient activation. It is mainly used for diagnosis in patients with recurrent unexplained episodes of syncope or palpitations, but is also useful for long-term monitoring in patients with documented or suspected atrial fibrillation, for risk stratification in patients who have sustained a myocardial infarction and those who have certain genetic disorders.

 48-year-old woman with extravascular placement of double-lumen

dialysis catheter. A, Anteroposterior chest radiograph shows catheter (arrow) inserted via right subclavian vein with its tip projecting over right atrium.

 48-year-old woman with extravascular placement of double-lumen

dialysis catheter. B, Because there was clinical suspicion of malpositioning of catheter, IV contrast medium was injected and was seen to extravasate into pleural space (arrows).

 72-year-old woman with pulmonary infarction as complication of

pulmonary artery catheter placement. Magnified anteroposterior chest radiograph shows that tip of catheter (black arrow) is too distal (i.e., > 2 cm lateral to hilum). There is wedged-shaped opacity (white arrows) distal to catheter, consistent with pulmonary infarction.

 75-year-old woman with displacement of pacemaker

lead. A, Posteroanterior chest radiograph shows dual-lead pacemaker. Tip of right ventricular lead (arrow) is projected at edge cardiac silhouette.

 67-year-old man with pacemaker lead fracture. Magnified

anteroposterior chest radiograph shows fracture (arrow) in pacemaker lead near battery-control pack. Lead fractures most commonly occur at venous access site, near tip, or near batterycontrol pack.

 7-year-old man with normal positioning of intraaortic counterpulsation balloon pump. B, Magnified anteroposterior chest radiograph obtained during diastole shows inflated radiolucent balloon (thin arrows) as well as radiopaque tip (thick arrow) within upper descending thoracic aorta. Catheter is inflated during diastole to increase myocardial perfusion and is deflated during systole to decrease left ventricular afterload.

 misplaced central venous catheters. 6-year-old girl. Posteroanterior chest radiograph shows two misplaced

catheters. Right internal jugular central venous catheter (black arrow) has its tip in right atrium. Left subclavian central venous catheter (white arrow) has its tip in right subclavian vein.

Conclusion
Various devices are used to monitor and treat critically

ill patients. The radiographic evaluation of these devices is important because the potentially serious complications arising from their introduction and use are often not clinically apparent. Familiarity with normal and abnormal radiographic findings is critical for the detection of these complications.

Recommendation
The American College of Radiology recommends daily

chest radiography for critically ill patients who have acute cardiopulmonary disease or are receiving mechanical ventilation, as well as immediate imaging for all patients who have undergone placement of endotracheal tubes (ETTs), feeding tubes, vascular catheters, and chest tubes. These recommendations are made because the malpositioning of these devices and the serious complications that may ensue are often not clinically apparent. Radiographic evaluation of these devices is important, albeit challenging, because of the technical limitations of portable chest radiography and the inability of patients to cooperate.

Thank You