Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients.

OBJECTIVE: The aim of our study was to illustrate the radiographic spectrum of the intrabronchial malposition of nasogastric tubes and subsequent complications, and to discuss the role of radiography in the detection of such malpositions. DESIGN: Retrospective clinical investigation. SETTING: Tertiary care university teaching hospital. PATIENTS AND METHODS: We reviewed chest radiographs of 14 intensive care patients with nasogastric tubes malpositioned in the tracheobronchial tree. The site and anatomic location of the malposition were recorded. Complications due to tube malpositioning were monitored on follow-up radiographs and on computed tomographic examinations, which were available in 4 patients. RESULTS: Nine of 14 nasogastric tubes were inserted in the right and 5 in the left tracheobronchial tree. Tube tips were malpositioned in the lower lobe bronchi (50%), the intermediate bronchus (36%), and the main bronchi (14%). There was perforation of the bronchial system with subsequent pneumothorax in 4 patients. In 4 other patients, pneumonia developed at the former site of the malpositioned tube tip. Radiographic detection of nasogastric tube malpositioning was prompt in 9 patients and delayed in 5 patients. CONCLUSIONS: Whereas clinical signs of nasogastric tube malpositioning in intensive care patients may be absent or misleading, chest radiography can accurately detect nasogastric tube malpositions in the tracheobronchial tree, may prevent complications, and avoid the use of further costly or invasive diagnostic techniques.

Azygos arch cannulation by central venous catheters: radiographic detection of malposition and subsequent complications.

The aim of this study was to determine the frequency of radiographically evident central venous catheter misplacement in the azygos arch and to analyze whether the frequency of azygos arch cannulation is dependent on the anatomical site of catheter insertion. We reviewed 1,287 postprocedural examinations and 3,441 follow-up examinations. Catheters had been inserted through the left (6%) or right (15%) internal jugular veins and through the left (32%) or right (46%) subclavin veins. Radiographs were analyzed for possible catheter malposition in the azygos arch and for complications related to this malposition. Catheter malposition in the azygos arch was seen on 16/1,287 (1.2%) postprocedural radiographic examinations. Of the 16 malpositioned catheters, 11 (69%) had been inserted in the left subclavian vein, three (19%) in the left jugular vein, two (12%) in the right subclavian vein, and none (0%) in the right jugular vein. There was a statistically significant difference in the frequency of azygos arch cannulation between left- and right-sided catheters (p = 0.001). All complications consisted of venous perforations and were seen in three of 16 cases (19%). Azygos arch cannulation is a rare but hazardous central venous catheter malposition that occurs early after catheter insertion and carries a substantial risk for complication. The risk for azygos arch cannulation is substantially increased if catheters are inserted in left-sided veins. Because of the severity of subsequent complications, radiologists should be vigilant in the detection of this rare malposition.

[Pleural and pulmonary changes within the scope of rheumatoid arthritis]. / Pleurale und pulmonale Veränderungen im Rahmen der rheumatoiden Arthritis.

Pulmonary complications caused by rheumatoid arthritis are a clinically relevant aspect of this chronic arthropathy. Those complications can involve all parts of the thorax, including the lung parenchyma, the pleura, and the thoracic cage. The most common complications are necrobiotic nodules, pleural abnormalities, Caplan's syndrome, parenchymal fibrosis, bronchiolitis obliterans, and iatrogenic damage of lung the parenchyma. This article reviews pulmonary abnormalities induced by rheumatoid arthritis and their clinical and radiological findings. In addition, the role of different imaging modalities in the diagnostic work-up of pulmonary complications caused by rheumatoid arthritis is discussed.

[Computerized tomography of AIDS associated thoracic diseases]. / Computertomographie AIDS-assoziierter Thoraxerkrankungen.

Pulmonary infections and tumors are a major cause of death in patients with AIDS. The combination of clinical, radiological, laboratory, and pathohistological data helps to narrow the spectrum of differential diagnoses or even allows a specific diagnosis in many patients. Nevertheless, an accurate diagnosis should be obtained as soon as possible during the clinical course of the illness to initiate treatment in time. Computed tomography (CT) has proven to provide promising results in the diagnosis of AIDS-related thoracic diseases. The aim of this paper was to demonstrate the diagnostic capacities of CT in the context of particular AIDS-related thoracic pathologies. Additional information on the spectrum of pathological agents and on differential diagnostic signs is summarized.

[Spiral CT in acute pulmonary embolism]. / Spiral-CT bei akuter Pulmonalembolie.

Pulmonary embolism is a frequent and potentially life-threatening event with uncharacteristic clinical manifestations. Diagnosis is commonly established by ventilation/perfusion scintigraphy and pulmonary angiography. Both methods, however, carry substantial drawbacks. Therefore, clinicians claim that there is a need for an accurate and non-invasive diagnostic modality. Spiral CT of the pulmonary arteries is a recent modality, that allows reliable visualization of emboli in pulmonary arteries up to fourth-order branches. This paper reviews the technical aspects, typical findings and diagnostic pitfalls of this recent technique. The potential role of spiral CT in the screening of patients with suspected pulmonary embolism is discussed and selected cases are presented.

[Spiral-CT [corrected] in chronic lung thromboembolism. / Spiral-CT bei chronisch-thrombembolischer Lungenerkrankung.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare result of recurrent pulmonary embolism and is treated by pulmonary thromboendarterectomy. Knowledge of the exact location of the thrombi is necessary in planning this operation. To date, pulmonary, angiography is the diagnostic imaging gold standard. Since the introduction of spiral CT excellent vascular opacification of the pulmonary arteries has become feasible, and thrombi in the pulmonary arteries can be visualized directly. Spiral CT is superior to angiography in demonstrating thrombi in the central pulmonary arteries, whereas angiography proves superior to CT in the evaluation of abnormalities within segmental arteries. The sensitivity of spiral CT in confirming the diagnosis of CTEPH is reported to be more than 90%. According to the literature and based on our own results, the decision concerning operability is possible on the basis of spiral CT images in more than 80% of patients with CTEPH. Spiral CT as a non-invasive tool may be used for CTEPH screening, for postoperative follow-up after pulmonary thrombendarterectomy and, combined with pulmonary angiography, to optimize operation planning.

Discrete lung involvement in systemic lupus erythematosus: CT assessment.

PURPOSE: To study the computed tomographic (CT) appearance of early lung involvement in systemic lupus erythematosus (SLE). MATERIALS AND METHODS: In a prospective study, 48 patients with serologically confirmed SLE but no prior clinical evidence of lung involvement underwent chest radiography, CT, and lung function tests. Radiographs and CT scans were compared, and CT scans were evaluated for signs suggestive of parenchymal and pleural disease. Extent and distribution of disease were determined. CT findings were correlated with clinical and functional data. RESULTS: Of 45 patients with normal chest radiographs, 17 (38%) had abnormal CT findings. Extent of disease was statistically significantly correlated with duration of clinical history (r = .93) and decreased single-breath diffusing capacity for carbon monoxide (r = .8) and ratio of forced expiratory volume in 1 second to forced vital capacity (r = .77). CONCLUSION: CT is superior to chest radiography for detection of functionally relevant pulmonary disease and is an important adjunct in early assessment of SLE.

Automatic patient-instruction devices in thin-section CT of the thorax: impact on image quality.

PURPOSE: To determine what influence automatic patient-instruction (API) devices have on image quality of chest computed tomographic (CT) scans and whether the qualitative outcome justifies their routine use. MATERIALS AND METHODS: Thin-collimation CT scans of two age- and sex-matched groups of 64 patients each were evaluated prospectively for the presence of breathing artifacts and for concomitant deterioration of image quality. Breathing commands in group 1 were given with the API device and in group 2 with technologist-performed patient instruction. Cardiac motion artifacts were not evaluated. The frequency of scans repeated owing to breathing artifact was determined. RESULTS: Image quality was worse in group 1 compared with that of group 2. The percentage of scans repeated was higher with API (38%) than without API (16%). CONCLUSION: API devices cannot be recommended for thin-section CT of the thorax. The large number of scans that must be repeated leads to a considerable increase in patient irradiation, scanning time, and cost.

Update: abdominal tuberculosis--unusual findings on CT.

To update our knowledge of abdominal tuberculosis as manifested on computed tomography (CT), we reviewed the CT scans of 12 patients with proven abdominal tuberculosis. The nature, range and extent of abdominal involvement was determined. The CT findings were compared to those reported in the literature. The aetiologic agent was Mycobacterium tuberculosis in all patients. One patient had an increased risk because of AIDS. In nine patients, tuberculosis was limited to the abdomen, and three patients had previously unknown thoracic tuberculous disease. Characteristic features in our patients included low density ascites and uncommon patterns of adenopathy. Findings reported to be typical in abdominal tuberculosis were present in only five of our 12 patients. Unusual findings in our patients included solitary and multiple pelvic, adrenal, splenic and hepatic lesions. In six of 12 patients, those findings mimicked malignancy. We conclude that knowledge and early recognition of these unusual manifestations of abdominal tuberculosis should help to optimize clinical management of the disease and avoid misdiagnosis.

Position of jugular oxygen saturation catheter in patients with head trauma: assessment by use of plain films.

OBJECTIVE: The purpose of this study was to establish a plain radiographic technique for the assessment of the position of a jugular oxygen saturation catheter in patients with head trauma. MATERIALS AND METHODS: In the experimental study, jugular oxygen saturation catheters were introduced into the internal jugular veins of four cadavers. Correct positioning of the catheter tips was monitored by CT. Concurrent anteroposterior radiographs of the skulls were obtained with the tubes angled in a transverse plane and in a sagittal plane at intervals of 5 degrees and within a total range of 70 degrees for each plane. Three radiologists judged the visibility of the catheter tips and measured the distance of the catheter tips to previously determined bony landmarks of the skull. Then, preliminary radiologic criteria for correct positioning of the catheters were defined. In the clinical study, we prospectively evaluated radiographs for 32 patients who received jugular oxygen saturation catheters. Eleven patients had digital radiographs done, and 21 patients had radiographs with a conventional screen film system done. Radiographs were analyzed for consistency of findings with the experimental results and for consistency of the suspected catheter position with laboratory data. RESULTS: Results of the cadaveric study showed that catheter position is best assessed on strict anteroposterior radiographs with the orbitomeatal-basal line perpendicular to the plane of the film. A correctly positioned catheter tip should lie cranial to a line extending from the atlantooccipital joint space and caudal to the lower margin of the orbit. The catheter tip also should lie cranial to a line connecting the tips of the mastoid processes, with a catheter tip-to-line distance averaging 20% of the overall distance between the tips of the mastoid processes. According to these criteria, the catheter was properly positioned in 26 of 32 patients. In three patients, the catheter obviously was improperly positioned. Catheter position was equivocal in three other patients; in two of these patients, the catheter was looped within the internal jugular vein. Whereas for all 26 patients with properly positioned catheters values for jugular venous oxygen saturation were congruent with other laboratory data, incongruent saturation values were recorded for five of the six patients with equivocally or obviously improperly positioned catheters. CONCLUSION: Accurate assessment of the position of a jugular oxygen saturation catheter can be made by use of specific bony landmarks seen on anteroposterior radiographs of the skull.