chest xray

i recommend doing this by answering with definition (might be hard the first time you look at these but the pics will be the term and definition will be answer)

densities from dark to bright

air, fat, soft tissue/fluid, calcium, metal

x-ray images

images produced with ionizing radiation

densities from dark to bright

air, fat, soft tissue/fluid, calcium, metal

x-ray images

images produced with ionizing radiation

x-ray advantages

inexpensive, readily accessible

x-ray disadvantages

limited detail and densities, potential for cell mutations

main CXR projections/views

posteroanterior (PA), anteroposterior (AP) erect lateral

additional CXR projections/views

lateral decubitus, oblique, rib

hilar abnormalities examples

bilateral symmetric enlargement, asymmetric enlargement

bilateral symmetric hilar enlargement conditions

sarcoidosis, TB

asymmetric hilar enlargement conditions

malignancy

pleural diseases

pneumothorax, pleural effusions

lobe consolidation condition

pneumonia

lobe masses condition

cavitary lesions

diaphragm conditions

pneumoperitoneum

gold standard for pneumonia

chest xray

indications for CXR

pathology, proper tube placement, pacemaker concerns, rib pain, chest pain

steps of CXR interpretation

assess image quality, airway, breathing, cardiac, diaphragm, everything else

image quality assessment

rotation, inspiration, projection, exposure

rotation assessment

make sure pt isn’t crooked, look at spine/spinous processes in relation to clavicles to ensure it’s straight

CXR MC with rotation issues

PA

result of rotation on CXR

costophrenic angles not visible, heart may appear different size

left rotation effect on heart size

heart looks enlarged

right rotation effect on heart size

heart looks smaller

inspiration assessment

number of ribs (should see 9-11 posterior ribs), costophrenic angles

meaning of/why we need inspiration on CXR

deep breath to look at all ribs

number of posterior ribs to visualize

9-11

number of anterior ribs to visualize

6-7

result of poor inspiration

low lung volume, false prominent lung markings (pulmonary edema), falsely enlarged cardiac silhouette

signs of hyperinflation

lungs look enlarged, diaphragm flattened, >6 anterior ribs visible, >10 posterior ribs visible

hyperinflation condition example

COPD

projection assessment

PA vs AP vs lateral

PA CXR technique

patient stands up and x-ray beams go from back to front

lateral CXR technique

side of interest is closer to XR machine (typically left)

lateral CXR useful for…

retrosternal or retrocardiac pathology

AP CXR

typically portable/mobile and not as good of an image

exposure assessment

identify thoracic vertebrae behind heart

if patient can get up and walk…

order a PA and lateral image

consequence of too much exposure

too bright

consequence of too little exposure

too much contrast

airway CXR assessment

trachea, carina and bronchi, hilar structures, lungs

trachea CXR assessment

deviation

pushing of trachea

large pleural effusion or tension pneumothorax

pulling of trachea

significant atelectasis

atelectasis

one or more areas of the lung do not inflate properly (think of a sponge being squished)

carina

ridge of cartilage at the bifurcation of the left and right bronchi

pneumothorax

air within the pleural cavity, deflated lung

CXR space occupying lesions

air, fluid

pleural effusion

fluid within the pleural cavity

meaning of trachea being pushed away

space occupying lesions

tension pneumothorax

mediastinum shifts due to large air buildup in pleural cavity

pneumothorax that has progressed to hemodynamic instability

carina importance

ensure correct tube placement

hilar structures

main pulmonary vasculature and major bronchi

pneumothorax on CXR

lack of lung markings/black area

kerley b lines CXR

pulmonary edema

consolidations on CXR

pneumonia (maybe specifically aspiration PNA)

pneumothorax causes

spontaneous (connective tissue disorders, COPD), traumatic (trauma, lung biopsy)

pneumothorax risk factors

COPD (blebs/bubbles), connective tissue disorders

pneumothorax hx

SOB, anxiety

pneumothorax PE

absent lung sounds, hyperresonant to percussion, absent tactile fremitus, subcutaneous emphysema

subcutaneous emphysema

air in soft tissue

pneumothorax dx

POC ultrasound, CXR, chest CT NC

POC ultrasound for pneumothorax

be sure to look where air would go (highest point since air rises)

most sensitive dx for pneumothorax

ultrasound

tension pneumothorax tx

needle decompression

PTX meaning

pneumothorax

1st PTX <20% or 3cm from apex and asymmetrical tx

non-rebreather (preferred)/nasal cannula with oxygen, observation, repeat CXR in 4h

large PTX >20% tx

chest tube/thoracostomy

needle decompression technique

2nd intercostal space midclavicular line with 18/16/14g needle

thoracostomy technique

anesthetize 2-3cm transverse from 5th intercostal space anterior to mid-axillary line, clamp tube and insert through incision in pleural space

tension PTX findings

deviated trachea, hypotension

needle decompression patient position

sitting up

potential complication of tension PTX

cardiac arrest

thoracostomy indication

large PTX (>20%) BUT not hemodynamically unstable (hypotensive)

kerley b lines description

vasculature/lines traveling to the very outside of lungs

silhouette sign

loss of margin between 2 opposing structure with same radiographic density

right tracheal wall lobe

right upper lobe

right heart border lobe

right middle and lower lobe

posterior border of heart lobe

left lower lobe

posterior left hemidiaphgragm lobe

left lower lobe

anterior right hemidiaphragm lobe

right middle lobe

posterior right hemidiaphgragm lobe

right lower lobe

consolidations appearance

white and fluffy

consequences of aspiration

pneumonitis, pneumonia, obstruction

aspiration pneumonia causes/RF

alcoholics, OD, seizures, stroke, esophageal disorders

aspiration pneumonia hx

cough, fever, SOB, chest pain

aspiration pneumonia PE

pneumonia with increased tactile fremitus, dullness to percussion, rhonchi or rales that does not clear with cough

aspiration pneumonia dx

CXR typically in RLL, sometimes RML

community aspiration pneumonia tx

abx that cover anaerobes

outpt - augmentin

inpt - unasyn

hospital aspiration pneumonia tx

zosyn (with renal adjustment)

aspiration pneumonia prevention

swallow studies, thickened liquids, semi recumbent position

semi recumbent position

30-45 degree elevation

types of masses

metastatic, hilar, cavitated

cardiac CXR assessment

evaluate heart size

heart size on PA films

<50% of chest diameter

heart size on AP films

<60% of chest diameter

diaphragm CXR evaluation

positioning, gas

normal diaphragm finding

R side higher for liver

flattened diaphragm condition

chronic lung disease

costophrenic angles normal finding

well defined and acute

pleural effusion on CXR

meniscus sign, blunting of costophrenic angles

meniscus sign

high to low curve on CXR instead of low to high like normal costophrenic angle