CXR interpretation

Question 1

Describe the BASIC DRSABCDE method of interpreting CXR

Answer 1

D – Details
DETAILS

R – RIPE (assessing the image quality)
RIPE

S – Soft tissues and bones
SOFT TISSUES/BONES

A – Airway & mediastinum
AIRWAY

B – Breathing
BREATHING

C – Circulation
CIRCULATION

D – Diaphragm
DIAPHRAGM

E – Extras
EXTRAS

Question 2

Describe the first D in CXR interpretation

Answer 2

Before you even begin interpreting a CXR you should have the correct details. This includes;

Patient name, age / DOB, sex
Type of film – PA or AP, erect or supine, correct L/R marker, inspiratory/expiratory series
Date and time of study

Question 3

Describe R in CXR interpretation

Answer 3

Next up, how “ripe” is the image. That is, what is the technical quality of the film?

Rotation – medial clavicle ends equidistant from spinous process
Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?
Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)
Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.

Question 4

Describe S in CXR interpretation

Answer 4

In CXR interpretation it is common to leave soft tissues until the end.

Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density
Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses
Breast shadows
Calcification – great vessels, carotids

Question 5

Describe A in CXR interpretation

Answer 5

Trachea – central or slightly to right lung as crosses aortic arch
Paratracheal/mediastinal masses or adenopathy
Carina & RMB/LMB
Mediastinal width <8cm on PA film
Aortic knob
Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.
Check vessels, calcification.

Question 6

Describe B in CXR interpretation

Answer 6

Lung Fields:

Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices
Pneumothorax – don’t forget apices
Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae
Horizontal fissure on Right Lung
Pulmonary infiltrates – interstitial vs alveolar pattern
Coin lesions
Cavitary lesions
Pleura

Pleural reflections
Pleural thickening

Question 7

Describe C in CXR interpretation

Answer 7

Heart position –⅔ to left, ⅓ to right
Heart size – measure cardiothoracic ratio on PA film (normal <0.5)
Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium
Heart shape
Aortic stripe

Question 8

Describe D in CXR interpretation

Answer 8

Hemidiaphragm levels – Right Lung higher than Left Lung (~2.5cm / 1 intercostal space)
Diaphragm shape/contour
Cardiophrenic and costophrenic angles – clear and sharp
Gastric bubble / colonic air
Subdiaphragmatic air (pneumoperitoneum)

Question 9

Describe E in CXR interpretation

Answer 9

ETT, CVP line, NG tube, PA catheters
ECG electrodes, PICC line, chest tube
PPM, AIDC, metalwork

Question 10

For RIPE for assessing quality of image in CXR interpretation, Explain R

Answer 10

Rotation – medial clavicle ends equidistant from spinous process

Question 11

For RIPE for assessing quality of image in CXR interpretation, Explain I

Answer 11

Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?

Question 12

For RIPE for assessing quality of image in CXR interpretation, Explain P

Answer 12

Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)

Question 13

For RIPE for assessing quality of image in CXR interpretation, Explain E

Answer 13

Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.