For each device: where the tip is, where it should be, and what complication it has caused — in the order endotracheal tube, central lines, nasogastric tube, chest drains, then the pneumothorax check.
Orient first
- Endotracheal tube tip about 5 cm (4–7 cm) above the carina with the neck neutral.
- Central venous catheter tip at the cavo-atrial junction or low SVC; the carina is a surrogate landmark.
- A nasogastric tube below the diaphragm, crossing the midline, tip in the stomach — a bronchial placement is a never event.
Acquire the study
- AP portable chest radiograph including the upper abdomen for the nasogastric tube; the same projection for comparison.
The manoeuvre
- Endotracheal tube: tip distance in cm above the carina; right main bronchus intubation; cuff over-distension.
- Central lines: course and tip level relative to the carina and right heart border; malposition into the azygos, internal jugular or arterial course.
- Nasogastric tube: follows the oesophagus, bisects the carina, crosses the left hemidiaphragm, tip below it on the left.
- Chest drains: side holes inside the pleural space; fissural or subcutaneous position.
- Complications: pneumothorax (deep sulcus sign when supine), haematoma, mediastinal widening.
What confirms it
- Each device tip named against its landmark on a radiograph that includes it.
What licenses you to exclude it
- A tip that is not visible has not been checked — say so and ask for the missing view.
The classic misread
- Accepting a nasogastric tube that coils in the oesophagus or enters the airway.
- Missing an arterial line course (to the left of the spine, tip in the aorta).
- Missing a supine anterior pneumothorax after line insertion.