2Why order a CXR? SYMPTOMS: Bad or persistent cough Chest pain Chest injuryCoughing up bloodFeverShortness of breathS/P fall
3Why order a CXR? Pleural effusion Lung cancer Pneumothorax HemothoraxPulmonary embolusTraumaMonitoring chest drainageTBLung cancerChest pain (MI?)HypertensionScreeningPneumoniaCOPDAsthma
4Normal Chest X-Ray Compare symmetry Review organs (bones, lungs, heart) in sequenceLeft to Right then… Top to BottomRandom free searchNormal Chest X-RayRecognition of abnormal first requires knowledge of normal. Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.
5Chest 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?
6The Normal Chest X-RaySystematically evaluate chest wall, mediastinum, lungs, pleural space, heart, large arteries, ribs & diaphragm.Also evaluate neck, axilla, thyroid gland & abdomenWhat does air under diaphragm signify?What is best position for this diagnosis?
7The Normal Chest X-RayYou can recognize air, water & bone density on chest x-rayLung fields appear dark because of air.99% of the lung is air.
8The Normal Chest X-RayThe pulmonary vasculature, interstitial space, constitutes 1% of the lungGives a lacy lung pattern.Most disease states replace air with a pathological process which usually is a liquid density and appears white.
9Poor Quality CXR Supine position Semi-upright position Decreases lung volume, increased heart sizeBasilar infiltrates & interstitial spaces accentuatedIncreases venous return to the heartSemi-upright positionEnlarges normal structuresChanges air-fluid levelsFailure to hold breathLung structures & diaphragm blurredExpiration filmIncreased heart size
10What is wrong with this lung tissue??? Missed Diagnoses10% of all x-ray interpretations have errorsNothing!!But the clavicle is fractured!What is wrong with this lung tissue???Especially if there are multiple problems, don’t focus on the most obvious abnormality!
11Systematic CXR Interpretation IDENTIFICATIONCorrect patientCorrect date & timeCorrect examinationRight vs. Left sideComparison filmTECHNIQUEComplete exam?All viewsEntire anatomical area included?ProjectionIs the film AP or PA?The width of heart & mediastinum larger on AP filmPosition
12Systematic CXR Interpretation TECHNIQUE, cont.InspirationNormal, erect, inspiratory CXR shows ribs.Less inspiration appears diffusely denserDiaphragms elevated causing heart & mediastinum to appear enlargedTECHNIQUE, cont.PenetrationOver-penetrated dark films can obscure subtle pathologiesUnder-penetrated white films may given impression of diffuse increased density
13Systematic CXR Interpretation Order of exam is important.Start with "less significant"Tendency to stop looking as soon as find pathologyIdentify atelectasis behind heart shadow!Don’t notice tip of ET tube is in right main stem bronchus, causing the atelectasis!
14Systematic CXR Interpretation TECHNIQUE, cont.RotationDetermined by distance between spinous process & medial clavicleAffects heart size & shape, aortic tortuosity, mediastinal widening, density of lung fields