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X-Ray Interpretation/Basics
Spiegel, Barry 2015
35
Nursing
Graduate
02/16/2013

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Cards

Term
Radiodensity
Definition
is the property of relative transparency to the passage of X-rays through a material
Term
Radiolucent
Definition

indicates greater transparencyto X-ray photons

i.e. Air/Fat

Term
Radiodense
Definition

indicates greater opacity to X-ray photons. 

Greatest radiodensity appears white i.e. bone, barium

Term
Anatomy of Trachea
Definition
Slants slightly to right
Bifurcates at Carina 
level of sternal angle anteriorly and
fourth thoracic spinous process posteriorly
Term
Counting Ribs
Definition
Identify first rib by finding its anterior junction with the manubrium and following this rib backward to the spine
Then count down the posterior ribs
Begin at the origin of the first rib at its junction with the first thoracic vertebra and trace each rib as far anteriorly as you can to the beginning of the radiolucent (and hence invisible) costal cartilage
If you can count 9 or more ribs àgood inflation
Term

CHF

PCWP 12-18 mmHg

Definition
•Upper zone veins dilate and are equal in size or larger
 
(Cephalization, The antigravitational redistribution of pulmonary blood flow that occurs with heart failure, caused by increased vascular resistance in the dependent part of the lung, a consequence of pulmonary venous hypertension; usually described on the basis of relative vascular size on chest radiography.)
 
 1st sign of early CHF, pulmonary edema
Term

CHF 

PCWP 18-24 mmHg

Definition
•Interstitial edema occurs with the appearance of Kerley B lines 
 
Term
Posterioranterior (PA) and Lateral Chest X-ray
Definition

Standard CXR. The films are read together.  The PA exam is viewed as if the patient is standing in front of you with their right side on your left. 

The patient is facing towards the left on the lateral view.  Comparison films can be invaluable - Old Gold! 

 

If you have comparison films, the old PA film is displayed adjacent to the new PA film and the old lateral is displayed adjacent to the new lateral.

 

Old PA, New PA    New LA, Old LA

Term
PA vs. AP
Definition

The PA film is obtained with the patient facing the cassette and the x-ray 6 feet away.  AP laying flat.


AP, Magnification of the heart and widening of the mediastinum The pulmonary vasculature is altered. Equalization of the pulmonary vasculature when the size of the lower lobe vessels are compared to the upper.

 

Term
Lateral decubitus position
Definition

Helpful to assess the volume of pleural effusion and if its mobile or loculated.

Dependant lung should increase in density d/t atelectasis from the weight of the mediastinum.  Failure to do so indicates air trapping.

 

You could also look at the nondependent hemithorax to confirm a pneumothorax in a patient who could not be examined erect. 

 

Term

Technically adequate

CXR


Definition

 

CXR should be examined in full inspiration. Helps the radiologist to determine if there are intrapulmonary abnormalities.

 

The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th 

anterior rib on good inspiration

 

Term
Good PA film
Definition

Thoracic spine disc spaces barely visible through the heart bony details of the spine are not usually seen
bronchovascular structures can usually be seen through the heart 

Term

Underpenetrated

Vs.

Overpenetrated

PA film

Definition

underpenetrated not enough photons




ovepenetrated too many photons

Term
Rotation
Definition

Assess rotation by observing clavicular heads
equal distance from the spinous process of the thoracic vertebral bodies


Magnification of clavicular head and spinous process alignment demonstrating a straight film

Term
Three locations that a mass can exist in the thoracic cavity
Definition

Intraparenchymal (part of the lung)


Pleural


Extrapleural

Term

Lobes and Fissures

Definition

PA & LA CXR, Right lung has 1 minor fissure dividing the right middle lobe from the right upper lobe. Also 1 major fissure dividing lower lobe from upper and middle lobes. 

 

Left lung has 1 major fissure and no minor.

 

 

The major fissures are usually not well seen on the PA view because you are looking through them obliquely. If there is fluid in the fissure, it is occasionally manifested as a density at the lower lateral margin.

Term
Pulmonary Artery
Definition

Left Pulmonary artery passes over the left mainstem bronchus to descend behind it

 

 

 

Right Pulmonary artery passes behind the ascending aorta

Term

How to Read a

Chest X-Ray

Definition
•Turn off stray lights,
    ▫optimize room lighting, view images in order
•Patient Data:(name history #, age, sex, old films)
•Routine Technique: (Under/over, see spinal process)
    ▫AP/PA, exposure, rotation, supine or erect
•Trachea:midline or deviated, caliber, mass
•Lungs:abnormal shadowing or lucency
•Pulmonary vessels:artery or vein enlargement
•Hila:masses, lymphadenopathy
•Hear:thorax: heart width>2:1? Cardiac configuration?
•Mediastinal contour:width? mass?
•Pleura:effusion, thickening, calcification
Bones:lesions or fractures
•Soft tissues:(Unilateral breast looks like Plural effusion)
▫don’t miss a mastectomy
•Identify tubes
Term
Silhouette Sign
Definition
Elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung
Term
Air Bronchogram 
Definition

alveoli are filled with fluid making the bronchi visible 

i.e. pulmonary edema

Term
Atelectasis
Definition
  almost always associated with a linear density with volume loss (Lobe will concortract)
Term
PCWP above 24mmHg
Definition
 Alveolar edema, often in a classic perihilar bat wing pattern of density.
 
Pleural effusions also often occur.
Term
Severe CHF
Definition
 Earliest CXR finding of CHF is cardiomegaly (cardiothoracic ratio >50%), alveolar edema, and haziness of vascular margins
Term
Cardogenic Pulmonary Edema
Definition
Increased hydrostatic pulmonary capillary pressure
 
Cephalization of pulmonary veins, Kerley B lines or septal lines
 
Peribronchial cuffing, “bat wing” pattern
 
Patchy shadowing with air bronchograms
 
Indistinct vascular margins
 
Enlarged heart
Term
Noncardogenic Pulmonary Edema
Definition
 
▫altered capillary membrane permeability or
▫decreased plasma oncotic pressure
▫NOT CARDIAC
 
–near-drowning, oxygen therapy, transfusion or trauma, CNS disorder, ARDS, aspiration, or altitude sickness, renal disorder or resuscitation, drugs, inhaled toxins, allergic alveolitis, contrast or contusion.  
Term
Kerley B lines
Definition
 horizontal lines less than 2cm long, commonly found in the lower zone periphery (thickened, edematous interlobular septa)                                                                                                               
Term
Atelectasis                    vs.                Pneumonia
Definition

Atelectasis                    vs.                Pneumonia

•Vol Loss Associated             •Normal or Increased Vol
Ipsilateral Shift                 •No Shift, or if Present then       
(toward atl lobe)                                    Contralateral
•Linear, Wedge-Shaped                        •Consolidation
•Apex at Hilum                                Air Space opacity
                                             •Not Centered at Hilum

Air bronchograms can occur in both.

Term
Pneumothorax 
Definition

Air inside the thoracic cavity but outside of the lung,

appears as air w/out lung markings in the least dependant part of the chest

•Generally found peripheral to the white line of the pleura
•upright film→ most likely seen in the apices
•best demonstrated by an expiration film
•difficult to see when the patient is in a supine position 
▫air rises to the medial aspect of the lung
▫may be seen as a lucency along the mediastinum
▫may also collect in the inferior sulci (deep sulcus sign)

 

 


Term
Tension Pneumothorax
Definition

 

This is a medical emergency → decreased venous return and death without immediate CT placement 

 

Right sided tension pneumothorax=leftward mediastinal shift. 

Term
Emphysema
Definition
  loss of elastic recoil of the lung with destruction of the pulmonary capillary bed and alveolar septa, bullae (lucent, air-containing spaces), diffuse hyperinflation with flattening of diaphragms, increased retrosternal space
 
Term
Rib fracture
Definition
Abrupt discontinuity in the smooth outline of the rib; a lucent fracture line may be seen
Term
Pericardial Effusion
Definition
 enlarged heart shadow (globular, transverse diameter disproportionately increased)
Term
Positioning of Endotracheal Tubes 
Definition
The ideal position for endotracheal tubes:

 

▫Midtrachea

 

▫5 cm from the carina, when the head is neither flexed nor extended

 

▫minimal safe distance from the carina is 2 cm. 
Term
Method For Locating Carina
Definition

 T4-T5 interspace

(95% project over T5, T6, or T7 vertebral bodies)

Term
Pulmonary Artery Catheter
Definition
PAC tip in the right pulmonary artery (rule of thumb à tip should be within the mediastinal shadow)
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