Gastric Tube Placement – CXR

Plan to spend 5-10 minutes familiarizing yourself with the animations of the PowerPoint and the key findings of this chest X-ray.

Instructions: Present the image either by expanding the window (bottom right) in a browser or downloading the PowerPoint file (downloading is recommended.  Have the image pulled up in presenter mode before learners look at the screen to avoid revealing the diagnosis.  Ask a learner to provide an overall interpretation.  Then advance through the animations to prompt learners with key questions and reveal the findings, diagnosis, and teaching points.  You can go back to prior graphics and questions by using the back arrow or scrolling back on the mouse wheel.

Official CXR Read: Extensive bilateral multifocal alveolar opacities. A new weighted tip feeding tube appears to course through the left mainstem bronchus, with tip projecting over the lateral left lung.  This may be in the pleural space. Endotracheal tube tip projects over the mid intrathoracic trachea (~4cm above the carina).  Right IJ central venous catheter tip projects over the superior vena cava terminating at the cavo-atrial juction.

Diagnosis: Mispositioned weighted feeding tube in left lung field requiring removal and replacement.

Teaching:

• The radiograph demonstrates multifocal alveolar opacities due to ARDS.
• If a malpositioned gastric tube extends to the pleura it may lead to a pneumothorax.  After repositioning the tube conder a repeat CXR in addition to the KUB.
• Gastric tubes (nasogastric, orogastric) are commonly placed for enteral access for medication administration and nutrition along with gastric decompression.

A 2-step process for determining appropriate gastric tube placement:

1. 1. Does the tube change directions at the carina?
   2. Does the tube end below the diaphragm/cardiac silhouette?
   3. (optional) Is the tip of the tube pointing towards the pylorus