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Chest X-Ray (CXR) Film Interpretation
This guide can be used to interpret a CXR film in a systematic manner
Introduction
We begin by confirming the patient’s details and introducing the CXR Film for presentation.
- “This is a Chest Radiograph of …”
- Check Name and Age.
- When was it taken?
- What position is the patient in?
- Are they standing (erect), prone, supine etc.
Note: X-Ray is the technique/radiation used during the procedure, not the resulting image. Therefore, you should refer to the resulting image as a Radiograph.
Image Quality – RIPE
- Is there Rotation?
- Are the clavicles aligned? Are they equally spaced from the spinous processes?
- Is there Inspiration?
- Are you able to see 5-6 anterior ribs, both costophrenic angles and the lateral rib edges?
- What is the Projection?
- Is it AP or PA? – most are PA
- If there is no label, assume it is PA
- Is the film adequately Exposed?
- Is the left hemidiaphragm visible?
- Can you see the spine and vertebrae behind the heart?
Airway – ABCDE Approach
- Look for the Trachea
- Is it centred or deviated?
- It is normally central or slightly to the right
- If it deviates, is it being pulled or pushed to the side?
- Pushed from large pleural effusion/tension pneumothorax
- Pulled from consolidation with lobar collapse.
- Note: the trachea may appear deviated if the patient was rotated.
- Is it centred or deviated?
- Carina & Bronchi
- Can you see the carina and bronchi?
- Can be used to determine if an NG tube has been placed correctly (ie not in the oesophagus)
- Hilum:
- Can you see any lymph nodes?
- If so, these are enlarged and suggest infection
- Are the hilum sizes equal?
- Enlargement may be caused by underlying malignancy.
- Can you see any lymph nodes?
Breathing – ABCDE Approach
- Look at the Lungs:
- Divide each into 3 zones (not correlating with lobes)
- Compare each zone together. Are there any changes?
- Do the lung markings occupy the entire space?
- If there is a lack of markings, suspect pneumothorax.
- Is there any consolidation present?
- Inspect the Pleura:
- Not normally visible, unless thickened
- Ensure the lung markings extend all the way to the edges of the lung fields.
- If there is black air space outside lung fields, suggests pneumothorax.
- If there is increased opacity, it suggests fluid or blood (haemothorax) build-up.
Cardiac – ABCDE Approach
- Assess heart size:
- Note: You can only assess heart size on a PA film, as AP films exaggerate heart size.
- A normal heart should not occupy more than 50% of thoracic width.
- Assess Heart Borders
- All borders should be well defined in healthy individuals.
- These may be hard to see when lung pathology blocks the view.
- Loss of Right border is associated with R Middle lobe consolidation
- Loss of Left border is associated with Lingular consolidation.
Diaphragm – ABCDE Approach
Note: The right hemi-diaphragm is higher than left in most patients.
- On an erect CXR, the diaphragm should be indistinguishable from underlying tissues.
- If there is free air in the abdomen, this may be seen
- You may be able to see gas within the colon as it passes near the diaphragm.
- Costophrenic Angles
- The area where the dome of the diaphragm meets the lateral chest walls.
- They should be clearly visible and a well-defined angle
- Loss of the angle suggests the presence of fluid or consolidation.
- A blunt angle can be secondary to lung hyperinflation (such as in COPD).
Everything Else – ABCDE Approach
Scan the entire CXR in an ordered approach, starting from the outside
- Have a look at the bones.
- Are there any fractures/lesions?
- Inspect the soft tissues
- Are there any abnormalities (such as haematomas)?
- Are there any medical instruments?
- Can you see any lines (ECG probes, central line)?
- Can you see any tubes (an NG tube, is it correctly placed)?
- Does the patient have a pacemaker/defibrillator?
- Has the patient had any artificial valves inserted?
Review
- Ensure you have looked at all areas of the radiograph