Chest X-ray Interpretation

Question 1

What are the X-ray views?

Answer 1

1. Postero-anterior
2. Antero-posterior
3. Lateral
4. Lateral Decubitus

Question 2

Basic first steps of X-ray interpretation?

Answer 2

NLSIQ
1. Name
2. Lateralisation
– left and right e.g. left - cardiac shadow, gastric bubble, aortic knuckle
3. Symmetry
– distance from heads of the clavicles to the midline
4. Inspiration
– number of ribs
– anterior and posterior
5. Quality
– visualize vertebral bodies behind the cardiac shadow

Question 3

Assessing symmetry?

Answer 3

clavicles equidistant from spinous processes of thoracic spine

Question 4

Assessing quality?

Answer 4

can just see the lower thoracic spine

Question 5

What artefacts can we see on the x-ray?

Answer 5

1. Sternal wires
   - implies previous thoracic surgery
2. Tip of endotracheal tube
   - 2cm above carina

Question 6

The order to present an x-ray?

Answer 6

ABCDE
1. airway - trachea
2. breathing - lungs
3. circulation - heart
4. disability - bones
5. everything else

Question 7

Approach to the mediastinum?

Answer 7

1. Hilar vascular structures should be crisply defined
2. No widening of mediastinum
3. Trachea should be central

Question 8

Approach to the heart?

Answer 8

Occupies up to 50% of the maximum internal thoracic diameter on a standard PA erect view
Note: Cannot comment on heart size on AP view because of magnification of heart

Question 9

Approach to the lungs?

Answer 9

1. Compare upper, mid and lower zones
2. Look between ribs for lung detail
3. Remember to look “behind” the heart

Question 10

Approach to the diaphragm?

Answer 10

1. Both diaphragms should form a sharp margin with the lateral chest wall
2. Both diaphragm contours should be clearly visible medially to the spine
3. gastric bubble can be seen below the left diaphragm

Question 11

Approach to the soft tissues?

Answer 11

1. Supraclavicular fossae
   - enlarged nodes
2. Lateral chest wall
   - surgical emphysema
3. Under diaphragm
   - pneumoperitoneum

Question 11

TB on an X-ray?

Answer 11

1. segmental or lobar airspace consolidation
2. ipsilateral hilar and mediastinal lymphadenopathy
3. pleural effusion

Question 12

Pancoast tumor on an X-ray?

Answer 12

1. soft tissue opacity at the apex of the lung
2. occasionally rib involvement or extension into the supraclavicular fossa
3. calcified nodes
4. para-tracheal nodes
5. apical mass

Question 13

Miliary TB on a X-ray?

Answer 13

1. miliary pattern - 2mm nodules that histologically are granulomas disseminated like millet seeds throughout the lung
2. interstitial nodules

Question 14

Lung abscess on an X-ray?

Answer 14

1. an irregularly shaped thick walled cavity with an air fluid level
2. anterior segment of left upper lobe
3. abscess is often unilateral and single involving posterior segments of the upper lobes and the apical segments of the lower lobes

Question 15

Emphysema on an X-fray?

Answer 15

1. hyperinflation
2. barrel shape
3. low set diaphragm
4. flat diaphragm best determined by lateral chest
5. hyperlucent lung fields
6. increased AP diameter
7. increased retrosternal air
8. vertical heart

Question 16

Pericardial effusion on an X-ray?

Answer 16

enlarged cardiac silhouette