Basic Concepts

1
Basic Concepts
of
Chest X-Ray
Interpretation
Kitty Chan School of Nursing,The Hong Kong
Polytechnic University Email hskittyc_at_inet.polyu.
edu.hk Date July 2005
2
Objectives

• Upon completion of the module, the students
  should
• have developed a basic understanding of pulmonary
  anatomy and physiology in relation to the
  pathological process
• have developed a systematic and pragmatic
  approach to preliminary CXR interpretation
• understand the clinical significance of chest
  radiograph interpretation in the assessment of
  critical care clients.

3
Indicative Readings
Corne, J., Carroll, M., Brown, I. Delany, D.
(2002). Chest X-Ray Made Easy. Edingburgh,
Churchill Livingstone .
4
Introduction

• Why do you need to deeply inspire and hold your
  respiration when taking CXR?
• Sometimes an expiratory radiograph is required...
• Would it save more in terms of time and manpower
  saving to take portable CXRs in the ward than to
  send clients to the radiological dept.?
• Is a CXR decubitus view the same as a portable
  CXR lateral view ?

5
WHY WOULD YOU CARE ?
As critical care nurses, we often provide
immediate care in detecting abnormalities and
take appropriate independent or collaborative
action. For instance, after the insertion of a
central line, we have to validate its position
before we can administer medication via the
access. Therefore, it is imperative for us to
have a basic understanding of X-rays Apart from
this, we often have to know the indications for
taking an X-ray and how to ensure that a
good-quality X-ray can be taken. In this way, the
relevant party or specialist can detect subtle
changes without delay. Patients will benefit from
prompt interventions.
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CXR Distinguish between PA Film AP Film

• Recall your own experience in taking a CXR
• What was your position posture?
• Where was the film placed?
• How about a portable CXR
• Are there any differences at all?

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Standard Additional Radiographic Examinations

• Erect PA (posteroanterior) view
• Taken in normal persons who are standing upright,
  arms embracing the film holding their breath
  with full inspiration

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Standard CXR PA filmMale
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Standard Additional Radiographic Examinations

• Portable CXR (anteroposterior view)
• valuable for aiding in diagnoses of critical care
  clients
• magnified heart redistribution of pulmonary
  blood flow
• false positive findings due the use of
  life-saving equipment

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Standard Additional Radiographic Examinations

• Left lateral view
• better view of the spine posterior costophrenic
  angles, lung bases retrosternal region
• Lateral decubitus view
• visualizing small quantities (less than 100ml) of
  gravity-dependent pathologies such as pleural
  effusions or subpulmonary fluid
• side-lying (right lateral decubitus right
  side-down vice versa for left side)

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Standard Additional Radiographic Examinations

• Apical lordotic view
• to detect apical lesions or middle lobe
  atelectasis
• to detect lesions behind the clavicle

12
Standard Additional Radiographic Examinations

• Oblique projection
• evaluate pleural lesions
• Expiratory radiographs
• reveal air trapping
• bulla, blebs
• air collection does not increase in bulla
  blebs
• small pneumothorax
• detect minimal pleural effusions

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Fundamental Knowledge Radiology Skills

• Pulmonary anatomy physiology
• The concept of density gradient contrast
• tissue density - dense cortical tissue gt lung
  parenchyma gt fat gt water gt air
• The concept of depth superimposed images

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Fundamental Knowledge Radiology Skills

• Technical quality
• Projection direction of X-ray beam e.g., AP or
  PA
• Orientation beware of destrocardia
• Rotation equidistance of clavicle medial ends to
  spinous process
• Penetration vertebral body just visible through
  cardia shadow
• Degree of inspiration anterior end of 6th rib
  visible above the diaphragm

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Interpreting CXR

• Points to note
• Review a clients particulars diagnosis
• Check the date time of the CXR film
• Use a good light source/viewing box
• Adopt a basic sequence to examine the film
• Always correlate the radiological findings with
  the patients clinical history physical signs
• Obtain the expert opinion of the radiologist
  related specialists

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Basic Sequence in CXR Interpretation

• Systematically scan the film at 4 ft. outward in,
  or vice versa. Repeat the steps close up
• bones
• soft tissue
• Be alert for abnormal black white spots
  abnormal sizes abnormal locations
• Compare the bilateral lung field and past
  present X-ray films to spot lesions
  abnormalities

• lung fields
• hilum
• trachea

• heart
• mediastinum
• diaphragms
• costophrenic angles

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• 1. Lung Fields
• presence of bronchovascular markings
• equal transradiancy
• discrete or generalized shadow?

• 4. Mediastinum
• contour generally clear

CXR Normal PA film 2
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CXR PA Normal Female

• Asymmetric or Missing Breast Shadow may indicate
  Mastectomy
• Basal lung changes may be obscured by breast
  tissue

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CXRLateral view

• Lt or Rt lateral makes little difference
• Vertebral Column on the right
• Front of the Chest on the left
• Be alert for density changes at the retrosternal
  space hilar region

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Common Abnormalities 1

• White Lung Field may suggest
• Hemothorax
• Pulmonary oedema
• ARDS
• Pleural effusion
• Atelectasis
• Consolidation

• Fibrosis
• Bronchiectasis
• Miliary shadow
• Carcinoma or other lesions
• Pneumonectomy

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CXR Pneumonia
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Common Abnormalities 2

• Black Lung Field may suggest
• COPD
• Pneumothorax/ Tension Pneumothorax
• Pulmonary embolism

23

• Slight deviation of trachea only
• Diversion of cardiac output leading to increased
  hazziness of left lung field

CXR Right-side Pneumothorax
24

• Lung markings noted in the periphery of the right
  lung field
• Lung re-expanded after chest tube insertion

CXR Right-side Chest Tube
25
For an Accurate CVP measurement Tip of Rt
jugular CVP line inserted to the junction of the
left subclavian vein to SVC (i.e., between
Proximal venous valve of subclavian/jugular vein
Rt atrium or midway between the azygous vein
and right atrium. This is approximately 2.5 cm
from the Brachiocephalic vein)
?Catheter placement beyond SVC will lead to
cardiac dysrhythmia or perforation !
CXR Central Line
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Junction of Superior Vena Cava, Brachiocephalic
Vein Azygous Vein
27

• Minimal safe distance
• at least 2 cm from carina (i.e., level of T5)
  3m below vocal cords to allow flexion extension
  of neck

CXR Endotracheal Tube Insertion
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More X-Ray Interpretations
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Implication to Critical Care Nurses

• Be Pragmatic !
• Attend to the proper positioning alignment of
  clients
• Take care with placement of lines or tubes to
  achieve an optimal view
• Be alert about the reasons for taking the
  radiographs
• locating trauma or injuries
• investigating pathological lesions diseases
• Complications of invasive procedures
• Conduct a preliminary screening of abnormalities
• Determine follow up actions or nursing
  interventions

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• Its YOUR turn now !
• Please choose either film 1 or film 2
• Discuss with your classmate next to youthe steps
  of interpreting the CXR your conclusion.

Film 1
31

• Its YOUR turn now !
• Please choose either film 1 or film 2
• Discuss with your classmate next to youthe steps
  of interpreting the CXR your conclusion.

Film 2
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References

• Corne, J., Carroll, M., Brown, I. Delany, D.
  (2002). Chest X-Ray Made Easy. Edingburgh,
  Churchill Livingstone .
• Sperber, M. (Ed.). (2001). Radiologic Diagnosis
  of Chest Disease. 2nd ed. London, Springer.
• Slone, R. M., Gutierrez, F. R., Fisher, A. J.
  (1999). Thoracic Imaging A Practical Approach.
  New York, McGraw-Hill.
• Siela, D. (2002). Using chest radiography in the
  intensive care unit. Critical Care Nurse, 22(3),
  22-34.

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Web Resources

• Chandrasekhar A.J. (2003). Chest X-ray Atlas.
  Retrieved July 20, 2005, from Loyola University
  Chicago, Stritch School of Medicine, Pulmonary
  Critical Care Division Web site
  http//www.meddean.luc.edu/lumen/meded/medicine/pu
  lmonar/cxr/atlas/cxratlas_f.htm.
• Spencer B. G., Juan Olazagasti, J., Higginbotham,
  J.W., Atul,  G. Wurm, A. (2003). Introduction
  to Chest Radiology. Retrieved July 20, 2005,
  from University of Virginia Virtual Hospital Web
  site http//www.med-ed.virginia.edu/courses/rad/c
  xr/index.html

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Web Resources

• Thompson, B. H. (2005). Introduction to Clinical
  Radiology Introduction to Chest Radiology for
  Providers. Retrieved July 20, 2005, from
  University of Iowa, Virtual Hospital Web site
  http//www.vh.org/adult/provider/radiology/icmrad/
  chest/chest.html
• Terry, J. (n.d.). Introduction to Chest X-Ray.
  Retrieved July 20, 2005, from Creighton
  University, School of Medicine Radiology Web
  site http//radiology.creighton.edu/