CXR

Question 1

How can you tell a paediatric CXR?

Answer 1

The growth plate (physis) will be seen on CXR in a child

Question 2

How can you tell on a CXR what area of the mediastinum an opacity etc is in?

Answer 2

• If Trachea is deviated on CXR
  
  • = Anterior mediastinum
• If hyelum if affected
  
  • = middle mediastinum
• if aorta is affected (lower down)
  
  • = posterior mediastinum

Question 3

What is the appropriate method for systematically checking a CXR?

Answer 3

• pt details
• RIPE
• ABCDE

Question 4

What patient details should be checked when/before analysing a CXR?

Answer 4

• pt details
• name
• DOB
• image type -
  
  • normally the image is PA
  • if it is AP then normally will be written
• imaging indications for CXR

Question 5

How do you present RIPE?

Answer 5

• R = rotation
• I = inspiration
• P = Penetration
• E = exposure

so ask/state:

• (R) are the clavicular heads and spinous processes equidistant? Spinous processes and clavicles level?
• (I) are there 5-6 anterior ribs / 8-10 posterior ribs?
• (P) Can you see the vertebral bodies in cardiac shadow? ~should be barely visible otherwise it is over or under penetrated
  
  • What penetration is this PA or AP?
  • NB: AP cant comment on cardiomeg
    
    • PA cant see scapula
• (E) can you see the glenohumeral joints, upper lobes/apices? & can you see the costophrenic and cardiophrenic angles?

Question 6

What is an air bronchogram?

Answer 6

an air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates. Six causes of air bronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary atelectasis, severe interstitial disease, neoplasm, and normal expiration.

• tubular outline because around is gunk
• pulmonary vascularture is more prominent
• boarder block = left lingular, (inferior protion of left upper lobe) or right middle

Question 7

What is reticular opacity?

Answer 7

• meshwork/spidery
  
  • e.g. fibrosis, oedema and some pneumonias

Question 8

What is patchy (fluffy) opacity?

Answer 8

• palignancy
• pneumonia
• oedema
• haemathorax

e.g. takes a lobe

Question 9

What is ABCDE in CXR interpretation?

Answer 9

• Airways
• Breathing
• Circulation
• Diaphragn
• Everything else
• THEN ‘in summary’ [ddx, conclusions –> investigations]

Question 10

What should you be thinking when looking at the airways (A) on x-ray?

Answer 10

• think: trachea, carina and bronchi
  
  • is trachea deviated?
  • is the carina narrowed?
  • are the bronchi blocked?
• hilum
  
  • are the hilar asymmetrical / symmetrical?
    
    • symmetrical hilar bulking = HTN / sarcoidosis ~more systemic
    • asymmetrical hilar bulking = malignancy or TB

Question 11

What should you be thinking when looking at the breathing (B) on x-ray?

Answer 11

• Lung fields
• Pleura
  
  • There are 3x zones in the lung fields to check
    
    • Upper zone / Apex; middle zone: lower zone
    • (as cba for 3xRHS and 2xLHS)
    • ?consolidation - pneumonia
    • ?solid mass - tumour/abcess
    • ?boule - emphsema
    • widespread bilateral shadowing e.g. pulm oedema?
  • there are 2 main boarders to check
    
    • cardiophrenic
    • costophrenic
  • are the pleura extending to the edges?
    
    • pneumothorax = gap of air on top of lungs as lungs are heavier

Question 12

What should you be thinking when looking at the circulation (C) on x-ray?

Answer 12

• heart boarder
• heart size
• mediastinum
  
  • heart boarder - LH = LV [e.g. cardiomegaly due to mitral regurg sloshing back in]; RH boarder mostly RA
    
    • -silhouette sign –> consolidation, pneumonia
      
      • can split into right upper, middle (cardiac boarder), lower (diaphragm blocked)
  • heart size- only commentable on PA (<50% heart:thorax ratio)
    
    • as ap is bigger due to heart being closer to rays
  • mediastinum - visible aortic knuckle/notch? - width ?coarctation of aorta & pulmonary trunks? & Hyelum - prominence?vasculature?

Question 13

What should you be thinking when looking at the diaphragm (D) on x-ray?

Answer 13

• diaphragm and hidden areas
  
  • should see clear definition above (lung air)
  • unclear definition below (abdo contents)
    
    • RHS is normally slightly higher due to liver
• ? perforation
  
  • free air under diaphragm
  • or perforation of abdo viscous

Question 14

What should you be thinking when looking at the everything else (E) on x-ray?

Answer 14

• everything else
  
  • bones
    
    • are bones intact?
  • soft tissue
    
    • any swellings?
  • Devices / lines / artefact
    
    • any lines? - NG tube, central lines
    • any artefact?
    • devices e.g. pacemakers?

after completed ABCDE do “in summary,” investigations: bedside, bloods scans

e. g. LFTs as derrangement can impact choice of Abx
e. g. urea to be done for CURB-65 + dehydration

Question 15

how can you tell the difference between pleural effusion and consolidation?

Answer 15

effusion e.g. free fluid has a meniscus (waterline) and is thicker than consolidation

• the air and fluid is horizontal
• homogeneous density throughout
• pleural effusions may push mediastinum away

Consolidation = fluid within the alveoli

• patchy opacity through lobe - can see air patches (black)

NB: if stuck say increased density which means its whiter

• while less density = clear black

Question 16

What are the signs of pulmonary oedema?

Answer 16

• horizontal fissre w/t lined in -
• kerley b lines
• hilar expansion (batwings)

Question 17

What should you do if you see pneumothorax on a CXR?

Answer 17

• 1* pneumothorax
  
  • spontaneous
  • if only small rim then no tx needed
• 2* pneumothorax
  
  • trauma / underlying disease
  • get chest drain as unlikely to expand on own
• tension pneumothroax
  
  • break in lung (flap of tissue) creates 1x way valve so air goes in that pushes mediastinum to the side

symptoms of tension pneumothorax:

deviated trachea, hyperesonance on pneumo side, ; unwell pt, use cannula in 2nd ICS

check scars e.g. lobectomy as rest of lung will fill the space

Question 18

How do you tell the difference between a pacemater and an implantable cardioverter defib?

Answer 18

• Pacemaker
  
  • single lead pacemaker
  • smaller
  • will have 1x area of increased density
  • screws into myocardium
• implantable cardioverter defib (ICD)
  
  • bigger - w/ability to shock
  • 2x density leads as need to shock across heart