Chest XR Flashcards
Interpreting CXR.
- RIP RIPE ABCDE
- Right patient?
- Inclusion - can you see all the relevant anatomy? (costophrenic angles, clavicles, etc.)
- Projection - PA (if not specified on image, it is PA), AP (if supine/ resus - likely AP), lateral, etc.
- Rotation (spinous processes should lie halfway between medial ends of the clavicles)
- Inspiration (diaphragm should be bisected in the midclavicular line by rib 5, 6 or 7. <5: under-expansion; >7: hyper-expansion. A better way of assessing hyperexpansion is if the hemidiaphragms are flattened)
- Penetration (Is the left hemi-diaphragm visible up to the vertebral column? Can you see ribs behind heart? Can you see the spinous processes?)
- Exposure: under-exposed (too dark), over-exposed (too bright), or just right
- Airway - tracheal deviation, tubes
- Breathing - lung fields (pneumothorax), hilum, apical, upper, middle and lower zones
- Circulation - heart and aortic knuckle; cardiomegaly
- Diaphragm - angles, elevation, pneumoperitoneum
- Everything else - tubes, bones (fractures of ribs, shoulders, clavicles), check everything again
RML vs RUL vs RLL pneumonia
RML - Obscured right heart border
RLL - Obscured right hemidiaphragm
Homogenous whiteout of the lung fields
a) Mediastinum central - DDx?
b) Mediastinum shifted towards side of whiteout - DDx?
c) Mediastinum shifted away from side of whiteout - DDx?
a) Consolidation (infection), mass (e.g. mesothelioma)
b) Lung collapse, rarer: pneumonectomy, pulmomary agenesis/ hypoplasia
c) Pleural effusion
Chest drain insertion - landmarks
5th IC space
Base of axilla
Lateral edge of latissimus dorsi
Lateral edge of pectoralis major
Widespread bilateral patchy alveolar shadowing
a) diagnosis
b) management (OMFG Sit them up)
c) distinguishing cardiogenic from non-cardiogenic
a) Pulmonary oedema
b) Rx: Oxygen Morphine Furosemide GTN Sit up
c) - Cardiogenic: generally more homogenous opacities, will likely also have cardiomegaly, kerley B-lines, fluid in the fissure, upper lobe diversion, pleural effusions, etc. (ABCDE)
- Non-cardiogenic: more patchy opacities, will lack cardiac features, air bronchograms may be visible
Widespread bilateral multiple rounded opacifications
- likely diagnosis?
- secondary to…?
Cannonball mets
Renal cell Ca
Cavitating pneumonia
- 2 causes
- differential
- Staph aureus, klebsiella
- TB - Ghon’s focus
NG tube
- checking placement
- Aspirate - pH: < 5.5 then safe placement (note: if on PPI/H2RA then could have safe placement with higher pH)
- CXR - should bisect the carina; tip of NG tube should be visible below level of diaphragm
Note: if feeding through NG - must do CXR beforehand as feeding into lung is a never event
Signs of heart failure (ABCDE)
- explain the appearance on CXR of each one
- Alveolar oedema - patchy bilateral opacities
- Kerley B lines - thin lines of opacity extending out from the pleura, perpendicular to them
- Cardiomegaly - cardiothoracic ratio > 0.5
- Upper lobe diversion - stag antler sign (prominent vessels, not necessarily fluid filled; reflect increased left atrial pressure)
- Pleural effusions - blunting of costophrenic angles, homoegenous whiteout of lung fields
Sequence of pulmonary oedema: perihilar haze»_space; Kerley B lines»_space; pleural effusion»_space; bat wing oedema (relative sparing of apex and bases)
What findings may be found on CXR of someone exposed to asbestos?
Pleural plaques
Pneumonia on CXR - possible findings
- Consolidation
- Air bronchogram (visible airways; also caused by non-cardiogenic pulmonary oedema)
- Effusion/ empyema
When should you do a CXR in the context of suspected rib fractures?
If worried about pneumothorax/ haemothorax
Lung zones
- Apical (supraclavicular) - look for pneumothorax/ mass
- Upper zone - clavicle to hilum
- Mid zone - level of hilar structures
- Lower zones - bases
Pleural effusion vs elevated hemidiaphragm
Effusion - meniscus sign; blunting of CP angles
Consolidation in the upper zone with hilar enlargement - possible diagnosis?
a) If unilateral
b) If bilateral
a) TB, primary lung malignancy
b) Sarcoidosis, lung secondaries
Hilar lymphadenopathy: differentials
- Sarcoidosis
- Infection: TB, mycoplasma
- Malignancy: lung, lymphoma, leukaemia
- Heart failure
Presenting a CXR.
- prior to ABCDE, what should you comment on?
Introduction:
- Confirm Patient Details
- Indication for CXR (brief history)
Projection:
- AP or PA (if it doesn’t say, the scapulae are more within the lung fields in an AP film and out of the way in a PA)
- Erect or supine
Quality of the film • Rotation • Inspiration (No of ribs) • Penetration • Exposure • Adequacy of the film?
Request to see the previous CXR
“The first observation to comment on…”
“… but going through the radiograph systematically…”
ABCDE
Presenting a CXR: airway (A)
- 2 thing to comment on
The trachea is…
- central, or deviated to the…
Mediastinum is…
- wide, or normal width
- central, or deviated to the…
Presenting a CXR: breathing (B)
a) Begin by commenting on the…?
b) Comment on any areas of…?
c) And state explicitly if there is or isn’t a…?
d) Comment on lung volume
e) Other things to comment on (2)
a) Upper, middle and lower lung fields
b) Areas of opacification / radiolucency
c) Pneumothorax (check apices as well)
d) Hyperinflation / Reduced lung volume
e) - Pleural markings – thickened?
- Pulmonary vascularity
- Hilar structures (bronchi, pulmonary veins and arteries, hilar lymph nodes) – size, shape, position
Presenting a CXR: circulation (C)
a) 3 things about the heart to comment on (1 will depend on if it is AP/PA and any rotation)
b) Other possible features to pick up on
a) - Heart size – enlarged (cardiothoracic ratio) - may be falsely enlarged in AP film or if rotated to the left
- Heart borders – RA, RV, LA, LV (may be obscured if there is consolidation)
- Heart position? – any displacement?
b) - Anything behind the heart?
- Aortic knuckle
- Hiatus hernia - gas above diaphragm in the cardiac area
Presenting a CXR: diaphragm (D)
a) 3 things to comment on
a) - Costophrenic angles - are they well-defined or blunted/obliterated (?pleural effusion) - note: hyperexpanded lungs will blunt the costophrenic angles
- Hemidiaphragm elevation or not (could indicate phrenic nerve palsy - may be due to mass compressing/eroding - differentiate from pleural effusion)
- Pneumoperitoneum or not (important negative)
Presenting a CXR: everything else (E)
a) Firstly, comment on…?
b) What other things should you comment on if seen? (if not seen, say…?)
a) Bones and soft tissues
– bony lesions? #s? (“imaged skeleton is intact)
- cervical rib?
- spine - scoliosis
- surgical emphysema - gas (black) in SC fat
b) - Vascular lines - CVC, PICC
- Tubes - NG, ETT, tracheostomy
- Surgical clips / wires (eg. median sternotomy)
- Other - PPM, SVC filter, cardiac monitoring
Summarising a CXR.
- The type of radiograph
- The patient details and indication
- The salient positive findings
- The important negative findings
- Comparison with previous CXR?
- The differential diagnosis
For a 74 year old man who had an erect AP CXR for ?LRTI (2/7 profuctive cough and SOB) and found LLZ consolidation but no other abnormality
In summary,
- This was an erect AP chest radiograph
- … of a 74 year old gentleman with a 2/7 history of productive cough and SOB (and no prior PMHx)
- Which found an area of increased opacity in the left lower zone, but no other findings.
- There were no effusions or pneumothoraces
- Given the history, this CXR is consistent with an area of LLZ consolidation, likely due to bacterial pneumonia
- I would like to compare this to previous CXRs
Talking about lung shadowing.
a) Types of consolidation
b) Homogenous vs heterogenous
c) Interstitial vs. alveolar
d) When should patients with consolidation have repeat CXR?
a) Focal vs diffuse/patchy
- also consider bronchopneumonia vs lobar pneumonia
- multiple foci - consider lung mets
b) - Homogenous - effusion, collapse
- Heterogenous - if multiple foci, consider lung mets
c) Interstitial:
- Reticular: too many lines (DDx: IPF, connective tissue disease)
- Nodular: too many dots (DDx: miliary TB, lung mets, rheumatoid nodules)
- Reticulonodular: too many lines and dots
Alveolar:
more fluffy, cloud-like (DDx: pulmonary oedema)
d) 6 weeks later
