Chest X-Rays

Question 1

After checking the patient name and DOB, what must you do when interpreting a chest x-ray?

Answer 1

RIPE

• check rotation (the spinous processes should line up with the medial aspects of the clavicles equally)
• check inspiration (anterior 5-6 ribs should be visible)
• check projection (whether AP/PA - if scapula is projected within the chest then AP)
• check exposure (the left hemidiaphragm should be visible to the spinous processes, and the spinous processes should be visible behind the heart)

Question 2

A

Answer 2

AIRWAY (inspect trachea, carina, bronchi and hilar structures)

• check for tracheal deviation (if there is, look for anything that could be pushing/pulling it)
• look for paratracheal masses/lymphadenopathy
• inspect the carina (useful for checking adequate NG tube placement)
• inspect hilum (look for enlargement or abnormal placement) - left normally higher than right

Question 3

B

Answer 3

BREATHING (inspect the lungs)

• divide the lungs into 3 zones and compare each zone, noting any asymmetry (lung markings should be present in each zone)
• complete loss of lung markings should raise suspicion of a pneumothorax
• inspect for any pleural abnormalities (shouldn’t be visible in a healthy individual)

Question 4

C

Answer 4

CARDIAC (inspect the heart)

• inspect size: should occupy no more than 50% of thoracic width (if AP cannot do as heart shadow can lead to misinterpretation)
• inspect lung borders, should be well-defined (if decreased definition, can be due to overlying lung pathology)

Question 5

D

Answer 5

DIAPHRAGM

• right hemidiaphragm is usually higher then the left
• inspect for free gas under the diaphragm (raises suspicion of bowel perforation)
• inspect costophrenic angles (should be acute and well-defined), loss of the angle (blunting) can be due to consolidation/fluid

Question 6

E

Answer 6

EVERYTHING ELSE (mediastinal contours, bones, soft tissue, tubes, valves and pacemakers)

• look for aortic knuckle on the left lateral side of aorta (decreased definition= aneurysm)
• inspect aortopulmonary window (between aorta and pulmonary vessels) - if lost can be due to malignancy
• look at bones and soft tissues for abnormalities (eg. fractures, haematoma)
• look for medical devices for adequate placement

Question 7

What chest x-ray signs are indicative of a tension pneumothorax?

Answer 7

• trachea pushed away from side of pneumothorax

- area of lower density with no lung markings where the pneumothorax is located

Question 8

What pathologies can cause symmetrical bilateral hilar enlargement?

Answer 8

• sarcoidosis
• lymphoma
• metastatic disease
• infection

Question 9

Describe what consolidation looks like on a chest x-ray

Answer 9

• areas of increased density

- larger airways may be spared which causes dark lines through the area of white

Question 10

What can pleural thickening be signs of?

Answer 10

• decreased lung volume

- associated with mesothelioma

Question 11

Describe what pleural effusion looks like on a chest x-ray

Answer 11

• if upright x-ray will gather in lower zones and form a ‘meniscus’
• blunting of costophrenic angle and hemidiaphragm

Question 12

What are CXR signs of pulmonary oedema?

Answer 12

• interstitial oedema: Kerley B lines

- alveolar oedema: batwing appearance