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Imaging > CXR > Flashcards

CXR Flashcards

1
Q

Which projection of CXR produces the best images of the thorax? What is the problem with this?

A

PA

Require patient to be able to stand/sit up straight

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2
Q

Why are AP CXRs less favourable for assessing the thorax?

A

magnification of heart size

position of scapulae

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3
Q

When might you perform an AP CXR?

A

In haemodynamically unstable pt

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4
Q

If a CXR isn’t marked with AP or PA, how can you tell which projection it is?

A

Scapulae are pulled almost out of lung fields in PA. Scapulae projected further in to the lungs

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5
Q

What are the key things that must be included in a CXR to make sure you have imaged full thorax?

A

both lung apices
Lateral sides of ribcage
both costophrenic angles

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6
Q

How do you assess the technical quality of a CXR?

A

RIP: rotation, inspiration and penetration

Rotation: heads of clavicles should be equidistant from the spinous processes of the vertebral bodies. If not = rotated

Inspiration: count down to lowest rib crossing through diaphragm - should show 6 anterior ribs or 10 posterior ribs.

Penetration: should be able to see vertebral bodies behind the heart
Under-penetrated = cannot see behind heart
Over-penetrated = see the vertebral bodies v. clearly

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7
Q

Why might an CXR be under-inspired?

A

Timing of X-ray (all X-rays taken at deep inspiration)

Pt. unable to take and hold a deep breath (due to pain, SOB or confusion)

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8
Q

What problems are there with interpreting an under-inspired CXR?

A

Crowding of lung markings at bases
Incorrectly giving impression of consolidation or other pathology
False impression of cardiomegaly

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9
Q

Why might a CXR be over-inflated?

A

airway obstruction eg. COPD

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10
Q

What might you see on a CXR that indicate hyperinflation?

A

More than desired no of ribs (6 anterior, 10 posterior)

FLATTENED DIAPHRAGM

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11
Q

What should you say about any obvious abnormalities you’ve spotted on a CXR?

A

Describe them:

Lung
Lobe/zone
Size
Shape (focal/diffuse, round/spiculated, well/poorly demarcated)
Density (compared to other surrounding tissue eg. more or less dense aka. increased opacity or increased lucency/reduced density)
Texture (uniform ot heterogenous)

Other features eg. bronchogram, fluid levels, volume change, boney abnormalities, surgical clips

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12
Q

After RIP and obvious abnormalities, what should you next do when interpreting a CXR?

A

Systematic review of the X-ray
ABCDD (airways, breathing, circulation, diaphragm and delicates)
Assess from zoomed-out image first, THEN close up

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13
Q

What are you looking for when assessing the ‘airways’ of a CXR?

A

trachea central? If not: rotation or pathology.

If a trachea is deviated due to pathology is it being:
pulled to one side due to volume loss? eg. lobar/lung collapse
pushed to one side due to increased volume? eg. large pleural effusion or mediastinal mass

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14
Q

What are you looking for when assessing the ‘breathing’ of a CXR?

A

Start in apices
Move down to costophrenic angles
Compare both of differences

L hilum should never be lower than R If this is the case, look for volume loss (pushing R hilum up or L hilum down)
Both hila should have same density, no lumps or convex margins

Look around edges of lungs, looking for pneumothoraces

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15
Q

What are you looking for when assessing the ‘circulation’ of a CXR?

A 
Heart size (cardiothoracic ratio >0.5/cardiac diameter > 50% of thoracic diameter = cardiomegaly)
Best to assess this is PA projection

Cardiac and mediastinal borders clearly visible
Mediastinum and heart should be positioned over thoracic vertebra (not the case: assess volume changes in lungs which might cause this)
Size of mediastinum (widening may be due to: AP projection, vascular structures (unfolding of thoracic aorta aortic dissection), masses, haemorrhage (eg. ruptured aorta)

R paratracheal stripe should be <5mm (shows tissue between medial wall of R lung and R wall of trachea)

aortopulmonary window (shows lack of tissue between aortic arch and L pulmonary artery). Lack of window: consider lymph node enlargement

Assess presence of gas in mediastinum (pneumomediastinum) - linear lucencies over mediastinum. May be associated with surgical emphysema

Whether cardiac shadow is of uniform density (if not, invert colours, could indicate retrocardiac pathology)

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16
Q

What are you looking for when assessing the ‘diaphragm’ in a CXR?

A

both hemidiaphragms should be visible and upwardly convex
flattening = lung hyper expansion eg. COPD, tnesion pneumothorax

R hemidiaphragm normally slightly higher than L due to liver. If not = ?pathological cause

Look behind diaphragm to assess base of lungs (invert image colour)

Look for free air under diaphragm

COSTOPHRENIC ANGLES reduced: pleural fluid likely

17
Q

What are you looking for when assessing the ‘delicates’ of a CXR?

A

Bones: ribs

Rib spaces (should be roughly equal). Narrowing = volume loss of underlying lung

Rest of skeleton

Signs of surgical emphysema

previous surgery: surgical clips, mastectomy etc.

18
Q

What forms the L heart border in a CXR?

A

LV

19
Q

What forms the R heart border in a CXR?

A

RA

20
Q

Where should an ET tube have its tip?

A

Proximal to the carina to ventilate both lungs

Only in one bronchi = collapse of non-ventilated lobe

21
Q

What is the correct position of an NG tube in a CXR? What are common positioning errors?

A

well below L hemidiaphragm of stomach
misplacement in to lungs
tip being within distal oesophagus

22
Q

Where is the common correct position of a central line? What are the complications associated with incorrect placement?

A

mid or lower SVC

pneumothorax

23
Q

After you have completed a systematic review of a CXR, what should you do?

A 
Review areas: 
Apices
Hila
Behind heart
Costophrenic angles
Under diaphragm
24
Q

What is the general pattern with which you should interpret a CXR?

A

Pt details
Technical quality: RIP (rotation, inspiration, penetration)
Obvious abnormality (site, size, shape, density, texture)
Systematic review: ABCDD (airways, breathing, circulation, diaphragm, delicate bits)
Lines
Review

25
Q

How might you summarise the findings of a CXR when presenting to a senior?

A 
Summary of findings
Differential list (given Hx etc.)
Whether you would like to review previous images
Further investigations
Management plan
26
Q

What might you expect to find on a CXR in a patient with pneumonia?

A

dense or patchy consolidation (usually unilateral)
bronchograms (air-containing bronchioles running through consolidated lung)

in lower zones, pneumonia may be difficult to distinguish from effusions - both should be in differentials (can also get parapneumonic effusion)

Silhouette sign (loss of silhouette of heart border or diaphragm)

27
Q

Which lobes contact the heart and diaphragmatic borders?

A

Diaphragm: R and L lower lobes (R and L hemidiaphragm respectively)

R heart border: R middle lobe

L heart border: lingual (part of L upper lobe)

28
Q

What might you expect to find on a CXR in a pt. with pleural effusions?

A

Blunting of costophrenic angles
Homogenous opacification
fluid level (meniscus)

29
Q

What might you expect to find on a CXR in a pt. with pulmonary oedema?

A

ABCDEF (may not all be present)

A: alveolar and interstitial shadowing
B: Kerley B lines 
C: cardiomegaly 
D: upper lobe venous blood Diversion (prominent upper lobe vasculature relative to lower zones)
E: effusions
F: fluid in horizontal fissure
30
Q

What might you expect to find on a CXR in a pt. with pneumothorax?

A

air within pleural space
loss of lung marking in peripheral lung field
discrete lung edge

tension pneumothorax: tracheal, mediastinal deviation, flattened ipsilateral diaphragm (BUT SHOULDN’T BE HAVING AN XRAY)

31
Q

What might you expect to find on a CXR in a pt. with lobar collapse?

A

loss of volume: raised hemidiaphragm, tracheal and mediastinal shift towards collapse side, displacement of hola, narrowing of space between ribs

32
Q

What sign should you look out for in left upper lobe (LUL) collapse?

A

Veil sign - whole lung field looks like it’s covered by a veil

Luftsichel sign - radiolucency in LU zone around aortic arch

33
Q

What sign should you look out for in left lower lobe (LLL) collapse?

A

Sail sign - sharp line like the edge of a sail AT SAME ANGLE AS HEART BORDER (double L heart border)

indistinct L hemidiaphragm border, preserved L heart border

34
Q

What sign should you look out for in right upper lobe (RUL) collapse?

A

opacification in RU zone
raised horizontal fissure (usually has concave border)
abnormality well demarcated

Golden S’s sign ( right hilar mass)

35
Q

What sign should you look out for in right middle lobe (RML) collapse?

A

depression of horizontal fissure

indistinct R heart border

36
Q

What sign should you look out for in Right lower lobe (RLL) collapse?

A

Sail sign (similar to LLL collapse)
Indistinct R hemidiaphragm
Preserved R heart border

37
Q

Which projection is usually used for abdominal X-rays?

A

AP (pt. will be supine in position)

38
Q

What should be included in the X-ray for it to be considered complete?

A

hemidiaphragm down to symphysis pubis and herbal orifices

39
Q

How should you systematically review a film of a small bowel?

A

large and small bowel
diameter of bowel
bowel wall thickness

Imaging (2 decks)

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