Chest X-ray interpretation Julee Waldrop, MS, PNP School of Nursing UNC

Chest X-ray Generally get AP and Lateral views Fullest inspiration if possible (see example of difference in expiration and inspiration in module) Dimensions A:P < 2 years – 1:1 > 2 years – 2:1

Normal Chest X-ray Cardiac Structures Position Size More central in younger infants and children More on the L side in older infants and teens Size In AP view if < 2 years – take up to ~ 65% If > 2 years - ~ 50%

Normal Chest X-ray 1. Soft tissue structures 2. Bony structures Shadows, most commonly, breast 2. Bony structures Count the ribs ~ 8 – 9 ribs should be visible on inspiration Clavicle placement at ~ 2-3 intercostal space (if not, may be malrotated)

Normal Chest X-ray 3. Diaphragm Contour Rounded with sharp pointed costophrenic and costocardiac angles Right diaphragm is usually 1-2 cm higher Blunting of costalphrenic or costocardiac angles suggests plueral effusion

Normal Chest X-ray 4. Lungs Start at the top and compare the R and L Trachea should be midline over the thoracic vertebrae and air filled Lung parenchyma becomes lighter as you go down the lung. If not, it may indicate a lower lobe or pleural effusion

Abnormal Chest X-ray Radiopacity (whiteness) means increased density Radiotranslucency (blackness) means decreased density Radiopacity can be of 3 causes Alveolar pattern – fluffy, soft, poorly demarcated opacifications < 1 cm in diameter Possible causes: Pulmonary edema Viral pneumonia Pneumocystis Alveolar cell carcinoma

Note: ground glass appearance of the lungs here Abnormalities: R side: radiolucency – air (pneumothorax) L side: “ground glass” appearance of radiopacity – pleural effusion

Tracheal deviation to the Right caused by posterior tumor Posterior chest wall tumor

Abnormal Chest X-ray Interstitial pattern Consolidation of interstitial tissue (alveolar walls, intralobular vessels, interlobar septa and connective tissue) Looks like branching lines radiating toward the periphery of the lung Possible causes: Interstitial pneumonitis Pulmonary fibrosis

Middle lobe infiltration Boot shaped heart: enlarged heart Right middle lung field infiltrate Enlarged heart

Abnormal Chest X-ray Vascular pattern – assessment of the pulmonary arteries and capillaries If there is an increase in the size of the pulmonary arteries as they extend out into the lung – pulmonary hypertension If there is a decrease in size, truncation, or obliteration of a pulmonary artery – embolus Lack of vascular making in the periphery - pneumothorax

Trace the lung vascular markings out to the border of the rib cage Trace the lung vascular markings out to the border of the rib cage. When the lung markings stop short of the rib cage and thrre is increased radiolucency in the pleural space, the patient has a pneumothorax.