Chest X Rays Flashcards
Before looking at the chest x ray
Check database - is it the right patient, date, is it a PA or AP x ray; this will affect how you interpret the x ray, are there previous images that you can compare the current one with
Considerations - size of the heart, scapular edges, AP slightly lower quality as acquired with portable machines
Viewing the chest x ray
Look at the chest x ray as if your are looking at the patient face to face
Their left (and the heart) is always on the right when viewing the image
Quality of the image
Exposure - can be changes digitally, toast, underexposed; too white, overexposed; too black
Quality of position
Check the clavicles - is the distance equal. Both sides
Shoulder rotation - is one rotated forwards compared to the other
Rotation impacts the ratios of the heart
Often unavoidable and is the normal posture of the patient
A-H approach
Airway
Bones and soft tissue
Cardiac
Diaphragms
Expansion
Fields and fissures
Gadgets
Hidden areas
Airway
Trachea and bronchi
Anything obstructing it
Straight or deviated
Central
Artificial
Pneumothorax - collapsed lung, increased pressure causes the trachea to deviate to the other side of the collapsed lung
Bones and soft tissue
Scapular, vertebra, ribs, clavicles
Pathologies - fractures, dislocations, rib crowding, previous surgery; plates, pins, cages
Soft tissue - breasts, fat, air in muscles after surgery
Cardiac
Normal - heart boarders; 1/3 to the right and 2/3 to the left, no larger than one half of the thorax
Cardiomegaly - big, huge, identified by the borders, hypertrophy of the heart
Pneumothorax - pressure pushes it over to one side
Silhouette sign - can’t see the heart boarders
Sail sign - wedge of collapsed tissue behind the heart boarder, appears like a boat sail
Diaphragms
Normal - domed, different places; right is higher than the left due to the liver, different angles
Loss of costophrenic angle - rounded, fluid build up
Expansion
Count the anterior ribs
Mid clavicular line - 5-7th rib means good expansion
The 7th rib should intersect with the diaphragm
Fields and fissures
Lung markings - fine grey lines that extend throughout the lung fields to within 2cm of the lung edge, equal density within the left and right lung fields, looking for areas that appear whiter (dense tissue/ field) or darker (air) than you would expect
Fissure - horizontal, easier to see when there is an abnormality
Gadgets
Examples - pacemaker, ECG leads, tracheostomy, chest drain, NG tube, sternal wires, ETT, spinal fixation
Hidden areas
Hidden by the - clavicles, aortic notch, heart, diaphragms
Hilar - increased density around the hiller, bats wing pattern, suggests pulmonary oedema/ fluid overload/ heart failure and increased blood glow to the area
Common abnormalities
Consolidation
Atelectasis
Pleural effusion
Pulmonary oedema
Bullae
Pneumothorax
Consolidation
Patchy opacity
May affect - one side, lobe, a whole lung or both lungs
Silhouette sign
Air bronchograms
All structures in expected position
Atelectasis
Collapse/ loss of volume
Uniform white appearance
Can be localised to one lobe or a whole lung
There may be rib crowding
Evidence of reduced expansion
Movement of structures towards the area that is more white
Pleural effusion
Blunting of the costophrenic angles
Uniform white appearance with a defined line and a meniscus
Uniform white appearance throughout a whole lung field with movement of structures away from this
Pulmonary oedema
Bilateral increased lung markings
Classically peri-hilar and shaped like bats wings
Septal (Kerley B) line - at the costophrenic angles, horizontal lines reaching the lung edge
Effusions may also be present
Bullae
Common in COPD
Areas of lung that appear more black within/ adjacent to areas with lung markings in
These areas may have defined margins
Large Bullae to both superior and mid zones
Severe chronic emphysematous changes bilateral lung fields
Increased air space opacification right mid and lower zones
Pneumothorax
There may be movement of structures away from the area that appears darker or black
3 cardinal features - 1. A clearly defined line is visible that parallels the chest wall, 2. The upper part of the line is curved at the apex, 3. There’s an absence of lung markings between the lung edge and the chest wall
