interpreting chest chest x-ray · • assess heart size • in a healthy individual the heart...
TRANSCRIPT
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INTERPRETING CHEST X-RAY
DR ODEYEMI A.O.
DEPARTMENT OF MEDICINE
COLLEGE OF HEALTH SCIENCES
BOWEN UNIVERSITY
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• How to take a standard chest X-ray (PA)
• Why is it taken PA - reduces heart magnification
• AP views are taken in the ICU and the ER
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NORMAL CHESY X-RAY (PA VIEW)
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CHEST X-RAY (AP VIEW)
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Confirm details
• Patient details (name / DOB)
• Date and time the film was taken
• Any previous imaging (useful for comparison)
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Assess image quality
• Rotation
• The medial aspect of each clavicle should be equidistant
from the spinous processes
• The spinous processes should also be vertically
orientated against the vertebral bodies.
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• Inspiration
• Number of ribs helps you determine how much lungs are
inflated.
• 9 or more posterior ribs or 7 anterior ribs = good inflation.
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• Projection
• AP vs PA film
• Tip- if there is no label, then assume it’s a PA.
• Also, if the scapulae are not projected within the chest, it’s
PA.
• Exposure
• Left hemidiaphragm visible to the spine and vertebrae
visible behind heart
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CXR interpretation (ABCDE approach)
• A - Airway
• Trachea
• The trachea is normally located centrally or just slightly off
to the right
• If the trachea is deviated, look for anything that could be
pushing or pulling at the trachea.
• Also inspect for any paratracheal
masses/lymphadenopathy
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• B - Breathing
• Lungs
• When looking at a CXR we divide each of the lungs into 3
zones, each occupying 1/3 of the height of the lung.
• These zones do not equate to lung lobes (e.g. the left
lung has 3 zones but only 2 lobes).
• Inspect each of the zones of the lung first ensuring that
lung markings occupy the entire zone.
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• Compare each zone between lungs, paying close
attention for any asymmetry (some asymmetry is normal
and caused by the presence of various anatomical
structures e.g. the heart).
• Some lung pathology causes symmetrical changes in the
lung fields, which can make it more difficult to recognise,
so it’s important to keep this in mind (e.g. pulmonary
oedema)
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Right sided pneumonia
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Lung mass probably malignant
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• Pleura
• Not normally visible, except there is an abnormality such
as pleural thickening.
• Fluid (hydrothorax) or blood (haemothorax) can
accumulate in the pleural space, causing an area of
increased opacity
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Pleural thickening in the context of mesothelioma
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• C - Cardiac
• Assess heart size
• In a healthy individual the heart should occupy no more
than 50% of the thoracic width i.e. a cardiothoracic ratio
(CTR) of <0.5.
• This rule only applies to PA chest x-rays (as AP films
exaggerate heart size)
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• If the CTR is > 0.5 (on a PA CXR) then this suggests
abnormal enlargement (cardiomegaly).
• Cardiomegaly can occur for a wide variety of reasons
including valvular disease, cardiomyopathy, pulmonary
hypertension and pericardial effusion.
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• Assess heart borders
• This should be well defined in healthy individuals
• The right atrium makes up most of the right heart border.
• The left ventricle makes up most of the left heart border.
• The heart borders may become difficult to distinguish from
the lung fields as a result of various pathological
processes (e.g. consolidation) which cause increased
opacity of the lung tissue
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Cardiomegaly
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• D - Diaphragm
• The right hemi-diaphragm is in most cases higher than
the left in healthy individuals (as a result of the underlying
liver).
• The stomach underlies the left hemi-diaphragm and is
best identified by the gastric bubble located within it.
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• The diaphragm should be indistinguishable from the
underlying liver in healthy individuals on an erect CXR
• Air may accumulate under the diaphragm causing it to lift
and become visibly separate from the liver(often as a
result of bowel perforation)
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Air under the diaphragm (pneumoperitoneum)
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• Costophrenic angles
• The costophrenic angles are formed from the dome of
each hemi-diaphragm and the lateral chest wall.
• In a healthy individual the costo-phrenic angles should be
clearly visible on a normal CXR as a well defined acute
angle.
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• Loss of this acute angle (sometimes referred to as
costophrenic blunting) can suggest the presence of fluid
or consolidation in the area.
• Costophrenic blunting can also occur secondary to lung
hyperinflation (seen in diseases such as COPD) as a
result of diaphragmatic flattening and subsequent loss of
the acute angle.
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Costophrenic blunting secondary to pneumonia
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Massive left sided pleural effusion
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• E - Everything else
• Aortic knuckle:
• Left lateral edge of the aorta as it arches back over the
left main bronchus.
• Loss of definition of the aortic knuckles contours can be
caused by an aneurysm.
• It may also be unfolded
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• Bones
• Inspect the visible skeletal structures looking for any
abnormalities (e.g. fractures / lytic lesions).
• Soft tissues
• Inspect the soft tissues for any obvious abnormalities (e.g.
large haematoma)
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