ICU Chest Radiography Pearls and Pitfalls

Document Type

Conference Proceeding

Publication Date

5-2024

Abstract

Background
ICU patients require incredibly thorough and complicated care, with placement of a wide variety of lines, tubes, and devices oftentimes paramount to the care provided. Familiarity with the spectrum of lines, tubes, and devices that can be placed, and their typical locations radiographically, is critical for radiology trainees and staff interpreting the radiographs, particularly given the often-difficult nature of obtaining a quality radiograph in these patients. Additionally, these patients have frequently undergone recent surgical intervention and are more prone to develop complications, which the radiologist needs to recognize. The purpose of this presentation is to review various pathologies and pitfalls that may be encountered when interpreting ICU chest radiographs.

Educational Goals / Teaching Points
Review a wide variety of chest pathologies, both expected and unexpected, that can be seen and occasionally overlooked in ICU patients with emphasis on radiographic appearance. Provide relevant background information, important clinical history, and crucial imaging characteristics to broaden the diagnostic knowledge of radiology trainees and staff and avoid pitfalls when interpreting ICU chest radiographs.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
In our case-based presentation, we provide a review of lines, tubes, devices, and procedures that are commonly seen in ICU patients with an emphasis on chest radiographs. Cases from our institution are classified into five categories as follows: a) malpositioned lines and tubes; b) postsurgical complications (example cases: sternal dehiscence, retained surgical item after aortic repair); c) mediastinal and airway pathology (example cases: mediastinal hematoma s/p central venous catheter placement, tooth aspiration); d) pleural pathology; and e) upper abdominal pathology. Other cases not shown in the example slides include esophageal intubation, overinflated tracheal cuff, malpositioned implantable cardioverter-defibrillator, peripherally inserted central catheter, central venous catheter, Swan-Ganz, intraaortic balloon pump and nasogastric tube, misplaced chest tube in abdomen due to transsplenic placement, gastropericardial fistula causing pneumopericardium, deep sulcus sign in patient with pneumothorax, tension pneumothorax, or presence of portovenous gas.

Conclusion
Familiarity with normal postoperative appearance of chest in ICU patients, and possible complications, as well as expected position of various lines and tubes on chest radiographs, will allow the radiologist to guide patient management and improve clinical outcomes.

Comments

American Roentgen Ray Society (ARRS) Annual Meeting, May 5-9, Boston, MA

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