Expansion
Every device has a correct position and a characteristic malposition
Expansion
| Device | Correct position | Watch for |
|---|---|---|
| Endotracheal tube | Tip 5 cm above the carina, roughly at the clavicles | Right main bronchus intubation, causing left collapse; oesophageal placement |
| Nasogastric tube | Bisects the carina, stays midline, tip below the left hemidiaphragm and 10 cm beyond the gastro-oesophageal junction | Coiling in the oesophagus, deviation into a bronchus, tip in the oesophagus |
| Central venous catheter | Tip at the cavoatrial junction, around the level of the carina | Arterial placement, tip in the right atrium or ventricle, pneumothorax after insertion |
| Chest drain | Tip in the pleural space, all side holes inside the chest wall | Side hole outside, tube in the fissure or in the lung |
| Pacemaker | Leads to right atrial appendage and right ventricular apex | Lead fracture, displacement, perforation |
| Tracheostomy | Midline, tip about half way between stoma and carina | Displacement, which is an airway emergency |
| Swan-Ganz catheter | Tip in the right or left pulmonary artery, not beyond the proximal branches | Distal migration causing infarction |
Nasogastric tube confirmation in the UK follows a strict sequence: aspirate with pH 5.5 or below is sufficient; if that cannot be obtained, a radiograph is required and must be interpreted and documented by a competent person. Misinterpretation of that film is a Never Event, and auscultation of an air bolus is not an acceptable test.
After any central line insertion, look specifically for a pneumothorax, for the catheter tip position, and for an unexpected course suggesting arterial or mediastinal placement.
Always ask what has changed compared with the previous film, since a device that has migrated is far more common than one that was wrong from the outset.