Chest Xray Interpretation
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Transcript of Chest Xray Interpretation
Chest X-ray Interpretation
By: Lacey Burke, RN, BSN, FNP-S
Know the Normal.
• To have the ability to interpret chest xrays, knowing what’s normal will help you to see when its not.
Steps to Analyze a Chest X-ray
• Side Marker• Projection• Patient Positioning• Rotation• Penetration• Lung Volume• Artifacts
Side Marker
• Ensure correct orientation. • There have been reports of chest drain
insertion on the opposite side to a pneumothorax because of mislabeling.
Projection
• Most films are from posterior to anterior (PA). – X-ray source situated 1.5-1.8 m posterior to the
patient– X-ray plate positioned immediately anterior to
patient’s chest.• Film may be taken anterior to posterior if the
patient has difficulty due to acute illness or general immobility.
Patient Positioning
• PA films taken with patient standing• AP films taken either standing or sitting
position• All films other than those taken PA should be
labeled with the position• Positioning is significant due to the
appearance of air, fluid and blood vessels within the chest.
Air
• Air tends to rise to the highest point within the chest cavity.
• A pneumothorax is most commonly seen at the lung apex in the erect position.
• When the patient lies on the side opposite to the suspected pneumothorax, any air in the pleural cavity will rise along the lateral chest wall.
Fluid
• Pleural fluid usually collects in the lung base and appears dense and opaque, obscuring adjacent structures.
• Fluid usually reaches a higher point along the lateral chest wall than along the mediastium= meniscus sign.
Pulmonary Vessels
Rotation• Rotation should
be minimal.
• Assessed by looking at the medial ends of the clavicles. Distance should be equal from the medial ends of the clavicles and the thoracic spinous processes.
Penetration
• End plates of the lower thoracic vertebral bodies should be just visible through the cardiac shadow.
• Under-penetrated: film looks diffusely opaque• Over-penetrated: film looks diffusely lucent.
Lungs appear blacker than usual and vascular markings are poorly seen.
Lung Volume
• To detect abnormalities-Full inspiration• Diaphragm should be seen at the level of the
8th-10th posterior ribs or the right 6th anterior rib with good inspiration
• Poor inspiration- cause increased opacification of the lungs because of atelectasis
Artifacts
• Common artifacts: – ECG stickers– Patient’s hair and clothing– Hospital bedding
Normal Chest X-ray
Systematic Approach
• Airway• Bones• Circulation• Diaphragm• Review Areas
Airway- Large Airways, Lung, and Pleura
• Check whether trachea is midline or deviated.• Carina lies at the T4 level on expiration and
will move to T6 on inspiration• Right main bronchus has a steeper angle than
the left- in adults.• Lungs divided into lobes by fissures: right lung
has 3 lobes, left lung has 2 lobes.
Bones- Clavicles, Ribs, and Spine
• Assess for fractures and bone destruction– Ribs– Clavicles– Scapulae– Spine
• Ribs and intercostal spaces should be symmetrical.
Circulation-Heart, Mediastinum, and Vascular Markings
Knowledge of the normal anatomical structures that form the mediastinal and cardiac outline helps to detect abnormality. • Left: Superior to inferiorly by the left brachiocephalic
vein, aortic knuckle, left main pulmonary artery, left atrial appendage, and left ventricle.
• Right: right brachiocephalic vein, superior vena cava and right pulmonary artery, right atrium and interior vena cava.
Diaphragm
• Check the shape, height, and angles.• Right diaphragm: approx. 1-3 cm higher than
the left. • Look through diaphragmatic shadow for
pathology of lung bases and pleural reflections for evidence of pleural fluid.
Review Areas• Lines and Tubes: Chest position for complications, ex:
pneumothorax• Central Lines: pass to lower superior vena cava. Should not
enter right atrium• Pulmonary Artery Catheters: should not be wedged into
small branches• Endotracheal Tubes: Tip at least 3 cm above the carina. • Gastric Tubes: pass below the diaphragm and into stomach• Chest drains: Check position. Tip of the tube should lie in
an effective position and not be displaced into lung tissue.
Key Points• Silhouette Sign: Describes loss of normal lung/soft tissue
interface applied to the heart, mediastinum, chest wall and diaphragm.
• Air Bronchogram: Commonly signifies alveolar disease and also atelectasis.
• Consolidation: Result of filling of the alveoli by any cause (Ex: fluid, pus, blood, tumor)
• Pleural Effusion: Greater than 150ml must be present for pleural effusion to be detected on chest X-ray.
Air Bronchogram• If area of lung is consolidated, it becomes dense and white.• If the larger airways are spared, they are relatively low
density “blacker”• Characteristic sign of consolidation
What is this?
Answer:
Pneumonia
What is this?
Answer:
Pneumothorax
What is this?
Answer:
Tuberculosis in the right upper lobe
What is this?
Answer:
Total Atelectasis on RT side.
What is this?
Answer:
Pulmonary Embolism
What is this?
Answer:
Cardiomegaly
What is this?
Answer:
Pleural Effusion
What is this?
Answer
Free Air under the diaphragm
seen in bowel perforation
What is this?
Answer:
Congestive heart failure
Notice the numerous small circular “doughnuts” that represent fluid in
bronchial walls.
And sometimes…Coin
O.R. InstrumentsEarring Back
13-cm steak knife
Resources
• http://www.medscape.com/viewarticle/560163_3