Chest X-ray

Question 1

What does the DRSABCDE of the CXR stand for?

Answer 1

Details
RIPE (rotation, inspiration, picture, exposure)
Soft tissue and bone
Airways and mediastinum
Breathing
Circulation
Diaphragm
Extras

Question 2

How many ribs should be visible in full inspiration on CXR?

Answer 2

5-6.5 anterior ribs

8-10 posterior ribs

Question 3

How can you tell if the film is appropriately exposed?

Answer 3

• spinous processes to ~T4

- L hemi-diaphragm visible through cardiac shadow

Question 4

What should be noted when looking at the soft tissue?

Answer 4

Is there any:

• swelling
• subcut air
• symmetry
• masses

Question 5

What should be noted when looking at bone?

Answer 5

• fractures
• dislocations
• hyperdensities
• lytic lesions
• symmetry

Question 6

At what level does the trachea bifurcate?

Answer 6

T4-5 (starts at C6)

Question 7

At what level are the hilums?

Answer 7

T6-7 intravertebral disc (left hilum is 2cm higher than the right)

Question 8

Is the hilum higher on the left or right?

Answer 8

Left by ~2cm

Question 9

What should be looked for in the lung fields?

Answer 9

• vascularity
• pneumothorax
• lung field outlines
• R lung horizontal fissure
• pulmonary infiltrates
• coin lesions
• cavitary lesions

Question 10

What is normal vascularity of the lungs?

Answer 10

• vessels to 2cm of pleural surface (3cm in apices)

- vessels in bases > apices when erect

Question 11

Describe the normal heart position?

Answer 11

1/3 to the right, 2/3 to the left

Question 12

normal cardiothoracic ratio?

Answer 12

<0.5 on PA film

Question 13

What extras may be seen on CXR?

Answer 13

• metal work
• pacemaker
• central venous catheter
• nasogastric tube
• chest drain
• endotracheal tube

Question 14

What are 3 causes of small lung volumes (ant ribs <5)?

Answer 14

• pulmonary fibrosis
• kyphosis
• atelectasis

Question 15

What is a major cause of large lung volume (ant ribs >7)?

Answer 15

COPD

Question 16

What makes the heart appear larger on CXR?

Answer 16

• supine (heart rotates to the left)
• AP projection
• if supine and AP -> adds 20% diameter
• poor inspiration

Question 17

What are some issues with the supine film?

Answer 17

• heart appears larger

- lungs appear small and congested due to the dependent posterior veins

Question 18

What are 5 causes of increased opacity in the lung fields?

Answer 18

• pleural fluid
• atelectasis
• fluid or cells in the airspaces
• fluid or cells in the lung interstitium
• tumours or other masses in the lung

Question 19

What are 4 causes of increased lucency in the lung fields?

Answer 19

• pneumothorax
• bullous emphysema
• lobar collapse
• PE

Question 20

What is the correct position of the central venous catheter (CVC)?

Answer 20

tip should be at about the level of the carina

Question 21

What is the correct position of the endotracheal tube? and what is the issue if its too far down?

Answer 21

• 5cm above the carina (up to 2cm)
• if its too close to the carina it runs the risk of slipping into one bronchus and overventilating one lung whilst underventilating the other

Question 22

What is the correct position of the nasogastric tube?

Answer 22

• inferior to the diaphragm