CT diagnosis of malpositioned chest tube

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					    CT diagnosis of
malpositioned chest tube

               Intern 劉一璋
     Abstract (1)
   Insertion of a chest tube into the pleural space is
    standard management for various pleural
   Malpositioning of chest tubes in extrathoracic,
    intraparenchymal and
    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.
       Abstract (2)
   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
   pneumothorax,
   penetrating chest injuries,
   haemothorax,
   empyema,
   bronchopleural fistula
    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
   CT
    (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
anterior pneumothorax.
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
                                            probably haematoma
      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
        around it.
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
      chest tube
   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.
Thanks for your attention

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