Answer: Post-intubation Eval

December 6, 2012

Chest XR, Devices, Non-Trauma, Respiratory, XR

This radiograph was posted yesterday and I posed the question:  Is the endotracheal tube (ETT) in good position?

normal-intubation2 edited 1

This ETT is in great position on the AP chest radiograph.  Every ETT should have a radiopaque line extending to the tip in order to identify the tube length.  Ideally the tip of the ETT (arrow) should be midway between the thoracic inlet (top dotted line) and the carina (bottom dotted line).  Some pointers:

  • The thoracic inlet on chest XR is roughly at the level of the clavicles.  Anatomically it is the superior portion of the manubrium anteriorly.  This is the level of the subglottis area and upper trachea.
  • The carina is usually located around T5-T7 and is usually easily identified on chest XR.  If you have difficulty draw a line from the inferior main bronchi and they intersect at the carina.
  • The ETT in a normal adult can advance and retract up to 2cm with neck flexion and extension.  Therefore it is recommended that the ETT is at least 2cm from the carina and 2cm from the thoracic inlet.
  • Most commonly the ETT will be placed in the right mainstem bronchus if placed improperly in the airway.
  • Signs that the ETT is in the esophagus include a dilated, air filled stomach and esophagus.  And…oh yeah…the patient may not be doing well.
  • With digital imaging it is easy to play with the intensity if you cannot identify the tube or carina.  Also, inverting the image to a “negative” image can sometimes help.

Author:  Russell Jones, MD

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