Chest X-Ray Indications

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Questions and Answers

Which of the following is a normally accepted indication for ordering a chest x-ray?

  • Routine pre-employment screening
  • Asymptomatic preoperative evaluation
  • Suspected elevated diaphragm (correct)
  • Daily routine intensive care portable with no clinical change

A patient presents with acute onset chest pain and shortness of breath. Which of the following, if present in their history, would be considered a normally accepted indication for a chest x-ray?

  • Minor chest trauma reported the day prior
  • Uncomplicated acute exacerbation of asthma
  • Suspicion for pulmonary embolism (correct)
  • Thoracic aneurysm follow up

Which of the following is NOT generally considered an appropriate indication for a chest x-ray?

  • Positive TB skin test
  • Routine monitoring in ICU without clinical changes in the patient (correct)
  • Hemoptysis
  • Suspected pneumonia

A clinician orders a chest x-ray on an asymptomatic patient to screen for lung cancer. Is this an appropriate indication?

<p>No, lung cancer screening is not typically performed via x-ray. (D)</p> Signup and view all the answers

When assessing chest x-ray quality using the acronym RIPE, what does 'I' stand for?

<p>Inspiration (D)</p> Signup and view all the answers

You are evaluating a PA chest x-ray. Which of the following is characteristic of a well-inspired film?

<p>5-7 anterior ribs visible (D)</p> Signup and view all the answers

On a chest x-ray, what does rotation affect the most?

<p>The apparent size of the heart (A)</p> Signup and view all the answers

What does overexposure of a chest x-ray result in?

<p>Decreased visualization of lung vessels (C)</p> Signup and view all the answers

In which type of chest x-ray view is the heart most likely to appear magnified?

<p>Anteroposterior (AP) (A)</p> Signup and view all the answers

In a PA view radiograph, which structure should NOT be visible?

<p>Hilar lymph nodes (B)</p> Signup and view all the answers

If you were to identify the carina on a PA chest x-ray, where would you expect to find it?

<p>At the bifurcation of the trachea (D)</p> Signup and view all the answers

Which of the following is TRUE regarding the hilum of the lung?

<p>Each hilum contains major bronchi and pulmonary vessels. (C)</p> Signup and view all the answers

What does the silhouette sign on a chest x-ray typically indicate?

<p>Loss of clear border between structures due to consolidation (C)</p> Signup and view all the answers

On a frontal chest radiograph, the right hemidiaphragm is typically higher than the left. What is the primary reason for this?

<p>Presence of the liver (C)</p> Signup and view all the answers

A patient with suspected pleural effusion undergoes a chest x-ray. Which view is MOST effective in identifying small effusions?

<p>Lateral decubitus view (B)</p> Signup and view all the answers

Which of the following best describes the correct positioning for a posteroanterior (PA) chest radiograph?

<p>X-ray beam enters through the patient's back and exits through the chest. (A)</p> Signup and view all the answers

Of the options below, what is the MOST likely finding of an anteroposterior (AP) film compared to a PA film?

<p>Scapulae obscuring more of the lung field (A)</p> Signup and view all the answers

Which view is taken routinely with a PA view to localize lung lesions that may be hidden behind the heart or diaphragm?

<p>Lateral view (A)</p> Signup and view all the answers

What finding on a chest x-ray would lead you to suspect dextrocardia with situs inversus?

<p>The 'L' marker on the image is on the opposite side of the heart (C)</p> Signup and view all the answers

Elongation of the clavicles, rib fractures, and increased space between the ribs could mean that the reading should include what?

<p>Emphysema (A)</p> Signup and view all the answers

What is the normal cardiothoracic ratio (CTR) on a PA chest x-ray?

<p>Less than 50% or 1:2 (A)</p> Signup and view all the answers

You are examining a chest x-ray and note that the mediastinum appears widened. Which of the following is the MOST likely significance of this finding?

<p>Possible aortic dissection or mediastinal mass (A)</p> Signup and view all the answers

From the list below, what is a key characteristic of the mediastinum?

<p>It should be centered and symmetrical. (D)</p> Signup and view all the answers

What do infiltrates visualized on a chest x-ray indicate?

<p>Increased densities in air spaces (A)</p> Signup and view all the answers

What is the clinical significance of identifying Kerley B lines on a chest radiograph?

<p>They suggest pulmonary edema or interstitial lung disease (C)</p> Signup and view all the answers

What does the acronym RIPE stand for when evaluating chest x-rays?

<p>Rotation, Inspiration, Position, Exposure (A)</p> Signup and view all the answers

What is the MOST likely finding of underexposure to a chest x-ray?

<p>The spine cannot be seen behind the heart (B)</p> Signup and view all the answers

Where would you expect to find the major (oblique) fissure in a chest radiograph?

<p>Thin linear shadow on lateral view. (D)</p> Signup and view all the answers

What can pneumothorax obscure on a chest x-ray, making it hard to see?

<p>Lung marking (C)</p> Signup and view all the answers

Regarding fractures, what area should be focused on?

<p>Lateral aspect of rib (A)</p> Signup and view all the answers

Regarding the diaphragm, what would indicate to you to be problematic?

<p>Assess position sharpness, and countour. (A)</p> Signup and view all the answers

After reviewing the chest radiograph of a 60-year-old male complaining of one week of dyspnea, you notice blunting of the patient's right costophrenic angle. What is the next appropriate step?

<p>Get a lateral decubitus film. (A)</p> Signup and view all the answers

In an upright patient who has a right-sided tension pneumothorax, which of the following would you expect to be displaced toward the left side?

<p>The trachea (D)</p> Signup and view all the answers

The tip of a correctly placed central venous catheter (CVC) should ideally be located where?

<p>Within the superior vena cava (SVC) at or just above the level of the carina. (C)</p> Signup and view all the answers

How far above the carina should the tip of an endotracheal tube (ET tube) be ideally positioned on a chest radiograph?

<p>5-7 cm (D)</p> Signup and view all the answers

On a chest radiograph, at what level is a tracheostomy tube typically located?

<p>At the level of the clavicles. (B)</p> Signup and view all the answers

Which of the following anatomical landmarks should a nasogastric tube (NG tube) pass through or bisect on a chest radiograph to confirm correct placement?

<p>The carina. (D)</p> Signup and view all the answers

Where is the pulse generator typically located in a patient with a pacemaker?

<p>Right pectoral region. (D)</p> Signup and view all the answers

Which of the following best describes the radiographic appearance of an aortic valve replacement on a chest x-ray?

<p>Appears as a metallic or opaque ring structure somewhat medially over the spine. (A)</p> Signup and view all the answers

What is the significance of surgical clips visualized on a chest radiograph?

<p>They are a normal finding after certain surgical procedures. (B)</p> Signup and view all the answers

A chest radiograph reveals a coin-shaped object in the lower airway of a child. Which of the following diagnostic procedures is the gold standard for both diagnosis and removal of the foreign body?

<p>Bronchoscopy (C)</p> Signup and view all the answers

What radiographic finding suggests hyperinflation in a child with suspected foreign body aspiration?

<p>Mediastinal shift away from the affected side. (A)</p> Signup and view all the answers

What anatomical area is defined as the retrosternal space on a chest radiograph?

<p>The space between the sternum and the ascending aorta. (B)</p> Signup and view all the answers

On a lateral chest radiograph, increased soft tissue density in the retrosternal space may indicate pathology in which anatomical area?

<p>Anterior mediastinum. (B)</p> Signup and view all the answers

In the context of chest radiography, what are airspaces referring to?

<p>Respiratory bronchioles, alveolar ducts, and alveoli (D)</p> Signup and view all the answers

In chest radiography, what does the term 'interstitium' refer to?

<p>The tissue surrounding the airspaces (A)</p> Signup and view all the answers

After a median sternotomy, which of the following would be expected to be seen on a chest x-ray?

<p>Sternotomy wires (A)</p> Signup and view all the answers

Radiopaque foreign bodies are best visualized with which imaging modality?

<p>Chest X-ray (D)</p> Signup and view all the answers

A patient has undergone a CABG. What radiographic finding would be least likely to be present?

<p>Pericardial effusion. (B)</p> Signup and view all the answers

Flashcards

Indications for chest X-ray

Normally accepted indications include acute respiratory/cardiac disease, major chest trauma, hemoptysis, chronic dyspnea, suspected PE/pneumonia, positive TB skin test.

Contraindications for chest X-ray

Routine/regular orders for asymptomatic patients, daily ICU portables with no clinical change, minor chest trauma, uncomplicated URI/COPD exacerbations, routine post pacemaker/tracheostomy.

Systematic CXR Interpretation

Name, DOB, film direction, technical quality (RIPE), cardiac shadow, mediastinum, hila, lungs, plural space, bones, soft tissue.

PA View

Taken with patients front against the film. X-ray shot from the pt's back. Heart minimally magnified.

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AP View

Taken if patient is too sick to stand or sit for PA. X-ray shot from front to back. Heart appears larger.

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Lateral View

Taken with the patient in profile to localize lung lesions behind the heart or diaphragm.

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Decubitus View

A PA view with the patient lying down on their side to identify fluid in the pleural space.

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CXR Rotation

The distance between each medial end of the clavicles and the interposed spinous process should be equal.

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CXR Inspiration

A deep inspiration is needed to obtain a good image of the lungs, spanning 9 posterior or 5-7 anterior ribs.

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CXR Position

Look for gastric air/fluid levels in upright positions.

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CXR Exposure

If the spine cannot be seen behind the heart, the film is underexposed (too white); vessels not seen.

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Cardiothoracic Ratio (CTR)

Calculated by dividing the cardiac width by the thoracic width. Should be <50% or 1:2 on PA view.

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Mediastinum Assessment

Should be centered and symmetrical, <1/3 the transthoracic distance, soft tissue density, and concave.

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Hila Contents

Major bronchi and pulmonary vessels; hilar lymph nodes are not visible unless abnormal. Left hilum is usually higher.

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Lung Assessment

Assess size (enlargement/reduction), translucency (silhouette sign), fissures, consolidation.

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Pleural Space Assessment

Check for effusion (costophrenic angles), soft tissue, masses, calcification, pneumothorax (lung markings).

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Rib Fracture Diagnosis

Often see fractures at the lateral aspect of rib. Initial testing: CXR; Definitive dx: CT wo contrast.

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Diaphragm Assessment

Position and sharpness- Rt hemidiaphragm higher than the left due to the presence of the liver

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Central Venous Catheters (CVC) Placement

Tip of CVC should be within the SVC at or just above the level of the carina.

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Endotracheal Tube (ET tube) Placement

The distal tip of the endotracheal tube should be 5-7 cm above the carina.

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Tracheostomy Tube Placement

The tracheostomy tube should be at the level of the clavicles on a chest radiograph.

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Nasogastric Tube (NG Tube) Placement

The NG tube should descend midline, bisect the carina, cross the diaphragm, and enter the stomach.

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Pacemaker on CXR

Pulse generator in right pectoral region, lead through subclavian vein to superior vena cava, two electrodes in right ventricle.

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Sternotomy Wires and Aortic Valve Replacement on CXR

Sternotomy wires appear midline on CXR. Aortic valve replacement appears medially over the spine.

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Artifact Recognition on CXR

Artifacts include motion, external objects, hair, and skin folds. Recognize as non-anatomical.

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Foreign Body Aspiration (FBA) – Direct Signs, Diagnosis

Direct signs include radiopaque objects. Bronchoscopy is gold standard for diagnosis and removal.

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Foreign Body Aspiration (FBA) – Indirect Signs

Indirect signs: hyperinflation, mediastinal shift, atelectasis/lobar consolidation. Though a normal CXR doesn't rule it out.

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Normal Air Spaces

Airspaces include respiratory bronchioles, alveolar ducts, and alveoli (dark areas).

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Retrosternal Space Assessment

Retrosternal space should be radiolucent and <2.5cm between sternum and ascending aorta.

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Interstitium

Interstitium is the tissue surrounding the airspaces (thin, faint lines).

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Study Notes

  • Chest radiography helps to evaluate the placement of support lines, cardiac support devices, post-surgical changes, and artifacts.
  • Chest radiography also helps identify foreign body aspiration and to explain the radiographic appearance of air space and interstitium.

Common Support Lines

  • Central Venous Catheters (CVC) tip should be within the SVC at or just above the level of the carina.
  • Endotracheal tube (ET tube) should be 5-7 cm above the carina.
  • Tracheostomy tube should be at the level of the clavicles.
  • For a Nasogastric Tube (NG Tube) look for midline descent, carina bisection, diaphragm crossing, left hemidiaphragm.

Cardiac Support Devices

  • Pacemakers have a pulse generator in the right pectoral region.
  • Pacemaker leads go through the right subclavian vein into the superior vena cava.
  • Pacemakers have two electrodes in the right ventricle.

Post-Surgical Changes

  • Sternotomy wires should be midline after sternotomy.
  • Aortic valve replacements are somewhat medially located over the spine.
  • Surgical clips are sometimes seen.

Artifact

  • Types include motion, external objects, hair, and skin folds.
  • An example of an artifact in the right lung can be hair braids.

Foreign Body Aspiration (FBA)

  • Inspiratory and Expiratory Films can help visualize hyperinflation.
  • CT Scan can be used if high clinical suspicion but the CXR is inconclusive.
  • Fluoroscopy can be used.
  • Bronchoscopy is the gold standard for diagnosis and removal.
  • Direct signs of radiopaque Foreign Bodies are metal objects visible.
  • Indirect signs of radiolucent Foreign Bodies include hyperinflation, mediastinal shift away from the affected lung, and atelectasis/lobar consolidation

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