CHEST X-RAY
NOTES
ChestXrayNotes1
Chest X-ray
Outline
An X-ray is a common imaging test that’s been used for decades which helps
doctors to diagnose and treat many medical conditions. Ex. A quick diagnosis
such as Pneumothorax can save life by Inserting a Needle on the 2 nd Intercostal
space.
When do you need to get an X ray?
To evaluate respiratory symptoms like cough, shortness of breath, fever,
weight loss, Hemoptysis.
Evaluation of physical signs like Hypoxia, Rhonchi, Crepitations.
To check the position of endotracheal tubes Or central lines.
How to approach an X ray :
Make sure the X ray is of the same person.
If any earlier X ray; Then see it to compare.
Purpose e.g. Pre-Op patient, OPD, etc.
System for analysing X ray k/as { RIP-ABCDE } :
R stand for Rotation, I - Inspiration, P - Penetration.
A - Airway, B - Breathing, C - Circulation,
D - Diaphragm / Delicate (Bone) And E - Extra (Lines/Tubes/Foreign Body, etc.)
ChestXrayNotes1
How do things looks on xray?
Tissue Absorption from Least ( Air or Gas ) to Most Dense ( Metal ) :
ChestXrayNotes1
Airway
Is a conduit which conducts air from the environment to the lungs.
( Pharynx - Larynx - Trachea - divides in Principal bronchus - Bronchioles )
Points to notice :
ChestXrayNotes1
Is trachea centrally placed or not ?
Black in appearance ?
Trachea And its deviation
Carina ( trachea is divided Into Left & Right principal bronchus )
Carina Angle
Right Bronchus is a direct continuation And left appears as a side branch
reasoning this with Ex.
1. If the patient aspirates (Gastric contents in trachea) the content goes and
deposits in Rt. Lower Lobe. Hence k/as right lower lobe pneumonia.
2. On Endotracheal intubation; the tube should be placed 2 ngers breadth
above the Carina. But if inserted further It goes to the right main bronchus
represented as bronchial Intubation.
Deviation of trachea
Either Pulling of Trachea ( d/to the collapse of lung or Atelectasis) OR
Pushing of the trachea ( d/to Tumour {on the left will deviate Trachea to the
right side}, Big pneumothorax, Pleural e usion.
Breathing
If both lung appears black as in Emphysem
Only one lung appears black than Pneumothorax
ChestXrayNotes1
If Normally black Area on X ray Is appearing as Grey Means presence of water,
blood, pus, etc.
Whole area on the X ray which should be black will appear as white than most
likely it Represents pulmonary edema. Alveoli lled with water represents
alveolar edema. And the water in tubings represents an interstitial edema.
Diagnosis of pneumonia can't be done just by the X ray; We also need to check for
Fever, WBC counts, Auscultate the patient ( Bronchial breath sounds )
Tuberculosis :
X rays represent tubercular [Link] [Link] [Link] old
[Link] [Link] primary suspect for TB.
Speci c ndings on X ray of TB patients :
1. Pleural e [Link] the bracket tubercular e usion.
2. Old TB / Healed TB - Appears brosed, thickened, more whitish than normal
which further gets calci ed Such as Miliary Tuberculosis, Cavities appears as
white border with air lled (Black) in centre represents numerous cavitary
lesions.
ChestXrayNotes1
ChestXrayNotes1
Circulation
On X ray ; we visualise the central compartment as follows ~
Heart (For cardiomegaly)
Curved outlines of heart
Aorta
Chamber enlargement
Pericardial e usion
Mediastinal shift
Cardiac Silhouette
is the shadows that allow the assessment of the size and shape of the heart and
major vessels.
Right side. Left side.
Superior vena cava. Aorta
Right atrium. Portion of the left ventricle.
Pulmonary artery.
ChestXrayNotes1
We need to see cardiothoracic [Link] should [Link] than 50% of [Link]
more than 50%.Then known as cardiomegaly.
Position:
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PA view AP view
Beam comes from back Beam from the front
Generally, X rays in the OPD Usually in bed ridden pts like X rays taken in
the ICU.
The medial borders of the scapula are The scapular is projected over more of the
projected over the little aspects of lungs in AP view
the lungs indicating a PA view.
9 anterior ribs and visible indicating a Comparatively in PA View heart looks big
well inspired X ray. and congested.
Well inspired PA view.X Ray allows AP [Link] relatively poor in Spirit re
for an accurate assessment of achievement make the heart an
hearts, eyes [Link] cardiothoracic ratio appear falsely
ratio. increased.
Aortic knob :
Patient is an Old hypertensive While visualising X ray It shows prominent aortic
knob or aortic knuckle. Shows untreated comma uncontrolled hypertension/ may
be an Abnormality in the aortic wall.
Left atrium can not be visible [Link] X [Link] visibility means left atrium
enlargement and a ects left heart [Link] is concave but appears as
straight border.
ChestXrayNotes1
Boot shaped heart.
Diaphragm
Normally, the left room is down and the right Dome is up because the liveris
placed just below it.
Things to look at X ray while observing diaphragm :
Elevation
Flattening
Subpulmonic e usion
Cardiophrenic Angle ( between heart and pleura) & Costophrenic (Between ribs
and Pleura) angles
Pleura :
There are two types of pleura ~ Parietal pleura and Visceral pleura.
Between lungs and pleura :
If air is present, then known as the pneumothorax
If water or uid known as pleural e usion
ChestXrayNotes1
Delicates
Bones like ribs, clavicles, vertebra , fractures
Kyphosis ( Severe one might represent Respiratory di culties )
Rotation and inspiration
Ideally the clavicle should be equidistant from the centre. If overlap or not
equidistant then most likely the patient was rotated while X ray was taken
which will a ect the diagnosis.
Nine ribs are visible above the diaphragm means its an inspiratory X-ray
lm
Emphysema :
Hyperin ated lungs that are deep black areas exceeding the normal
inspiratory rib region
Barrel shaped chest
Dyspneic patient
Tubular shaped heart
No speci c treatment just manages symptomatically.
ChestXrayNotes1
Extra
Foreign [Link] bullets, jewellery, Coins, etc.
Ryles tube, Endotracheal tubes and central lines.
Arti cial heart [Link] pacemakers
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Penetration
Outlines for vertical bodies should be just visible.
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