Misplaced Lines & Tubes
- Every line and tube has a "happy place" — your job is to confirm the tip landed there, not just that the device exists.
- An endotracheal tube that's too deep slides down the right main bronchus and quietly drowns the left lung.
- A central line tip belongs near where the SVC meets the right atrium; a line that wandered into an artery or out of the vein is an emergency.
- A nasogastric tube that took a wrong turn into the airway can deliver tube feeds straight into the lungs — confirm it before anyone feeds through it.
- The post-procedure film exists to catch the complication (pneumothorax, malposition) before it catches the patient.
A hospitalized patient is a pincushion of plastic: a breathing tube, a feeding tube, a central line, maybe a chest tube and a pacemaker for good measure. Someone shoves each one in based on feel and landmarks, then orders a chest X-ray to ask the radiologist one quietly terrifying question: did it go where I think it went? This is the lines and tubes checklist with the stakes turned up, because here a wrong answer hurts someone in the next ten minutes.
The trap is that these films look boring. There's the tube, snaking down, present and accounted for. But "present" is not "correct," and the difference is the whole game.
The breathing tube: aim for the middle, not the basement
An endotracheal (ET) tube is the straw that keeps the patient breathing. It goes in through the mouth, down the windpipe, and ideally stops in the mid-trachea — a few centimeters above the carina, the spot where the windpipe forks into the two main bronchi. Think of parking in the middle of a driveway: too far back and you're in the street, too far forward and you're in the garage wall.
Push it in too far and the tube takes the path of least resistance — the right main bronchus, which comes off more steeply, in a straighter line with the trachea than the left. Now you're ventilating one lung. The abandoned left lung, getting no air, slowly collapses (atelectasis). The fix is gloriously low-tech: pull the tube back a few centimeters and re-image.
Remember that the neck flexes and extends, and the ET tube tip moves with it — roughly toward the carina when the chin tucks down, away when it lifts. So note head position before you panic about a borderline-low tip.
Central lines: respect the vein, fear the artery
A central venous catheter is a long IV threaded through a big vein toward the heart. Where the tip lands matters: the sweet spot is around the junction of the superior vena cava (SVC) and the right atrium — a roomy, high-flow highway where harsh medications get instantly diluted. A tip jammed too far into the right atrium or ventricle can irritate the heart; a tip pointing up the wrong vein doesn't dilute anything. (For how these are placed, see central lines and ports.)
The genuine emergency is a line that ended up in an artery instead of a vein, or that punctured its way out of the vessel entirely. Either can bleed dramatically or deliver drugs to the wrong address. And because any needle near the lung apex can nick the pleura, every central line attempt earns a hunt for a pneumothorax on the follow-up film.
A central line that takes a sharp turn and heads up toward the neck or across the midline isn't "fine, it's in" — it's malpositioned. Trace the catheter along its entire length, not just to the first reassuring curve. A line can look perfect for 20 cm and then betray you at the tip.
The feeding tube: the one that can fill a lung
A nasogastric or feeding tube is supposed to go nose → esophagus → stomach, comfortably below the diaphragm. The esophagus and the trachea start as next-door neighbors, so a misdirected tube can slide down the airway instead and park in the lung. That's uncomfortable but survivable — until someone pours tube feeds down it and effectively pours liquid nutrition directly into the lung.
This is why the rule is so strict: confirm position on imaging before using a newly placed feeding tube. On the film, you want to see the tube run down the midline, cross the diaphragm, and have its tip well into the stomach — not veering off into a bronchus or coiling in the chest.
A quick "where should the tip be" cheat sheet
| Device | Tip belongs | The scary miss |
|---|---|---|
| Endotracheal tube | Mid-trachea, above the carina | Down the right main bronchus → left lung collapse |
| Central venous line | SVC / right-atrial junction | In an artery, or out of the vessel |
| Nasogastric / feeding tube | Below the diaphragm, in the stomach | In the airway → feeds into the lung |
| Chest tube | In the pleural space, toward the problem | Kinked, outside the pleura, or in the lung |
How not to miss it
Treat every post-procedure chest film as a deliberate scavenger hunt, the same way you'd run any chest X-ray approach: name each device, follow it from entry to tip, and decide if the tip is in its happy place. Then do the second sweep for the complications a placement can cause — a new pneumothorax, a collapsed lung, free air in the soft tissues (a clue toward pneumomediastinum).
The line is only as good as its tip and only as safe as its complications. Confirm the tip is where it should be, then prove the placement didn't break anything.
These films feel routine, which is exactly why they're dangerous. The device is almost always fine — but "almost always" is the whole reason someone ordered the picture. When it's the one that wandered, you're the last checkpoint before a too-deep tube, an arterial line, or a lung full of tube feed turns into a very bad afternoon.