Chest xrays

Question 1

Systematic review of chest xrays

Answer 1

DCBA (LAMDA)
Documentation
Chest (Lungs, Airways, Mediastinum, Diaphragm, And pleura)
Bones and soft tissues
Abdomen And review Areas

Question 2

Important factors to assess in “Documentation” when assessing chest xray

Answer 2

Patient details
Radiograph details (projection, side markings, position of patient)
Quality of film

Question 3

How to assess quality of chest xray film

Answer 3

Rotation
Inspiratory effort
Exposure

Question 4

How to assess rotation of Chest xray

Answer 4

Spinous process should be central between clavicles

Question 5

How to assess inflation of chest xray

Answer 5

6-7 ANTERIOR ribs above the diaphragm in adult. 5-6 in child

Diaphragm dome >1cm above costo-cardiac line

Question 6

How to assess exposure in chest xray (3)

Answer 6

1. Thoracic spinal discs should be just visible through the heart (not under exposed)
2. Pulmonary vasculature should be visible to lung periphery (not overexposed)
3. Air outside patient should be black

Question 7

Areas to assess in “chest” section of interpretation of chest xray

Answer 7

Lungs
Airways
Mediastinum
Diaphragm
And pleura

Question 8

Assessing “lungs” in chest xray

Answer 8

Compare opacity side to side using diamond shapes between ribs, then up and down.
?Opacities/lucencies
Describe lesions
If diffuse disease note pattern (interstitial v alveolar) and location (upper v middle v lower zone)

Question 9

Causes of interstitial pattern of diffuse lung disease

Answer 9

Pus (pneumonia)
Blood (haemorrhage)
Water (interstitial oedema)
Fibrosis
Malignant cells

Question 10

Appearance of interstitial disease on chest xray

Answer 10

White linear pattern

Question 11

Appearance of alveolar disease on chest xray

Answer 11

White, tiny dots which may coalesce

Question 12

Causes of upper zone fibrosis of lungs (7)

Answer 12

Silicosis
Tuberculosis
Allergic alveolitis
Ankylosing spondylitis
Wegener's syndrome
Sarcoidosis
Coal-worker's lung/pneumoconiosis

Question 13

Describing lesions on xrays

Answer 13

Seven Ss
Site
Size
Shape
Surface (distinct v regular)
Substance
Single (or multiple)
Solid (or cystic)

Question 14

Areas and what to assess when looking at airways on chest xray

Answer 14

Trachea position - central or slightly to right in normal
Main bronchi - left should be long and narrow, right short and wide
- left hilum (thus bronchus) higher than right
Peripheral bronchi
- not usually visible
- bronchiectasis = dilated, thick walls, “tram tracks”
- Air bronchograms = air filled bronchi surrounded by fluid-filled alveoli

Question 15

Structures of mediastinum (from 12 o’clock clockwise)

Answer 15

Aortic arch
Pulmonary artery
Left ventricle
Right ventricle - touches diaphragm
Right atrium - touches diaphragm
Left atrium (only if enlarged) - does not touch diaphragm

Question 16

Identifying and normal hilar points on CXR

Answer 16

<> shapes, lateral to mediastinum. Left usually slightly higher than right

Question 17

Causes of abnormal height of hilar points

Answer 17

Elevation or depression:

• collapse of lobe
• fibrotic tethering

Question 18

Causes of hilar lymphadenopathy (4)

Answer 18

Lymphoma (large, knobbly node)
Tuberculosis
Sarcoidosis (most likely to be bilateral)
Metastatic disease

Question 19

Definition and causes of flat diaphragm

Answer 19

<1cm “dome”

due to hyperinflation of lungs, usually COPD

Question 20

Causes of raised hemidiaphragm

Answer 20

Poor patient compliance/positioning
Damage to phrenic nerve (may be associated with Pancoast tumour)
Volume loss (collapsed lobe, fibrous tethering)
Congenital causes (hernia)
Pushed from below (e.g. dilated stomach)
Trauma to diaphragm (e.g. rupture with bowel herniation)

Question 21

Features to look for when assessing pleura on CXR

Answer 21

Effusions
Pneumothorax
Pleural based lesions
Pleural calcifications

Question 22

Appearance and cause of hydropneumothorax on CXR

Answer 22

HORIZONTAL meniscus of effusion, due to air AND fluid in pleural space, often occurs post drainage of effusion

Question 23

Cause of a horizontal meniscus of pleural effusion

Answer 23

hydropneumothorax often post drainage of effusion

Question 24

Appearance of pleural based lesions

Answer 24

Obtuse angle of pleura to lesion, “ball-under-carpet” sign, v pulmonary mass touching pleura (acute angle, “ball-on-carpet”)

Question 25

Where to look for pleural calcification on CXR

Answer 25

Where xray is tangential to pleura e.g. lateral edges on AP film, and above diaphragm

Question 26

What to assess Re: bones and soft tissue on CXR

Answer 26

Overall dysplasia, osteoporosis
Ribs: fractures, metastatic deposits
Shoulders: arthritic disease - may indicate rheumatoid lung disease if fibrosis present
Sternum: pectus carinatum/excavatum
Vertebra: osteophytes, previous procedures (e.g. fusion), metastatic disease
Breast tissue: ?mastectomy
Soft tissue of neck/axilla: metastatic deposits, lymphadenopathy, subcutaneous emphysema

Question 27

What to assess in ABDOMEN AND REVIEW AREAS on CXR interpretation

Answer 27

ABCD
Apices: bronchiectasis, consolidation, tumours
Behind the heart: hiatus hernia, obscuration of left hemi-diaphragm (= LLL pneumonia)
Costophrenic angles : blunting = small pleural effusion
Diaphragm (below): Free gas, appearance of liver, spleen and any bowel visible

Question 28

Causes of perihilar disease on CXR

Answer 28

AKA Batwing distribution 
Pneumocystis jiroveci pneumonia
Pulmonary oedema (cardiogenic and noncardiogenic)
Viral pneumonia
Bronchopneumonia

Question 29

What is the Golden S sign in terms of chest xrays

Answer 29

Horizontal fissure forms back to front S shape due to neoplasm in the right hilum

Question 30

Radiographic finding of neoplasm in right fissure

Answer 30

Golden S sign - horizontal fissure forms back to front S shape