Chest X-Ray and EBM

OBJECTIVE: Demonstrate one systematic way to read a chest x-ray (ABCDEFGH)

A: Airways

• Top midline and review airways, trace trachea to carina.

• air where it shouldn’t be?

B: Bones

• Check clavicles and ribs for fractures/other issues

C: Cardiac Silhouette

• Size (<50% chest Diameter on PA)

D: Diaphragm

• Check for hemidiaphragm position and shape

• Look inferior for free gas

E: Equipment

• Check for tubes, wires, pacemaker, and CV lines

• Check for pleural effusion (blunted costophrenic angles may indicate small effusions)

F: Fields

• Check lung fields for infiltrates, masses, consolidations, vascular markings

• Vessels should taper off to invisible at periphery

• Evaluate fissures for thickening

G: Great Vessels

• SVC, IVC, Aorta (asc, arch, and desc), Pulm. Art

H: Hila

• Pumonary vasculature, major bronchi and lymph nodes (invisible in healthy)

What is A in ABCDEFGH

Review Airways

Go to top midline and trace trachea to carina

Is there Air where it shouldn’t be

What is B in ABCDEFGH

Bones

Check clavicles and ribs for fractures and other issues

What is D in ABCDEFGH

Diaphragm

Check for hemidiaphragm position and shape

Look inferior for free gas

What is D in ABCDEFGH

Diaphragm

Check for hemidiaphragm position and shape

Look inferior for free gas

What is E in ABCDEFGH

Equipment/effusion

Check for tubes, wires, pacemaker (in the right places)

Check for pleural Effusions

What is F in ABCDEFGH

Fields

Check lung fields for infiltrates, masses, consolidations, vascular marking

Vessels should taper off to invisible at periphery

Evaluate Fissures for thickening

What is G in ABCDEFGH

Great Vessels/Gastric Bubble

SVC, IVC, Aorta (sac, arch, knob, desc) Pulm Art.

Gastric bubble (stomach) Lower left (low right on image)

What is H in ABCDEFGH

Hila

Pulmonary vasculature, major bronchi and lymph nodes

Lymph nodes tend to be invisible in healthy pt

OBJ: Practice formulating a clinical question using the PICO format

P: Patient, Population, Problem

I: Intervention

C: Compare

O: Outcome

I.e. What is the effect of Med A(I) vs Med B(C) on Bed Wetting Elimination (O) in children with Bed Wetters Disease(P)?

OBJ: Demonstrate an understanding of the difference between primary, secondary, and tertiary resources in medical literature and what types are most reliable

Primary: From da source.

• Journals

• Theses

• Conferences

• Reports

• Patents

Secondary: Discusses the research of others

• Review Journal

• Reviews

• Compilations

Tertiary: (typically need backgroud knowledge to interpret)

• Encyclopedia

• Almanac

• Fact book

• Wikipedia

CXR Positions?

Posterior-Anterior (PA) - Xray goes posterior to anteror, perfomed standing and with full inspiration, hugging the detector to pull scapulae laterally (Gold Standard)

Anterior-Posterior (AP) - Opposite of PA, often done on sitting up pt in bed (ICU pt). Disadvantages: heart may appear magnified bc further from detector, often poorly inspires and scapulae cover lungs

Lateral: erecct lateral and labeled side closest to cassette. Helps localize pathology when paired with PA. Examines retrosternal spaces, retrocardiac spaces, and costophrenic recesses.

Best Technique to examine lungs, bony thoracic cavity, mediastinum & Great vessels

PA

Why do lateral CXR?

Localization of pathology when paired with PA, examines tretosternal/cardiac spaces and costophrenic recesses

Why do lateral CXR?

Localization of pathology when paired with PA, examines tretosternal/cardiac spaces and costophrenic recesses

Good Chest X-ray looks like…

Right Exposure (too dark/too light to see lung markings)

Inpiratory effort (count 10 ribs)

positioning (Trachea midline w/ aligned clavicles)