Chest X-Ray (CXR)

Last updated 20.09.12

 

Index

 

Definition

-   

 

Features

-  Reading a CXR

 

Indications

-  Chest pain

-  Abdo pain

-  Exclude pneumoperitoneum (erect film)

 

Request

-   

 

Procedure

-   

 

Complications

-   

 

Types of views

- Images usually taken at full inspiration

- AP vs PA

-  AP: scapulae overlap, vertebral endplates more clear

-  PA: scapulae clear of lung fields, laminae more clear, heart enlarged

- Lateral

-  Usually taken to cofirm lesion on AP in 3D

- Mobile vs Erect

-  Erect: gastric bubble in fundus

-  Mobile gastric bubble in antrum, increased pulmonary blood flow (esp if supine)

 

 

 

Systematic Approach to CXRs

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AP & PA CXR

- ID: correct pt (name, DOB), correct CXR, correct date

- Technical

-  Side marker (L, R): dextrocardia, situs inversus vs misplaced marker

-  Projection

-  PA: most common, if not labeled assume PA

-  AP: if patient cannot stand, cardiac shadow enlarged

-  Posture: erect, mobile, supine

-  Rotation: compare medial ends of clavicles to margins of vertebral bodies

-  Timing

-  Inspiration: usually taken at full inspiration

-   Diaphragm at 6th rib anteriorily 9th posteriorly (right higher than left)

-  Expiration: views taken to accentuate pneumothorax

-  Penetration (duration & power)

-  Poor penetration: diffusely light, soft tissue obscured

-  Over penetration: diffusely dark, poor lung markings

-  Good penetration: vertebral bodies visible through cardiac shadow

- Pathology

-  Obvious opacities: chest drains, pacemaker, foreign body

-  DDx artifacts: bra clips, buttons, piercings

-  Size & shape, number & location

-  Clarity of structures & margins, homogeneity

-  Consolidation = presence of fluid in lung

-   Air bronchograms = airway highlighted against consolidation

-   Blurring or absence of the normal heart border

-   Cannot DDx infection vs infarction (PE) if consolidation

-  Collapse = atelectasis

-   Shift of fissures between lobes

-   Crowding of vessels & airways

-   Collapsed or raised hemidiaphragm

-   Possible shift of midline towards effected side

-  Cardiac shadow

-   Blurring or absence suspect consolidation

-   Deviation (as per tracheal)

-   Cardiomegaly

-  Mediastinal contours: right to left

-  Central trachea

-   Ipsilateral deviation: collapse (atelectasis..)

-   Contralateral deviation: pleural effusion, tension pneumothorax

-  Aortic arch

-  Pulmonary a.

-  SVC

-  Cardiomegaly: >1/2 lateral width, internal ribs

-  Check for signs of LV failure

-  Upper lobe diversion, Kerley B lines, Bats wings, alveolar shadowing

-  Heart borders

-  Right: right atrium, right ventricle not viewed on PA

-  Left: left atrium & ventricle

-  Hila

-  Enlarged lymph nodes: TB, lymphoma, sarcoidosis..

-  Pulmonary artery hypertension: chronic PE, MV disease, pulmonary HTN

-  Main bronchus: carcinoma

-  Lungs

-  Apicies to bases

-  Check behind heart

-  Lung markings: pneumothorax, interstitial oedema

-  Hemidiaphragms

-  Costophrenic: blunting, meniscus: effusion

-  Cardiophrenic

-  Free air: bowel perforation

-  Soft tissues

-  Breast shadows

-  Subcutaenous emphysema

-  Bones

-  Rib fractures

-  Bone lesions: sclerotic

- Double check

-  Lung apicies & peripheries

-  Under & behind hemidiapgragms

-  Posterior to heart

 

Lateral CXR

- ID & technical as for AP, PA

- Pathology

-  Anterior mediastinum: should be black

-  Posterior mediastinum: should be black