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PHTY3250 > ILP 4: CAL2 Chest X-Rays > Flashcards

ILP 4: CAL2 Chest X-Rays Flashcards

1
Q

What are 5 chest xray features of common respiratory conditions?

A
  1. Collapse
  2. Consolidation
  3. Pneumothorax
  4. Pleural effusion
  5. Emphysema
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2
Q

What are the 2 systemic approaches for analysing a CXR?

A
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3
Q

What is the ABCDEFGHI systemic approach to analysing CXR?

A
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4
Q

What is the RIPE systemic approach to analysing CXR?

A
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5
Q

What are 4 types of the A in the ABCDEFGHI approach to analysing a CXR?

A
  1. Admin
  2. Assessment of quality
  3. Airway
  4. Attachments
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6
Q

What are 3 types of the F in the ABCDEFGHI approach to analysing a CXR?

A
  1. Fields
  2. Fissures
  3. Foreign bodies
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7
Q

What is Admin in the ABCDEFGHI approach to analysing a CXR?

A

Ensure you have the correct patient (name, DOB, UR) and note the image date and time - this can be found on a label at top corner of the CXR. Check correct orientation of the film – view the CXR as though you are looking face on to the patient (look for an L or R).

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8
Q

What is assessment of quality in the ABCDEFGHI approach to analysing a CXR?

A
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9
Q

What is RIPE** in the **assessment of quality in the ABCDEFGHI approach to analysing a CXR?

A
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10
Q

What is rotation (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

What does this CXR show?

A

Measure the distance between the end of each clavicle and the Thx spinous processes. This distance should be equal if there is minimal rotation; or it will be increased on the side to which the patient is rotated. This patient is slightly rotated to the left.

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11
Q

What is rotation (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

What does this CXR show?

A

The distance between the end of each clavicle and the Thx spinous processes is equal. This patient is not rotated (or ‘neutral rotation’).

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12
Q

What is rotation (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

What does this CXR show?

A

In comparison, this patient is rotated to the left, shown by the increased distance between the L) clavicle and the Thx spinous processes, compared to the distance on the R).

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13
Q

What is inspiration (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

A
  • At full inspiration, apex of right hemi-diaphragm lies in the space between ribs 9-10 posteriorly; apex of the left hemi-diaphragm lies in the space between ribs 10-11 posteriorly.
  • Full inspiration is ideal, but patient may be unable to breathe in fully, eg: reduced consciousness, neurological impairment, position (supine), lung pathology, pain, infant.
  • Shallow inspiration means less lung is visible and affects contour of heart and mediastinum.
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14
Q

What is projection (& position) (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

A
  • Check how the image was projected onto the film; typical projections are postero-anterior (PA), antero-posterior (AP), lateral. Another is decubitus (side-lying).
  • The projection is usually stated on the top corner of the CXR (or if it is not stated, assume it is PA which is the standard view).
  • Check the position of patient for the CXR, eg: erect, supine, sitting, side-lying (if not stated, assume it is erect which is the standard position).
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15
Q

What are 6 features of PA view for projection (& position) (RIPE) in the assessment of quality in the ABCDEFGHI approach to analysing a CXR?

A
  1. X-ray machine is behind patient, film is at front, so beams pass from back to front (P –> A = “PA”)
  2. Preferred view (sharper, realistic cardiac size)
  3. Patient erect standing
  4. Scapulae protracted to minimize overlap with thoracic cage
  5. Size of heart & mediastinum is more realistic than AP
  6. Taken on maximal inspiration
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16
Q

What are 6 features of AP view for projection (& position) (RIPE) in the assessment of quality in the ABCDEFGHI approach to analyse a CXR?

A
  1. X ray machine is in front of patient, film is at front, so beams pass from front to back (A –> P = “AP”)
  2. Used when patient is unable to stand (or sit) for PA view (eg: in ICU, too unwell)
  3. Usually taken using a mobile system
  4. Patient may be unable to do full inspiration
  5. Dressings and lines may obstruct view
  6. The heart is enlarged because it is further from the film than in a PA view
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17
Q

What are 3 features of lateral view for projection (& position) (RIPE) in the assessment of quality in the ABCDEFGHI approach to analyse a CXR?

A
  1. Used in combination with a PA view film – to assist interpretation of the PA view
  2. Mediastinal structures are more visible in this view; useful to detect pathology in this area
  3. Orientate film with spine to the right and heart to the left (irrespective of whether film is labelled L or R)
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18
Q

What is exposure (RIPE) in the assessment of quality in the ABCDEFGHI approach to analyse a CXR?

A
  • Spine should be faintly visible behind the heart; the L hemi-diaphragm should be visible to the spine. This CXR is correctly-exposed: the spine is faintly visible behind the heart; the L hemi-diaphragm is visible to the spine.
  • *Exposure can now be easily adjusted on modern digital viewing systems, so over/under exposure is rarely a problem.
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19
Q

What is 3 types of exposure (RIPE) in the assessment of quality in the ABCDEFGHI approach to analyse a CXR?

A

If the x-ray is too white, it is under exposed / penetrated (not enough xrays pass through); If the x-ray is too black, it is over exposed / penetrated (too many x-rays pass through).

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20
Q

What is airway in the ABCDEFGHI approach to analyse a CXR?

What does the CXR show?

A
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21
Q

What is attachments in the ABCDEFGHI approach to analyse a CXR?

A
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22
Q

What is attachments in the ABCDEFGHI approach to analyse a CXR?

What do the CXR show?

A
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23
Q

What is bones & soft tissue in the ABCDEFGHI approach to analyse a CXR?

A
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24
Q

What is bones & soft tissue in the ABCDEFGHI approach to analyse a CXR?

What does this CXR show?

A

Note the angle of the ribs relative to horizontal. If the ribs are close to the horizontal, this indicates hyperinflation of the lung.

(NB: this is in the section of lungs adjacent to the ribs being observed and maydiffer in parts within the same lung).

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25
Q

What is bones & soft tissues in the ABCDEFGHI approach to analyse a CXR?

What does this CXR show?

A

Note the shape of the chest. Compare the vertical and mediolateral diameters. Increased vertical diameter is often observed in patients with emphysema. This may relate to depression of the diaphragm due to hyperinflation.

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26
Q

What is bones & soft tissues in the ABCDEFGHI approach to analyse a CXR?

What does this CXR show?

A

Observe the soft tissue (normal soft tissue appears white, as is it does not contain air). Note any breast tissue.

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27
Q

What is bones & soft tissues in the ABCDEFGHI approach to analyse a CXR?

What does this CXR show?

A

Note any abnormalities in the soft tissue, eg subcutaneous emphysema (arrows). This is air in the soft tissues (subcutaneous), so appears as black patches / shadows, around the thorax and neck.

28
Q

What is bones & soft tissues in the ABCDEFGHI approach to analyse a CXR?

What does this CXR show?

A

Note air below the diaphragm (arrows). This is a benign finding if a patient has just had abdominal surgery (eg: laparoscopy in which the abdomen is inflated with gas). In the absence of surgery, it may indicate trauma or perforation (eg, perforated gastric ulcer).

29
Q

What is cardiac in the ABCDEFGHI approach to analyse a CXR?

30
Q

What is cardiac in the ABCDEFGHI approach to analyse a CXR?

What does CXR show?

A
  • On a PA film, note the heart:thorax ratio (cardiothoracic ratio - CTR).
  • Usually, the CTR is 1:3 (or 1:2). Remember, on an AP film, the heart is magnified so cannot be used as an accurate measure.
31
Q

What is diaphragm in the ABCDEFGHI approach to analyse a CXR?

32
Q

What is the costophrenic angle of diaphragm in the ABCDEFGHI approach to analyse a CXR?

What does pathology look like?

A
  • between the ribs and diaphragm.
  • Are both sides sharp and clear?
  • Loss/blunting of this angle indicates pathology involving the lower lobe/s. Loss of an angle is called a “silhouette sign”.
33
Q

What is effusions in the ABCDEFGHI approach to analyse a CXR? What are 5 signs?

A

Pleural effusion is fluid in the pleural space.

Signs will depend on position of the patient, as the fluid will settle depending on gravity.

  1. Upright – fluid level will be visible (meniscus); may show blunting of cardiophrenic and / or costophrenic angles (depending on lobes involved)
  2. Supine – fluid may be generalized giving a hazy appearance
  3. Side-lying (decubitis) –> meniscus visible
  4. Fluid may be seen in fissures
  5. Fluid may be ‘loculated’ – contained in a “pocket” within the lung
34
Q

What is fields (lung) in the ABCDEFGHI approach to analyse a CXR?

What does the CXR show?

A
  • Now look at the lung fields.
  • Are the lungs similar in their transradiency?
  • Are any areas whiter or darker?
35
Q

What is fields (lung) in the ABCDEFGHI approach to analyse a CXR?

What does the CXR show?

A
  1. Can you see pulmonary vessels (vascular markings) in the lung?
  2. The markings are usually more prominent in the bases than in apical
  3. areas due to effects of gravity on blood flow.
36
Q

What are horizontal fissures in the ABCDEFGHI approach to analyse a CXR?

37
Q

What are oblique fissures in the ABCDEFGHI approach to analyse a CXR?

38
Q

What are foreign bodies in the ABCDEFGHI approach to analyse a CXR? What is an aspirated foreign body?

A

Check for signs of an aspirated foreign body; this is more common in infants and children (eg, small toy). The location of the inhaled object will dictate the impact (eg, the screw (3rd image) has occluded the L) main bronchus and prevents air going into the L) lung, shown by the white lung (air is black). Often (but not always) the object is inhaled into the R) middle lobe (due to the R) main bronchus being more vertical).

39
Q

What are gastric bubble in the ABCDEFGHI approach to analyse a CXR?

A

Note the gastric (air) bubble on this CXR. The bubble is generally nestled under the left hemidiaphragm, showing gas in the fundus of the stomach. This is a normal finding.

40
Q

What are hilar region in the ABCDEFGHI approach to analyse a CXR?

A

Observe the hilar region. This is a complex summation of pulmonary vessels and lymph nodes. Usually the L) is 1-2cm higher than the R). An increase in hilar density suggests pathology (eg: hypertension, calcification, enlarged nodes).

41
Q

What are impression in the ABCDEFGHI approach to analyse a CXR?

42
Q

What are 11 features of normal chest – PA CXR?

A

(A) Normal PA chest radiograph. (B) Normal structures visible on a PA chest radiograph:

  1. right atrium
  2. left ventricle
  3. right pulmonary artery
  4. left pulmonary artery
  5. air within trachea
  6. clavicle
  7. first rib
  8. lateral border of hemithorax;
  9. right hemidiaphragm
  10. costophrenic angle
  11. gastric air bubble.
43
Q

What are 9 features of normal chest – lateral CXR?

A

(A) Normal lat chest radiograph. (B) Normal structures visible on a lat chest radiograph:

  1. sternum
  2. position of left ventricle
  3. pulmonary artery
  4. air within trachea;
  5. ascending aorta
  6. inferior angle of scapula
  7. dorsal vertebra
  8. aortic arch
  9. hemidiaphragm.
44
Q

What are the 5 signs of collapse of a lung segment?

A
  1. Shift of structures towards the collapse, as there is a LOSS in lung volume.
    1. Airway (trachea)
    2. Bones (crowding of ribs)
    3. Diaphragm (elevated)
    4. Fields (vascular markings) & Fissures
      1. Increased density (whiteness) of collapsed lobe
      2. Separation of lung markings in non-involved area
    5. Hilar & mediastinum
      1. Crowding of vessels

Collapse of a lung segment is characterised by the above features.

45
Q

What signs suggest L) LL collapse in this CXR?

46
Q

What signs suggest L) lung collapse?

47
Q

What are 5 fluids that become consolidated (when air filled spaces are replaced (and become ‘solid’))?

A
  1. Water
  2. Pus
  3. Blood
  4. Fungus
  5. Gastric contents
48
Q

What is the problem with fluid that become consolidated (when air filled spaces are replaced (and become ‘solid’))?

A

The space stays ‘filled’, so there is NO shift of structures, but diaphragm may be higher on that side due to less ventilation / air entry to that area.

49
Q

What are 4 signs of consolidation?

A
  1. No shift of structures
  2. Air bronchograms (air trapped in bronchi = opaque markings as air is black on CXR)
  3. Infection = localized areas of consolidation
  4. Bronchial breathing can be heard on auscultation
50
Q

What signs suggest R) LL consolidation?

51
Q

What signs suggest R) ML consolidation?

52
Q

What is a pneumothorax?

A

Pneumothorax is air in the pleural cavity

53
Q

What are 5 signs of a pneumothorax?

A

Shift of structures AWAY from pneumothorax, as there is INCREASE in volume in that area:

  1. Airway (trachea no longer midline)
  2. Bones (widening of ribs)
  3. Diaphragm (flattened)
  4. Fields (no vascular markings; black space due to air in the pleural cavity)
  5. *Other lung may have increased vascular markings (‘hazy’) due to CO being redirected
54
Q

What signs suggest R) pneumothorax?

55
Q

What is tension pneumothorax?

A

A tension pneumothorax occurs when air is able to enter the pleural cavity (pneumothorax), but is unable to leave –> this causes large pressures (tension) within the thorax compromising the great vessels (in the hilar region).

56
Q

What are 5 signs of a tension pneumothorax? What is the management?

A

Shift of structures AWAY from pneumothorax (as before):

  1. Airway (trachea shifted)
  2. Bones (widening of ribs; +/- rib #s)
  3. Diaphragm (flattened)
  4. Fields (no vascular markings)
  5. Compression of other lung

It is a medical emergency

57
Q

What are the 6 suggesting signs of R) tension pneumothorax?

58
Q

What is pleural effusion?

A

Pleural effusion is fluid in the pleural cavity.

59
Q

What are 6 signs of pleural effusion?

A

Signs will depend on position of the patient, as the fluid will settle with gravity.

  1. Upright – fluid level will be visible (‘meniscus’)
  2. Supine – general haziness as fluid ‘spreads’ without gravity forcing it to bases
  3. Blunting of angle/s (silhouette sign)
  4. Fluid in a fissure makes the fissure easier to see
  5. May be loculated = contained in a “pocket” within the lung
  6. NO shift of structures
60
Q

What are 5 signs that indicate pleural effusion?

61
Q

What are 3 signs of a bilateral pleural effusion?

62
Q

What are 6 signs of emphysema?

A
  1. Airway = TML (but long, thin)
  2. Bones = ribs horizontal & widened
  3. Diaphragm = low, flattened
  4. Fields (lung) = hyperinflation
      • decreased vascularity
      • bullae or blebs
  5. Hilar region = long, thin mediastinum
  6. Lateral CXR = large retrosternal space
63
Q

What are 4 characteristic signs of emphysema?

64
Q

What is the ABCDEFGHI approach to analyse the CXR?

What do you think this CXR shows?

  1. R) UL consolidation
  2. R) ML consolidation
  3. L) ML consolidation
  4. R) ML collapse
A

R) middle lobe consolidation.

65
Q

What is the ABCDEFGHI approach to analyse the CXR?

What do you think this CXR shows?

  1. L) LL consolidation
  2. L) pleural effusion
  3. R) pneumothorax
  4. L) LL collapse
A

L) pleural effusion

66
Q

What is the ABCDEFGHI approach to analyse the CXR?

What do you think this CXR shows?

  1. L) LL collapse
  2. R) middle lobe consolidation
  3. R) pneumothorax
  4. R) tension pneumothorax
A

R) tension pneumothorax

67
Q

What is the ABCDEFGHI approach to analyse the CXR?

What do you think this CXR shows?

  1. L) LL collapse
  2. R) middle lobe consolidation
  3. R) pneumothorax
  4. L) lung collapse
A

L) lung collapse

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