Review chest X-ray By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP Lone Star College: Kingwood Respiratory Care Program

1. In the chest x-ray of a person with pneumocystis carinii pneumonia (PCP) one would most likely see______ because this diseases progresses rapidly to ARDS. a. lobar consolidation b. pneumomatoceles c. Kerley B lines in the bases d. left-sided effusions e. diffuse tiny opacities & air bronchograms

answer e. diffuse tiny opacities & air bronchograms because this is what we see in an alveolar problem. We would see this in any diffuse pneumonia or in ARDS or IRDS.

2. In the chest X-ray of a person with staphylococcal pneumonia one would most likely see : a. lobar consolidation b. pneumomatoceles c. Kerley B lines in the bases d. left-sided effusions e. diffuse tiny opacities and air bronchograms

answer b. Pneumomatoceles a pneumomatocele is a air-filled cavity that shows up in 24 hours or less. They will be seen in staph pneumonia and in aspiration of hydrocarbons.

3. In the chest X-ray of the patient with left sided pleuritic pain and diminished LLL breath sounds, one might expect to see: a. LUL consolidation b. pneumomatoceles c. Kerley B lines d. left-sided effusions e. diffuse tiny opacities and air bronchograms

answer d. left-sided effusions Effusions will be seen as homogenous opacities that collect in the plural space in the dependent part of the thorax. One would have dullness to palpation and chest pain from the pluresy that would accompany the effusion

4. Kerley B lines are seen: I. when alveoli are full of fluid ii. when interstitial spaces are edematous iii. in tuberculosis iv. in pulmonary edema a. i and iv b. ii and iv c. iii only d. iii and iv

answer b. ii and iv Kerley B line are short, horizontal lines seen on the bases of the lung. The lines reflex thickened alveolar septal walls. They are seen in diffuse interstitial disorders such as interstitial pneumonia, pulmonary edema [interstitial and alveolar filling patterns]

5. One would see an air bronchogram at the level of the RML in an area of: a. consolidation b. air trapping c. atelectasis d. abscess

answer Consolidation Consolidation is an alveolar filling pattern where the air is replaced by fluid. Fluid is white [opaque] on the X-ray Because the airway is black, we now see the airway against the white opacities

6. Persons with emphysema would most likely have the following on chest film: a. right-sided pleural effusion b. bullea/ bleb c. Kerley B lines d. abscess

answer b. bullea/ bleb Is an air pocket, seen in serious airtrapping. These will be seen in empysema and COPD.

7. Within a few hours of the incident, a baby who has aspirated a toy would most likely have distal to the obstruction: a. consolidation b. a cavitation c. atelectasis d. abscess e. a or c are both possible

answer e. a or c are both possible If the baby inhales a foreign object that completely cuts off gas flow to the lower airways, then there will be atelectasis If the object only causes a ball-valve obstruction, the there can be localized airtrapping below the object

8. If one sees homogenous opacities in the RML & narrowed intercostal spaces overlying this area, one is seeing: a. RML consolidation b. localized RML airtrapping c. RML atelectasis d. a RML mass

answer c. RML atelectasis One of the signs of atelectasis is a movement of adjacent objects into the place where the lung has collapsed. Ribs will be closer together and fissures may move toward the atelectasis While atelectasis is opaque like consolidation, there will be no air-bronchograms in atelectasis It is possible to have both atelectasis and consolidation in the same patient with many alveolar disorders

9. A thick walled opacity with an air/fluid interface is most likely: a. consolidation b. a mass c. atelectasis d. abscess e. b or c are possible

answer d. abscess An abscess is a thick-walled opacity that is filled with pus. It is caused by a necrotizing bacterial pneumonia. If the abscess ruptures into an airway, we might see the air/fluid interface inside the abcess

10. A tumor compressing the RUL bronchus could result in: a. RUL abscess b. RUL consolidation c. RUL atelectasis d. both a and b e. both b and c

answer e. both b and c Just like the F.O. a tumor compressing the airway can cause atelectasis & consolidation downstream If the tumor is smaller, it might cause a ball valve obstruction and result in a localized airtrapping and you might hear a wheeze over one spot—that will not respond to bronchodialators

11. When compared to viral pneumonia, bacterial pneumonias are more associated with: i. diffuse alveolar opacities with air bronchograms ii. localized alveolar opacities with air bronchogram iii. abscesses iv. cavitations a. i, iii b. ii, iii c. ii, iii and iv d. i only

answer c. ii, iii and iv Viral pneumonias tend to be diffuse, while bacterial pneumonias will be characterized by local problems such as abscesses, effusions or cavitations

12. Immediately after drainage of a small right-sided empyema by needle aspiration, a AP chest film is ordered. You see an area of hyperlucency without lung markings in the RUL. The heart shadow is almost completely to the left of the sternum. What has happened? a. the needle has successfully aspirated the fluid from the empyema b. the needle was too small, the fluid is too thick and the aspiration attempt was not successful. A chest tube must be inserted. c. the needle has punctured the lung and a tension pneumothorax has resulted

answer c. the needle has punctured the lung and a tension pneumothorax has resulted The heart has shifted, and the hyperlucency is air in the chest. This is a common hazard of thoracentesis. All procedures involving a needle and the chest must be followed by a chest x-ray to rule out pneumothorax

13. Immediately after the insertion of a flow directed pulmonary artery catheter, a chest film is ordered. You see a radiopaque line enter the right subclavian vein and you see that the tip of the catheter is in the right atrium. a. the catheter has migrated into the wedged position b. the catheter is not inserted far enough c. the catheter is in the proper position d. the catheter has transected the right subclavian vein

answer c b. the catheter is not inserted far enough The RA is an excellent position for a central line but the pulmonary artery catheter should sit in the pulmonary artery

14. Immediately after a right-sided chest tube has been removed from the 3rd intercostal space in the anterior, a chest film is ordered. You see that there are lung markings from the hilar down to the pleura in the right apical area. This probably means that: a. the effusion has returned, the chest tube may need to be reinserted. b. the pneumothorax has returned, the chest tube may need to be reinserted. c. there in now a pulmonary infarction in this are d. the pneumothorax has resolved

answer d. the pneumothorax has resolved You want to see lung markings all the way to the plural. We know that the most common site for a chest tube to drain a pneumothorax is in the anterior upper chest

15. Signs of cardiogenic pulmonary edema include the following: i. Kerley B lines ii. cardiomegaly iii. increased opacities in the hilar area, in a butterfly pattern iv. segmental airtrapping a. i, ii, iii and iv b. ii, iii only c. i, ii only d. i, ii, iii

Answer d. i, ii, iii In all pulmonary edema we will see alveolar filling patterns and thickened alveolar septal walls, but if the heart is enlarged, it is cardiogenic pulmonary edema Another sign it is cardiogenic is the butterfly pattern [or bat wing] created by engorged pulmonary arteries

16. Air bronchograms are seen in cases of alveolar consolidation, because the opacity of the consolidation creates a contrast to the radiolucency of the airway as it lies over the area of consolidation. a. true b. false

Answer a. true Just like a black cat disappears in a dark room, we don’t normally see the black airways against black [air filled] alveoli if the alveoli are filled with fluid we now see the black airways against the opaque

d. no other lung disorder Diffuse lesions of tiny opacities of less than 4 mm in diameter are seen in varicella pneumonia. This is also seen in: diffuse pulmonary tuberculosis multiple fat emboli c. ARDS d. no other lung disorder

Answer diffuse pulmonary tuberculosis When one has dissiminated TB, there are tiny opacities that look like millet seeds. This is seen in chicken pox pneumonia also…very bad sign

18. It is not possible for one to have a combination of diffuse interstitial and alveolar filling patterns in the same patient who is diagnosed with non-cardiogenic pulmonary edema. a. true b. false

Answer False Because both interstitial and alveolar filling patterns are seen in problems with the alveoli, you can have both show up in the X-ray. These persons will have low compliant lungs and refractory hypoxemia

19. A person who has flattened diaphragms with wide intercostal spaces and bronchial thickening would most likely have: a. emphysema b. bilateral pneumothorax c. bilateral effusions d. a lobectomy e. pulmonary infarction

Answer a. emphysema the intercostal spaces are widened by airtrapping, the bronchial walls are thickened by secretions and the diaphragm has been pushed down by the airtrapping

20. The mediastinal structures tend to shift towards a : a. pneumothorax b. an area of airtrapping c. an area of atelectasis d. an area of consolidation e. c and d

Answer c. an area of atelectasis Structures move away from pneumothorax or from airtrapping Nothing moves in consolidation

21. Mr. Reese had a LLL lobectomy 21. Mr. Reese had a LLL lobectomy. Several months after this surgery, one would not be surprised to find what abnormal findings on a PA chest film ? a. the LUL seems smaller or seems pulled to the right b. the LUL seems to be larger and it's inferior borders seem to bulge into the space where the LLL used to be. The heart seems to be more on the left than normal c. there is a hyper-lucency in the LLL and the left hemi-diaphragm is depressed d. there will be no changes

Answer b. the LUL seems to be larger and it's inferior borders seem to bulge into the space where the LLL used to be. The heart seems to be more on the left than normal Remember: objects move into a vacuum when the lung is removed, the other lobes move into the area—the fissures will be altered

22. When looking at a RUL pneumothorax, one would expect to see: i. hyperlucency without lung markings in the RUL ii. hyperlucency without lung marking in a column on the right side of the heart. iii. the superior aspect of the RML may be opaque iv. the 3rd-5th right intercostal spaces will be closer together than the same intercostal spaces on the left a. i, iii only b. ii, iii only c. i, iv only d. i, iii and iv

Answer a. i, iii only Pneumthorax always show up as hyperlucency The air would push on the superior aspect of the RML so that it starts to collapse. It will become opaque

23. When the right hemi-diaphragm is paralyzed, one would see what derangement on the PA chest film during the inspiratory phase? a. the right hemi-diaphragm is 2 cm higher than the left b. the right hemi-diaphragm is 2 cm lower than the left c. the right hemi-diaphragm is 4 cm higher than the left d. the right hemi-diaphragm is 4 cm lower than the left

Answer c. the right hemi-diaphragm is 4 cm higher than the left This is tricky. Remember: the normal position for the right hemi-diaphragm is to be 2 cm higher than the left. When the diaphragm is paralyzed, it sits in the resting position which is up so the right is higher than it should be.

24. A homogenous opacity located in the basal aspect of the LLL which causes the costophrenic angle to be blunted would most likely be a (an): a. LLL consolidation b. LLL atelectasis c. left sided effusion d. none of these

Answer c. left-sided effusion Blunting of the costophrenic angle is caused by fluid in the plural cavity. Fluid is opaque.

25. If you were to see an area in the LUL, which you would describe as a sharp and distinct round opacity you might be describing a/an: a. cavitation b. pneumatocele c. bullae or bleb d. abscess without an air/fluid interface e. an abscess with an air/fluid interface

Answer d. abscess without an air/fluid interface Cavitations, bullae or blebs & pneumatoceles are all black because they are filled with air

26. A mass is: i. a sharply demarcated homogenous opacity ii. a sharply demarcated hyperlucency iii. less than 4 cm in diameter iv. more than 4 cm in diameter a. i, iv b. ii, iv c. i, iii d. ii, iii

Answer b. ii, iv The only difference between a nodule and a mass is the size. Both are opacities that replace normal tissue

27. Wide-spread multiple nodules of less than 4 mm in diameter are called a milliary pattern. a. true b. false

Answer True Tiny opacities look like millet seeds

28. The presence of a single nodule in the lung fields is: a. never a sign of bronchogenic carcinoma b. always seen in bronchogenic carcinoma c. is most likely not lung cancer if it is calcified

Answer c. is most likely not lung cancer if it is calcified Single nodules may or may not be cancer, but they are less likely to be if they are calcified

29. You view a PA upright chest film 29. You view a PA upright chest film. The heart is 12 cm wide and the internal diameter of the thorax is 20 cm wide. a. there is cardiomegaly b. there is hepatomegaly c. the heart size is WNL

Answer A. cardiomegally The heart should be able to fit into the internal chest at the level of the diaphragms twice. If not, there is cardiomegally. This is also called the CT ratio [cardiothoracic ratio] 1:2 is normal

30. To find a mass that is pushing the trachea toward the anterior you would require a type of x-ray. a. apical lordotic b. lateral chest c. bronchogram d. lateral decubitus

Answer b. lateral chest A side view would see the object that is shifted forward or backwards from its normal position

31. Normally the right hilum is at least: a. 2 cm higher than the left b. 2 cm lower than the left c. 5 cm higher than the left d. 5 cm lower than the left

answer The left hilum is pushed up to make room for the heart b. 2 cm lower than the left The left hilum is pushed up to make room for the heart

32. To visualize an apical mass better one might want to see a x-ray. a. apical lordotic b. lateral chest c. bronchogram d. lateral decubitus e. PA standard upright

answer a. apical lordotic This view looks up at the apical area from an angle that spreads out the structures so that mass in the apical area could be seen better if it was hidden behind something

33. Of the following x-ray densities, which is the MOST RADIO-LUCENT? a. water b. air c. bone d. fat e. tissue

answer b. air Radiolucent is black, so air is the darkest Metal is most opaque, then heart, then thicker fluid.

34. When viewing a PA standard, if the sternal notch does NOT lie over the vertebral column and the left clavicle is 2 cm higher than the left, the Xray is: a. an example of good technique b. not well centered c. over penetrated d. under-penetrated e. done on exhalation, not end inspiration

answer b. not well centered Like any photograph if the picture is lined up right, the sternum should be right over the vertebral column

35. When viewing a PA standard, if the diaphragms extend only to the level of the 4th anterior intercostal space, this chest film is: a. an example of good technique b. not well centered c. over penetrated d. under-penetrated e. done on exhalation, not end inspiration

answer e. done on exhalation, not end inspiration On a deep inspiration the diaphragm should be down to the level of the 6th – 6th intercostal spaces

36. If you are unable to tell if the patient has suffered a pneumothorax or has airtrapping because of the general darkness of the film, your x-ray is : a. an example of good technique b. not well centered c. poorly penetrated d. a bronchogram e. done on exhalation, not end inspiration

answer poorly penetrated Like any other photograph, an X-ray can be over-exposed or under-exposed. Both are problems. You want to be able to see the vertebra through the heart

37. The patient faces the film 37. The patient faces the film. The rays enter from his back and the tube is placed at a 45 degree angle below the patient and the film. This describe the following technique: a. oblique b. lateral chest c. apical lordotic d. apical decubitus e. lateral neck

answer c. apical lordotic. This view is used to separate close structures to see objects in the apical lobes better patient X-ray

answer 38. To find retro-sternal air one would want to do a film. a. oblique b. lateral chest c. apical lordotic d. apical decubitus

answer b. lateral chest When the picture is taken from the side, the air behind the sternum that collects in airtrapping, will be seen as a blackness just behind the breast bone. This is responsible for creating the barrel chest

39. To find a lung lesion hidden behind a structure one could do the following: a. oblique b. lateral chest c. apical lordotic d. apical decubitus e. all but d could be used to find hidden lesions

answer e. all but d could be used to find hidden lesions The lateral is from the side, the oblique view is when the x-ray tube is moved to the right or the left to see objects better & the apical lordotic spreads out the objects in the picture There is no such animal as the apical decubitus

40. This view is used to find free fluid in the pleural cavity. a. lordotic b. oblique c. lateral decubitus d. bronchogram e. c and d

answer c. lateral decubitus In a lateral decubitus, the patient lies on his side and any free fluid in his chest will layer out along the mattress. This layering of fluid is call the ‘gutter’ The picture is taken from the front.

41. When looking at the chest film of a newborn infant, one must remember that one would normally see the following: there are only 10 ribs b. the thymus gland is huge c. the ribs are mostly cartilage and seem thin d. a and c e. b and c

answer the babies bones are mostly cartilage so they seem thin e. b and c the babies bones are mostly cartilage so they seem thin The thymus gland is so huge in an infant that it looks like there are bilateral apical opacities near the midline—or that there is something wrong with the cardiac shadow

42. One would want to see an end- expiratory film to look for the following: a. small pneumothorax b. localized airtrapping c. small effusion d. a and b e. a, b and c

answer d. a and b if the picture is taken on exhalation, small areas of black will show up better against the general whiteness of the exhalation shot

43. The injection of a contrast media into the pulmonary vasculature to observe the blood flow is done to diagnosis the following: a. pulmonary embolism b. pulmonary artery stenosis c. pleural effusion d. a and b e. a and c

answer d. a and b An angiogram used contrast media to see arteries better, a venogram is used to see viens.

45. Injection of tagged albumin into the pulmonary vasculature which is followed by an inhalation of a couple of breaths of a xenon gas to create a "dot matrix" type of a picture is a description of what type of radiographic technique: a. bronchogram b. angiogram c. CAT scan d. ventilation/ perfusion scan

answer d. ventilation/ perfusion scan A V/Q scan is used to screen for pulmonary emboli because the ventilation and the perfusion should match. If there is ventilation without perfusion, then there is an obstruction to blood flow Ventilation and perfusion both down may only reflect the pulmonary vasoconstriction seen in alveolar hypoxia

46. The quickest, least invasive way to diagnosis pulmonary emboli is to perform the following: a. bronchogram b. angiogram c. CAT Scan d. ventilation/ perfusion scan

answer The V/Q scan is quick and can be done at the bedside d. ventilation/ perfusion scan The V/Q scan is quick and can be done at the bedside

answer 47. The procedure,most likely to be the most accurate method to diagnosis pulmonary embolism is to perform the following: a. bronchogram b. angiogram c. CAT Scan d. ventilation/ perfusion scan

answer b. Angiogram The V/Q scan will miss about half of the pulmonary emboli, while the angiogram will catch most of them. The angiogram involves insertion of a flow directed pulmonary artery catheter, so it is dangerous and invasive—and expensive

Reference page Pathological films & techniques: George Burton’s Respiratory Care 4th ed. Techniques: Wilkin’s Respiratory Assessment