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Basic Concepts

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... the use of life-saving equipment Standard & Additional Radiographic Examinations Left lateral view better view of the spine; ... indications for taking an X-ray ... – PowerPoint PPT presentation

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Title: 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.
6
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?

7
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

8
Standard CXR PA filmMale
9
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

10
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)

11
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

13
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

14
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

15
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

16
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

17
  • 1. Lung Fields
  • presence of bronchovascular markings
  • equal transradiancy
  • discrete or generalized shadow?
  • 4. Mediastinum
  • contour generally clear

CXR Normal PA film 2
18
CXR PA Normal Female
  • Asymmetric or Missing Breast Shadow may indicate
    Mastectomy
  • Basal lung changes may be obscured by breast
    tissue

19
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

20
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

21
CXR Pneumonia
22
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
26
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
28
More X-Ray Interpretations
29
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

30
  • 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
32
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.

33
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

34
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/
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