Chest Xray Flashcards
Projection Views
Posterior-Anterior (PA)
- Xray plate is on anterior chest wall
- X ray penetrates back to front
- Pt standing
- Change on xray: Allows fuller inspiration compared to supine,
Anterior posterior
- Person supine
- Plate on posterior chest wall
- Heart is enlarged
- Change on Xray
○ Abdominal contents push hemidiaphragm up
○ Chest appears hypo inflated
Lateral view
- Plate is on left or right
How to evaluate image quality
- Rotation
RIPe
Rotation
- Patient centered or rotated
- Are the Xrays perpendicular to the patient?
- Can distort anatomy of patient (e.g. size of heart)
-Side facing the machine appears enlarged
-Check the alignment of clavicle (SC jt to spine) or evaluate length or ribs
Evaluate image quality
- Inspiration
- PTs asked to inspire during Xray
- Xray should how 9-10 ribs posteriorly or 6 ribs anteriorly
1) Front ribs angle down and back are horizontal, first posterior rib is easy to miss
2) Anteriorly, 6th rib intersects with hemidiaphragm - Tips: count the ribs and identify the 9-10 ribs post and 6 ant
1) Fewer ribs could mean decreased lung volume or abnormal max inspiration or poor image
Evaluate image quality
- Penetration
i. Did Xray penetrate well into the body?
ii. Under penetration: excessive white and over penetration: excessively black
iii. If you cant see thoracic spine through heart, under penetration
Is lungs vascular marking decreased or absent, then over penetration
What is the ABCDE of analyzing xrays
a. Airway (Trachea + bronchi)
b. Bones (ribs, scapula, clavicle, sternum, manubrium)
c. Cardiac (heart & vessel, hilum, aortic arch)
d. Diaphragm
e. Everything else + Lungs (breast shadow, bowel gas, etc)
Analyzing xrays
- Airways
- Look for deviation of trachea and bifurcation
- Relation to pathology
○ Ipsilateral deviation - pathologies that decreased pressure
Contralateral deviation - pathologies that increase pressure in hemithorax
- Relation to pathology
Analyzing xrays
- Bones
- Examine for missing fx
Assess clavicle, humerus, ribs
Analyzing Xray
- Cardiac
- Assess heart and mediastinum for size and abnormalities
- Cardio-Thoracic ratio: cardiac width shoulder be <50% of thoracic width
○ CTR> 1:2 (50%) is abnormal - All cardiac borders sharp and well defined
○ If not, positive silhouette sign
Look at cardio phrenic border
- Cardio-Thoracic ratio: cardiac width shoulder be <50% of thoracic width
Analyzing Xrays
-Diaphragm
- Right hemidiaphragm is typically higher (due to liver)
- Flattened diaphragm can suggest lung hyper inflammation
Loss of sharp border = positive silhouette sign
- Flattened diaphragm can suggest lung hyper inflammation
Analyzing Xray
- everything else
- Anatomical and non anatomical
○ Endotracheal tubes, central lines, NG tubes, implants- Lung field should be clear, uniformly dark grey and with vascular marking
○ Abnormal opacity or lucency
§ Can be fluid or air
Increases = atelectasis, consolidation, pneumonia, pleural effusion, pulmonary edema, heamothorax
- Lung field should be clear, uniformly dark grey and with vascular marking
Pathological signs
- Loss of silhouette sign - due to increase opacity
- Other signs of increased opacity (don’t need to be able to distinguish)
a. Consolidation
b. Collapse of alveoli
i. Can cause shift of trachea or mediastinum to same side
c. Lung or lobar collapse
Same side trachea or mediastinal shift - Hyper inflation
○ Ribs –> If more than 6 ant and 10 post,. can be hyper inflammation
○ Flattened diaphragm
○ Mediastinum narrowed
○ Possibly horizontal looking ribs - Signs of pleural pathology
Signs of pleural pathology
a. Fluid in pleural space (pleural effusion, empyema, hemothorax)
i. Increased opacity in pleural space
ii. Loss of costophrenic angles for erect position images
iii. Meniscus of fluid may be present (image on right)
iv. Loss of diaphragmatic border if fluid is large
v. Large ones could cause contralateral tracheal and/or mediastinal shift
vi. Loss of vascular markings
b. Air in pleural space (pneumothorax)
i. Increased radiolucency in pleural space
ii. Large ones can cause contralateral mediastinal shift
Loss of vascular markings
Signs of impaired secretion clearnce
Increased opacity
Signs of hypoventilation/reduced lung volume
Fewer ribs above diaphragm
Increased opacity (from collapse)
Sign of airflow limitation/hyperinflation
More ribs above diaphragm
Horizontal ribs
Flat diaphragm
Narrow mediastinum
