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Chest X-Ray Review

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Page 1: 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

Chest X-Ray Review

Page 2: 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?

SYMPTOMS: Bad or persistent

cough Chest pain Chest injury Coughing up blood Fever Shortness of breath S/P fall

Page 3: 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?

Pleural effusion Pneumothorax Hemothorax Pulmonary

embolus Trauma Monitoring chest

drainage TB

Lung cancer Chest pain

(MI?) Hypertension Screening Pneumonia COPD Asthma

Page 4: 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

Normal Chest X-Ray

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.

Page 5: 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

Chest X-Ray

Findings

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?

Page 6: 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

The Normal Chest X-Ray 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?

Page 7: 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

The Normal Chest X-Ray

You can recognize air, water & bone density on chest x-ray

Lung fields appear dark because of air. 99% of the lung is air.

Page 8: 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

The Normal Chest X-Ray

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.

Page 9: 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

Poor Quality CXR

Supine position Decreases lung volume, increased heart size Basilar infiltrates & interstitial spaces accentuated Increases venous return to the heart

Semi-upright position Enlarges normal structures Changes air-fluid levels

Failure to hold breath Lung structures & diaphragm blurred

Expiration film Basilar infiltrates & interstitial spaces accentuated Increased heart size

Page 10: 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

Missed Diagnoses

What is wrong with this lung tissue???

Nothing!!

But the clavicle is fractured!

10% of all x-ray interpretations have errors

Especially if there are multiple problems, don’t

focus on the most obvious abnormality!

Page 11: 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

Systematic CXR Interpretation

IDENTIFICATION Correct patient Correct date &

time Correct

examination Right vs. Left

side Comparison film

TECHNIQUE Complete exam?

All views Entire anatomical

area included? Projection

Is the film AP or PA?

The width of heart & mediastinum larger on AP film

Position

Page 12: 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

Systematic CXR Interpretation

TECHNIQUE, cont. Penetration

Over-penetrated dark films can obscure subtle pathologies

Under-penetrated white films may given impression of diffuse increased density

TECHNIQUE, cont. Inspiration

Normal, erect, inspiratory CXR shows 9.5-10.5 ribs.

Less inspiration appears diffusely denser

Diaphragms elevated causing heart & mediastinum to appear enlarged

Page 13: 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

Systematic CXR Interpretation

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!

Page 14: 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

Systematic CXR Interpretation

TECHNIQUE, cont. Rotation

Determined by distance between spinous process & medial clavicle

Affects heart size & shape, aortic tortuosity, mediastinal widening, density of lung fields

Page 15: 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

Systematic CXR Interpretation

INTERPRETATION Extraneous material

Contrast Lines, tubes, clips All properly located?

Soft tissues Asymmetry Calcifications

Diaphragms & Below Free air Dilated bowel Abnormal position

INTERPRETATION Bones

Fracture, dislocation

Mineralization Lung fields

Asymmetry Consolidation Nodules, lesions

Heart Size & shape Cardiothoracic ratio

Page 16: 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

Systematic CXR Interpretation

INTERPRETATION Mediastinum

Width Masses Contour

Hila Asymmetry Vessel aneurysm Trachea & carina

INTERPRETATION Pulmonary vascularity

Taper at periphery Narrow toward

upper lobes with erect film

Asymmetry Interstitial

markings Very fine If indistinct,

prominent suspect edema, fibrosis

Page 17: 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

CONSOLIDATION

Alveolar space filled with inflammatory exudate WBC, bacteria,

plasma, and debris

Page 18: 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

Congestive Heart Failure

Increased heart size: cardiothoracic ratio >0.5

Large hila with indistinct markings

Fluid in interlobar fissures

Pleural effusions, alveolar edema

Page 19: 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

ARDS

Congestion Interstitial and

alveolar edema

Collapsed or distended alveoli

Bilateral

Page 20: 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

SARCOIDOSIS Granulomatous

Inflammation Bilateral &

symmetrical hilar & mediastinal LAD

Generalized fibrosis

Page 21: 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

ATELECTASIS No ventilation to lobe

beyond the obstruction

Trapped air absorbed by pulmonary circulation

Segmental/lobar density

Compensatory hyper-inflation of normal lungs.

Page 22: 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

TENSION PNEUMOTHORAX

Page 23: 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

PLEURAL EFFUSION

Page 24: 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

COPD

Page 25: 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

Let’s See How Much You Paid Attention

Page 26: 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

Right Lower Lobe

Pneumonia

Page 27: 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

ET tube in right mainstem bronchus

Page 28: 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

Right side

tension pneumot

horax

Page 29: 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

Fracture of posterior rib #7

Page 30: 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

Right Side

Pleural Effusio

n

Page 31: 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

Left Sided Pneumothorax

Page 32: 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

Right Squam

ous Cell

Carcinoma

Page 33: 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

GOOD LUCK


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