CXR

• 1. Confirm CXR belongs to Pt.

  2. Compare to earlier film.

  3. Rotation, AP/PA/Lat/oblique,

  4. Penetration

     • You should be able to faintly see the intervertebral spaces, and faint vascular markings through the cardiac silhouette. Also markings through the dome of the diaphragm.

     • The spinous processes and trachea should be midline.

     • The clavicular heads should be equidistant from the spinous processes. Rotated films distort the appearance of the cardiac silhouette and hila.

  5. Inspiratory effort. The apex of the dome of the diaphragm on the right side should be below the 9 - 10th anterior rib.

  6. Soft tissues for symmetry, subcutaneous air, edema, and breast tissue.

  7. Bony structures: look for spinous process, clavicle, ribs, scapulae, sternum, any Fx.

  8. Airway: tracheal deviation, PTx, pneumomediatinum.

  9. Pleural space, fluid collections, HTx, pleural effusion.

  10. Hilar structures: L. hilum is usually higher than R. hilum. Enlarged hila means LAD.

  11. Lung parenchyma.

      • Look for normal lung markings all the way out to the chest wall to rule out PTx.

      • Normal lung markings taper as they travel out to the periphery and are smaller in the upper lungs.

      • Lung markings in the upper lung fields that are large or larger ("cephalization") suggest pulmonary edema.

      • Kerley's B lines (small linear densities at the lateral lung bases) are also seen in CHF.

      • Look for infiltrates, consolidation (pneumonia, pulmonary contusion, hematoma, or aspirated FB).

      • Obscured R. costophrenic angle = RLL consolidation, pleural effusion

        • Obscured L. costophrenic angle = LLL consolidation, pleural effusion

        • A straight horizontal fluid level indicates a concurrent PTx.

        • Lateral decubitus films should be done to ensure that the effusion is free flowing and large enough to attempt thoracentesis.

      • Obscured heart border implies that the lesion is anterior.

        • Obscured R. heart border: RML consolidation

        • Obscured L. heart border: LLL consolidation

  12. Heart and Mediastinum:

      • Cardiac sihoutte >1/2 Thx width @ base of heart which may represent CHF, CM or pericardial effusion.

      • Aortic knob should be distinct. Aorto-pulmonary window should be visible.

      • Size, widening >8 cm goes with Aortic dissection.

      • Mediastinal and tracheal deviation may be seen with PTx

      • Use lateral films to confirm findings on PA and look for retrocardiac infiltrates.

        • Look for the retrocardiac and retrosternal spaces.

        • Look for flattening of the diaphragm on lateral view.

  13. Diaphragm:

      • The sides of the diaphragm should be equal and slightly rounded. The right side may be slightly higher.

      • Look for blunting of the costophrenic angles to suggest small pleural effusions.

      • Free air under R. hemidiaphgram (free air as in perforation). Look for stomach, bowel, or NGT.

      • Flat diaphragm suggest emphysema.

      • Unilateral high or tented diaphgram may suggest paralysis due to phrenic nerve damage (cardiac surgery), loss of lung volume on that side, or eventration.

  14. Tubes and lines: identify them all.

      • ET should be 2 cm above carina.

      • Chest tube (including the most proximal hole) must be within pleural cavity and not lung parenchyma.

      • NGT should be in stomach and uncoiled.

      • Tip of central venous cath. should be in SVC (not in R. atrium).

      • Tip of Swanz-Ganz catheter should be in the pulmonary artery.

      • Tip of tranvenous pacemaker should be R. atrium. AICD

Example: This is the CXR of Mr. Jones. The film is PA view with good inspiratory effort. Soft tissue appear symmetrical. The thoracic cage shows no significant abnormality. No tracheal deviation or mediastinal shift. No evidence of PTx. Cardiac silhoutte appear to be of normal size. The diaphragm and heart borders on both sides are clear, no infiltrates are noted. There is a central venous cath present, with the tip in the SVC.