1. Chest X-Ray Review

2. Why order a CXR? SYMPTOMS: Bad or persistent cough Chest pain
Chest injury
Coughing up blood
Fever
Shortness of breath
S/P fall

3. Why order a CXR? Pleural effusion Lung cancer Pneumothorax
Hemothorax
Pulmonary embolus
Trauma
Monitoring chest drainage TB
Lung cancer
Chest pain (MI?)
Hypertension
Screening
Pneumonia
COPD
Asthma

4. Normal Chest X-Ray Compare symmetry
Review organs (bones, lungs, heart) in sequence
Left to Right then… Top to Bottom
Random free search
Normal Chest X-Ray
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.

5. 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?

6. 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?

7. 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.

8. 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.

9. Poor Quality CXR Supine position Semi-upright 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
Increased heart size

10. What is wrong with this lung tissue???
Missed Diagnoses
10% of all x-ray interpretations have errors
Nothing!!
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!

11. 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

12. Systematic CXR Interpretation
TECHNIQUE, cont.
Inspiration
Normal, erect, inspiratory CXR shows ribs.
Less inspiration appears diffusely denser
Diaphragms elevated causing heart & mediastinum to appear enlarged
TECHNIQUE, cont.
Penetration
Over-penetrated dark films can obscure subtle pathologies
Under-penetrated white films may given impression of diffuse increased density

13. 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!

14. 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

15. Systematic CXR 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

16. Systematic CXR Interpretation
Pulmonary vascularity
Taper at periphery
Narrow toward upper lobes with erect film
Asymmetry
Interstitial markings
Very fine
If indistinct, prominent suspect edema, fibrosis
INTERPRETATION
Mediastinum
Width
Masses
Contour
Hila
Asymmetry
Vessel aneurysm
Trachea & carina

17. CONSOLIDATION Alveolar space filled with inflammatory exudate
WBC, bacteria, plasma, and debris

18. Congestive Heart Failure
Increased heart size: cardiothoracic ratio >0.5
Large hila with indistinct markings
Fluid in interlobar fissures
Pleural effusions, alveolar edema

19. ARDS Congestion Interstitial and alveolar edema
Collapsed or distended alveoli
Bilateral

20. SARCOIDOSIS Granulomatous Inflammation
Bilateral & symmetrical hilar & mediastinal LAD
Generalized fibrosis

21. ATELECTASIS No ventilation to lobe beyond the obstruction
Trapped air absorbed by pulmonary circulation
Segmental/lobar density
Compensatory hyper-inflation of normal lungs.

22. TENSION PNEUMOTHORAX

23. PLEURAL EFFUSION

24. COPD

25. Let’s See How Much You Paid Attention

26. Right Lower Lobe Pneumonia

27. ET tube in right mainstem bronchus

28. Right side tension pneumothorax

29. Fracture of posterior rib #7

30. Right Side Pleural Effusion

31. Left Sided Pneumothorax

32. Right Squamous Cell Carcinoma

33. GOOD LUCK