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Chest X-Ray InterpretationLearning Outcomes • Learn a systematic approach in interpreting CXR • Identify and describe common findings on a chest radiograph filmWhat do you think? A) Consolidation B) Pneumothorax C) Pleural effusion D) Pulmonary oedema E) Normal Vote your answer at www.slido.com #967144General Principles • Systematic approach • Clinical correlation: Interpret the CXR in conjunction with clinical findings • Always compare with previous CXR. What has changed? Increasing Basics Density •Gas •Black •Dark Grey •Fat •Light Grey •Soft Tissue • Calcium •White T echnical details • Demographics - name, DOB, gender, date taken Technical Details Orientation Left(L) or Right(R) - look out for marker Projection AP or PA – look out for marker Image quality RIP Rotation Spinous process of thoracic vertebrae should be midway between medial ends of clavicle Inspiration Midpoint of R hemidiaphragm should be between 5-7th ribs anteriorly, 9-10 ribs posteriorly Penetration Vertebral bodies should be just visible through the cardiac shadowPA VS AP Approach • Everyone has different methods! • ABCDE ABCDE Structures A Airway Trachea B Breathing Lung fields and silhouettes C Circulation Heart size, great vessels, mediastinum, hila D Disability Bones for fractures E Everything Review areas: apices, soft tissues, cardiac Else shadow, diaphragm, edge of image, foreign body, artefactCardiothoracic ratio • Cardiac width/ Thoracic width • Normal: <50% • Cardiomegaly: >50%Review Areas ABCDE • Apices - Pneumothorax? • Bones/soft-tissues - Fractures/density? • Cardiac shadow- Consolidation/mass? • Diaphragm - Pneumoperitoneum? • Edge of the image - Unexpected findings?Abnormal CXRCASE 1 40y/o male, one week history of shortness of breath. A) Consolidation B) Pneumothorax C) Pleural effusion D) Pulmonary oedemaConsolidation • Replacement of alveolar space with pus/fluid/cell/blood • Increase in density makes it white • Radiological features:  Opacification  Air bronchograms • Management  CURB 65 -> Antibiotics, Home/Hospital Localisation • Difference in density between 2 borders produces a silhouette • Loss of density Loss of border demarcation Silhouette sign Loss of border Which lobe is the pathology in? R heart border RML R hemidiaphragm RLL L heart border LUL, lingula L hemidiaphragm LLLCASE 2 28 y/o male, one day history of worsening breathlessness A) Consolidation B) Pneumothorax C) Pleural effusion D) Pulmonary oedemaPneumothorax • Air in pleural space • Best seen on expiration as lung density increases • Radiological features  Loss of vascular markings - check the lung apices in an erect CXR as air rises  Defined edge of the visceral pleura28 y/o male, one day history of worsening breathlessness. BP 90/60mmHg HR 110bpm SPOT DIAGNOSIST ension Pneumothorax • Can kill rising in lungs -> Impaired venous return -> • Clinically: Signs of cardiovascular compromise • CLINICAL DIAGNOSIS – do not wait for CXR • Radiological features:  Depression of ipsilateral hemidiaphragm  Mediastinal shift to opposite shift  Tracheal deviation to opposite side (this is late) • Management  Nnddle decompression: Large bore cannula into HISSSSS!!!tal space along the midclavicular line ->CASE 3 56 y/o female, three weeks history of worsening breathlessness. A) Consolidation B) Pneumothorax C) Pleural effusion D) Pulmonary oedemaPleural effusion • Accumulation of fluid in the pleural cavity • Transudates and exudates - Light’s criteria • Radiological features:-  Obliteration of costophrenic angle  Homogenous dense opacity (white)  Meniscus  Volume shift (Push -> away from the effusion) • Management  USS guided aspiration, chest drain  Treat underlying causeCASE 4 62 y/o male, one week history of worsening breathlessness. A) Consolidation B) Pneumothorax C) Pleural effusion D) Pulmonary oedema Pulmonary oedema • Pulmonary oedema may manifests in two forms:  interstitial oedema (septal lines)  alveolar oedema (airspace shadowing). • Radiological features ABCDE A – Alveolar oedema bat wing appearance B – kerley B lines (interstitial oedema) C - Cardiomegaly D - Dilated upper lobe vessels E – pleural EffusionManagement of acute pulmonary oedema • LMNOP • L – Loop diuretics • M – Morphine • N – Nitrate • O – Oxygen • P – PositionBLEEP…You are the oncall FY1... Dr, can you please come and see this patient? 60 y/o male, unwell, in significant distress. High NEWS: BP 100/60mmHg, HR 110bpm, Temperature 38.C SPOT DIAGNOSISPneumoperitoneum • Gas within peritoneal cavity • Radiological feature on erect CXR  Air under diaphragm • Causes: PERFORATION - Post operative free intraperitoneal gas - Perforated hollow viscus eg. appendix/bowel/diverticulum • Management ABCDE, sepsis bundle, erect CXR + AXR, CT abdomen and pelvis, call surgeonYou are the oncall FY1... Dr, can we start feeding?NG T ube Placement • Two types of NG tube:  Fine- bore: Feeding  Wide-bore(Ryle’s tube): Drainage • How do we confirm NG tube position?  Measuring the pH of aspirate using pH indicator strip  Radiography CXR  Check local hospital protocol: CXR to check NG tube placement • Complication of misplaced NG tubes: aspiration pneumonia, pneumothorax and DEATH!• To confirm NG tube placement, all of the following key features should be present: 1. The chest x-ray view should be adequate – upper oesophagus down to below the diaphragm 2. The NG tube should remain in the midline down to the level of the diaphragm 3. The NG tube should bisect the carina (T4) 4. The tip of the NG tube should be clearly visible and below the diaphragm 5. The tip of the NG tube should be 10 cm beyond the GOJ to be confident that it’s within the stomachUseful for foundation years Dr, can you have a look at the CXR? • Post pacemaker insertion • Post chest drain insertion/removal • Post endotracheal intubation • Look for tube/lead position, look for pneumothorax…. • If in doubt, ask for help…How would you summarise this? Systematic Approach Description Demographic CXR of Mr XYZ, taken on 8/10/2021 18:00 Image quality Erect CXR, PA not Rotated, well Inspired, adequate Penetration A Trachea is central B Lung fields are clear C Heart is not enlarged. Mediastinal contours are normal D No bony abnormality E Nil Clinical Correlation + Normal chest X-ray Impression If running out of time in OSCE, state the obvious abnormalitySummary • Have a systematic approach • Clinical correlation • Always compare with previous CXR • Practice, practice, practice! You can do it!References References and image credit: Radiology Masterclass https://www.radiologymasterclass.co.uk/ Radiopaedia https://radiopaedia.org/?lang=gb Useful resources: Radiology masterclass Geeky medics https://geekymedics.com/