Chest X-Ray Interpretation

Summary

This on-demand session, with Anna Stylianides, Morgan Nunez, Andra Stefan, offers a comprehensive guide on chest radiology and specifically, chest X-Rays. Designed for medical students, you'll delve into basic chest anatomy, the A-E approach of analysis and will engage in several case-based discussions. This includes how to assess the quality of a CXR, using the RIPE (Rotation, Inspiration, Position, Exposure) approach and understanding the A-E (Airway, Breathing, Cardiac, Diaphragm, Effusions, Fractures, Great Vessels, Hila) approach of interpreting X-rays. Structured in a Q&A format, it covers different cases from trauma-related pneumothorax to pneumonia, lung cancer and heart failure, providing a realistic learning experience. This teaching session is beneficial to anyone seeking to improve their understanding and interpretation of chest X-rays in a clinical context.

Description

We are excited to come back with our first event this academic term focusing on chest radiology! Our teaching on chest radiology will consist of two sessions.

During this first session, we will review the systematic approach to chest X-ray interpretation and discuss clinical case studies which have been matched to the MLA content map on Clinical Imaging. The teaching will be delivered by three final year medical students. The content of the session has been proofread and crosschecked for accuracy by a radiology registrar.

The clinical case studies will cover a broad range or respiratory and cardiovascular pathologies, including pneumothorax, pneumonia, lung cancer, pleural effusion, and cardiac failure.

The second session will be organised subsequently and the teaching will be delivered by a radiology trainee, involving more complex cases and additionally covering CT chest interpretation and CTPAs. More details coming soon! We would strongly recommend attending both sessions to gain the most from our teaching and ace your OSCE stations or multiple choice finals questions on chest radiology!

Learning objectives

To understand and identify the basic chest anatomy on a chest x-ray.
To evaluate the quality of a chest x-ray using the 'R-I-P-E' approach.
To master the A-E approach to interpreting a chest x-ray and apply this method in various case-based discussions.
To recognize common pathologies present on a chest x-ray, including pneumothorax, pneumonia, lung cancer, and heart failure.
To develop an initial management plan for conditions based on the findings of a chest x-ray.

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CHEST RADIOLOGY PART 1 CHEST X-RAYS A-E APPROACH AND CASE BASED DISCUSSIONS Anna Stylianides, Morgan Nunez, Andra StefanCONTENT 01 BASIC CHEST ANATOMY 02 ASSESSING QUALITY OF A CXR 03 A-E APPROACH CASES + MCQ PART 1 (ALIGNED WITH MLA) 04 05 CASES + MCQ PART 2 (ALIGNED WITH MLA) 06 Q&A Steps 1) Patient details 2) “RIPE” – assessing quality of x-ray 3) A->E – interpreting x-ray Assessing Quality "RIPE" •R – rotation –>medial aspect of each clavicle should be equidistant from the spinous processes. •I – inspiration -> 6 anterior ribs, 10 posterior ribs •P – position –> AP? PA? Lateral? o "AP is crAP" •E – exposure - > vertebral bodies visible behind heart A-E APPROACH Airway – trachea central? If not, is it deviated due to patient rotation or pathology? Breathing •upper, middle and lower zones. Compare zones in both lungs. •Lung markings to peripheries (go around edge of lungs) Cardiac •outline of heart borders (crisp), •heart <50% of chest diameter on PA (<60% on AP) •Look BEHIND heart! Diaphragm – flattened? Free gas below? Effusions – sharp costophrenic angles Fractures – bony deformities Great vessels - mediastinum (not widened), size of aortic notch Hila – lymphadenopathy, masses, calcifications Everything else! E.g. lines, clipsCompare current x-ray with a previous one!CASE 1 A 45-year-old man is involved in a high impact car accident. He is now complaining of right sided chest pain. O/E pain in his chest but he has decreased air entry on the right side. HR 110 bpm, RR 20, Spo2 90% Q1. Using the A-E approach, what findings are present on this CXR? Q2. What is the most likely diagnosis? Q3. How is this condition managed?CASE 1: PNEUMOTHORAX A 45-year-old man is involved in a high impact car accident. He is now complaining of right sided chest pain. O/E You struggle to examine his chest expansion and percussion given the pain in his chest but he has decreased air entry on the right side. HR 110 bpm, RR 20, Spo2 90% BP 100/70 Q1. Using the A-E approach, what findings are present on this CXR? A moderate right sided pneumothorax is present alongside multiple consecutive right sided rib fractures Q2. What is the most likely diagnosis? Primary pneumothorax (trauma related) Q3. How is this condition managed? Perform an A-E assessment. Manage the reduced oxygen saturation with a 15L non-rebreathe mask; ABG to quantify hypoxia. IV access for fluid resuscitation given history of trauma and bloods. Chest drainage depending on size of pneumothorax CASE 1: PNEUMOTHORAX Pneumothorax management, adapted from BTS guidelinesCASE 2 A 30-year-old man who has recently been diagnosed with HIV presents with new onset of shortness of breath. O/E Warm peripheries. Equal chest expansion and air entry. Added crepitations in the right upper zone. RR 16, BP 122/83, SpO2 95%, Temp 38.3 Q1. What abnormalities are seen on this CXR? Q2. What is the most likely organism causing this presentation?CASE 2: PNEUMONIA A 30-year-old man who has recently been diagnosed with HIV presents with new onset of shortness of breath. O/E Warm peripheries. Equal chest expansion and air entry. Added crepitations in the right upper zone. RR 16, BP 122/83, SpO2 95%, Temp 38.3 Q1. What abnormalities are seen on this CXR? Right upper zone opacity Q2. What is the most likely organism causing this presentation? Pneumocystis jirovecii (commonly known as PCP pneumonia) Day 11: Progressive consolidation, you can see the patient has now been intubatedCASE 3 A 76- year- old female presents to her GP with two episodes of haemoptysis. She a significant smoking history. O/E Finger clubbing, warm peripheries. HR 100bpm, RR 18, Spo2 95%. Areas of reduced air entry bilaterally. Q1. What is the most likely differential diagnosis? Q2. What further investigations are required?CASE 3 LUNG CANCER A 76- year- old female presents to her GP with two episodes of haemoptysis. She a significant smoking history. O/E Finger clubbing, warm peripheries. HR 100bpm, RR 18, Spo2 90%. Areas of reduced air entry bilaterally. Q1. What is the most likely differential diagnosis? Given this womans smoking history, it is most likely squamous cell lung cancer CXR findings: There is a right midzone mass and a peripheral left mid zone caviating lesion Q2. What further investigations are required? In a GP setting, a 2-week wait referral to respiratory is required for patients with suspected malignancy Further investigations would include bronchoscopy for biopsy, CT chest/abdo/pelvis for confirmation and metastasis, PET-CT for staging, FBC, U&Es, LFTs, serum calcium CASE 4 65-year-old woman presenting with acute-on-chronic shortness of breath. PMH: IHD and AF. O/E centrally cyanosed with cool extremities. HR 110 bpm, BP 90/60 Respiratory rate 22 , SpO2 89% Widespread crackles and wheezes on chest examination. Bilateral lower extremity swelling Q1. Based on the A-E approach, what abnormalities can you spot on the X-ray? A B C D E Q2. What is the most likely diagnosis? A. Pneumonia B. Pneumothorax C. Cardiac Tamponade D. Pericarditis E. Acute heart failure Q3. How would you initially manage this patient as an FY1? Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 15434CASE 4: Heart failure (Pulmonary Oedema) 65-yearl old woman presenting with acute-on-chronic shortness of breath. PMH: IHC and CABG. O/E centrally cyanosed with cool extremities. HR 110 bpm, BP 90/58 Respiratory rate 22 , SpO2 89% Widespread crackles and wheezes on chest examination. Q1. What is the most likely diagnosis? A. Pneumonia B. Pneumothorax C. Cardiac Tamponade D. Pericarditis E. Acute heart failure Q2. Based on the A-E approach, what abnormalities can you spot on the X-ray? A B C D E A: N/A, B: Kerley B lines/interstitial oedema, C: Cardiomegaly, D: minor blunting of costophrenic angles, E: pacemaker Q3. How would you initially manage this patient as an FY1? A-E approach: e.g. A+B: Oxygen (High-flow) 15L/NBM-> call ICU for CPAP/BiPAP if sats not improving C: ECG, bedside ECHO (rule out tamponade/PE + estimate ejection fraction) catheter + fluid balance (NO IV fluids -> escalate to vasopressors in ICU), bloods (imp: troponin (MI), BNP, D-dimer -> if d-dimer positive: CTPA), IV furosemide bolusCASE 4: A-E of Heart Failure (CXR) A – Alveolar oedema: batwing opacities (hallmark of alveolar oedema) B – Kerley B lines (interstitial oedema - often precedes alveolar oedema) C – Cardiomegaly D – Dilated upper lobe vessels E – Effusion (pleural)CASE 5 40-year-old female patient with a 1-week onset of cough, fever and malaise. Previous history of rheumatoid arthritis, on biologics (immunosuppression). What is the most likely diagnosis? A. Lung cancer B. Rheumatoid nodule C. Lung abscess D. Pulmonary embolus E. Pneumatocele Case courtes.revef dna hguoc ti wtneitap l -raey- 04 desserpusonu mmi na t sgnol eb RXCgni wll f ehTCASE 5 40-year-old patient with a 1-week onset of cough, fever and malaise. Previous history of rheumatoid arthritis, on biologics (immunosuppression). What is the most likely diagnosis? A. Lung cancer B. Rheumatoid nodule C. Lung abscess D. Pulmonary embolus E. Pneumatocele Case courtes.revef dna hguoc ti wtneitap l -raey- 04 desserpusonu mmi na t sgnol eb RXCgni wll f ehTCASE 5 Differential diagnosis for cavitating lung lesions (CAVITY): Cancer: most frequently squamous cell carcinoma Autoimmune: rheumatoid arthritis (rheumatoid nodules) Vascular: pulmonary emboli Infection: lung abscess or TB Trauma: pneumatocele Youth: congenital pulmonary airway malformationsCASE 6 A 75-year-old woman presented to the ED with worsening breathlessness and cough. The patient is a known smoker. Based on the CXR, what is the most likely diagnosis? A. Pulmonary Embolism B. Pneumomediastinum C. Pneumoperitonem D. Lobar atelectasis E. Pneumonia Case courtesy of Dr Yusra Sheikh, Radiopaedia.org, rID: 45715CASE 6 A 75-year-old woman presented to the ED with worsening breathlessness and cough. The patient is a known smoker. Based on the CXR, what is the most likely diagnosis? A. Pulmonary Embolism B. Pneumomediastinum C. Pneumoperitonem D. Lobar atelectasis E. Pneumonia Left upper lobe collapse, most likely secondary to lung malignancy. Case courtesy of Dr Yusra Sheikh, Radiopaedia.org, rID: 45715CASE 6 – Lobar Collapse Common causes of lobar collapse: • Luminal: • Aspirated foreign body • Mucus plugging • Endobronchial mass • Misplaced endotracheal tube • Mural • Lung cancer • Extrinsic • Compression by an adjacent mass CASE 7 70-year-old woman underwent an uncomplicated hip replacement. Three days after the surgery she experiences sudden shortness of breath with decreasing SpO2. Q1. What abnormalities can you spot on this X-ray? Q2. What is the most likely diagnosis? Q3. What radiological sign is found in this CXR? https://www.radiologymasterclass.co.uk/gallery/chest/airways/airways_h CASE 7 70-year-old woman underwent an uncomplicated hip replacement. Three days after the surgery she experiences sudden shortness of breath with decreasing SpO2. Q1. What abnormalities can you spot on this X-ray? Q2. What is the most likely diagnosis? Q3. What radiological sign is found in this CXR? https://www.radiologymasterclass.co.uk/gallery/chest/airways/airways_h