Chest X-ray Radiology

Assess image quality

Next, you should assess the quality of the image: a mnemonic you may find useful is ‘RIPE’.

Rotation

The medial aspect of each clavicle should be equidistant from the spinous processes.

The spinous processes should also be in vertically orientated against the vertebral bodies.

Inspiration

The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be visible.

Projection

Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are not projected within the chest, it’s PA).

Exposure

The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart.

ABCDE approach

The ABCDE approach can be used to carry out a structured interpretation of a chest X-ray:

Airway: trachea, carina, bronchi and hilar structures.

Breathing: lungs and pleura.

Cardiac: heart size and borders.

Diaphragm: including assessment of costophrenic angles.

Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas.

Airway

Trachea

Inspect the trachea for evidence of deviation:

The trachea is normally located centrally or deviating very slightly to the right.

If the trachea appears significantly deviated, inspect for anything that could be pushing or pulling the trachea. Make sure to inspect for any paratracheal masses and/or lymphadenopathy.

Causes of true and apparent tracheal deviation

True tracheal deviation:

Pushing of the trachea: large pleural effusion or tension pneumothorax.

Pulling of the trachea: consolidation with associated lobar collapse.

Apparent tracheal deviation:

Rotation of the patient can give the appearance of apparent tracheal deviation, so as mentioned above, inspect the clavicles to rule out the presence of rotation.

Carina and bronchi

The carina is cartilage situated at the point at which the trachea divides into the left and right main bronchus.

On appropriately exposed chest X-ray, this division should be clearly visible. The carina is an important landmark when assessing nasogastric (NG) tube placement, as the NG tube should bisect the carina if it is correctly placed in the gastrointestinal tract.

The right main bronchus is generally wider, shorter and more vertical than the left main bronchus. As a result of this difference in size and orientation, it is more common for inhaled foreign objects to become lodged in the right main bronchus.

Depending on the quality of the chest X-ray you may be able to see the main bronchi branching into further subdivisions of bronchi.

AND MUCH MORE.........

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