Learning Objectives Covered LO 04.01 – Describe the procedure for interpreting chest x-rays LO 04.02 – Identify normal findings on chest x-rays Background On a normal chest x-ray the lungs will appear dark (radiolucent) with no abnormalities or fluid in the alveoli, interstitium or airways. A chest x-ray that is normal and free of any abnormalities is said to be clear. Anatomical landmarks should always be examined and identified. The key to a successful x-ray interpretation is evaluating fundamental structures and their normal appearance. These structures include the lungs, heart, mediastinum, diaphragm and bony structures such as the clavicles and sternum. Refer to the anatomical landmarks identified in the figure. Chest X-Ray Procedure Watch this short video describing how CXR’s are performed. After you watch the video you will gain a better understanding of its process in diagnosing respiratory disorders. (total time 1:47 minutes) Chest X-Ray by Amy Lehman (Links to an external site.) Chest X-Rays key points Normally the lung fields appear as dark shadows on the chest x-ray Consolidation appears as a white patch on the chest film Lung tissue that is hyperinflated appears as darker shadows The heart, pulmonary arteries, and diaphragm are water densities and appear as whitish gray shadows The ribs are very dense and appear as white shadows A certain sequence that calls for evaluation of all structures in the chest is needed. For example, many clinicians start by evaluating the peripheral soft tissues and work their way inward, evaluating the lungs, heart, mediastinum and hilum, then the bony structures The silhouette sign is used to determine if a pulmonary infiltrate is in contact with the heart border. Right middle lobe pneumonia will be in the same plane as the right heart border and result in no ability to see the right heart border. A pneumonia in the superior segment of the right lower lobe will appear adjacent to the right heart but will not obscure the border Air bronchograms are seen when air-filled bronchi are surrounded by consolidated alveoli This will indicate that the whiteout is due to lung infiltrates and not pleural fluid When interpreting chest x-rays there are many approaches that can be followed. A simple approach includes the following: Determine the right side from the left side on the x-ray Verify if the x-ray is an anterior posterior (AP) or posterior anterior (PA) exposure Verify that the x-ray is taken on full inspiration Assess for any patient rotation on the x-ray by evaluating the distance between the medial end of the clavicles and midline of the chest Assess that the costophrenic angles on the x-ray are present. These angles should be sharp and pointed. If the costophrenic angles are blunted a pleural effusion may be indicated Assess the lung fields on the x-ray to be sure that there is no significant loss of lung volume. Lung parenchyma should appear lighter at the bases. If not lower lobe atelectasis or pleural effusion may be indicated Chest X- Ray Limitations Small lesions in blind areas may not be seen The chest x-ray is not sensitive to all lung problems and may appear normal despite significant respiratory problems (e.g., asthma) Clinical and Radiographic Findings in Lung Diseases Atelectasis Loss of lung volume is seen on the chest film Areas of white shadows are common Major structures may demonstrate displacement Elevation of a hemidiaphragm is common Pneumothorax Pleural line may be seen on the lateral part of the chest Shift of mediastinal structures may be seen with tension pneumothorax Hyperinflation Most often seen with asthma and COPD Large lung volumes seen on the chest film Increased anterior airspace seen on the lateral view Depressed hemidiaphragms common Small narrow heart seen with severe COPD Interstitial Lung Disease Most fibrotic lesions form in the lower lung fields An alveolar pattern is seen when alveoli begin to fill up with blood, pus, protein, or cells Air bronchograms may be seen with alveolar pattern Congestive Heart Failure Chest x-ray reveals redistribution of pulmonary vasculature to the upper lobes The width of the heart shadow exceeds half the width of the thorax on the chest film Kerley B lines are often present when pulmonary edema is a problem Pleural Effusion Blunting of the costophrenic angle Partially obscured diaphragm Whiteout of the involved side with large pleural effusion Lateral decubitus useful for recognition of small pleural effusions Consolidation Minimal signs of volume loss Lobar pattern of whiteout common Homogeneous density late in the process Air bronchograms may be seen Prompt When interpreting chest x-rays, evaluating the fundamental structures of the thoracic cavity is important. For this assignment, you will provide detailed responses to the following questions. Describe each of the following x-ray abnormal patterns listed below. In your answer indicate the disease of which it is associated. Bat wing Kerley B lines Honeycomb appearance Ground glass appearance Air bronchograms 2. What is the optimal position of the tip of the endotracheal tube? What are 3 procedures you could perform at the bedside immediately after intubation to evaluate tube position before the CXR? 3. Case Study Sam brings a 71-year-old man to the emergency department. He claims that her father has experienced breathing problems for many years, but now he’s worse. The patient is alert and has trouble completing sentences because of apparent shortness of breath and pursed-lip breathing. His temperature is 100.8o F; his respiratory rate is 28 breaths per minute, with diminished breath sounds. Low-flow oxygen is administered, and the patient appears to be in less distress. A chest radiograph reveals diaphragms that are lowered and flattened with blunted costophrenic angles, and possible presence of bullae. What disease process do these radiographic findings suggest? Explain. Submit your answers in at least 500 words on a Word document. You must cite at least three references in IWG format to defend and support your position.
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