Interpretation of Normal Chest X Rays

Question 1

What are some indications for requesting an X-ray?

Answer 1

• Acute deterioration in SOB
• Acute chest pain
• Suspected malignancy
• Pneumonia (covid)
• Pleural disease (mesothelioma)
• Peritonitis (erect for at least 10 mins pre image)
• Chronic lung disease
• Following invasive procedure e.g. central line, chest drain

Question 2

What should you consider when looking at an X-ray?

Answer 2

• Correct patient (2 point ID)
• Correct date of the radiograph (are there any other radiographs to compare?)
• PA or AP? (Posterioanterior (from the back) Anteroposterior (from the front))
• Orientated correctly?
• Exposure?
• Rotation?

Question 3

What is the default side of a lateral CXR?

Answer 3

Left

Question 4

What is a systemic approach to searching a CXR?

Answer 4

A Airway
B Breathing
C Cardiac (heart)
D Diaphragm
E External Structures & Equipment
F Fat & soft tissue
G Great vessels
H Hidden areas

Question 5

What should you look at when considering the airway on a CXR?

Answer 5

• Check if trachea is straight
• Aim to see carina (T4)
• Right main bronchus is more vertical, wider & shorter than the left main bronchus

Question 6

What should you look at when considering the lungs (Breathing) on a CXR?

Answer 6

• Check expansion
• Anterior 6th rib should cross dome of right hemi-diaphragm
• Under-expansion
• Over-expansion

Question 7

What should you look at when considering the cardia on a CXR?

Answer 7

• Measure the heart
• Should be <50% diameter of the chest
• 1/3 should be visible to the right of the sternum (2/3 to the left)

Question 8

What should you look at when considering the diaphragm on a CXR?

Answer 8

• Right hemi-diaphragm is usually
one rib higher than the left
• Identify the gastric bubble
• Look below the right (and the left) hemi-diaphragm for air from a ruptured hollow abdominal viscus

Question 9

vWhat should you look at when considering the external structures, including hardware on a CXR?

Answer 9

• Bones
• Ribs, thoracic spine, clavicles,
scapulae & humeral heads
• Medical devices
• Oxygen tubing
• Pacemakers / heart valves / sternotomy wires
• Chest drains
• NG tubes

Question 10

What should you look at when considering the fat and soft tissues on a CXR?

Answer 10

• Look for breast shadows

* Examine subcutaneous fat for signs of surgical emphysema

Question 11

What should you look at when considering the great vessels on a CXR?

Answer 11

• Look for aortic arch, pulmonary arteries & veins in the mediastinum
• Look for calcium deposits in the elderly

Question 12

What should you look at when considering the hidden areas (commonly missed) on a CXR?

Answer 12

• Neck
• Apices
• Mediastinum: widening, adenopathy, mediastinal emphysema
• Behind the heart
• Costophrenic angle
• Behind/below diaphragm
• Soft tissues
• Bones