Lines and tubes: neonatal (chest radiograph)

Last revised by Dr Jeremy Jones on 19 Sep 2021

Neonatal lines and tubes are widely used in the NICU (neonatal intensive care unit) in the management of critically ill neonates. Examples include:

The NG tube serves the function of providing parenteral nutrition and a route for suction if needed. A chest radiograph (CXR) should only be used to check the position of an NG tube if clinical assessment has failed to confirm that the tube is within the stomach, e.g. testing the pH of gastric aspirate. Many nurses continue to rely on auscultation to verify NGT placement 4.

The tip of this tube should be in the stomach, past the gastro-esophageal junction. This can be seen on a CXR as a radiopaque line passing in the midline passing below the diaphragm and to the left.

The ET tube provides the ability to ventilate a neonate. Given the size of a neonate, accurate positioning of the tube may be challenging.

The tip of this tube should be in the trachea approximately midway between the interclavicular line and the carina. In older children and adults, tube tip position is dependent on head position, with the tip descending when the chin is depressed.

It is a direct venous access for administration of drugs and monitoring hemodynamic pressure changes. The tip of this tube should be in the superior vena cava. On the CXR, this position corresponds to the inner aspect of the first rib 1.

It provides a direct access for medications, fluids, blood sampling and measurement of arterial blood pressure. The tip of this tube is placed in the aorta at the level of the T6-T10 vertebrae (high position), which is the preferred position 1.

It provides vascular access for measurement of pressures and administration of fluids and electrolytes. The tip should reach the base of the right atrium or superior most part of the IVC, which is approximately at the level of T8-T9 vertebrae 1.

  • chest x-ray following the insertion of a tube or catheter is the basic investigation to be carried out for assessment of the correct placement of tubes
  • a good understanding of the normal position on the radiograph is valuable
  • in general, there should be no coiling or kink in the catheter and in case of malposition look for possible complications
  • malposition of nasogastric tube into the trachea and bronchus can lead to pneumonia and pulmonary laceration
  • vascular catheters can cause perforation of the vessel and also predispose to thrombosis

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