CXR

Dr. med. Ann-Marie B.M. Kabba

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INTRODUCTION

SYSTEMATIC APPROACH
1. Projection

2. Patient details

3. Technical adequacy

4. Obvious abnormalities

5. Systematic review of the X-ray

6. Review areas

7. Summary
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INTRODUCTION

1. PROJECTION
- can affect the appearance and
interpretation of a chest X-ray

- two possible projections for a frontal

chest X-ray are
anteroposterior (AP)
posteroanterior (PA)
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INTRODUCTION

PA Projection
-standard view
-best assessment of the thorax
-requires the patient to be able to stand
(or sit on a stool)

AP Projection
- usually only performed for patients who cannot stand (or sit), e.g.
haemodynamically compromised patients, or young children
- less comprehensive assessment than PA due to the effects of
magnification and the position of the scapulae

“AP is ´crAP´, so PA is standard”

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INTRODUCTION

2. PATIENT DETAILS
Correct X-ray from the correct patient ??

Patient´s details are supposed to be on the X-ray??

name
age/date of birth
=> Differential Diagnosis
date of examination
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3. TECHNICAL QUALITY

X-ray includes all of the thorax

????

Important pathology can be missed if

the entire thorax is not imaged.
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3. TECHNICAL QUALITY

If you don´t want ,

Rotation
assess Inspiration
Penetration
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3. TECHNICAL QUALITY RIP

Rotation ?

Heads of the clavicles equidistant from

spinous processes ???
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Rotation

Patient rotation can erroneously

give the impression of mediastinal
or lung pathology.
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Inspiration ?

PA and AP X-rays are taken in held deep inspiration.

!!!!!!!!

Ten posterior ribs indicate adequate inspiratory

achievement.

Fewer ribs: underinspiration

More ribs, particularly with flattened hemidiaphragms:

hyperinflation
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Inspiration
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Penetration

- The X-ray is adequately penetrated if you can just see the vertebral bodies
behind the heart.
- “underpenetrated”: you cannot see behind the heart
- “overpenetrated”: you can see the vertebral bodies very clearly

- Over and under penetration can obscure or obliterate significant findings,

particularly in the lungs.

- This is less of a problem with the advent of digital viewers which allow the X-ray
“windows” to be manipulated to a certain degree. However, penetration also
correlates to the dose the patient is exposed to.
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Penetration
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4. OBVIOUS ABNORMALITIES

- Which lung is involved?

- Which part of the lung? (which
lobe/zone)
- Size
- Shape, distribution, outline (focal or
diffuse, rounded or spiculated, well or
poorly demarcated)
- Density (in relation to the normal tissue:
e.g increased opacification or density,
increased lucency or reduced density)
- Texture (uniform or heterogeneous
appearance)
- Other features (e.g. air bronchogram, fluid
levels, volume change, bony abnormalities,
surgical clips)
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5. SYSTEMATIC REVIEW OF THE X-RAY

- Initially assess from a distance to see differences in lung

shadowing/obvious masses.

- After that, reassess from close-up to look for subtle abnormalities.

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5. SYSTEMATIC REVIEW OF THE X-RAY

A useful system is ABCDE

- Airway,
- Breathing,
- Cardiac and mediastinum/Circulation,
- Diaphragm + Delicates
- Extras + Review Areas
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5. SYSTEMATIC REVIEW
OF THE X-RAY
ABCDE
Airway
- Is the trachea central?
- If not, is it deviated due to patient rotation or
pathology?
- If the cause is pathological, is the trachea being pulled to
one side (volume loss, such as lobar or lung collapse) or
pushed away (increased volume such as a large pleural
effusion or mediastinal mass)?
- Identify carina and estimate the angle (normally 60-100°).
- Increased angle: e.g. left atrial enlargement, adenopathy
- Trace out right and left mainstem bronchi.
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ABCDE

Airway
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ABCDE

Airway
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ABCDE

Airway
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ABCDE

Breathing
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ABCDE

Breathing
Check that both lungs are of similar volume
(allowing for mediastinal asymmetry)
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE

Breathing
Review each zone in turn, comparing it to the
other side.
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ABCDE

Breathing
Look around the edge of the lungs, assessing for
pneumothoraces.These can be particularly
subtle at the lung apex.
Lung markings should extend to the edge.
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ABCDE - It is important to remember that the lung

continues behind the heart (a large
portion of the left lower lobe is behind the
heart).
Breathing
- The cardiac shadow should be of uniform
density.
If not: retrocardiac pathology? e.g.
DD pneumonia,
DD lobar collapse,
DD mass
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ABCDE

Cardiac and
mediastinum/
Circulation
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ABCDE

Cardiac and
mediastinum/
Circulation
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5. SYSTEMATIC REVIEW OF THE X-RAY

- The cardiac and mediastinal borders should be

ABCDE clearly visible.
If not: Pathology in the adjacent lung?!
- The mediastinum and heart should be positioned
central over the thoracic vertebra.
Cardiac and If not: Rotation? Volume change in the lungs?
mediastinum/ The mediastinum should not be widened.

Circulation - If it is widened:
- technical factors (e.g. AP projection) ??
- vascular structures (e.g. unfolding of the
thoracic aorta or aortic dissection) ??
- masses (mediastinal tumours or lymph node
enlargement
- haemorrhage (e.g. ruptured
aorta)
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE - Assess the size of the cardiac silhouette.

- Cardiothoracic ratio=
ratio of maximal horizontal cardiac diameter to
Cardiac and maximal horizontal thoracic diameter (inner edge of
ribs/edge of pleura)
mediastinum/ - Normal measurement: 0.42 – 0.50

Circulation - >0.50: - cardiomegaly

- pericardial effusion
- prominent epicardial fat pad
- expiratory radiograph
- patient rotation to the left
- AP projection

- Can only be accurately assessed on a well-inspired

PA X-ray due to the effects of magnification on AP
and underinspired X-rays.
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ABCDE

Cardiac and
mediastinum/
Circulation
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ABCDE

Cardiac and - Hila

- The left hilum should never be lower than
mediastinum/ the right. If this is the case, you must look for
volume loss either pulling the right hilum up or
Circulation pulling the left hilum down.
- Both hila should be the same density and have
no lumps or convex margins.
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ABCDE

Diaphragm +
Delicates
The costophrenic angles should be sharp. If not,
there is likely to be pleural fluid present.
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- Both hemidiaphragms should be visible and

ABCDE crisp all the way to the vertebral bodies
and upwardly convex.
- Flattening of a hemidiaphragm suggests raised
intrathoracic pressure, DD lung
Diaphragm + hyperexpansion, as seen in air trapping in
COPD, DD tension pneumothorax
Delicates - The right hemidiaphragm is normally
slightly higher than the left due to the mass
effect of the adjacent liver.
- Remember that the lungs extend behind
the diaphragms, so you need to look for
lung pathology through the hemidiaphragms.
- Look for free air under the diaphragm.
This can be difficult , as the gastric bubble and
bowel loops can have a similar appearance.
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-Assess the bones.

-Look at the ribs for fractures or bone
Diaphragm + destruction.
-Assess the rib spaces, which should be
Delicates roughly equal. Narrowing can be seen
with volume loss in the underlying lung.
-Review the rest of the imaged skeleton
for fractures or destructive bone lesions.
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ABCDE Left-sided 3rd-7th rib

fractures with 6th and 8th
rib fractures displaced. No
pneumothorax or pleural
fluid collection.
Diaphragm +
Delicates

Although easily seen on

this chest x-ray, plain
History: films are considered
Fall backwards insensitive to detect rib
fractures. Chest
radiography's role is in the
assessment of potential
complications including
pneumothorax,
haemothorax or
pneumonia.
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE
There are bilateral mid-
clavicular fractures.
Diaphragm + Lung are pleural spaces
are clear. Normal
Delicates cardiomediastinal
contour.
History:
Brought in ambulance
following a high speed RTA
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE

Diaphragm + Don’t forget the soft

Delicates tissues!

Left mastectomy.
History: Thickened sclerotic left
Retired female with 8th rib.
prior history of breast Lungs clear.
cancer. Left sided Heart size normal.
thoracic pain
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE

Diaphragm +
Delicates
History:
Retired female with
prior history of breast
cancer. Left sided
thoracic pain
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5. SYSTEMATIC REVIEW OF THE X-RAY

ABCDE
Extras:
Are there any vascular lines,
tubes or surgical clips?
Extras +
Review Areas
Review Areas:
- Lung Apices
- Hila
- Behind the Heart
- Costophrenic Angles
- Below the Diaphragm
A: NORMAL (GASTRIC BUBBLE)
B: PNEUMOPERITONEUM
C: CHILAIDITI SIGN
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5. REVIEW AREAS
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INTRODUCTION

- Caveats:

- Remember you are looking at a chest X-ray, not a lung X-ray. Ensure you assess all of the X-ray,
including the soft tissues, bones such as the clavicles, scapulae and visible humeri, and the upper
abdomen.

- Satisfaction of search (SOS) error:

- A common error in diagnostic radiology. It occurs when the reporting radiologist/person fails to continue to
search for subsequent abnormalities after identifying one. This initial detection of an abnormality satisfies the
“search for meaning” and the reporting of the case is prematurely ended.
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7. SUMMARY

Summarise your findings and give a differential (list). Think

about the history and clinical examination as well as the X-ray
findings when making your differential diagnosis.

Say whether you would like to review previous imaging if you

think this would help.

Suggest further investigations, including imaging, which may

be useful.