Slide 1

Chest X ray interpretation

David O’Neill MSc BSc RN NMP FHEA

Associate Lecturer Cardiff University (Non Medical Prescribing)

Respiratory Advanced Nurse Practitioner Royal Gwent Hospital Newport

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Slide 2 Learning Outcomes

• Understand role of chest x-rays in acute care

• Review surface anatomy of the lungs

• Identify normal structures on an x-ray

• Recognise the types of densities in chest x-

ray

• Understand the steps involved in interpreting

a chest x-ray

• Interpret examples of X rays you may be

asked to review

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Slide 3 Clinical Patient Assessment

• Clinical Patient Assessment (CPA) involves:

– Patient history (75-85% of diagnosis stems from this)

– Clinical examination

– Formulating a working diagnosis

– Differential diagnosis

– Choosing appropriate investigations

– EVALUATION OF THE ABOVE(Longmore et al 2002)

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Slide 4 X ray in acute care

• Used to evaluate for:

• NORMALITY

• Consolidation (Pneumonia)

• Pneumothorax

• Atelectasis

• Pleural effusion (including haemothorax)

• COPD

• TUBERCULOSIS

• MALIGNANCY

• POSITIONING OF MEDICAL DEVICES

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Slide 5 Be systematic

• Some anatomical structures in the

chest should be assessed on every

chest x-ray

• Each of these anatomical structures

should be viewed using a systematic

approach

• There are also important structures that

are obscured or become visible only

when abnormal

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Slide 6 Mnemonic

Some S=Skin

Body B=Bones

Lost L=Lungs and pleura

My M=Myocardium (Heart)

Toy T=Trachea

Dinosaur D=Diaphragm

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Slide 7 Visible structures

• How many anatomical structures can you see on this x-ray ?

• Can you think of any important structures in the chest that are difficult to see on the x-ray ?

• Visible structures

• 1 - Trachea

• 2 - Aortic knuckle

• 3 - Scapulae

• 4 - Hila

• 5 - Lungs

• 6 - Heart

• 7 - Ribs

• 8 - Breasts

• 9 - Diaphragm

• 10 - Stomach

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Slide 8 Obscured structures

• Important obscured structures

• Sternum

• Oesophagus

• Spine

• Pleura

• Fissures

• Aorta

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Slide 9 Chest x-ray anatomy

• Many structures of the chest are readily visible

• Others, are difficult to see.

• Some important structures, such as the phrenic nerve, are not visible at all.

• The pleura, only become clearly visible when abnormal.

• Trachea and major bronchi

• Are visible on most good quality chest x-rays.

• Contain air and so are of lower density (blacker) than the surrounding soft tissues.

• The trachea branches at the carina, into the left and right main bronchi, and these can often be followed as they branch beyond the hila and into the lungs.

• TRACHEA SHOULD BE CENTRAL

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Slide 10 Assessing airways

• Normal chest x-ray

• The trachea and

bronchi are visible -

branching at the carina

• The trachea passes to

the right of the aorta

and so may be slightly

off mid-line to the right

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Slide 11 Normal chest x ray

• If the trachea is deviated, is this

because:

• The patient has been incorrectly

positioned (rotated),

• There is pathology.

• If the trachea is genuinely deviated you

should then try to decide if it has been

pushed or pulled by a disease process.

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Slide 12 Hilar structures

• Each hilum contains major bronchi and pulmonary vessels

• There are also lymph nodes on each side (not visible unless abnormal)

• The left hilum is often higher than the right

• If a hilum is out of position, ask yourself if it has been pushed or pulled

• As well as position - check the size and density of the hila

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Slide 13 Pleura & pleural spaces

• The pleura and pleural spaces are only visible when abnormal

• Lung markings should reach the thoracic wall

• Trace round the entire edge of the lung where pleural abnormalities are more readily seen

• Start and end at the hila

• Is there pleural thickening?

• Is there a pneumothorax? The lung markings should be visible to the chest wall

• Is there an effusion? The costophrenic angles and hemidiaphragms should be well defined

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Slide 14 Chest X ray anatomy

• The left lung has two lobes

and the right has three

• Each lobe has its own

pleural covering

• The horizontal fissure

(right) is often seen on a

normal frontal view

• The oblique fissures are

often seen on a normal

lateral view

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Slide 15 Surface anatomy R Lung

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Slide 16 Costophrenic angles

• The costophrenic

angles are limited

views of the

costophrenic recess

• On a frontal view the

costophrenic angles

should be sharp

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Slide 17 Diaphragm

• The hemidiaphragms are domed structures

• Each hemidiaphragm should be well defined

• The left hemidiaphragm should be visible behind the heart

• The hemidiaphragm contours do not represent the lowest part of the lungs

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Slide 18 Cardiac assessment

• The heart size is

assessed as the

cardiothoracic ratio

(CTR)

• A CTR of >50% is

abnormal - PA view only

• The left hemidiaphragm

should be visible behind

the heart

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Slide 19 Soft tissue

• Assess the soft tissues on every chest x-ray

• Thick soft tissue may obscure underlying structures

• Black within soft tissue may represent gas

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Slide 20 Bones

• Assess the bones on every chest x-ray

• Check for abnormalities of single bones

and for diffuse bone disease

• The bones are helpful in assessing the

quality of the chest x-ray

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Slide 21 Clavicles, spinous processes and ribs

• Clavicles are clearly seen on a chest x-ray.

• Spinous processes of the vertebrae (posterior structures) should lie midway between the medial ends of the clavicles (anterior structures).

• If the spinous processes are not central, the patient is rotated, that is, positioned obliquely to the x-ray beam.

• The anterior and posterior ends of the 5th rib are also shown.

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Slide 22 Ribs

• The anterior end of approximately 5-7 ribs should be visible above the diaphragm in the mid-clavicular line.

• Less than this indicates an incomplete breath in, and more than 7 ribs or flattening of the diaphragm, suggests lung hyper-expansion.

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Slide 23 Assessing the lungfields

• The lungs are assessed and described by dividing them into upper, middle and lower zones

• Refer to 'zones' not 'lobes'

• Compare left with right

• Compare an area of abnormality with the rest of the lung on the same side

• Note that the lower zones reach below the diaphragm. This is because the lungs pass behind the dome of the diaphragm into the posterior sulcus of each hemithorax.

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Slide 24 Densities

• Different tissues have

different density on X

ray

• Bones are white

• Lung tissue is 99% air

and is black

• Blood vessels give the

lacy pattern (1%)

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Slide 25 Interpretation of CXR

• Basic interpretation is EASY. They are

either:

– TOO WHITE

– TOO BLACK

– TOO LARGE

– IN THE WRONG PLACE

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Slide 26 Technical details

• Check the patient name

• Date of X ray

• Whether its PA or AP

• Check Left/Right marker

• Check for Rotation

(clavicles not equally

positioned)

• Check

exposure/penetration

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Slide 27 Consolidation

• Compare the left and right upper, middle and lower lung zones

• Decide which side is abnormal

• Compare an area of abnormality with the rest of the lung on the same side

• The whiter side is not always the abnormal side

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Slide 28 Pleural disease- too white

• Pleura only

become visible

when diseased

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Slide 29 Air fluid interface too white/black

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Slide 30 Too black

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Slide 31 Too large

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Slide 32 Too large

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Slide 33 In the wrong place

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Slide 34 Pneumoperitoneum

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Slide 35 Checklist 1

• Check patient name, position, technical quality.

• Soft tissue including breast, chest wall,

companion shadow.

• Review soft tissues and skeletal structures of

shoulder girdles and chest wall.

• Review abdomen for bowel gas, organ size,

abnormal calcifications, free air, etc.

• Review soft tissues and spine of neck.

• Review spine and rib cage: check alignment,

disc space narrowing, lytic or blastic regions,

etc.

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Slide 36 Checklist 2

• Review mediastinum:

– overall size and shape

– trachea: position

– margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle

– lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic

– retrosternal clear space

• Review hila:

– normal relationships

– size

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Slide 37 Checklist 3

• Review lungs and pleura:

– compare lung sizes

– evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery

– pulmonary parenchyma

– pleural surfaces

• fissures - major and minor - if seen

• compare hemidiaphragms

• follow pleura around rib cage

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Slide 38 Examples 1

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Slide 39 Examples 2

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Slide 40 Examples 3

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Slide 41 Examples 4

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Slide 42 Examples 6

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Slide 43 Examples 7

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Slide 44 Example 8

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Slide 45 Example 9

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Slide 46 Example 10

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Slide 47 Example 11

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Slide 48 References

• Corne, D, J, Carroll M, Brown I, Delaney D (2002) Chest X ray Made Easy (2nd ed) Edinburgh Churchill Livingstone

• Longmore, M, Wilkinson, I, Torok, E (2001) Oxford Hnadbook of Clinical Medicine Oxford Oxford University Press.

• Medscape http://emedicine.medscape.com/pulmonology[Accessed 31/3/2010]

• McCance KL, Heuther, SE. (2006). Pathophysiology-The biologic basis for disease in adults and children. St Louis. Elsevier-Mosby

• Parson PE Heffner JE. (2002) Pulmonary/Respiratory Therapy Secrets (2nd Ed.) Philadelphia. Hanley & Belfus

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