Transcript Chest X-Ray Review

Chest X-Ray Review
Why order a CXR?
SYMPTOMS:
 Bad or persistent cough
 Chest pain
 Chest injury
 Coughing up blood
 Fever
 Shortness of breath
 S/P fall
Why order a CXR?
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Pleural effusion
Pneumothorax
Hemothorax
Pulmonary embolus
Trauma
Monitoring chest
drainage
TB
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Lung cancer
Chest pain (MI?)
Hypertension
Screening
Pneumonia
COPD
Asthma
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Normal Chest X-Ray
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Compare symmetry
Review organs (bones,
lungs, heart) in sequence
Left to Right then…
Top to Bottom
Random free search
Recognition of abnormal
first requires knowledge
of normal. Over
diagnosis of normal
variation may be more
serious than omission &
may lead to needless &
harmful therapy.
Chest X-Ray
Findings
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Is heart enlarged or normal?
Signs of heart failure and
fluid overload?
Does patient have pneumonia
or collapsed lung?
Is there evidence of
emphysema?
Are there findings of an
aortic aneurysm?
Is there fluid in the sac that
surrounds the lung?
Is there free air under the
diaphragm?
Is there a tumor in the lung
that could represent cancer?
The Normal Chest X-Ray
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Systematically evaluate
chest wall, mediastinum,
lungs, pleural space, heart,
large arteries, ribs &
diaphragm.
Also evaluate neck, axilla,
thyroid gland & abdomen
What does air under diaphragm signify?
What is best position for this diagnosis?
The Normal Chest X-Ray
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You can recognize air,
water & bone density on
chest x-ray
Lung fields appear dark
because of air.
 99% of the lung is air.
The Normal Chest X-Ray
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The pulmonary vasculature,
interstitial space, constitutes
1% of the lung
Gives a lacy lung pattern.
Most disease states replace air
with a pathological process
which usually is a liquid
density and appears white.
Poor Quality CXR
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Supine position
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Semi-upright position
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Enlarges normal structures
Changes air-fluid levels
Failure to hold breath
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Decreases lung volume, increased heart size
Basilar infiltrates & interstitial spaces accentuated
Increases venous return to the heart
Lung structures & diaphragm blurred
Expiration film
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Basilar infiltrates & interstitial spaces accentuated
Increased heart size
Missed Diagnoses
10% of all x-ray interpretations have errors
What is wrong with
this lung tissue???
Nothing!!
But the clavicle is
fractured!
Especially if there are
multiple problems,
don’t focus on the
most obvious
abnormality!
Systematic CXR Interpretation
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IDENTIFICATION
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Correct patient
Correct date & time
Correct examination
 Right vs. Left side
 Comparison film
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TECHNIQUE
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Complete exam?
 All views
 Entire anatomical area
included?
Projection
Is the film AP or PA?
 The width of heart &
mediastinum larger on
AP film
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Position
Systematic CXR Interpretation
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TECHNIQUE, cont.
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Penetration
 Over-penetrated dark
films can obscure
subtle pathologies
 Under-penetrated
white films may given
impression of diffuse
increased density
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TECHNIQUE, cont.
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Inspiration
 Normal, erect,
inspiratory CXR shows
9.5-10.5 ribs.
 Less inspiration
appears diffusely
denser
 Diaphragms elevated
causing heart &
mediastinum to appear
enlarged
Systematic CXR Interpretation
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Order of exam is important.
Start with "less significant"
Tendency to stop looking as soon as find pathology
Identify atelectasis behind heart shadow!
Don’t notice tip of ET tube is in right main stem
bronchus, causing the atelectasis!
Systematic CXR Interpretation
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TECHNIQUE, cont.
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Rotation
 Determined by
distance between
spinous process &
medial clavicle
 Affects heart size &
shape, aortic tortuosity,
mediastinal widening,
density of lung fields
Systematic CXR Interpretation
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INTERPRETATION
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Extraneous material
 Contrast
 Lines, tubes, clips
 All properly located?
Soft tissues
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INTERPRETATION
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Asymmetry
 Consolidation
 Nodules, lesions
Asymmetry
 Calcifications
Diaphragms & Below
Free air
 Dilated bowel
 Abnormal position
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Lung fields
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Bones
 Fracture, dislocation
 Mineralization
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Heart
Size & shape
 Cardiothoracic ratio
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Systematic CXR Interpretation
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INTERPRETATION
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Mediastinum
 Width
 Masses
 Contour
Hila
Asymmetry
 Vessel aneurysm
 Trachea & carina
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INTERPRETATION
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Pulmonary vascularity
 Taper at periphery
 Narrow toward upper
lobes with erect film
 Asymmetry
Interstitial markings
Very fine
 If indistinct, prominent
suspect edema, fibrosis
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CONSOLIDATION
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Alveolar space filled
with inflammatory
exudate
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WBC, bacteria, plasma,
and debris
Congestive Heart Failure
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Increased heart size:
cardiothoracic ratio >0.5
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Large hila with
indistinct
markings
Fluid in
interlobar
fissures
Pleural effusions,
alveolar edema
ARDS
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Congestion
Interstitial and
alveolar edema
Collapsed or
distended alveoli
Bilateral
SARCOIDOSIS
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Granulomatous
Inflammation
Bilateral &
symmetrical hilar &
mediastinal LAD
Generalized fibrosis
ATELECTASIS
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No ventilation to lobe
beyond the obstruction
Trapped air absorbed by
pulmonary circulation
Segmental/lobar density
Compensatory hyperinflation of normal lungs.
TENSION PNEUMOTHORAX
PLEURAL EFFUSION
COPD
Let’s See How
Much You Paid
Attention
Right
Lower Lobe
Pneumonia
ET tube in right mainstem bronchus
Right side
tension
pneumothorax
Fracture of posterior rib #7
Right Side
Pleural
Effusion
Left Sided Pneumothorax
Right
Squamous
Cell
Carcinoma
GOOD LUCK