CXR Interpretation

Chest X-ray Interpretation

https://litfl.com/drsabcde-of-cxr-interpretation/

Details - Before you even begin interpreting a CXR you should have the correct details. This includes;

• Patient name, age / DOB, sex

• Type of film – PA or AP, erect or supine, correct L/R marker, inspiratory/expiratory series

• Date and time of study

RIPE - Next up, how “ripe” is the image. That is, what is the technical quality of the film?

• Rotation – medial clavicle ends equidistant from spinous process

• Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?

• Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)

• Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.

Soft Tissue and Bones - In CXR interpretation it is common to leave soft tissues until the end.

• Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density

• Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses

• Breast shadows

• Calcification – great vessels, carotids

Airway and Mediastinum - Trachea – central or slightly to right lung as crosses aortic arch

• Paratracheal/mediastinal masses or adenopathy

• Carina & RMB/LMB

• Mediastinal width <8cm on PA film

• Aortic knob

• Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.

• Check vessels, calcification.

Breathing - Lung Fields:

• Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices

• Pneumothorax – don’t forget apices

• Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae

• Horizontal fissure on Right Lung

• Pulmonary infiltrates – interstitial vs alveolar pattern

• Coin lesions

• Cavitary lesions

Pleura

• Pleural reflections

• Pleural thickening

Circulation - Heart position –⅔ to left, ⅓ to right

• Heart size – measure cardiothoracic ratio on PA film (normal <0.5)

• Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

• Heart shape

• Aortic stripe

Diaphragm -

• Hemidiaphragm levels – Right Lung higher than Left Lung (~2.5cm / 1 intercostal space)

• Diaphragm shape/contour

• Cardiophrenic and costophrenic angles – clear and sharp

• Gastric bubble / colonic air

• Subdiaphragmatic air (pneumoperitoneum)

Extras - ETT, CVP line, NG tube, PA catheters

• ECG electrodes, PICC line, chest tube

• PPM, AIDC, metalwork