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College of Medicine: Department of Radiology

Misplaced Lines And Tubes

Last modified: October 13, 2022
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As critically infants often need life saving devices placed to reduce infant mortality and morbidity in the intensive care units, it is important to be familiar with the normal placement of these lines and tubes as a malpositioned line can have dire consequences for the patient. A simple portable chest radiograph is all that is needed to ensure proper tube positioning (1, 3). Here are some pediatric specific lines with a short discussion of their appropriate positioning:

  1. Umbilical artery catheter
    • Use – provides direct access for fast and accurate blood pressure measurement, arterial blood gas sampling and IV access for both fluids and medications in babies <5 days old
    • Placement – Passes through the patent umbilical artery and makes a U turn to enter the internal iliac artery before entering the aorta, lies posteriorly on lateral radiographs
    • Appropriate Position – avoid carotid and renal origins, can be in
      High position: T6-10
      Low position: L3-L5 (1, 2)
  2. Umbilical Venous Line
    • Use – provides direct access for parenteral nutrition, venous blood sampling and IV access for both fluids and medications in babies <5 days old
    • Placement – Passes through the patent umbilical vein into the left portal vein, ductus venosus and into the IVC through the hepatic vein, lies anteriorly on lateral radiographs
    • Appropriate Position – At the level of T8-9 (1)
      • Avoid low position in the umbilical vein, or in the portal venous system (can cause thrombosis)
      • Avoid high position in the right (or left through patent foramen ovale or atrial septal defect) atrium (can cause arrhythmia or perforation) (2)
Frontal and Cross Table X-Rays - Umbilical Lines
Frontal and cross table lateral views of the chest and abdomen in this neonate demonstrate multiple umbilical lines. Red arrow points to the malpositioned UVC catheter which is seen terminating in the portal venous system. Green arrow points to the high position (T10) of the UAC catheter (appropriate positioning).

For more leisurely reading, check out this article on Radiology Assistant to learn about all the NICU lines and tubes.

Selected References

  1. Jain, S. N. (2011). A pictorial essay: Radiology of lines and tubes in the intensive care unit. In Indian Journal of Radiology and Imaging (Vol. 21, Issue 3, pp. 182–190). Wolters Kluwer — Medknow Publications. https://doi.org/10.4103/0971-3026.8536
  2. van Schuppen, J., Onland, W., & van Rijn, R. (2020). The Radiology Assistant : Lines and tubes in Neonates. Retrieved 13 September 2020, from https://radiologyassistant.nl/pediatrics/lines-and-tubes/lines-and-tubes-in-neonates
  3. Aquino SL. Routine chest radiograph. ACR appropriateness criteria, 2006. American College of Radiology. [Last accessed on 2020 Sep 12]. Available from: http://www.acr.org.

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