CLIN SKILLS: Chest X-Ray Interpretation

Question 1

what details to check for in a CXR

Answer 1

• Pt identifying details
• date and time taken
• view: AP or PA, erect or supine, inspiratory or expiratory etc.

Question 2

why does it matter if the CXR is AP or PA

Answer 2

• if PA: more lung visible b/c they’re at the back so look bigger
• less heart visible b/c closer to front so looks smaller

Question 3

DRSABCDE method for interpreting X-rays

Answer 3

• Details
• RIPE (image quality)
• Soft tissue + bones
• Airway + mediastinum
• Breathing
• Circulation
• Diaphragm
• Extras

Question 4

how to check for image quality in a CXR (RIPE)

Answer 4

• rotation – check that clavicles and scapulae are symmetrical
• inspiration – check whether its at full inspiration (5-6 anterior ribs and 8-10 posterior ribs) - want lungs to be expanded so we can see more
• picture – straight vs oblique, entire lung fields, scapulae OUTSIDE lung fields, angulation (tilt in vertical plane)
• exposure (penetration) – check radio-opacity of bones (radiolucency can also indicate osteoporosis)

Question 5

what extras to check for in a CXR

Answer 5

• any other tubes, catheters, wires, foreign artefacts e.g. pacemaker, sternotomy

Question 6

what to check for in soft tissue and bones on a CXR

Answer 6

• ribs, sternum, spine, clavicles – check for symmetry, fractures, dislocations, lesions, density
• soft tissues – subcutaneous emphysema, masses
• check for calcification of great vessels and carotids

Question 7

what to check for in airway and mediastinum in a CXR

Answer 7

• trachea – central or deviated? patent?
• paratracheal/mediastinal masses or adenopathy
• carina & bronchi
• hilum – left hilum is usually smaller and higher

Question 8

how to check breathing in a CXR

Answer 8

• pneumothorax: pleural thickening or absence of lung markings (don’t forget apices)
• pleural effusion: blunting of costophrenic angles
• lung fields should be black with fine markings for alveoli: check for opacity/whiteness (consolidation, infection) and lucency/too black (pneumothorax, emphysema)

Question 9

how to check circulation in a CXR

Answer 9

• heart position – ⅔ to left, ⅓ to right
• heart shape
• heart size (up to 50% of chest space - cardiothoracic ratio)
• heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

Question 10

how to check diaphragm in a CXR

Answer 10

• R hemidiaphragm higher
• sharp/clear cardiophrenic (pleural/pericardial effusion) and costophrenic angles (pleural effusion, pneumonia)
• normal gastric bubble
• pathological subphrenic air: pneumoperitoneum

Question 11

features of pneumothorax on CXR

Answer 11

• no white/streaky lung markings (fully black b/c filled with air, not lung tissue)
• sharp white line indicating visceral pleura (since there’s air on both sides, visceral pleura stands out more)
• R hemidiaphragm @ same height as L
• if tension pneumothorax: contralateral mediastinal shift including tracheal deviation