cxr self-study manual 2013

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Units 1&2 Introduction & Cardiorespiratory and Exercise Physical Therapy Practice 2013Chest X-ray Self Study Package© Department of Physical Therapy, University of Toronto

1

UNITS 1&2: INTRODUCTION AND CARDIORESPIRATORY AND EXERCISE

PHYSICAL THERAPY PRACTICE

CHEST RADIOGRAPH

LEARNING UNIT


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Chest Radiograph Learning Unit

The chest radiograph (Chest X-ray) learning unit has 3 components:

1. Self-study package (included in this manual)

2. Chest X-ray Workshop (week 10)3. Chest X-ray SCS (week 12)

The information in the self-study package must be reviewed prior to the Interview,Assessment and Treatment SCS during weeks 5 & 6.

Learning Objectives and format:

1) This self-study package will provide a basic introduction to viewing,understanding and interpreting chest X-rays. The objectives are:

Understand the basic physical properties and techniques of chest radiographs

Differentiate between antero-posterior (AP) and postero-anterior (PA) radiographsand understand the advantages and disadvantages of each

Identify normal anatomy (heart, lungs, soft tissues, bony structures and otherthoracic and abdominal organs)

Recognize common lines and tubes

Develop a systematic approach to chest X-ray interpretation

Identify common cardiorespiratory pathologies (i.e. atelectasis, lobar and lungcollapse, pneumonia, pleural effusion, pulmonary edema and pneumothorax) and

chronic lung conditions (emphysema, pulmonary fibrosis, cystic fibrosis).

Format: These chest radiographs are posted on the Unit 1 & 2 website throughBlackboard under MANUAL. It is your responsibility to work through this package

and the quizzes on your own time (answers included at the end of the manual),

identify areas that are unclear to you and seek assistance from the Unit 1 & 2coordinators. Chest X-ray material is testable on the unit tests and the Practical Skills

Exam

2) The chest X-ray workshop learning objectives are:

Understand the role of chest X-rays in the physiotherapy management of thecardiorespiratory patient

Detailed review anatomical features

“Dee Method” for locating the carina

Review of the silhouette sign

Practice identifying cardiorespiratory pathologies


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Format: The chest X-ray workshop will be facilitated by a physiotherapist. This

workshop will expand upon the basic skills outlined in the self-study package, and

spend further time identifying cardiorespiratory pathologies and discuss the role ofchest X-rays in the physiotherapy management of the cardiorespiratory patient. It will

be held Thursday November 7th

, 2013 1-4 pm 4

th Floor Computer Lab at 500

University. Group A and B will attend a 90 minute session separately.

3) The chest X-ray SCS objectives are:

Understand the role of a radiologist in the acute care setting

Be familiar with a systematic approach to chest radiograph interpretation

Be able to identify the differences between an AP and PA chest radiograph

Be able to identify the normal anatomy in an AP and PA chest radiograph

Have been exposed to a variety of chest radiographs demonstrating commoncardiorespiratory abnormalities

Be able to identify these common abnormalities in a chest radiograph Have been exposed to other diagnostic tests (CT/MRI) of the chest

Format: The chest X-ray SCS will be held at St. Michael’s Hospital and facilitated by

a radiologist. This SCS will continue to build on chest X-ray interpretation skillscovered in the self-study package and workshop, and also include CT scans and

MRIs and the role of the radiologist in acute care. The structured clinical session

(SCS) will be held in a large group format with group A and B attending the same

session. It will be held on Monday November 18th, 2013 1-3pm, Paul Marshall Lecture

Theatre , St. Michael’s Hospital


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Part 1: Chest X-ray Self Study Package


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Chest X-ray Self Study Package

Objectives 1 & 2: Chest X-ray Properties & Techniques

1.

Exposure

Different structures of the body absorb x-rays to varying degrees. The following termsare used to describe the extent to which different materials absorb x-rays.

RADIOPAQUE

Heavily absorptive of x-rays

White in the radiograph

Examples: metal, bone

RADIOLUCENT

Moderately absorptive of x-rays

Gray in the radiograph

Examples: fat

RADIOPARENT

Hardly absorptive of x-rays

Black in the radiograph

Examples: tissue, skin, air (lungs)

The relative order of density from least dense (dark on the radiograph/radioparent) to

most dense (white on the radiograph/radiopaque) is as follows:

Gas(present in the lungs, stomach, intestines)

Fat(surrounds kidney, present along the abdominal wall and other organs)

Water(same density as heart and blood vessels)

Bone

(more dense that other tissues)

Metal

(foreign objects, contrast media)


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The absolute degree of whiteness or darkness in a chest radiograph is a function of two

factors:

1) Tissue density in the chest – the density produced on a radiograph depends on thethickness of the chest tissue. For example: the heart (water density) appears whiter

than the ribs.

2) Intensity and degree of exposure to x-rays (technical factors) – the film can beunderexposed or overexposed depending on technical factors.

Underexposed films show an increased whiteness of the lung fieldsresulting from less x-ray beam reaching the film.

Overexposed films show an increased darkness of the lung fields dueto too much x-ray beam reaching the film. The radiograph appears to

be so black that even the bony skeleton cannot be seen with its normal

white tone.


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Normal

Underexposed

Overexposed


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2. Positions

Posteroanterior (PA) Position

This is the standard position for obtaining a routine, adult chest radiograph. The

patient is either sitting or standing upright.

In this position, the patient’s chest is placed against the film, and the x-ray source is

aimed horizontally at a distance of 6 feet from the film. The shoulders are rotatedforward to touch the film, ensuring that the scapulae do not obscure the lung fields.

The radiograph is usually taken with the patient in full inspiration, lowering thediaphragm from the 9

th to 11

th ribs posteriorly.

Advantages:

The scapulae are rotated out of the lung fields. With the 6 foot distance between the x-ray tube and the film, the

magnification is reduced and the sharpness of the image is enhanced.

Since the heart is located in the front half of the thorax, placing the frontof the chest against the film and having the x-ray beam strike from behind,reduces the magnification of the heart.

The diaphragm is lower in an upright position than in a recumbent position.

Fluid, if present, will gravitate to dependent portions of the lung or chest,and may be more easily seen.

Air-fluid levels are identifiable.

The appearance of anatomical landmarks on the PA upright position will be seen as it is usually described anatomically.

Normal PA Chest X-ray


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2. Anteroposterior (AP) Position

The AP radiograph is ordered when the patient is debilitated, immobilized, or too

young to cooperate with the procedure for a PA radiograph, or when a posterior

abnormality is to be viewed. The erect AP radiograph is utilized for medically stable patients while the supine AP radiograph is utilized for patients who very ill and those

who are unable to sit up.

The AP radiograph may be taken with a portable unit. The film is placed behind the

patient’s back, with the x-ray source usually about 3 feet from the film.

Considerations when viewing an AP radiograph:

There may be distortion, greater coarseness and less resolution

Good inspiratory radiographs or symmetrical chest positions may not be

possible Artifacts (shadows) from ventilator tubing, invasive lines or other devices will

often be present

The heart shadow is larger than in the PA view because it is farther away fromthe film

The shadows of the scapulae are superimposed on the lateral half of the lungfields since they are not rotated out of view in this position

Normal AP Chest radiograph


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Table 1: Essential Differences between PA and AP Chest Radiographs

PA Chest Radiograph AP Chest Radiograph

Heart Close to radiographSmaller

Magnified image

Scapulae Normally rotated awayfrom lungs

Superimposed on lungfields

Clavicles Cross lung fields about 2”

below the apex

Frequently project above

apex of lungsRibs Diagonal, posterior portions

are higherHorizontal

Diaphragm Normal position Elevated


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3. Lateral Position

The PA radiograph is complemented by the lateral upright radiograph in which the patient’s side is placed against the film. The patient usually stands with their arms

above their head to prevent them from obscuring the thorax. A left lateral radiograph

is usually taken (left side of the patient against the film) to decrease the heartmagnification since the heart occupies more of the left chest. However, if an

abnormality is known to be present in the chest, the side that brings the abnormality

closest to the film is placed against the film.

Advantages:

Allows the viewer to see behind the heart and the domes of the diaphragm.

Can be put together with the PA radiograph to determine the 3-dimensional position of organs or abnormalities.

Normal Lateral Radiograph


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QUIZ # 1

Do you recognize any differences between the two? Which one is

TRUE OR FALSE??

Please answer the following questions.

1. The PA position is the best position for the patients who are able to stand. _____

2. There are no differences between the PA and AP chest radiographs. _____

3. On the AP chest radiograph, the heart is magnified because it is placed fartheraway from the film. _____

4. To visualize a lesion in the left thorax, it is better to get a right lateral view. _____

LIST THREE ADVANTAGES OF THE PA CHEST RADIOGRAPH

LIST THREE DIFFERENCES BETWEEN PA AND AP CHEST RADIOGRAPHS


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Objective 3: Normal Anatomy

Correct identification of anatomical structures and knowledge of their normal variationsis essential when examining a chest radiograph. Misinterpretation of an opacity due to a

normal structure may lead to errors in diagnosis. It is important to become familiar with

the normal chest anatomy before moving on to detecting chest abnormalities.

THE BONY SKELETON OF THE THORAX

The bony skeleton is composed of the ribs, sternum, thoracic vertebrae and clavicles.

1) Most of the first ten RIBS should be seen. The rib outlines can be traced fromtheir posterior to anterior ends. The ribs may be counted from the 1

st downwards.

The posterior portions of the ribs are higher than the anterior portions as the ribs

slope downwards. Anteriorly, the ribs will appear to hang in space, not joined to

anything. In fact, they are attached to the costal cartilages which are not seen onthe radiograph because the cartilage is radioparent.

2) The two CLAVICLES should be clearly defined and the medial ends shouldappear equally distant from the midline. If the patient has been positioned

correctly, the midline may be represented by a vertical line drawn through the

shadows of the spinous processes of the upper dorsal vertebrae and project downthe spine.

3) The SCAPULAE should be seen clear of the lung tissue if the shoulders wereappropriately protracted when the radiograph was taken. However, the medial

borders and the inferior angles of the scapulae should be identified as it may not

always be possible to place the patient so that they are clear of the lung fields.

The female breast outlines are seen as curving shadows with the convexity downwards.

They may overlie the lung fields towards the basal area. They may be higher or lowerthan this and they may extend laterally beyond the boundaries of the bony thorax.


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Normal chest radiograph counting posterior portions of ribs 1-10

Rib 1Rib 2

Rib 3

Rib 4

Rib 5

Rib 6

Rib 7

Rib 8

Rib 9

Rib 10

Clavicles Medial border

of scapula

Posterior and

anterior portions of

rib 5


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THE DIAPHRAGM

The DIAPHRAGM is a fibromuscular structure which separates the thoracic andabdominal cavities. It forms a dome with the convexity upwards.

The two arcs run medially towards the midline but are not seen to meet each other because they become lost in the heart shadow. The angles formed where the two arcs of

the diaphragm meet the heart are called the CARDIOPHRENIC ANGLES. The angles

formed where the two arcs of the diaphragm meet the thoracic wall are called theCOSTOPHRENIC ANGLES.

The radiographic arcs of the diaphragm represent its upper surface against the air-filled

lungs. The lower surface of the diaphragm is not seen unless there is air beneath it.

The level of the left dome of the diaphragm is consistently 1-2cm lower than the right,

unless it is elevated by an unusually large amount of air in the stomach or colon.

Right diaphragmLeft diaphragm

Cardiophrenic angles

Costophrenic angles


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THE TRACHEA

The TRACHEA is seen as a tubular radioparency, with the lower cervical and upperthoracic vertebrae superimposed on it. At the level of the 4

th or 5

th thoracic vertebra, the

trachea ends by dividing into the right and left mainstem bronchii. At the point of

bifurcation, it lies slightly to the right of the midline.

On the standard PA chest radiograph, the trachea is seen in the midline as a shadow

which is radioparent (black) because it contains air. At approximately the level of thesternoclavicular joints (T3), the radioparency of the trachea becomes lost behind the

mediastinal shadow. Thus the end of the trachea and its bifurcation into the right and left

mainstem bronchii may be harder to visualize.

Trachea

Bronchial

bifurcation

Left mainstem bronchus

Rightmainstem

bronchus


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THE LUNGS

The LUNG FIELDS of a PA chest radiograph appear radioparent (dark) areas over whichthe shadows of the ribs are superimposed. This radioparency is greatest on deep

inspiration and least on deep expiration.

The radiographic lung fields are roughly divided into six separate parts as follows:

1. Apical region – lying above the clavicles2. Infraclavicular region – lying between the clavicle and the upper part of the

hilum of the lung.

3. Middle region – the region of the hilum of the lung below the infraclavicularregion

4. Basal region – below the middle region and reaches from the lower part of thehilum down to the diaphragm

5. Cardiophrenic angle – dome of the diaphragm meets the heart

6. Costophrenic angle – dome of the diaphragm meets the thoracic wall

The right and left lungs lie on either side of the mediastinum within the thorax. They are

made up of LOBES which are separated by deep fissures. FISSURES are invaginations

of the visceral pleura into the interlobar space. In order for a fissure to be visible on the

radiograph, the x-ray beam must strike it parallel to the long axis. If it is not parallel tothe x-ray beam, it will not be visualized.

The RIGHT LUNG is slightly larger than the left lung and has 3 lobes: upper, middle andlower. The horizontal (transverse) fissure separates the upper and middle lobe, and the

oblique fissure separates the middle and lower lobe. The LEFT LUNG only has 2 lobes,

an upper and a lower lobe. They are separated by the oblique fissure.

The OBLIQUE FISSURE lies in an oblique plane, coursing downward and forward. It is

usually not visible on the normal PA radiograph because it is not parallel to the x-ray

beam. The HORIZONTAL FISSURE of the right lung lies in a horizontal plane at thelevel of the anterior portion of the 4

th rib. In approximately 80% of normal adults, a hair-

line shadow can be seen on a PA radiograph extending transversely from the region of the

hilum of the lung (level of the 4th

costal cartilage) out towards the periphery to meet theoblique fissure in the axilla at the level of the 6

th rib.

The HILAR REGION of each lung can easily be identified on the PA projection as thedense white areas at the level of the 6th and 7th intercostals spaces on either side at the

medial border of each lung. It is here that the structures which form the root of the lung

enter and exit. For each lung, these structures are:

the main branches of the bronchi

the pulmonary artery and veins

the bronchial arteries and veins

nerves, lymph vessels and glands


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In the PA radiograph, these vessels are not individually delineated, but shadows radiating

from the root of the lung can be seen. The most prominent of these hilar shadows in eachlung is formed by the main artery and vein passing downwards and laterally. The shadow

of the pulmonary vessels is a little higher on the left side compared with the right.

IDENTIFY: RUL, RML, RLL, LUL AND LINGULA, LLL

Horizontal

issure

Oblique fissures


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THE MEDIASTINUM

The mediastinum is seen as a white shadow in the midline of the thorax in a PA chestradiograph. This shadow is formed by the:

heart

pericardium great vessels

The right border of the mediastinal shadow is formed from above by the right innominate

vein, the superior vena cava and the right atrium of the heart and from below by the

inferior vena cava. The right ventricle occupies most of the central portion of theradiopaque region of the mediastinal shadow. The left border is formed by the left

subclavian artery, the arch of the aorta, the pulmonary artery, the auricle of the left atrium

and the left ventricle.

The ratio of transverse diameter of the heart shadow to that of the thorax on inspiration

should be approximately 1:2.

Normal cardiothoracic ratio 1:2


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Cardiomegaly


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Normal chest radiograph


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QUIZ # 2

IDENTIFY THE DIFFERENT STRUCTURES MARKED WITH ARROWSA. _______________________________B. _______________________________C. _______________________________D. _______________________________

E. _______________________________F. _______________________________

Identify the specific rib (is it the anterior or posterior portion?)

G. _______________________________H. _______________________________I. _______________________________Is this a male or female chest radiograph? ____________

A

G

CB

C

F

I

E

H


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QUIZ # 3

IDENTIFY THE DIFFERENT STRUCTURES MARKED WITH ARROWSA. __________________________________________

B. __________________________________________C. __________________________________________D. __________________________________________E. __________________________________________F. __________________________________________G. __________________________________________H. __________________________________________I. What organ would you find here? _______________

A

C

B

D

H

E

F

G


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QUIZ # 4

ANSWER THE FOLLOWING QUESTIONS

A. Is this an AP or PA view? ___________B. Is this a good quality radiograph?C. Give two reasons for your answer in Question A.

_____________________________________________ _____________________________________________

D. What is the phase of respiration? __________________E. Are there any positional faults?

- Are the clavicles symmetrical? _______- Are the scapulae out of the lung fields? ____________


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Objective 4: Lines & TubesETT tube

CG

eads

wananz

atheter

Sternalwires

Chest tube

NG tube

External

pacemaker

wire


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Objective 5: Systematic Approach to Interpretation

THE TECHNICAL QUALITY

The first step in examining a chest radiograph is to quickly evaluate its quality. Thefollowing points should be reviewed.

1. Position: The spinous processes should project midway between the medialheads of the clavicles.

2. Inspiration: The dome of the right hemi-diaphragm should be at the level of the

9th

to 11th

ribs and the dome of the left hemi-diaphragm should beat the level of the 10

th to 12

th ribs posteriorly.

3. Penetration: You should see the thoracic vertebrae clearly through the

mediastinal shadow up to T5 or T6. If the x-ray is underexposed,the film will increase in whiteness. If the x-ray is overexposed, the

film will become more radioparent (dark).

ANATOMICAL INSPECTION

Once the technical quality of the radiograph has been determined, the next step is to

review the entire chest radiograph. It is important to use a systematic method in order toreduce the likelihood of missing important features. An example of a systematic order is

as follows:

Bony skeleton – humerus, clavicles, scapulae, vertebrae, ribs

Domes of the hemi-diaphragms

Pleural surface – costophrenic and cardiophrenic angles

Mediastinum – trachea, carina, bronchii, heart, great vessels

Hilum – pulmonary veins, pulmonary arteries

Lungs – pulmonary vasculature

Skin and soft tissue

Sub-diaphragm

Also note the presence of lines, catheters or wires if applicable.


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Objective 6: Common Cardiorespiratory Pathologies and Conditions

ATELECTASIS

ATELECTASIS is defined as collapse of or loss of volume in a lung, lobe or segment of

a lobe.

The three radiographic DIRECT SIGNS of collapse are:

Displacement of interlobar fissures in the direction of the collapse lung*

Increased radiopacity

Vascular or bronchial crowding

The three radiographic INDIRECT SIGNS of collapse are:

The displacement of the hilum in the collapse direction* (remember the left hilumis already higher than the right)

Elevation of the diaphragm

Shift of mediastinal structures towards the collapsed side

(* indicates the most reliable sign)

RML collapse - note radiopacity and obliteration of right heart border


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Left lung collapse – note radiopacity of left lung, obliteration of left hemi-

diaphragm, and mediastinal and tracheal shift towards the collapse


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SILOUETTE SIGN

The silhouette sign is a chest radiographic finding that is helpful in localizing a density orabnormality. A mass or consolidation touching a border of the heart, aorta or diaphragm

will obliterate that border on the radiograph. A mass or consolidation that is not in

physical contact with the border of these organs or vessels will not obliterate that border,even though the mass and organ are superimposed on that particular radiograph.

Summary of the location of important structures in the chest when observing for the

Silhouette Sign

Anterior Location Posterior Location

Heart

Right heart border Aortic arch (aortic notch)

Left heart border Descending aorta

Ascending aorta

Lungs

Anterior segment of the right

upper lobeRight middle lobe Apical-posterior segment of

left upper lobe

Lingula of the left upper lobe Left lower lobe

Anterior segment of the left

upper lobe

Right lower lobe

Silhouette Signs of Segmental Collapse

Lobes Segments Collapsed Location Silhouette Sign

RUL

Anterior Segment Anterior Obliterate the ascending aortaand upper portion of the right

heart

Posterior Segment Posterior None

Apical Segment Anteriorand

posterior

None

LUL

Anterior Segment Anterior Obliterate the uppermost

portion of the left heart border

Apical-posterior Segment Posterior Obliterate the aortic arch

Lingula (superior/inferior) Anterior Obliterate most of the left

heart borderRML Medial/lateral Anterior Obliterate the greater part of

the right heart border

RLL/LLL Superior

Anterior basal/Lateral

basal/Posterior or basal/Medial

basal

Posterior

Posterior

Obliterate the descending

aortaFail to obliterate the right

heart border (RLL) and the

left heart border (LLL)


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QUIZ # 5

Which lobe/segment do you think is collapsed in each chest radiograph? For each chestradiograph, state the direct and indirect signs of collapse and use the silhouette sign to

determine the involved lobe/segment.

Lobe Segment Direct

Signs

Indirect Signs Silhouette Sign

Chest radiograph # 1



RUL Apical Radio-opacityelevation of diaphragm

LLLAnterior basal

increased

opacity

movement of

mediastinum towards

collapsed side

fail to obliterate

left heart border

RLL Anterior basal


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PNEUMONIA

Pneumonia is defined as an infection of the lung parenchyma. Infection is a state orcondition in which part of the body is invaded by a pathogen which multiplies and

produces injury. An inflammatory process ensues as the body attempts to destroy or limit

the spread of injury.

On chest radiograph, pneumonia is characterized by opacified pulmonary infiltrates in the

affected lung segments. If the process has extended into the alveolar spaces, air bronchograms (dark tubular densities) will be evident.

RIGHT LOWER LOBE PNEUMONIA

Area of

increased

opacification


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PLEURAL EFFUSION

PLEURAL EFFUSION is defined as the presence of an abnormally large amount of fluidwithin the pleural space. The fluid is able to move freely within the pleural space (unless

it is loculated), migrating to gravity dependent positions.

The presentation of pleural effusion on chest radiograph, therefore, is dependent on the

position in which the x-ray is taken. For example, in an upright PA chest radiograph, you

will likely see a “fluid level” as an opacified line. In a supine AP chest radiograph, theopacification will be more diffuse due to the distribution of the fluid throughout the

pleural space.

LEFT PLEURAL EFFUSION, UPRIGHT

LEFT PLEURAL EFFUSION, SUPINE

Visible fluid level

and blunting of

costophrenic and

cardiophrenic angles

Diffuse opacificatio

thoughout lung field


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PNEUMOTHORAX

PNEUMOTHORAX is defined as the presence of air within the pleural space. Theabnormal presence of air in the pleural space will generally cause adjacent lung segments

or lobes to collapse or consolidate towards the hilum.

On chest radiograph, an area of pneumothorax will become extremely radioparent (dark)

with no visible vascular markings.

RIGHT PNEUMOTHORAX

Areas of increasedradioparency with no

vascular markings

Collapsingright lung


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PULMONARY EDEMA

PULMONARY EDEMA is defined as the presence of fluid accumulation and swelling inthe lung. A significant increase in pulmonary vasculature will be seen throughout the

lung fields on chest radiograph.

Increased vascular

markings seen bilaterally


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CHRONIC LUNG CONDITIONS

COPD/ emphysema – compare to the normal radiographs on pages 14 & 15. What do

you notice about the chest circumference and location and shape of the diaphragm?Compare to the radiographs on the next page showing pulmonary fibrosis. What

differences do you observe?

http://www.google.ca/url?sa=i&rct=j&q=lateral+chest+xray+of+copd&source=images&cd=&cad=rja&docid=bpW6hFPg0SBX0M&tbnid=NTnMwopyejkIsM:&ved=0CAUQjRw&url=https://en.wikipedia.org/wiki/Emphysema&ei=iknUUaGaEKGIyAHayoHIDw&bvm=bv.48705608,d.aWc&psig=AFQjCNESiuintvFenVBwALigB3zByT_Q7Q&ust=1372953350066413http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+copd&source=images&cd=&cad=rja&docid=uPOnDA1Wq4a4LM&tbnid=s0djojq6hxxsQM:&ved=0CAUQjRw&url=http://www.sciencedirect.com/science/article/pii/S1357303912000357&ei=REnUUbqqH4TIywG0j4DoBA&bvm=bv.48705608,d.aWc&psig=AFQjCNHFZzm3j_IJ4ZWkDbacXz_afaTwKw&ust=1372953219743461http://www.google.ca/url?sa=i&rct=j&q=lateral+chest+xray+of+copd&source=images&cd=&cad=rja&docid=bpW6hFPg0SBX0M&tbnid=NTnMwopyejkIsM:&ved=0CAUQjRw&url=https://en.wikipedia.org/wiki/Emphysema&ei=iknUUaGaEKGIyAHayoHIDw&bvm=bv.48705608,d.aWc&psig=AFQjCNESiuintvFenVBwALigB3zByT_Q7Q&ust=1372953350066413http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+copd&source=images&cd=&cad=rja&docid=uPOnDA1Wq4a4LM&tbnid=s0djojq6hxxsQM:&ved=0CAUQjRw&url=http://www.sciencedirect.com/science/article/pii/S1357303912000357&ei=REnUUbqqH4TIywG0j4DoBA&bvm=bv.48705608,d.aWc&psig=AFQjCNHFZzm3j_IJ4ZWkDbacXz_afaTwKw&ust=1372953219743461


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Pulmonary fibrosis – what level are the hemi-diaphragms? What else do you observe?

Cystic Fibrosis – what do you observe in this radiograph?

http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+cystic+fibrosis&source=images&cd=&cad=rja&docid=Ix2XGSR6TuXfmM&tbnid=CQugFfkAHxZOCM:&ved=0CAUQjRw&url=http://www.learningradiology.com/archives03/COW%20058-Cystic%20fibrosis/cysticfibrosiscorrect.htm&ei=mUrUUeeIE6PkyQGM5YC4CA&bvm=bv.48705608,d.aWc&psig=AFQjCNFEZCerwyTl-yeNthQIb9yXw1T3cw&ust=1372953618310798http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+pulmonary+fibrosis&source=images&cd=&cad=rja&docid=_5rilkMfaXU2ZM&tbnid=EvQwX0Fl4SGD7M:&ved=0CAUQjRw&url=http://pulmonaryroundtable.blogspot.com/2006_06_01_archive.html&ei=BErUUZPSKYOcyQHhhoH4CQ&bvm=bv.48705608,d.aWc&psig=AFQjCNFslxAR7FoEG0JDuTSwqr3TU-hEmg&ust=1372953398700093http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+cystic+fibrosis&source=images&cd=&cad=rja&docid=Ix2XGSR6TuXfmM&tbnid=CQugFfkAHxZOCM:&ved=0CAUQjRw&url=http://www.learningradiology.com/archives03/COW%20058-Cystic%20fibrosis/cysticfibrosiscorrect.htm&ei=mUrUUeeIE6PkyQGM5YC4CA&bvm=bv.48705608,d.aWc&psig=AFQjCNFEZCerwyTl-yeNthQIb9yXw1T3cw&ust=1372953618310798http://www.google.ca/url?sa=i&rct=j&q=chest+xray+of+pulmonary+fibrosis&source=images&cd=&cad=rja&docid=_5rilkMfaXU2ZM&tbnid=EvQwX0Fl4SGD7M:&ved=0CAUQjRw&url=http://pulmonaryroundtable.blogspot.com/2006_06_01_archive.html&ei=BErUUZPSKYOcyQHhhoH4CQ&bvm=bv.48705608,d.aWc&psig=AFQjCNFslxAR7FoEG0JDuTSwqr3TU-hEmg&ust=1372953398700093


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Answer Key for Quizzes

QUIZ 1: PA & AP radiographs

1. True

2. False3. True4. False

Three advantages of the upright PA radiograph:

a. scapula are rotated out of the lung fields

b. size of the heart is reducedc. increased sharpness of the image

Three essential differences between the PA and AP radiograph:a. magnification of the heart (smaller in the PA)

b. sharpness of the image (more sharp in the PA)c. position of the scapulae (rotated out of the lung fields in PA)

d. position of the ribs (diagnonal in PA, horizontal in AP)

QUIZ 2:

A. right scapula

B. tracheaC. right clavicle

D. soft tissue

E. right cardiophrenic angleF. inferior angle of the right scapulaG. posterior portion of the 6

th rib

H. anterior portion of the 3rd

rib

I. posterior portion of the 5th

ribJ. male

QUIZ 3:

A. right dome of diaphragm

B. left dome of diaphragm

C. gastric air bubbleD. right costophrenic angle

E. arch of the aorta

F. right hilar regionG. left heart border

H. Liver


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QUIZ 4:

A. PAB. Yes

C. 1. You can trace the ribs. 2. The spinous process projects midway between the medial

clavicular heads 3. The domes of the hemi-diaphragms are between the 9-11

th

ribs on theright and the 10th

-12th

ribs on the left.

D. Inspiration

E. No. The clavicles are symmetrical and the scapulae are out of the lung fields.

QUIZ 5:


RIGHT UPPER LOBE COLLAPSE

Direct signs:1. Radiopacity of the collapsed lobe2. Increased vascular and bronchial crowding in the RUL

Indirect signs:

1. Elevation of right hemidiaphragm2. Trachea is shifted towards the right

Silhouette signs:The upper portion of the right heart is still visible; therefore this is likely a collapse of the

apical or posterior segments of the RUL.


LEFT LOWER LOBE ATELECTASISDirect signs:

1. Radiopacity of the left lower lobe regionIndirect signs:

1. Mediastinum is shifted towards the left2. The left hemi-diaphragm is elevated and obliterated with heart tissue

Silhouette signs:Failure to obliterate the left heart border since the LLL is a posterior structure. Note- The

left costo-phrenic angle decreases its sharpness due to the collapse.


RIGHT LOWER LOBE COLLAPSEDirect signs:

1. Radiopacity of the right lower lobe regionIndirect signs:


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1. Mediastinal shift towards the right.2. The right hemi-diaphragm is elevated3. Note – the right cardiophrenic and costophrenic angles both decrease in

sharpness due to the collapse

Silhouette signs:

Failure to obliterate the right heart border

CHRONIC LUNG CONDITIONS:

COPD/emphysema – there is hyperinflation as shown by the flattened and lowered hemi-

diaphragms (level of the 12th

rib), darker lung fields (more radiolucency not caused by anoverexposed X-ray), narrowed transverse diameter of the heart and increased size of the

chest particularly seen on the lateral radiograph (barrel-chest and excessive air in the

retrosternal space).

Pulmonary Fibrosis- there is lung volume loss with the dome of right hemi-diaphragm at

the level of the 8th

-9th

ribs and the dome of the left diaphragm at the level of the 9th

-10th

ribs posteriorly. There are also prominent reticular interstitial markings bilaterally.

Cystic Fibrosis- there is hyperinflation (flattened, lowered diaphragms) and diffuse,

bilateral bronchiectasis.


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References

• Parker MS, Rosado-de-Christenson ML, Abbott GF. Teaching Atlas of ChestImaging. New York, NY: Thieme Medical Publishers Inc.; 2006.

• Boyars MC. The power of chest films: evaluating infiltrates. Journal of

Respiratory Diseases. 1994; 15(3):697-711.• Goodman LR. Felson’s Principles of Chest Roentgenology. 2nd ed. Philadelphia,PA: W.B. Saunders Co.; 1999.

• Kersten LD. Chest roentgenology. In: Comprehensive Respiratory Nursing.Philadelphia, PA: W.B. Saunders Co.;1989:400-452.

• Miller WT, Miller WT Jr. Field Guide to the Chest X-ray. Philadelphia, PA:Lippincott, Williams, & Wilkins; 1999.

• Rodriquez MR, Moyers JP, Light RW. A guide to chest radiology in the ICU. TheJournal of Critical Illness. 1999;14(10):538-549.

• Sanchez F. Fundamentals of chest x-ray interpretation. Critical Care Nurse.1986(5):41-61.

• http://www.med-ed.virginia.edu/courses/rad/cxr/index.html
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cxr self-study manual 2013

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