Pediatric Endotracheal Tube Malfunction / Malposition / Misposition / Misplacement

  • Etiology: placed in patients who require ventilatory assistance
  • Imaging: endotracheal tube should usually lie over the right side of the spine and its tip should lie between the thoracic inlet and the carina, when the neck is in flexion the tip appears deeper than it really is and when the neck is in extension the tip appears higher than it really is, if the endotracheal tube does not overlie the trachea or if the endotracheal tube lies over the left side of the spine and / or if there is esophageal or gastric distension after intubation consider esophageal intubation – a lateral view is helpful in diagnosing this
  • Complications: initial malposition or subsequent migration of endotracheal tube tip to a position above the thoracic inlet, initial malposition or subsequent migration of endotracheal tube tip to a position in the right mainstem bronchus causing atelectasis or pneumothorax, initial malposition of endotracheal tube tip into esophagus causing gastric distension
  • Treatment: further advancement of proximally placed endotracheal tube, retraction of distally placed endotracheal tube, replacement of endotracheal tube in esophagus
  • Clinical: presents as difficulty in ventilating the patient

Radiology Cases of Endotracheal Tube Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Endotracheal Tube in Normal Position

CXR of correctly positioned endotracheal tube in a patient with respiratory distress syndrome
CXR AP shows the tip of the endotracheal tube to be between the clavicles and carina. The lungs are hypoinflated and there are symmetrical ground glass opacities present bilaterally.

Radiology Cases of Endotracheal Tube in High Position

CXR of a highly positioned endotracheal tube in a patient with meconium aspiration syndrome
CXR AP shows the tip of the endotracheal tube to be above the thoracic inlet. The lungs are hyperinflated and there are coarse interstitial infiltrates bilaterally.

Radiology Cases of Endotracheal Tube in Right Mainstem Bronchus

CXR of an endotracheal tube in the right mainstem bronchus
CXR AP shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is partial atelectasis of the left upper lobe and left lower lobe and mediastinal shift to the left.
CXR of endotracheal tube in right mainstem bronchus
CXR AP shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is partial atelectasis of the left upper lobe and left lower lobe but no mediastinal shift.
CXR of endotracheal tube in the right mainstem bronchus and after it is pulled back
CXR AP (above) shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is complete atelectasis of the left lung with mediastinal shift to the left. CXR AP (below) was obtained after the endotracheal tube tip had been pulled back to an appropriate position between the clavicles and the carina with subsequent complete re-expansion of the left lung.
CXR of endotracheal tube in the right mainstem bronchus and after it is pulled back
CXR AP (above) shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is complete atelectasis of the left lung with no mediastinal shift. CXR AP (below) was obtained after the endotracheal tube tip had been pulled back to an appropriate position just above the carina with subsequent near-complete re-expansion of the left lung.
CXR of endotracheal tube in the right mainstem bronchus in a patient with respiratory distress syndrome
CXR AP shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is partial atelectasis of the right upper lobe with no mediastinal shift. There are diffuse ground glass opacities present throughout the lungs.
CXR of endotracheal tube in the right mainstem bronchus and pneumothorax in a patient with respiratory distress syndrome
CXR AP shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is complete atelectasis of the left lung with no mediastinal shift. There is diffuse lucency in the right hemithorax which is also surrounding the right upper lobe.
CXR of umbilical venous catheter in right atrium and superior vena cava
CXR AP shows the tip of one umbilical venous catheter to be in the superior vena cava with the tip of the other umbilical venous catheter curled within the right atrium. The tip of the endotracheal tube is in the right mainstem bronchus. The lungs have ground-glass opacity.

Radiology Cases of Endotracheal Tube in Esophagus

CXR of endotracheal tube in the esophagus
CXR AP shows an endotracheal tube with its tip projecting over the left side of the spine with its tip beneath the carina. There is complete atelectasis of the left lung with mediastinal shift to the left. The stomach is massively distended with air.
CXR of esophageal intubation
CXR AP (above) shows nasogastric tube with its tip within a distended stomach. An endotracheal tube is present to the right of the nasogastric tube and is projecting over an air-distended esophagus. There is near-complete atelectasis of the right lung. CXR AP (below) after reintubation now shows the endotracheal tube to the left of the nasogastric tube and interval resolution of the esophageal and gastric distension.
CXR of endotracheal tube in the esophagus in a patient with respiratory distress syndrome
CXR AP shows an endotracheal tube with its tip projecting beneath the carina and not over either mainstem bronchus and a distended stomach. There are diffuse ground glass opacities present throughout the lungs. CXR lateral shows the endotracheal tube to be posterior to the trachea and in the esophagus.
CXR of esophageal intubation
CXR AP (above) shows the endotracheal tube tip projecting over the left side of the spine and a distended stomach. CXR AP (below) after re-intubation shows the endotracheal tube tip projecting over the right side of the spine and a nasogastric tube projecting over the left side of the spine in the position of the formerly placed endotracheal tube.