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What is the ABCDE approach?
A-airway (trachea, carina, bronchi, hilar structures)
B-breathing (lungs and pleura)
C-cardiac (heart size and borders)
D-diaphragm (costcophrenic angles)
E-everything else (mediastinal contours, bones, soft tissues, tubes, valves, pacemakers, wires)
What are you inspecting with clavicles in regards to rotation (Ripe)?
Ensure that the medial ends of the clavicles are equidistant from the spinous processes of the vertebrae indicating patient was not rotated during the xray
What should you inspect to ensure the patient did not rotate during the x-ray?
Medial aspect of clavicles, spinous processes alignment, vertebral bodies
What should you confirm visibility of in regards to inspiration (rIpe)?
7 anterior ribs, lung apices, costophrenic angles, lateral rib edges
If there is blunting of the costophrenic angles, what can be indicated?
Pleural effusion
Why should the lateral edges of of the ribs be visible?
To ensure the entire lung field is included in the image
In PA view, how are x ray beam passes?
From the posterior to the anterior
standard view for chest xrays
*more accurate representation of heart size and lung fields
How are x ray beam passed in AP view?
From anterior to the posterior
*used for patients who are unable to stand, just like those in a hospital bed
-can magnify heart and mediastinum, making them appear larger
What position is used for routine CXRs?
PA and lateral views
What are AP and supine films used for?
Portable films; can make the heart appear enlarged and lungs hypoinflated
What is useful for identifying pleural effusions?
Lateral decubitus films
What type of film is used to view the apices of the lungs?
Lordotic films
What is helpful for detecting pneumothorax?
Expiratory view
What features are seen in the PA positioning?
scapula in the periphery, clavicles project over lung fields, posterior ribs are distinct
What features are seen in the AP positioning?
scapula over the lung field, clavicles above the apex of the lung, anterior ribs are distinct
What should be visible in normal exposure?
Vessels should be visible to at least the peripheral 2/3 of the lung
What is visible with inspiratory effort?
Visualization of more than 7 ribs
What should be visible with left hemidiaphragm exposure?
Left hemidiaphragm should be visible to the spine ensuring xray has adequate penetration
What should be visible with vertebrae exposure?
vertebrae should be visible behind the heart indicating that x rays are neither underexposed (too light) or overexposed (too dark)
-proper exposure allows for clear visualization of lung markings and any potential pathology
Describe the silhouette sign
-helps localize pathology
-Loss of the normal borders between structures of the same radiographic density indicates pathology
ex: loss of the right heart border suggests right middle lobe pathology
What should be noted with heart size and shape in CXR?
Should be less than half the width of the thoracic cavity
What should you be checking for with hemidiaphragms?
Gastric bubble and position
What are the CXR structures?
Heart, Mediastinal contours, airway, lung symmetry, lung infiltrates/masses/nodules, hemidiaphragms, pleural effusions, bones, tubes/wires
What is the collapse or incomplete expansion of lung tissue?
Atelectasis
What is the presence of fluid in the pleural space?
Pleural Effusion
What disease is characterized by air in the pleural space?
Pneumothorax
What are tumors or large cysts that can compress lung tissue?
Space-occupying lesions
What can chronic conditions like tuberculosis and radiation therapy cause?
Fibrosis and scarring
Conditions such as ARDS can lead to a lack of _______________
Surfactant
Due to volume loss (hallmark of atelectasis) can be identified by?
-Structures (heart, trachea, and mediastinum) may shift towards side of atelectasis
-Diaphragm on affected side may appear elevated
-Ribs on affected side may appear closer together due to volume loss
How will collapsed lung tissue appear on the xray?
Denser or whiter
-Linear or wedge shaped opacities can be seen at lung bases
-Lobar or segmental opacities (can be entire lobe or segments)
What are air bronchograms?
Tubular outlines of air filled bronchi made visible by surrounding collapsed alveoli
What are the 3 signs you should look for in Atelactasis?
Displacement of fissures, increased density, volume loss in affected area
What key features should you looks for in cardiogenic PE?
Kerley B lines, perihilar haze, pleural effusions
*Caused by increased pressure in heart’s left side leading to fluid leakage into the lungs
What key features should you look for in non cardiogenic pulmonary edema?
Diffuse alveolar infiltrates without cardiomegaly
*Due to increased permeability of lung capillaries allowing fluid to leak into alveoli
What refers to the redistribution of blood flow to the upper lobes of the lungs appearing more prominent on the xray?
Cephalization of pulmonary vessels
What are short, horizontal lines at the lung periphery, representing interstitial edema? (caused by fluid in interlobular space)
Kerley B lines
What appears as a thickening around the bronchi due to fluid accumulation?
Peribronchial cuffing
What is a pattern of alveolar edema that shows up as central symmetrical opacities around the hilum?
Batwing or butterfly
What are common causes of cardiogenic pulmonary edema?
Heart failure, myocardial infarction, valvular heart disease
What are common causes of noncardiogenic pulmonary edema?
ARDS, high altitude pulmonary edema, toxins or meds
What features might you see on an xray of a pt with pneumonia?
Airspace opacification, air bronchograms, silhouette sign
What is the difference between lobar and bronchopneumonia?
Lobar: Shows consolidation in one or more lobes of the lung
Broncho: bilateral patchy shadows, predominating at the bases
What features should you look for on an xray of a pt with pleural effusion?
blunting of the costophrenic angle and meniscus sign
*earliest sign can be seen with as little as 200 mL of fluid
What is a meniscus sign?
Fluid forms a curved line (meniscus) that is higher laterally and lower medially
*indicates presence of free flowing pleural fluid
What is homogeneous opacity?
uniform white area on the xray, usually at lung bases
*suggests large pleural effusion, can obscure diaphragm and heart borders
What is mediastinal shift seen in pleural effusion?
Mediastinum shifts away from side of effusion
*seen in large effusions and indicates significant volume
What is loculated effusion?
Fluid is trapped in pockets w/in pleural space due to adhesions
*appears as irregular opacities and does not change with patient positioning
What is the significance of lateral decubitus view?
Helps differentiate free flowing fluid from loculated fluid and can detect smaller effusions
What symptoms would you see with pleural effusion, what might you find on a physical exam?
Dyspnea, chest pain, cough
*Dullness to percussion, decreased breath sounds, reduced tactile fremitus on affected side
What should you identify with pneumothorax?
Absence of lung markings and visible pleural line
How can you identify a visceral pleural line?
A thin white line
In cases of tension pneumothorax, the trachea may deviate to which side?
Affected side
What are key features on an xray of a patient with COPD?
Hyperinflation (flattened diaphragm)
Inc retrosternal air space (seen on lateral views, also indicates hyperinflation)
Bullae (large air filled spaces due to alveolar destruction, seen in emphysema)
Dec vascular markings (in upper lobes, due to destruction of lung tissue)
Barrel chest (inc AP diameter)
What features may be seen on an xray of a patient with asthma?
Hyperinflation (less pronounced than COPD)
Bronchial wall thickening (due to chronic inflammation)
Atelectasis (partial collapse of lung segments, due to mucus plugging)
Normal CXR
How are benign nodules usually seen?
Well defined and calcified
How are malignant nodules usually seen?
Irregular borders and are not calcified
Note 
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