CXR Interpretation

Question 1

What must be done first?

Answer 1

Who is it of, and when was it taken?

Name and DOB

Question 2

Assess image quality:

RIPE mneumonic - what is it?

Answer 2

Rotation
Inspiration
Projection
Exposure

https://www.youtube.com/watch?v=iKNBs8EU9i0&list=PLjE4r9GDEhhOoBZ21ial4TzbOWoKuayEk&index=6

Question 3

Assess image quality:

Rotation - how can you tell if an image is rotated using the clavicles?

Inspiration:

• How many anterior ribs should be in view?
• How many posterior ribs should be in view?
• How would you know you are looking at anterior ribs on a PA CXR?
• Over how many anterior ribs suggests hyperinflation?

Answer 3

The medial aspect of each clavicle should be equidistant from the spinous processes

5-6 anterior ribs
10 posterior ribs

The posterior ribs are brighter so you would see the lighter anterior. Just use the direction of the CXR to determine it.
The opposite would be said for AP XR.

> 6 ribs

Question 4

Assess image quality:

Inspiration:

• Why may cardiomegaly be mimicked in poor inspiration?
• Why may consolidation/collapse be mimicked in poor inspiration?
• What type of patient may have poor inspiration?

Answer 4

The heart is usually pulled down and elongated with inspiration so this doesn’t happen in poor inspiration.

Crowding of vessels at the lung bases

Those acutely unwell
In pain
Those unconscious

Question 5

Assess image quality:

Projection:

• What 2 types of projection are there?
• If there is no label, what projection should be assumed?

Exposure:

• Does over-penetration look darker/whiter?
• Why is this important?
• How do you know if it is well penetrated using the hemidiaphragm and the vertebrae?

Answer 5

PA assumed

AP - anterior-posterior
PA - posteroanterior

It looks darker - less x-rays are getting through everything and not stopping at the bones and solid structures.

Causes a loss of definition and quality

Left hemidiaphragm visible to the spine
Vertebrae visible behind heart

Question 6

Interpretation - ABCDE approach:

What does the mneumonic stand for?

Answer 6

Airway 
Breathing 
Circulation
Diaphragm
Everything else

Question 7

Interpretation - ABCDE approach:

Airways - Trachea:

• Which side may the trachea normally be deviated to?
• What pushes the trachea away? - 2 - think of what adds to the volume
• What pulls the trachea towards it? - 1
• What part of the RIPE mneumonic may affect the appearance of the trachea?

Answer 7

The right side

Large pleural effusion
Tension pneumothorax

Consolidation with lobar collapse - causes uneven pressure in the thorax

Rotation - it may appear deviated

Question 8

Interpretation - ABCDE approach:

Airways - Carina and Bronchi:

• What is the carina?
• Why is the right main bronchus more common for inhaled foreign objects to become lodged?

Airways - Hilar structures:

• What within the hilar region?
• Which hilum is higher than the other? - The left or right?
• Are the hilar regions usually symmetrical or asymmetrical?
• What is a hilar point?
• What does a loss of the hilar point suggest?

Answer 8

Where the trachea divides into the L and R bronchi.

It is wider, shorter and more vertical.

Main pulmonary vasculature
Bronchioles
Lymph nodes

Left - but it varies between individuals.

It is usually the same size and density - asymmetry raises suspicion of pathology

An indent into the hilum - descending pulmonary artery intersects the superior pulmonary vein

Lung tumour or enlarged lymph nodes

Question 9

Interpretation - ABCDE approach:

Airways - Hilar structures:

• What does bilateral symmetrical enlargement suggest?
• What does unilateral/asymmetrical enlargement suggest?

The abnormal hilar position could be caused by a range of pathology.

• What can push on the hilum?
• What can pull the hilum? - think the same as trachea?

Answer 9

Sarcoidosis - BHL

Underlying malignancy

===

Enlarge soft tissue mass - cancer

Lobar collapse

Question 10

Interpretation - ABCDE approach:

Breathing - Lungs:

• How many zones (not lobes) do we divide the lungs into?
• What lung has 3 lobes?
• How do you look at both lung?
• What is a consolidation?
• What does increased airspace shadowing suggest? - 2

Answer 10

3 zones - upper, middle, lower

Right lung

You compare each zone on each lung

Lung consolidation occurs when the air that usually fills the small airways in your lungs is replaced with something else. Depending on the cause, the air may be replaced with: a fluid, such as pus, blood, or water. a solid, such as stomach contents or cells.

Consilodation (e.g. pneumonia)
Malignant lesion

Question 11

Interpretation - ABCDE approach:

Breathing - Pleura:

• Are the pleura usually seen on XR?
• How do you check if there is no pneumothorax?
• What will hydro/haemothoraces look like?
• What does pleural thickening suggest?

Answer 11

No, they should not be seen

Check lung markings reacht he borders in each lung

Increased opacity

Mesothelioma

Question 12

Interpretation - ABCDE approach:

Cardiac:

• What ratio is used to work out if there is cardiomegaly?
• What projection is used to calculate this?

Heart borders:

• What makes up most of the right heart border?
• What makes up most of the left heart border?
• What is the loss of definition of the right heart border associated with?
• What is the loss of definition of the left heart border associated with?

Answer 12

Left ventricle

Cardiothoracic ratio (<50%)

PA - AP exaggerates heart size

======
Right atrium - that is why you can see if there is cor pulmonale with hypertrophy

Right middle lobe consolidation

Lingular consolidation

Question 13

Interpretation - ABCDE approach:

Cardiac - Aortic knuckle:

• What structure causes the aortic knuckle?
• What does the loss of this knuckle suggest?

Cardiac - Aorto-pulmonary window:

• What structures cause this?
• What could the loss of the window suggest?

Answer 13

Left lateral edge of the aorta as it arches back over the left main bronchus

Space between the arch of the aorta and the pulmonary arteries

Mediastinal lymphadenopathy - malignancy

Question 14

Interpretation - ABCDE approach:

Diaphragm:

• Which hemi-diaphragm is usually higher?
• What may be seen under the left-hemidiaphragm indicating the stomach?
• What is air under the diaphragm called?
• What is Chilaiditi syndrome and why does it cause the false appearance of air under the diaphragm?
• What should you do as a junior if you see free air under the diaphragm and why?

Answer 14

The right one due to the liver

Gastric bubble

Pneumoperitoneum

The colon becomes positioned between the liver and diaphragm.

Seek senior colleague
- Could be result of bowel perforation

Question 15

Interpretation - ABCDE approach:

Diaphragm - Costophrenic angles:

• What is another way of saying you have lost the angle?
• What causes loss of the angle?
• Why does hyperinflation such as COPD cause a loss of the angle?

Answer 15

Costophrenic blunting

Consolidation or presence of fluid (pul O)

The diaphragmatic flattening cause subsequent loss of the acute angle

Question 16

Interpretation - ABCDE approach:

Everything else:
- What else are you looking at?

Answer 16

Bones:
- Inspect the visible skeletal structures looking for any abnormalities (e.g. fractures / lytic lesions).

Soft tissues:
- Inspect the soft tissues for any obvious abnormalities (e.g. large haematoma).

Tubes – nasogastric tubes are something you’ll often be asked to assess on a chest x-ray to confirm it is safe for feeding

Lines (e.g. central line / ECG cables).

Artificial valves (e.g. aortic valve replacement).

Pacemaker (often located below the left clavicle).

Question 17

https://geekymedics.com/chest-x-ray-interpretation-a-methodical-approach/

Answer 17

https://geekymedics.com/chest-x-ray-interpretation-a-methodical-approach/