Chest X-ray interpretation

Question 1

what are indications to get someone a chest x-ray?

Answer 1

• acute changes in Chest symptoms
• suspect pneumonia
• suspect cancer
• suspect pleural disease
• peritonitis
• chronic lung disease
• following an invasive procedure

Question 2

when doing a chest x-ray what are the basic things you have to get right?

Answer 2

• correct patient
• correct date of the radiograph
• PA or AP
• orientated correctly
• rotation
• exposure/penetration

Question 3

what is the problem with a radiograph that is too black or too white?

Answer 3

too black= increased translucency
too white = increased density

Question 4

what could be the cause of a chest x-ray that is ‘too black’?

Answer 4

air = collapsed lung or revealing air (not lung) on that side
loss of tissue density = bone thinning, where less white than it should be

Question 5

what could be the cause of a chest x-ray that is ‘too white’?

Answer 5

fluid = ‘effusion’ in the pleural space (consider pneumonia, heart failure, cancer)
tissue = consider cancer, TB, sarcoid

Question 6

what happens if a chest x-ray is really white?

Answer 6

unnatural?- hardware, prosthesis, piercing, artefact

• pacemaker
• endotracheal tube
• nasogastric tube
• sternal wiring
• chest drain
• prosthetic heart valve

Question 7

ABC approach to interpretation chest x-ray

Answer 7

Airway
Breathing
Cardiac (HEART)
Diaphragm
External Structures
Fat & Soft tissue
Great Vessels
Hidden areas

Question 8

what is the most commonly missed thing on a chest x-ray?

Answer 8

pneumothorax

Question 9

airway?

Answer 9

• check if the trachea is straight
• aim to see Carina (T4)
• right main bronchus is more vertical, wider & shorter than the left main bronchus

Question 10

Breathing?

Answer 10

• check expansion
• anterior 6th rib should cross dome of the right hemisphere-diaphragm
• look for under or over expansion
• remember to ask someone to take a big deep breathe in

Question 11

what are the 3 zones of the lung?

Answer 11

upper
middle
lower

Question 12

what are 2 lung markings?

Answer 12

opacity will increase from top to bottom
- lesser lung marking as you move peripherally

Question 13

cardiac?

Answer 13

• measure of the heart
• should be <50% diameter of the chest
• 1/3 should be visible to the right of the sternum (2/3 to the left)

Question 14

what are the posterior and anterior borders of the heart?

Answer 14

posterior = left atrium
anterior = right ventricle

Question 15

what are the right lateral and left lateral border of the heart?

Answer 15

right lateral = right auricle + right atrium
left lateral = left auricle + left ventricle

Question 16

what is the inferior border of the heart?

Answer 16

right ventricle + left ventricle

Question 17

Diaphragm

Answer 17

• right hemi diampghram is usually one rib higher than the left
• identify the gastric bubble
• look below the right and left hemisphere diaphragm for air from a ruptured hollow abdominal viscus

Question 18

External structures, including hardware?

Answer 18

• bones = ribs, thoracic spine, clavicles, scapulae, humeral heads
• medica devices = oxygen tubing, pacemakers, chest drains, NG tubes

Question 19

Fat and soft tissue

Answer 19

• look for breast shadows
• examine subcutaneous fat for sigs of surgical emphysema
• they could have a mastectomy?

Question 20

great vessels?

Answer 20

• look for aortic arch, pulmonary arteries and veins in the mediastinum
• look for calcium deposits in the elderly

Question 21

hidden areas?

Answer 21

• neck
• apices
• mediastinum
• behind the heart
• costophrenic angle
• bones
• soft tissue