Radiology in the

Intensive Care Unit

William
William Herring,
Herring, M.D.
M.D.
Department
Department ofof Radiology
Radiology
Albert
Albert Einstein
Einstein Medical
Medical Center
Center
Philadelphia,
Philadelphia, PA
PA
 Atelectasis
Types
Types

● Lobar
● Subsegmental, discoid, plate-like
● Compression-as in pleural effusion
 Atelectasis
Lobar
Lobar

● Area of increased density with shift towards

that side
■ Fissures, heart or trachea, diaphragm
● Predictable x-ray patterns
● Especially likely with mucous plug or
malplaced ETT
■ Usually involves left lung and right upper lobe
● May respond to respiratory PT or bronch
 Atelectasis
Subsegmental
Subsegmental

● Hypoventilation/surfactant deactivation
● Horizontal, linear densities at bases
● Asymptomatic
■ May herald pneumonia
● Responds to deep breathing
● Disappears in several days
 Pleural Effusions
X-ray
X-ray Appearance
Appearance

● Subpulmonic at first
● Need 250cc to blunt angle
● Meniscus appearance
● Straight line indicates presence of PTX
● Free-flowing on decub
● Ultrasound for guidance
 Pleural Effusion
Causes
Causes

● CHF-mostly right sided or bilateral

● Post-operative irritation
● Pulmonary thromboembolic
disease
● Para-pneumonic effusion
● Trauma-blood
 Pneumonia

● Consolidation of lung with air bronchograms

● No shift of heart or mediastinal structures
● Frequently staph or gram negative
 Aspiration

● Fleeting, patchy infiltrates-very

common in ICU
● Usually at bases, mostly on right
 Aspiration
Appearance
Appearance Based
Based on
on Cause
Cause

● If bland, disappears within day or two

● If HCl, chemical pneumonitis lasts for
days
● If infected with gram negatives,
pneumonia ensues
 Pneumothorax

● Must identify visceral pleural white line to dx

● Careful search required
● Small require upright film
● Deep sulcus sign
● Always get x-ray after failed CVC attempt
 Pulmonary Embolism
Without
Without Infarction
Infarction

● More common than suspected

● Chest x-ray most often normal in
appearance
● Discoid atelectasis, elevation of
hemidiaphragm
● Lung scan for screen
 Pulmonary Embolism
With
With Infarction
Infarction

● Usually multiple
● Usually at bases
● Pleural effusion, infiltrate
● “Hampton’s Hump” is very unusual
● Clear with scarring; “melting sign”
 Congestive Heart Failure
X-ray
X-ray Findings
Findings

● Pleural effusions-> on right or bilateral

● Fluid in fissures-thicker than a sharpened pencil
● Kerly B lines-perilymphatic, interstitial fluid
● Peribronchial cuffing
● NOT cardiomegaly
● NOT “pulmonary vasculature congestion”
● NOT cephalization
 ARDS
Causes
Causes

● Shock
● DIC
● CNS injury
● Sepsis
● Drug overdose
 ARDS
X-ray
X-ray Findings
Findings

● Diffuse alveolar infiltrates hours after insult

● No fluid in fissures or pleural effusions
● Characteristically lasts days-weeks
● May become interstitial
■ Fibrosis or disappears
Iatrogenic Complications
Central Venous Catheters
Normal
Normal Anatomy
Anatomy

● Subclavian joins brachiocephalic vein

behind medial end of clavicle
● Catheter should reach this point before
descending
● Catheter should descend lateral to spine
and tip should be in either brachiocephalic
v. or SVC
 Central Venous Catheters
Malpositioned
Malpositioned

● Most often malpositioned in RA or internal

jugular
● Sometimes contralateral subclavian
● Occasionally outside blood vessel
■ Look for sharp bends in catheter
Central Venous Catheters
Two
Two or
or more
more attempts
attempts

● Should initial placement fail, get

a chest x-ray before trying other
side to avoid bilateral
pneumothoraces
Central Venous Catheters
Potential
Potential Causes
Causes of
of Fatalities
Fatalities

● Air embolism
● Pneumothorax
● Hemothorax
● Cardiac perforation
● Sepsis
● Venous perforation
 Swan-Ganz Catheters
Normal
Normal Anatomy
Anatomy

● Ideally located tip lies within

Right or Left pulmonary artery
 Swan-Ganz Catheters
Complications
Complications

● Most common significant complication is

pulmonary infarction
■ From occlusion by catheter
■ From embolization off of catheter
● Uncommon
■ Cardiac arrhythmia
■ Pulmonary artery perforation
■ Intracardiac knotting
 Endotracheal Tube
Normal
Normal Anatomy
Anatomy

● Tip should lie between clavicles and carina

● Carina usually at level of T4
● Tip should be at least 5cm above carina
● Tip may change by 2cm with flex/extension
● Balloon should never occupy more than half
of lumen
 Endotracheal Tube
Complications
Complications

● Most common malposition: tip in right

mainstem bronchus
■ Atelectasis
■ R sided tension pneumothorax
● Tube in pharynx: aspiration
● Sinusitus 2° nasal mucosa edema
 Tracheostomy
Normal
Normal anatomy
anatomy

● Tip at T3
● Tip half-way between stoma and carina
● Tip placement not affected by
flex/extension
 Tracheostomy
Complications
Complications

● Immediately after
■ Subcutaneous emphysema
■ Pneumomediastinum
■ Pneumothorax
● Cuff should not be >1 1/2 X diameter of
lumen
● Tracheal stenosis
 Tracheostomy
Tracheal
Tracheal Stenosis
Stenosis

● Most common late-occurring complication of

tracheostomy tube
● May occur at stoma, at level of cuff or at tip of
tube
● Most common at stoma
● Very common; in fact, it may occur in every
patient with prolonged intubation
● Trachea should narrow to 4mm for stridor to
occur
 Pleural Drainage Tubes

● Ideal position is anterosuperior for PTX

and posteroinferior for effusion
● Usually work well no matter where
positioned
● Look for holes outside of chest
 Nasogastric Tube
Complications
Complications

● Perforation usually involves cervical esophagus

● Tube can also perforate stomach
● Indwelling tube leads to GE reflux which may
cause esophagitis and stricture
 Nasogastric Tube
Complications
Complications

● NG tubes may be inserted in trachea

leading to
■ Infection
■ Pneumothorax
■ Pleural effusion
● Usually right mainstem bronchus
 Pacemakers
Normal
Normal anatomy
anatomy

● Catheter should have gentle curves

● Tip positioned at apex of R ventricle
 Pacemaker
Complications
Complications

● Leads can fracture

● Leads can perforate heart producing cardiac
tamponade
● Look for sharp bends in leads indicating
perforation of blood vessel
● Leads may be ectopically placed, e.g. hepatic vein
● Pacemaker battery may migrate subcutaneously