Chest X-Ray

Question 1

What is represented by black on an x-ray?

Answer 1

Air

Question 2

What is represented by dark grey on an x-ray?

Answer 2

Fat

Question 3

What is represented by light grey on an x-ray?

Answer 3

Soft tissue

Question 4

What is represented by white on an x-ray?

Answer 4

Bone/fluid

Question 5

What is represented by bright white on an x-ray?

Answer 5

Metal

Question 6

Describe how you assess an x-ray for quality

Answer 6

> Check patient orientation: PA or AP
Check coverage: should show the lung apices and the costophrenic angles
Check to see if the patient is straight or rotated (rotated is indicated by rotated clavicles)
Check that there is a full inspiratory effort (should be able to count 6 ribs)
Check the penetration: you should be able to see the vertebra just behind the heart

Question 7

How do you know which orientation the x-ray is in?

Answer 7

PA is conducted when standing, and AP is conducted in bed;

In AP the heart appears larger and it can’t be commented on in this angle

Question 8

What is the mnemonic for x-ray image interpretation?

Answer 8

Airways 
Breathing
Circulation 
Diaphragm
Everything else

Question 9

How do you assess the airways in a chest x-ray?

Answer 9

Is the trachea deviated?

Do the main bronchi have a clear lumen?

Question 10

How do you assess breathing in a chest x-ray?

Answer 10

> Should be white lungs markings to the edges of the lungs
Visible hilar
Clear lung fields
Is there consolidation (diffuse whiteness due to fluid?)

Question 11

How does consolidation appear on x-ray and what may this indicate?

Answer 11

Where the small airways appear to fill with dense, white material (fluid).

This can occur in:

• Pneumonia (fluid and sometimes pus)
• Haemorrhage (blood)
• Pulmonary oedema (fluid)
• Cancer (cells cause white density)

Question 12

How may a pneumothorax present on chest x-ray?

Answer 12

There will be an asymmetric chest x-ray with lack of lung markings to the edge of the affected lung field

Question 13

How may a pleural effusion appear on x-ray?

Answer 13

There is white homogenous region with a meniscus on x-ray in the affected lung (there is fluid in the pleural space)

Question 14

What is a pleural effusion?

Answer 14

When there is fluid in the pleural space

Question 15

How do you assess circulation on chest x-ray?

Answer 15

> Is there cardiomegaly?
Is there a widened aortic knuckle?
Are there visible heart contours? (if not may be due to pathology in adjacent lung tissue)

Question 16

How do you assess the diaphragm on chest x-ray?

Answer 16

> Is it dome shaped?
Is it higher on the right (due to liver)?
Is there a gastric bubble in the stomach?
Is there any blunting of the cardiophrenic and/or costophrenic angles?
Is there air beneath the diaphragm? (MEDICAL EMERGENCY)

Question 17

How do you assess ‘everything else’ in a chest x-ray?

Answer 17

> Are there any fractures in the bones?
Are there any soft tissue swellings?
Are there any lines? (pacemaker, ECG etc.)

Question 18

How may COPD appear on a chest x-ray?

Answer 18

> Hyperinflation of the lungs (more than 6 anterior its or 8 posterior ribs are visible)
Flattening of the hemidiaphragm

Question 19

What are the classic signs of congestive heart failure on chest x-ray?

Answer 19

A - alveolar oedema
B - kerley B lines
C - cardiomegaly
D - upper lobe divisions
E - bilateral effusions