The structured interpretation of chest x rays.
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The structured interpretation of the chest X-ray
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The structured interpretation of chest x rays.
- 5. AIRWAY Is the trachea central? AIRWAY Has the trachea been pushed across? Pneumothorax Has the trachea been pulled across? Consolidation AIRWAY www.criticalcarepractitioner.co.uk
- 6. BONES Posterior ribs Anterior ribs Clavicles Verterbral bodies Evidence of fractures? BONES 6 Anterior or 10 Posterior ribs. www.criticalcarepractitioner.co.uk
- 7. CARDIAC Edges of the heart and mediastinum should be clear. Silhouette sign. Right middle lobe opacity Right upper lobe opacity CARDIAC CARDIAC www.criticalcarepractitioner.co.uk
- 8. CARDIAC Edges of the heart and mediastinum should be clear. Silhouette sign. Left lower lobe opacity Left upper lobe opacity CARDIAC CARDIAC www.criticalcarepractitioner.co.uk
- 9. CARDIAC Edges of the heart and mediastinum should be clear. Silhouette sign. Is width of Heart less than half of thorax? CARDIAC www.criticalcarepractitioner.co.uk
- 10. DIAPHRAGM Edges of the diaphragm should be clear. Silhouette sign. Right lower lobe opacity Left lower lobe opacity DIAPHRAGM DIAPHRAGM www.criticalcarepractitioner.co.uk
- 11. DIAPHRAGM Edges of the diaphragm should be clear. Silhouette sign. Air under diaphragm Gastric bubble. DIAPHRAGM DIAPHRAGM www.criticalcarepractitioner.co.uk
- 12. EQUAL LUNG FIELDS Equal translucency Air Bronchograms EQUAL LUNG FIELDS EQUAL LUNG FIELDS www.criticalcarepractitioner.co.uk
- 13. Right middle lobe opacity EQUAL LUNG FIELDS EQUAL LUNG FIELDS EQUAL LUNG FIELDS www.criticalcarepractitioner.co.uk
- 16. Your Turn!
- 24. Chest X Rays part II
- 25. •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas www.criticalcarepractitioner.co.uk
- 26. •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas 26 Air in the chest is pushing the lungs across Tracheal deviation www.criticalcarepractitioner.co.uk
- 27. Collapse of the lung is pulling the trachea towards it due to volume loss. •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Tracheal deviation www.criticalcarepractitioner.co.uk
- 28. Collapse of the lung is pulling the trachea towards it due to volume loss •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Tracheal deviation www.criticalcarepractitioner.co.uk
- 29. Left Heart Border- Lingual disease Hemidiaphragm- Left lower lobe disease Chest wall- Pleural, lung or rib disease •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Silhouette sign www.criticalcarepractitioner.co.uk
- 30. •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Right heart border- middle lobe disease Density above horizontal fissure- Anterior segment of the right upper lobe Aortic knuckle- anterior mediastinal or left upper lobe disease Paraspinal line - Posterior thorax disease Silhouette sign www.criticalcarepractitioner.co.uk
- 31. Lungs filling with: •Blood •Fluid •Pus •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Air Bronchogram Consolidation www.criticalcarepractitioner.co.uk
- 32. Lungs filling with: •Blood •Fluid •Pus Air Bronchogram Consolidation www.criticalcarepractitioner.co.uk
- 33. Collapse of the lung is pulling the trachea towards it due to volume loss •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Horizontal fissure pulled upwards Right upper lobe collapse Collapse www.criticalcarepractitioner.co.uk
- 34. Collapse •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Left lower lobe collapse www.criticalcarepractitioner.co.uk
- 35. Collapse •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas Left upper lobe collapse www.criticalcarepractitioner.co.uk
- 36. This 68 year old gentleman presented with gradual onset shortness of breath and frothy sputum. Examination of the chest: Displaced apex beat, raised JVP, diminished breath sounds and stony dull percussion at the lung bases bilaterally. Enlarged heart. High pressure in right side of heart Fluid in the lung or between the surface and the lung Stony dullness= pleural effusion Congestive Cardiac failure with bilateral pleural effusions www.criticalcarepractitioner.co.uk
- 37. This 83 year old gentleman presented with shortness of breath and increased sputum. Febrile and increased white cell count. Examination of the chest: Reduced air entry over right middle lobe. Crackles heard in inspiration Fluid in lung. Consolidation caused by secretions. Loss of silhouette by right heart border ?air bronchogram Right middle lobe consolidation www.criticalcarepractitioner.co.uk
- 38. This 74 year old gentleman presented with shortness of breath and poor saturations requiring oxygen. On examination there is reduced air entry in both bases and a stony dullness •Orientation •Patient details •Technicals •Bone •Trachea •Heart •Mediastinum •Hilum •Lungs •Fissures •Diaphragm •Soft tissue •Below diaphragm •Hidden areas www.criticalcarepractitioner.co.uk
Editor's Notes
- How many ribs?
- Air under diaphragm
- Left lower lobe collapse
- Pleural effusion
- Pulmonary oedema
- Pulmonary oedema
- Pulmonary oedema
- Pulmonary oedema
- The heart (a soft tissue density structure - near white) lies adjacent to lung tissue (near air density - near black). A crisp contour or 'silhouette' is formed at the interface of these two tissue densities. Loss of clarity of the right heart contour (formed by the right atrium) implies disease of the right middle lobe which lies next to the right atrium. Loss of distinction of the left heart contour indicates an abnormality of the lingula (part of the left upper lobe which wraps over the left ventricle).
- Azygous fissure An azygous fissure is seen on approximately 1-2% of chest x-rays. In fact autopsy studies suggest they are much more common. The azygous vein, lined by visceral and parietal pleura lies in the base of the fissure, and medially there is a small connection of the 'azygous lobe' with the rest of the upper lobe. An azygous fissure has a tadpole shape, the azygous vein itself forming the head of the tadpole. Because the azygous vein is a right sided structure, this accessory fissure is only ever seen on the right side of the chest.