CT diagnosis of
malpositioned chest tube
Insertion of a chest tube into the pleural space is
standard management for various pleural
Malpositioning of chest tubes in extrathoracic,
mediastinal locations and in the fissures is
Malpositioning results not only in inadequate
drainage of air and fluid but may also result in
increased morbidity and mortality.
Diagnosis of a malpositioned tube is sometimes
difficult to establish on a chest radiograph.
CT, however, has proven to be extremely accurate
in evaluating the position of a chest tube and has
often provided additional valuable information with
significant therapeutic impact.
Indication for chest tube insertion
penetrating chest injuries,
Optimal tube placement
for fluid drainage:
a dependent location at the posterior base
for air evacuation:
a non-dependent position is preferred,
apical and anterior
Risk of malpositioned chest tube
Malpositioning of chest tubes is common,
especially in traumatic chest injury.
Malpositioning not only results
in inadequate drainage of air and fluid but
also increased morbidity and mortality.
Usually require immediate repositioning or
Diagnosis of a malpositioned tube
is sometimes difficult to establish
(1) clinical manifestations may be absent
(2) a bed-side chest radiograph is usually
unreliable in demonstrating the exact
location of the tube
Diagnosis of a malpositioned tube
(1) is extremely accurate in evaluating the
position of a chest tube
(2) often provides additional valuable information
with significant therapeutic impact.
The aim of this pictorial review is to
provide an overview of malpositioned chest tubes
diagnosed on CT.
Recognition of malpositioned
chest tubes on CT
CT is indicated:
(1) when a chest tube does not drain adequately
(2) the chest radiograph is non-contributory.
CT for malpositioned chest tubes
Different window settings are necessary.
pulmonary and pleural lesions may conceal the
course of the tube on a lung window.
A bone window may be of advantage in an
extrapleural tube location, where its attenuation
may be similar to that of the ribs.
In addition, thin sections in a lung window setting
may clarify whether a tube is intrafissural or
Intraparenchymal tube placement
is most likely to occur with pre-existing pulmonary
disease or pleural adhesions.
On CT, the tube is seen traversing the lung.
Probably representing a haematoma due
to lung laceration.
A parenchymal tract may sometimes remain after
removal of a tube.
A chronic bronchopleural fistula or lung abscess
may also result
CT shows the tube is intraparenchymal
and does not reach the loculated
CT (mediastinal window) demonstrates
a tube entering through the left anterior
chest wall, coursing posteriorly in the Lung window:
apex of the left lung. Increased attenuation of the lung
parenchyma surrounding the tube is
Intrafissural tube placement
A chest tube is considered to be intrafissural
(1) when it is outlined by a residual pneumothorax
(2) when it is located in the region of a fssure but
without areas of an intraparenchymal opacity
Chest CT (mediastinal window), contiguous
sections at the lung base show the right tube within
the oblique fissure, crossing the hemithorax, with its
tip very close to the dilated contrast-filled oesophagus.
Mediastinal tube placemen
A tube that has been introduced too far into
the thorax may reach the mediastinum.
On CT, the position of the tube can easily be seen
abutting the mediastinum.
Reported complications include:
perforation of the heart, the
pulmonary artery and the esophagus.
A 3.5-year-old girl with a right pleural effusion and a lung infiltrate.
A tube was inserted into the right hemithorax.
(a) Chest CT (lung window):
a right hydropneumothorax is present. Part of the tube is seen anteriorly;
its tip cannot be accurately defined.
(b) Chest CT (mediastinal window, same level as (a)):
again the tip of the tube is not well visualized owing to artefacts from a
metallic device on the left chest wall, but it probably
abuts the superior vena cava and the ascending aorta.
Chest wall tube placement
When a tube tip is positioned outside the
parietal pleura it is considered to be in the chest
Inserting the tube too cranially and too
medially may cause bleeding from the pectoralis
major muscle, especially in men, and
may damage the breast in women.
High insertion in the posterior chest wall has
resulted in Horner's syndrome.
The tip of a left chest tube lies in the left
lateral chest wall (arrow).
A gunshot wound at the level of D3 in a29-year-old man.
CT demonstrates bilateral pneumothoraces.
A tube has been inserted anteriorly to drain
the left pneumothorax, causing a haematoma in the
pectoralis major muscle (asterisk).
Abdominal placement of a
When the tube is placed too low it may enter
the peritoneal cavity and can be seen on CT with
the tip below the diaphragm.
The spleen and liver have been injured most
commonly in such cases.
Gastric injury from a trocar has also been reported.
A tube is seen traversing the left On CT:
costophrenic angle (arrow). The lower tube is seen entering
the lateral aspect of the spleen
A 36-year-old woman with bilateral pleural effusions and pneumonia.
CT was performed because of a drastic drop of haemoglobin.
Chest CT (mediastinal window) at level of diaphragm shows:
a right pleural effusion posterior to an atelectatic segment of the right lower lobe.
The lateral aspect of the liver is surrounded by fluid of high density. Air bubbles
within the peritoneal fluid indicate an intra-abdominal placement of the tube.
A left tube had been inserted earlier to drain the left pleural effusion.
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