IDEAL Position of Endotracheal Tubes, UACs and UVCs on X-rays!!

Summary

In 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

00:00

😇 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.

05:01

😟 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.

10:06

😕 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.

15:08

😬 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.

20:11

😨 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.

Keywords

💡Neonatal lines and tubes

This term refers to the various medical devices used in the care of newborns, particularly those requiring intensive care. In the context of the video, these lines and tubes are crucial for administering medication, nutrition, and monitoring vital signs. The script discusses the importance of their proper positioning as seen on X-rays to ensure patient safety and effective treatment.

💡X-rays

X-rays are a form of medical imaging that uses radiation to provide a two-dimensional picture of the internal structures of the body. In the video, X-rays are used to check the placement of neonatal lines and tubes, which is essential for confirming that they are correctly positioned to function as intended without causing complications.

💡Endotracheal tubes (ETT)

An endotracheal tube is a device used to facilitate mechanical ventilation in patients who cannot breathe on their own. The video emphasizes the ideal position of an ETT, which should be in the mid-tracheal position, to ensure proper ventilation. Misplacement, as illustrated in the script with various X-ray examples, can lead to serious complications such as lung collapse.

💡Mid-tracheal position

The mid-tracheal position refers to the optimal location for an endotracheal tube to be situated within the trachea. Defined in the script as halfway down the trachea between the bottom of the clavicles and the carina, this position is critical for effective ventilation and is a central theme in the video's discussion on proper tube placement.

💡Carina

The carina is the point where the trachea bifurcates into the left and right main-stem bronchi. It is used as a landmark in the video to help determine the correct placement of an endotracheal tube, with the tube's tip ideally positioned just above the carina.

💡Umbilical venous catheters (UVC)

Umbilical venous catheters are long, thin tubes that are inserted through the umbilical vein for various medical purposes, such as administering medication or drawing blood. The script discusses the correct path and final position of a UVC, which should be just outside the right atrium in the inferior vena cava, and the potential complications of improper placement.

💡Inferior vena cava

The inferior vena cava is a large vein that carries blood from the lower half of the body back to the heart. In the context of the video, the final destination of an umbilical venous catheter should be the inferior vena cava, just outside the right atrium, to ensure proper functioning and avoid complications.

💡Umbilical arterial catheters (UAC)

Umbilical arterial catheters are inserted into one of the umbilical arteries to monitor blood pressure or deliver medication directly to the bloodstream. The video script explains the typical path of a UAC and the target position within the aorta between T6 and T9, highlighting the importance of correct placement to prevent complications.

💡Aorta

The aorta is the main and largest artery in the body, carrying oxygenated blood from the heart to the rest of the body. In the video, the aorta is mentioned in relation to the positioning of umbilical arterial catheters, which should be threaded up the aorta to a specific level to ensure accurate blood pressure monitoring and medication delivery.

💡Atelectasis

Atelectasis refers to the collapse of a part or all of the lung, which can occur due to various reasons, including the misplacement of an endotracheal tube. The script uses this term to describe a complication that can arise when an ETT is not correctly positioned, leading to inadequate aeration of the lungs and lung collapse.

💡Pericardial effusion

Pericardial effusion is the abnormal accumulation of fluid in the pericardial space, the sac surrounding the heart. The video script warns of this as a potential complication if an umbilical venous catheter is misplaced and pushed against the inside wall of the heart, allowing fluids to seep into the pericardial space and cause life-threatening conditions.

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.