Chest X-ray Flashcards
Systematic approach to the chest X-ray
D- Details ( Name, DOB, type of Film)
R- RIP (Image quality) : Rotation, Inspiration, Penetration
S- Soft tissues and bones
A- Airway – is the trachea normal? Deviated? To which side? Is the patient incubated?
B- Breathing – are both lungs normal? Is there effusion or consolidation? Lesions? Fluffy looking areas? Any evidence of collapse
C- Circulation – Is the silhouette sign present? What is the cardiac thoracic ratio? Heart position, size and shape? Are there any lines in?
D- Diaphragm – Costophrenic angles? Is the diaphragm in its usual location/ position?
E- Everything else- anything else relevant, ECG leads, pacemaker, NG tube
Types of X-ray
PA
- x-rays from the posterior to the anterior of the patient
- image is viewed as if looking at the patient face-face
AP
- xrays pass from the anterior to posterior of the patient
- image still viewed as if the patient is face to face
- usually unwell patients
Consolidation definition
alveolar air replaced with fluid/pus extra
Lobes and fissures of the lung
Right upper lobe collapse
Horizontal fissure separates RU for ML
Collapse fissure moves upwards and medially
Right middle lobe collapse
Horizontal and oblique fissures collapse up against the heart
Loss of right cardiact sillohette and haze!! with diaphragm maintained
Right lower lobe collapse
The Right Lower lobe is a posterior structure
lower lobe collapses medially against the diaphragm (loss of diaphragm) with maintained right heart border
Sharp edge
Which type of collapse is shown
Right lower lobe collapse
Left upper lobe collapse
Oblique fissure separates the two structures
- Left upper lobe collapses forward
- densely collapsed upper lobe
- Aortic arch is aeriated (heart is anterior)
- haze!!
What type of collapse is this?
Right upper lobe collapse
What does this radiograph show?
Complete collapse of the lung
white out!
heart moves towards where it has collapsed
What does this radiograph show?
Pneumonectomy
- lung is removed
- heart moves over
- pleura not removed “heart weeps for his missing buddy” causes an effusion
- fluid is dense and therefore WHITE
How to tell the difference between pneumonectomy and complete collapse
Look at the ribs
2-5 ribs are cut out in pneumonectomy !!!
Consolidation vs collapse
AIR BRONCHOGRAMS IN CONSOLIDATION
What is another name for collapse
Atelectasis
Review areas
- apex - often obscure underlying lung
- cardiac shadow- hiding a considerable amount fo lung posteriorly
- hilar vessels - obscuring lung anteriorly and posteriorly
Abnormal masses by site of origin
- within the lung
- arising from the mediastinum
- within the plerual space
Most common cause of multiple intrapulmonary nodules
Metastases or septic emboli
Causes of cavitating masses
tumours have air inside them! hollow cavity
- abscess - most common
- necrotic tumours
Solitary masses causes
Malignancy
- primary
- secondary
Infection
TB
Causes of pulmonary massess
Bronchial carcinoma - can arise in any bronchus
- peripheral- distal bronchioles
- central
Other pulmonary masses
- benign pulmonary masses
- non neoplastic pulmonary masses
Tuberculosis
Periperal tumour
- 40-60% patients have a peripherally located mass
- round or oval
- edge is usually spiculated- term corona radiata is sometimes used
size position shape margin
Central tumour
- unilaterlal hilar enlargement
- and/or unilateral dense hilum
- mass in, or superimposed on the hilum +/- hilar lymph nodes
- obstruction of a major bronchus leads to atalectasis (reduced ventilation of affected lung) or consoldation (failure to evacuate secretions)
If no airbronchograms + collapse whats the diagnosis
- foregin body
- most COMMON CAUSE CENTRAL LUNG CANCER
Hilar masses causes
Hilar and paratracheal lymph nodes
- spread from bronchial carcinoma
- spread from other tumours
- lymphoma
- sarcoid
- TB
Mediastinal masses causes
Rule of T’s
- Thyroid
- thymus
- teratoma
- tortous aorta
Pleural lesion causes
Pleural plaques
- due to asbestos exposure
- pleural plaques that are calcified
Cystic spaces causes
- normal lung tissue destroyed
- air filled cystic spaces
- emphysema/ COPD
TB is also known as
the great mimicker
Pneumonia definition
An inflammatiory reaction in the lungs, occurs either as primary infection of the lungs or secondary to bronchial obsrtuction
Chest- xray signs of pneumonia
CONSOLIDATION
Pleural effusion
A flud collection in the space between the parietal and visceral layers of the pleura usually contains serous fluid but may have different contents
haemothorax- Blood, following trauma
Empyema - Puruelnt fluid from extension of pneumonia
hydropneumothorax- fluid and air
Pleural effusion CXR features
Pleural fluid in the erect position, gravitates to the lower-most part of the thorax
- opacity with sharp border
- loss of diaphragm sillouehette
- miniscus
Main causes of pleural effusion
- heart failure
- infection (in TB)
- malignancy (mesothelioma)
- pulmonary embolism
Pneumothorax
occurs when air enters the pleural cavity via a tear in either the parietal or visceral pleura, the lung subsequently relaxs and retracts to a varying extent towards the hilum
tension pneumothorax
A tear in the visceral pleura may act as a ball valve allowing air to enter the pleural cavity during each inspiration and none to escappe during expiration
Idopathic pulmonary fibrosis radiological features
- fine nodular and streaky linear shadowing (reticulonodular shadowing) start at bases
- honeycomb pattern- with small cystic spaces and coarse reticulodnodular shadwng
- reduction in lumb volme
- poor cardiac outline
- dilation of pulmonary vessles
Lung abscess appearance
starts as area of pneumonic consolidation with subsequent development of cavitation
Types of tubes and lines
- NG tube
- ET tube
- Central line
Use of Nasogastric tubing
- feeding
- stroke
- dysphagia
- patient on ventilator
- gastric decompression
- bowel obstruction
- administration of medicines
NGT passage
- clearest nostril
- nasopharynx
- patient to swallow if gag reflex
- oesophagus
- tip in the stomach
- confirm position
How to confirm the position of an NG tube
- aspirate content if <5.5 tip is in the stomach
- if not adequate sample request CXR
- it is mandatory to incude epigastric region in the view
NGT consequences of incorrect position
- intrapulmonary feedig
- aspiration pneumonia
Problems with NG tubing
- Impaired gag reflex (stroke, pt under GA )
- Neck/mediastinum pathology –goitre, lymphadenopathy
- Thorax deformity – kyphosis
- Hiatus hernia
