Chest X-Ray PDF

CHEST X-RAY  OBJECTIVES  Explain some of the main reasons for ordering a chest x-ray.  List the standard views used for a chest x-ray and the view used most commonly used in a bed bound or unstable patient and select which series is most appropriate when given a clinical scenario.  Explain...

CHEST X-RAY  OBJECTIVES  Explain some of the main reasons for ordering a chest x-ray.  List the standard views used for a chest x-ray and the view used most commonly used in a bed bound or unstable patient and select which series is most appropriate when given a clinical scenario.  Explain the RIPE evaluation details that are specific for a chest x-ray.  Recall the ABCDEFGH pneumonic for chest x-ray evaluation- Airway, Bones & soft tissue, Cardiac, Diaphragm, Effusions & Extrathoracic soft tissue, Fields/Fissures/Foreign bodies, Great vessels & Gastric bubble, Hila & Mediastinum.  Describe how the ABCDEFGH systematic approach can be utilized when evaluating and interpreting a chest x-ray.  Define the terms consolidation, opacities, mass/nodule, atelectasis, effusion, edema, fibrosis, pneumothorax, hemothorax, cardiomegaly, and interstitial lung disease and explain how they correlate to chest x-ray interpretation.  CHEST X-RAY REASONING Assess Injuries from an accident Monitor progression of a disease (Cystic Fibrosis) To evaluate lung symptoms such as cough, fever, & shortness of breath (Pneumonia, Pneumothorax) To screen for other diseases (TB, Cancer) To evaluate heart symptoms such as chest pain, edema, & shortness of breath To assess if implanted devices are in place  Posteroanterior (PA)- This reduces the magnification of the heart and Standard other anterior mediastinal structures that are situated close Views to the film in the PA position. Lateral- Left side up to plate Anterior to Posterior (AP)- In the Portable/ ICU and ER, CXRs are often taken with the film placed behind the Mobile patient and the x-ray tube in front of the patient because the patient Views is bed bound or unstable and thus lying down (supine), or barely sitting up (semi-erect).  Inspirati Exposur Rotation Position on e QUALITY  A critical factor in the acquisition of a good-quality frontal radiograph of the chest is the patient's orientation with respect to the film or—in this age of digital images—with respect to the cathode ray (CR) device. Good-quality chest radiographs are described as truly "straight." ROTATION To acquire a straight film, the pt must be exactly perpendicular to the x-ray beam. Any degree of deviation from the perpendicular will result in a rotated film. In a radiograph in which the patient is rotated right posterior oblique, the medial aspect of the clavicle on the left will appear closer to the spinous process of the thorax than will that of the contralateral side. The opposite is also true. The degree of rotation can have a profound effect on the radiographic appearance of a normal chest. On a rotated film, the mediastinal and hilar regions can appear markedly different than they would on a straight film. This altered appearance could potentially lead one to incorrectly suspect a mediastinal mass or other abnormality. INSPIRATION If the patient's inspiratory result when the film was obtained was suboptimal, then the vascular structures may appear crowded and indistinct, giving an appearance that can mimic congestive heart failure. The cardiac silhouette may also appear falsely enlarged. Deeper inspirations show more lung and result in better overall images with less haziness at the lung bases and less enlargement of the heart and mediastinum. The diaphragm should be found at about the level of the 8th-10th posterior rib or 5th-6th anterior rib on good inspiration.  A supine radiograph or semi-erect film looks different from an upright radiograph. If pt's position in film is incorrectly identified, the appearance of the pulmonary POSITION The best way to assess vasculature may be patient position is to search misinterpreted. In upright the image for gas-fluid position, gravity causes the levels. These are most flow of blood in the lungs to go commonly seen in the to lower lobes. When gastric fundus. If one is pulmonary venous pressure increases (precursor to CHF), visible, you can be sure the upper lobe vessels become image was obtained with larger and resemble those in the patient upright. Exposure refers to the amount of x-ray energy that passes through the patient during the acquisition of the image. A good radiograph should demonstrate adequate penetration of the patient and sufficient contrast to distinguish between adjacent structures of different densities. Exposure is best assessed by trying to visualize the intervertebral disks in the lower thoracic spine through the heart. Normal anatomy is not well visualized on either overexposed or underexposed radiographs. In addition, certain abnormalities, such as a small nodule in the lung, may not be visible on an overexposed film; others, such as a small lucency of bone suggest-ing a focal cancerous metastasis, may not be visible on an underexposed film. EXPOSURE  ABCDEFGH Pneumonic for X-ray Interpretation The airway, or trachea, should be midline without any Airway deviation or stenosis after taking into account any rotational variations. Check the bones both in and out of the chest cavity Bones & Soft for fractures, lytic lesions (darkened areas), and deformities. Examine the joint spaces for widening or Tissue narrowing. Normal heart size is half the chest width. Examine the Cardiac shape of the heart. A water-bottle-shaped heart can be indicative of pericardial effusion. The borders around the heart should be clear. Evaluation of the diaphragm should reveal clear Diaphragm margins and sharp costophrenic angles bilaterally. When the diaphragmatic border is obscured, it indicates an adjacent disease process.  Effusions & Assess the pleura to ensure full expansion. Examine the soft tissues for abnormalities, specifically lymph nodes Extrathoracic and subcutaneous emphysema (air below the skin), as Tissues well as any other lesions. Divide the lungs into sections and look for symmetry Fields/Fissures/ between the lungs. Check for consolidation and fluid. Foreign bodies are generally supportive hardware such Foreign Bodies as chest tubes, central lines, endo-tracheal tubes, pacemakers, etc. Aorta, Pulmonary Arteries, & Superior Vena Cava. Below Great Vessels & the left hemidiaphragm you should notice a gastric bubble (from the stomach). There should be no other Gastric Bubble free air below the diaphragm. The hila are not symmetrical but contain the same basic structures on each side. The hila may be at the same level, but commonly the left hilum is higher than the Hila & Mediastinum right. Both hila should be of similar size and density. If either hilum is bigger and more dense, this is a good indication that there is an abnormality.  If alveoli and small airways fill with dense material, lung is Con said to be consolidated. May fill with pus in pneumonia, solid fluid in pulmonary edema, blood in pulmonary hemorrhage, atio or cells in cancer. n Capacity of a substance to absorb radiation, rather than per mit its passage. If there is an opacity in the lung where Opa there should be translucency you need to ask what is citie causing it. s Small round or oval-shaped growth in the lung. Pulmonary Mas nodules are < 3 centimeters in diameter. If the growth is s/ larger than that, it is called a pulmonary mass and is more Nod likely to represent a cancer than a nodule. ule TERMINOLOGY  Atalectasi Collapse of lung tissue with loss of volume s T E Fibrosis Scarring in the lungs R M Pleural Collection of fluid abnormally present in the pleural space, usually resulting from I Effusion excess fluid production and/or decreased lymphatic absorption N Presence of air or gas in the pleural cavity, O Pneumothor ax which can impair oxygenation and/or ventilation (AKA collapsed lung) L O Hemothor Accumulation of blood and fluid in the pleu ral cavity, between the parietal and viscer G ax al pleura Y Cardiomeg Enlargement of the heart aly CXR QUALITY TUTORIA L CXR ANATOMY TUTORI AL CXR SYSTEMATIC APPR OACH TUTORIAL