IDEAL Position of Endotracheal Tubes, UACs and UVCs on X-rays!!
Summary
TLDRIn this educational video, Dr. Tala, a seasoned neonatologist, discusses the optimal positioning of neonatal lines and tubes using X-rays, a standard practice set to evolve with bedside ultrasounds and AI assistance. She provides detailed guidelines for endotracheal tube placement, emphasizing the mid-tracheal position, and addresses complications such as misplaced tubes in the esophagus or main-stem bronchi. The video also covers umbilical venous and arterial catheters, their ideal positions, and the risks of improper placement, offering a comprehensive guide for medical professionals.
Takeaways
- 📸 X-rays are the standard of care for checking neonatal line and tube placements, but advancements in medicine may soon replace them with bedside ultrasounds or AI assistance.
- 🌟 Dr. Tala, a neonatologist with over 15 years of experience, emphasizes the importance of using X-rays to determine the correct positions of neonatal lines and tubes.
- 🔍 The ideal position for an endotracheal tube (ETT) is the mid-tracheal position, which is halfway down the trachea between the bottom of the clavicles and the carina.
- 📐 The Neonatal Resuscitation Program (NRP) recommends aligning the base of the ETT with T1 or T2, rather than using the clavicles as a landmark.
- 👶 The traditional equation for ETT insertion depth is weight in kilos plus 6 centimeters, but adjustments may be needed for very small babies.
- 🗂 Always verify ETT placement with an X-ray, as breath sounds and CO2 monitoring can sometimes be misleading.
- 🩺 Complications from incorrect ETT placement can include main-stem bronchus intubation, leading to lung collapse and atelectasis.
- 🩸 Umbilical venous catheters (UVC) should ideally end up in the inferior vena cava just outside the right atrium, and a lateral X-ray can help confirm correct placement.
- ⚠️ Incorrect UVC placement can lead to serious complications such as pericardial effusion, necessitating immediate correction.
- 🌐 Umbilical arterial catheters (UAC) should be threaded to T6-T9, with higher positions being associated with fewer complications than lower positions.
- 🚫 If a UAC is misplaced, such as going down the leg or into the wrong vessel, it must be removed to prevent severe complications like clotting.
Q & A
What is the standard of care for checking proper line and tube placement in neonatology?
-The standard of care for checking proper line and tube placement in neonatology has traditionally been the use of X-rays.
What is the ideal position for an endotracheal tube (ETT) on an X-ray?
-The ideal position for an ETT is considered to be the mid-tracheal position, which is halfway down the trachea between the bottom of the clavicles and the carina.
What does the carina represent in the context of ETT placement?
-The carina represents the point where the trachea splits off into two bronchi, and it is used as a reference point for the ideal placement of an ETT.
Why might the Neonatal Resuscitation Program (NRP) recommend against using clavicles as a landmark for ETT placement?
-The NRP recommends against using clavicles as a landmark for ETT placement because their position can vary depending on the baby's position and how the X-ray is taken.
What is the recommended equation for determining the depth of ETT insertion based on a baby's weight?
-The commonly used equation for determining the depth of ETT insertion is the baby's weight in kilos plus 6 centimeters.
What complication can occur if an ETT is mistakenly placed in the esophagus instead of the trachea?
-If an ETT is mistakenly placed in the esophagus, it can lead to inadequate ventilation, low lung volumes, and the appearance of a separate air column on the X-ray.
What is the ideal endpoint for an umbilical venous catheter (UVC)?
-The ideal endpoint for a UVC is just outside the right atrium in the inferior vena cava, typically at the level of T8-T9.
What is a potential risk of having a UVC placed too deeply within the heart?
-A UVC placed too deeply within the heart can cause fluids or TPN to seep into the pericardial space, potentially leading to life-threatening pericardial effusion.
What is the typical path of an umbilical arterial catheter (UAC) and where should it ideally reach?
-The UAC typically follows the umbilical artery, joins the internal iliac artery, and then the aorta, ideally reaching the level of T6-T9.
What can happen if a UAC is inserted too high?
-If a UAC is inserted too high, it may enter one of the great vessels off the aorta, increasing the risk of spasming, thrombosis, and difficulty in drawing blood or getting accurate blood pressure readings.
Why are lateral X-rays useful for verifying the placement of UVCs?
-Lateral X-rays are useful for verifying the placement of UVCs because they can show the catheter's position relative to the liver and heart, helping to identify if it takes a wrong turn or is placed incorrectly.
Outlines
😇 Neonatal Line and Tube Placement in X-rays
Dr. Tala introduces the topic of neonatal line and tube placements, emphasizing the standard use of X-rays and the potential future use of ultrasounds and artificial intelligence. The ideal position for endotracheal tubes (ETT) is discussed, with the mid-tracheal position being the target, between the clavicles and the carina. The Neonatal Resuscitation Program's recommendation against using clavicles as a landmark and the suggestion to align the ETT base with T1 or T2 vertebrae are highlighted. The common formula for ETT insertion depth, weight in kilos plus 6 centimeters, is critiqued for its inadequacy in smaller babies, as illustrated by the 8th edition of NRP charts. The importance of checking ETT placement with X-rays is underscored, with examples of misplacements such as the tube ending in the esophagus instead of the trachea.
😟 Complications of Improper ETT and UVC Placement
The script discusses complications arising from improper placement of endotracheal tubes (ETT), such as the tube ending up in the right mainstem bronchus, leading to lung collapse. The likelihood of the ETT going down the right bronchus due to its angle is mentioned, along with the consequences of incorrect placement, including hyperinflation and the risk of unplanned extubation. The discussion then shifts to umbilical venous catheters (UVC), detailing the correct path from the umbilical vein through the ductus venosus to the inferior vena cava, just outside the right atrium. Misplacements of UVC, such as entering the portal veins or ending up in the liver, are described, along with the serious risks they pose, including pericardial effusion and the need for removal or adjustment.
😕 Challenges with Umbilical Arterial Catheters (UAC)
This section delves into the complexities of umbilical arterial catheters (UAC), which require threading through the umbilical artery, the internal iliac artery, and up the aorta to the desired position between T6 and T9. Historical practices of keeping UACs at a 'low position' have been replaced with a preference for higher placements due to fewer complications. The script describes various misplacements, such as the catheter curling in the aorta, ending up too low near the kidney arteries, or going down the leg instead of up the aorta, all of which necessitate correction or removal. The importance of lateral X-rays for verifying correct UAC and UVC placement is also highlighted.
😬 Test X-rays for Self-Assessment of Line and Tube Placement
The script presents three test X-rays for self-assessment, starting with an ETT that appears to be in the esophagus rather than the trachea, indicated by its tip's position beneath the carina and a distended stomach. The second X-ray shows a UVC that is incorrectly identified, with the catheter extending too far into the superior vena cava and possibly up one of the jugular veins. The third X-ray reveals a UAC that is not deep enough, suggesting a mistake in the insertion of both the UVC and UAC, with the UAC likely inserted further than necessary. The importance of careful placement and verification of these lines and tubes is reiterated.
😨 Final X-ray Analysis and Catheter Misplacement
The final paragraph presents an X-ray with a misplaced gavage tube instead of an ETT, which needs to be adjusted into the stomach. Additionally, both the UAC and UVC are identified as being inserted too far, with the UAC reaching the great vessels off the aorta and the UVC positioned well within the cardiac silhouette. The need to correct these placements to prevent complications such as spasming, thrombosis, and inaccurate blood pressure readings is emphasized.
Mindmap
Keywords
💡Neonatal lines and tubes
💡X-rays
💡Endotracheal tubes (ETT)
💡Mid-tracheal position
💡Carina
💡Umbilical venous catheters (UVC)
💡Inferior vena cava
💡Umbilical arterial catheters (UAC)
💡Aorta
💡Atelectasis
💡Pericardial effusion
Highlights
Introduction to the topic of ideal neonatal line and tube positions on X-rays by Dr. Tala, a neonatologist with over 15 years of experience.
Discussion on the standard of care using X-rays for line and tube placement, with the anticipation of future advancements in bedside ultrasounds and artificial intelligence.
Explanation of the ideal position for endotracheal tubes, aiming for the mid-tracheal position between the clavicles and the carina.
Clarification on the Neonatal Resuscitation Program's recommendation against using clavicles as landmarks for ETT placement, suggesting alignment with T1 or T2 instead.
The traditional equation for determining ETT insertion depth: weight in kilos plus 6 centimeters, with adjustments for younger babies.
Case study of a 2-month-old ex-30-week infant with improper ETT placement leading to atelectasis and mediastinal shift.
Misplacement of ETT causing unilateral lung collapse due to the tube projecting into the right mainstem bronchus.
Importance of checking ETT placement with X-rays despite following guidelines, as improper positioning can still occur.
Description of umbilical venous catheter (UVC) path and the goal of ending up in the inferior vena cava just outside the right atrium.
Mnemonic for remembering the ideal UVC endpoint and the potential complications of improper placement, such as pericardial effusion.
Case of a misplaced UVC causing life-threatening pericardial effusion due to fluid seepage into the pericardial space.
Discussion on umbilical arterial catheters (UAC) path, aiming for a high position at T6-T9, and the shift from 'low position' practices.
Common issues with UAC placement, such as catheters going down the leg or curling in the aorta, and the need for repositioning or removal.
The use of lateral X-rays to assist in identifying correct placement of UVCs and UACs, with examples of proper and improper positions.
Test X-rays for self-assessment, including examples of ETT in the esophagus, UVC too deep in the superior vena cava, and UAC not deep enough.
Final thoughts on the importance of accurate line and tube placement in neonatal care and the value of learning from mistakes in published case studies.
Transcripts
Today we’re going to be talking about the ideal positions of neonatal lines and tubes
on X-rays. Stick around to the end because I’ll go over some trickier X-rays to test
you all and make sure you’ve absorbed it all! I’m Dr. Tala, and I’ve been a neonatologist
for over 15 years now, and so far, it’s been standard of care to use X-rays to check for
proper line and tube placement. But we’re in an exciting time in medicine- and in a
few years, we’ll probably all be using bedside ultrasounds to check placement of everything.
Or even before then- maybe artificial intelligence will help us with some of
these X-ray images- and after one is shot- it will tell us to “pull UAC out 1.5cms” That was
my robot voice by the way. Or in this X-ray the robot will tell you the UVC is too low.
But for now- this is where most of us are- using X-rays to check position and making
our own decisions based on what the X-rays show. Let’s start with ideal position of
endotracheal tubes. And ideal location is considered to be the mid-tracheal
position. So that’s like half way down the trachea between the bottom of the clavicles
and the carina. (The carina is where the trachea splits off into two bronchi). In
this figure the letter D represents the mid tracheal position. You can see the carina
here and the underside of the clavicles here. So D is what you’re aiming for.
And here is how we look for the mid tracheal position on an actual X-ray. So look at the
base of the clavicles- and notice this is right where the clavicles are closest to
the vertebral columns- so the lowest portion of the clavicles. Then you have to figure out
where the carina is. Sometimes- for example if the baby has RDS- then this can be pretty
easy. Other times it’s harder. But here again- if you were to intubate this baby,
this middle line is where you’d be aiming for the base of the ETT end up.
Interestingly, NRP, or the Neonatal Resuscitation Program recommends
that even though we’re aiming for the mid-tracheal position for ETT placement,
we probably shouldn’t be using the clavicles as a landmark because the position of the clavicles
really depends on the position the baby is in and how the X-ray is taken. Instead they
recommend that the base of the ETT should align with T1 or T2 (or the first or second
thoracic vertebrae). The carina is usually at around T3-T4, so the ETT should be above this.
So if we’re intubating a baby, how deep should we insert the tube. The equation we’re all used
to using is weight in kilos + 6cms. So a 2kg baby we would insert 2+ 6 or 8 cms from the lip. But as
younger babies are being intubated we all figure out that this was often too deep for the tiny
babies. This chart is from the 8th edition of NRP, and you can see that the weight + 6 pretty much
holds, but for the tiny ones, the tube is going in less than 6cms. BUT- as everyone who’s ever taken
care of a baby knows- sometimes we’ll follow the chart or equation perfectly and when we get the
X-ray it’s still in totally the wrong position. So we really should always check placement.
So let’s look at the position of the ETT on this CXR- it’s between T1-T2- exactly where Black arrow
pointing to the optimal ETT depth. (The tip of the tube is located in the mid-trachea adjacent to the
first or second thoracic vertebra as recommended by Neonatal Resuscitation Program). Note here that
tube looks like it’s at the level of the clavicles so maybe initially you’d be like- this is too
high- but more likely, the way the X-ray was taken- the clavicles are ‘lower’ than we’d expect.
This was in a paper from Anderson et al. A 2 month old ex- 30-week infant presented with
listlessness, apnea and bradycardia and so was intubated. After intubation, they were able to
hear breath sounds bilaterally and pedi cap carbon dioxide detector changed from purple
to yellow. But this was the X-ray they got after intubation. And here you can see low lung volumes,
and the esophagus and the stomach appears full of air, despite the fact there is a nasogastric
tube in place. Also you can see the ETT right next to the NG tube. So here what happened was
that the ETT is not in the trachea at all- but rather in the esophagus. As an aside- it’s great
when groups publish mistakes like these so we can all learn from them. It’s very selfless of them.
And here again- another X-ray that someone posted for our education. Here you can see
that there is a completely separate air column from where the ETT is placed. And
again the lungs are hazy and collapsed. This all adds up to the tube being in the
esophagus and not in the trachea. Obviously we’re rarely getting these X-rays but this is
just a reminder that sometimes breath sounds and C02 monitoring will trick you- but what
we really want to see is an improvement in the baby’s status- whether it’s their HR or sats.
Now let’s at least talk about what happens when the ETT is in the trachea but not in
an ideal place. In this X-ray we see that the ETT with its tip projecting
deep within the right main-stem bronchus. So as an aside- If the ETT goes too deep, it
is way more likely to go down the right bronchus because it has a less acute angle than the left
bronchus. So here that’s exactly what happened and it was a right mainstem intubation. And as a
result- the left side wasn’t getting any pressure, and so we ended up with a collapse of the left
side of the lung. There is complete atelectasis of the left lung with mediastinal shift to the left.
In the lower X-ray- the endotracheal tube tip had been pulled back to an appropriate position
between the clavicles and the carina. And with that you can see the left lung re-expanded again.
In this X-ray- the opposite thing happened- The ETT has been placed in the left main bronchus.
Again- this happens less frequently because the left bronchus goes off at a much smaller angle.
So often you’d have to go out of your way to get the tube here. But again- as you’d expect- you’re
not getting enough aeration to the right side- and here the right upper lobe is collapsed- so
probably getting minimal air at all. So here again- we need to pull the ETT out a little.
And another X-ray with the ETT too deep, so again below the carina.. Here again this X-ray
shows the endotracheal tube with its tip projecting deep within the right mainstem
bronchus. And here- there is partial atelectasis of the right upper lobe. So here- and probably
because of the way the ETT was pointing and the direction the air was coming out of the tube,
there was enough air getting to the left lung and the right middle and lower lobes,
but not to the upper lobes. And by the way- often when the tube is too
deep- we would see a sudden increase of carbon dioxide on the gas- so think about
ETT placement if you see that on a gas. Again- we have to pull the tube back here.
What do you think about this X-ray? Here the X-ray looks like the the tip of the
endotracheal tube is above the thoracic inlet. So above the clavicles and above T1. Clearly the
lungs are getting air in- because even though there are coarse infiltrates bilaterally,
the lungs are hyperinflated if anything. But as you all know- this baby could have
an unplanned extubation or what we used to call a ‘self-extubation’ very easily,
and in certain positions the vent could be pushing air down the esophagus into the
stomach. We don’t want either of those things at all. So this ETT needs to be pushed in.
This is another X-ray again showing the ETT to be slightly elevated- and also just pointing out
the calculation that should be done to figure out how far we should push in. On most computer
programs you can measure out the distance with little arrows and it will tell you how
many cms it needs to be pushed in or pulled out. Honestly- sometimes this is still wrong-
so when you move the tube, you should probably be getting another X-ray to recheck position.
Right- let’s move onto umbilical venous catheters. As you all probably know the umbilical venous
catheter enters the umbilical vein and the goal is you want it to end up in the inferior vena cava,
just outside the right atrium. So what path does it take- well- it goes up the Umbilical vein,
then through the ductus venosus (which as you all know is like the ductus arteriosus- it only exists
in utero for blood to have a short cut)- and then it ends up in the inferior vena cava. So as you
can see from this picture- loads of things can go wrong- the catheter can veer off into the portal
veins- this is especially true if the ductus venosus is closed or takes off a tough angle-
or the catheter could end up in the liver. Or It could randomly go down another vein- and end up
in completely the wrong place. Ideally we want the catheter to be through the liver but just
outside the heart. This Xray is perfect. Really we want the catheter to be somewhere around T8-T9.
And again the path of the UVC- from the umbilical vein through the ductus
venosus and to the IVC. Look at all the ways it could veer off and end up in the wrong place.
My Friend Dr. Reis taught me this mnemonic. This is for where you want the catheter to end up:
And look at this seemingly perfect position of the UVC. And notice the way it makes this
bend through the liver- that’s a good sign the catheter is passing through the ductus
appropriately. So it’s on the other side of the liver- but it’s outside the border of the heart.
What about this line placement? Well if you just count the vertebrae- then this looks
like the catheter is at T8-T9 which should be ok. But obviously this catheter is well within
the border of the heart. And if a catheter is pushed up against the inside wall of the heart
then the fluids or TPN or whatever can seep into the pericardial space just by osmosis (so it’s
not like the catheter has to poke through the wall) and cause a life threatening pericardial
effusion. And that’s exactly what happened here. Fluid collected in the space around
the heart and caused heart failure. It needed to be tapped. So take these lines very seriously!!
Another misplaced UVC- and this one is pretty impressive! This is not something
you often see- it looks like the catheter has gone through the right atrium and come
out through the superior vena cava and then carried on going to the confluence of the
jugular and subclavian veins. Obviously- way too deep and needs to be pulled back significantly.
OK and another one where the UVC is too deep. And normally if the UVC goes in too far,
then usually it travels through the PFO (which is the hole between the right and left atrium)
and ends up in the left atrium. This one carried on going through the mitral valve
and ended up in the left ventricle. Obviously this needs to be pulled out significantly too.
And these UVCs have ended up in the liver. If you’re still scrubbed up then you can try to
make these try to end up in the right place (and you can watch the video we made on UVCs
if you want some tricks which sometimes help). But if the line is already in and sutured, these
need to come out. I’m not sure if these are in the portal veins or in the hepatic veins, but if what
you’re worried about is administering fluids/ medications into this relatively smaller vein,
and causing a disruption to the vein and then
a cyst or abscess in the liver. So if the UVC is in the liver, pull it out.
This UVC did something super weird- it looks like it didn’t make it through the ductus,
but then instead of turning around and coming out of the same vessel-
it turned and entered into another vessel- possibly the mesenteric vessel. Again- this
is the wrong position and the catheter needs to be removed.
The last thing I want to mention about UVCs is that getting a lateral Xray can really
help you identify correct placement. The UVC runs superficially and hopefully you'll see it
above the margin of the liver and below the heart. You can see if it takes a weird turn
though. Check out the UAC though- which obviously is running in the aorta more
posteriorly. Many hospitals require lateral X-rays to check placement when lines are placed.
Now let’s talk about umbilical arterial catheters. Their path is a little weird-
we thread one of the two umbilical arteries and then the catheter veers
downwards and joins the internal iliac artery which then joins the aorta. We continue threading
the UAC up the aorta until it reaches T6-T9. Because the UAC has to go down before it comes
up again, we generally have to thread the UAC more- nearly double the distance of the UVC.
This is an aside- at one point- and I was in residency we used to do this. We’d keep UACs
in a ‘low position’ or at L3-L5. The logic was that if there was a problem
in the line then we’d be more likely to see discoloration of the toes/ feet with a lower
line. But more data has come out that there are fewer complications with higher lines,
and so now every institution aims for their UACs to be in a high position or T6-T9.
And this UAC looks like it’s at T7-T8- so again in a good position.
This UAC looks like it correctly went down, and back up again, and then seemed to curl
around in the aorta. Obviously this needs to be moved. Often you can pull this out and
twist the catheter as you reinsert it, and you may have more luck with the catheter going in.
This UAC is just too low, and can just be pushed in a little further. It looks
like the team thought this was the vein they were catheterizing because
here’s the other UAC. But this catheter has ended up at about L2- which is probably
the last place you’d want the catheter to be because the kidney arteries come off from L2,
so this would be a really good way to end up with affecting blood flow to the kidneys.
Because this is going in the right direction, this catheter should be really easy to replace.
This is one of the most frustrating things that happens when you’re threading a UAC,
and that’s when the catheters go down the leg. Or instead of going up the aorta, the catheter goes
down the gluteal arteries. There really isn’t a lot you can do here- once the catheer decides it
wants to go down the leg I haven’t had any luck in changing its mind! It needs to be pulled out-
otherwise you may end up with a pretty bad clot and lose the sacral area or the leg.
And our last Xray on UACs- you can see obviously this is way too high. This looks like its gone
all way up the aorta, but hasn’t threaded into the left ventricle- instead its gone into one of the
great vessels which comes off the aorta. Again, this has to come back. Apart from being in the
wrong position- you’re more likely to get spasming and a thrombosis, but also the catheter is less
likely to draw back blood and less likely to give a good wave reading for the blood pressures.
Ley's go over three test Xrays for some self-testing
First XRAY- Right- so what’s going on here with the ETT? Is it in the right place? Well weirdly
it looks like the endotracheal tube has its tip projecting beneath the carina and not
over either main-stem bronchus, and it looks like the stomach is distended. The lateral chest Xray
shows that there is a column of air, probably the trachea, in front of the ETT. So most likely this
ETT is in the esophagus and not in the trachea.
Second Xray- let’s look at the UVC- and this definitely looks like the UVC because it's to the right of the vertebral column
and you can see the little curve it seems to be making as it goes through the ductus venosus.
But it just carries on going. Through the right atrium and apparently up the other side through to the superior vena
were misidentified- which can happen especially if the vessels are really dried. OR the calculation
cava and then probably up one of the jugulars. So way way too deep. And then what about the UAC- it
looks like it’s no where in deep enough. So what may have happened here is that whoever put these
in, made one of two mistakes- both of which are super easy to make. Maybe the vein and artery
was done wrongly- so basically they ended up pushing the UVC much further in than the UAC.
And because as we said the UAC goes down before it goes up, the UAC goes in a further distance.
And our last one: what’s happening here? When I first saw this Xray- it looked like whoever
was taking care of this baby was just a little excited with all the instrumentation and pushed
everything in too far. But then I realized this tube is going below the carina so it’s a gavage
tube not an endotracheal tube. So first- this needs to be pushed in to the stomach- assuming
the esophagus is normal. Then it looks like both the UAC and the UVC is in too far. Again- the
UAC looks like it’s gone all the way up the aorta and into the superior vessels and as you
can see the UVC is well inside the cardiac silhouette- so that needs to come out too.
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