Chest x-ray readings

[Jenine]

Hello to all fellow colleagues!

As I have been out of practice for a while, I need some help to refresh my knowledge of reading Chest X-rays.

What do you look for?
How do certain diagnoses appear on an X-ray?
Especially in Intensive Care, what diagnoses would be a contra-indication to physiotherapy treatment?

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[physiobob]

Theres a useful article on the Basics of a chest x-ray here: USUHS Radiology Chest X-Ray Review

And also Elizabeth Dick compares collapse and consolidation of the lung and looks at pleural effusions in an online article from the BMJ here: Chest x rays made easy

Also the following information from the university of Alabama

Here are two equally good ways to read films, remembering that the first rule of thumb when reading films is to always make sure the correct patient’s name is on the x-ray!

Method 1: “ABCDEFGHI”


1. A = Airway: are the trachea and mainstem bronchi patent; is the trachea midline?
2. B = Bones: are the clavicles, ribs, and sternum present and are there fractures?
3. C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter (enlarged)?
4. D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged over another? is free air present beneath the diaphragm?
5. E = Effusion/empty space: is either present?
6. F = Fields (lungs): are there infiltrates, increased interstitial markings, masses, air bronchograms, increased vascularity, or silhouette signs?
7. G = Gastric bubble: is it present and on the correct (left) side?
8. H = Hilar region: is there increased hilar lymphadenopathy?
9. I = Inspiration: did the patient inspire well enough for 10 ribs to be counted, or was the patient rotated?


Method 2: A random method adapted from Ferri.


1. Check for over or underpenetration – if underpenetrated, you will not be able to see the thoracic vertebrae, a very common problem.
2. Verify right and left by looking for the gastric bubble and at the heart shape.
3. Check for rotation – does the thoracic spine align in the center of the sternum between the clavicles?
4. Was the film taken under full inspiration – are 10 posterior or 6 anterior ribs visible?
5. Is the film a portable, an AP, or a PA film? Remember that the heart will be enlarged on an AP film; thus the cardiac silhouette cannot be accurately judged.
6. Check the soft tissues for foreign bodies or subcutaneous emphysema.
7. Check visible bones and joints for fractures, metastatic lesions, cervical ribs, etc.
8. Look at the diaphragm for tenting, free air, and abnormal elevation.
9. Check hilar and mediastinal areas for: size and shape of aorta, presence of hilar nodes, prominence of hilar blood vessels, elevation of vessels.
10. Check the heart for size, shape, calcified valves, and enlarged atria.
11. Check costophrenic angles for fluid or pleural scarring.
12. Check lung fields for infiltrates, increased interstitial markings, masses, absence of normal margins, air bronchograms, increased vascularity, and silhouette signs.


Use the lateral film to confirm the position of questionable masses or infiltrates, AP diameter, and to check the posterior costophrenic angle for small effusions. If the lateral film is good, then you should be able to see the vertebrae better as you descend down the film. Another good rule of thumb for lateral films is that you should be able to follow the right hemidiaphragm all the way from the costovertebral angle to where the diaphragm meets the sternum; the left hemidiaphragm will be partially obscured by the heart.


For great examples of chest films and other cardiothoracic imaging, check out this site:
http://info.med.yale.edu/intmed/cardio/imaging

[emilie]

there is a fantastic book which goes through x-rays systematically and what to look for, it was suggested reading when i was a student and most respiratory clinicians i know suggest it as good reading for students and basic grades still. its also in a handy pocket size.

its Chest X-Ray Made Easy, 2nd edition. by; jonathan corne, mary carroll, david delany and ivan brown.

[physiobob]

there is a fantastic book which goes through x-rays systematically and what to look for, it was suggested reading when i was a student and most respiratory clinicians i know suggest it as good reading for students and basic grades still. its also in a handy pocket size.

its Chest X-Ray Made Easy, 2nd edition. by; jonathan corne, mary carroll, david delany and ivan brown.

This is a great book and we have included it on the Physio Shop. View it here: Chest X-Ray Made Easy, 2nd Edition, By Jonathan Corne, Mary Carroll, David Delany and Ivan Brown,Churchill Livingstone,ISBN 9780443070082

[PhysioArgos]

Just to back the other two guys

this is the book I have and the one I also suggest to read !!

[irishneurohead]

Contraindications to treatment on xray: Undrained pneumothorax (MHI contraindicated), rib fractures, if a large pleural effusion present be careful with positioning, bullae.......just remember xray is one part of integrating all your findings in the clinical reasoning process, take your time and you will be fine!