Chest X-Ray

Question 1

How would you technically evaluate a CXR?

Answer 1

Sternoclavicular joints equidistant from the spinous process?
Clavicle in the same horizontal plane
Maximum of ten posterior ribs are visualised above the diaphragm
Ribs and t.cage only faintly visible over heart
Clear vascular markings of lungs

Question 2

Differentiate between an AP and PA CXR?

Answer 2

Scapula within lung field in AP

Ribs more parallel

Question 3

What is RIPE?

Answer 3

Rotation? medial clavicle should end equidistant from spinous process
Inspiration? 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm , poor inspiration or hyperexpanded?
Picture? Straight vs oblique, entire lung fields, scapula outside lung fields, angulation (tilt in vertical plane, for example)
Exposure (penetration)? IV disc spaces, spinous processes to T4, hemidiaphragm visible through cardiac shadow

Question 4

Explain pneumonic DRABCDE

Answer 4

Details
RIPE
Airways and Mediastinum
Breathing
Circulation (position, borders, shape and size)
Diaphragm
Extras

Question 5

What are the extras??

Answer 5

Apices- pneumothorax
Bones/soft tissue: fractures/density?
Cardiac shadow? Consolidation/mass
Diaphragm- pneumoperitoneum
Edge of image- anything unexpected?

Question 6

Key aspect of ‘details’

Answer 6

Name, DOB, sex
PA or AP, erect or supine, L/R correct? inspiratory or expiratory?
Date and time of study

Question 7

What do you need to look for in terms of airway and mediastinum?

Answer 7

Central trachea: pushed or pulled? should slightly deviate to the right around aortic knuckle
Paratrachael stripe: widened in lymphadeonopathy
Hilar regions, Left should be higher but similar density on both sides 1cm and concave to heart

Question 8

right side hilum higher?

Answer 8

upper lobe collapse

Question 9

abnormal hilium?

Answer 9

sarcoid, lung ca, lymphoma, TB

Question 10

Key things to consider regarding breathing and CXR?

Answer 10

Divide into three zones: the lower one extends beyond the diaphragm as lungs pass behind the domes of it
Right lung has three lobes and two fissures, one being horizonal separating upper and middle lone
both have oblique fissure, with own pleural covering

Look at costophrenic angles, any blunting?
Compare lung volume both sides
Start at apices and work down

Question 11

What is the Silhouette Sign?

Answer 11

“An intrathorac lesion touching a border of the heart, aorta or diaphragm will obliterate that border… An intrathoracic lesion NOT anatomically contiguous with a border of one of these structures will not obliterate that border”

Look for which borders are obscured
Work out what structure(s) normally lie at that borders
This must be the part where the mass is

Question 12

What is lobar loss?

Answer 12

Volume loss
Hyperinflation of adjacent lobes
Change in position of the hila
Effacement of certain borders – Silhouette sign
Rib crowding (if prolonged)
Underlying cause – foreign body, mass, pneumothorax

Question 13

What is the golden S sign?

Answer 13

S shape opacity in upper middle zones
Typically seen in RUL collapse
Central mass obstructing upper lobe bronchus

DDx:
BRONCHOGENIC CARCINOMA
Mets, mediastinal tumour, enlarged LN

Question 14

What should you be mindful of with regards to ‘Circulation’?

Answer 14

Are the heart borders clear, or obscured?
Is the width of the heart no more than half of the chest?
Measure the cardiothoracic ratio: the largest cardiac diameter and the largest thoracic diameter

Question 15

Stage 1 Congestive heart failure signs

Answer 15

‘Redistribution’
Redistribution of pulmonary vessels
Cardiomegaly
Broad Vascular Pedicle

Question 16

Stage 2 Congestive heart failure signs

Answer 16

'Interstitial oedema'
Kerley lines
Peribronchial cuffing
Hazy contour of vessels
Thickened interlobar fissure

Question 17

Stage 3 Congestive heart failure signs

Answer 17

'alveolar oedema'
Consolidation
Air bronchogram
Cottonwool appearance
Pleural effusion

Question 18

What are Septal/Kerley Lines?

Answer 18

Sign of interstitial oedema. Perhaps pathology of LVF caused by thickening of intertitial septa

Question 19

What is the Bat Wings pattern?

Answer 19

Alveolar oedema: caused by leaking from interstitial tissue into the alveoli and small airways, manifesting as airspace shadowing
Radiates symmetrically from the hilar regions in a bat’s wing distribution of airspace shadowing

Question 20

How would you spot pleural effusion due to LVF?

Answer 20

Heart is enlarged, and the upper zone vessels appear prominent. Obviously the costophrenic angles are blunted

Question 21

CXR of an ASD? what symptoms might you find?

Answer 21

Atrial Septal Defect: pulmonary artery large relative to aortic knuckle. Combination associated with increased pulmonary blood flow, left to right shunt

Adult patient had mild shortness of breath and a subtle systolic murmur

Question 22

Symmetrical enlargement of hilium?

Answer 22

Sacroidosis

If unilateral, tends to be cancer