Side Marker
Projection
Patient Positioning
Rotation
Penetration
Lung Volume
Artifacts
Side Marker
Ensure correct orientation.
There have been reports of chest
drain insertion on the opposite side
to a pneumothorax because of
mislabeling.
Projection
Most films are from posterior to
anterior (PA).
X-ray source situated 1.5-1.8 m
posterior to the patient
X-ray plate positioned immediately
anterior to patients chest.
Patient Positioning
PA films taken with patient standing
AP films taken either standing or
sitting position
All films other than those taken PA
should be labeled with the position
Positioning is significant due to the
appearance of air, fluid and blood
vessels within the chest.
Air
Air tends to rise to the highest point
within the chest cavity.
A pneumothorax is most commonly
seen at the lung apex in the erect
position.
When the patient lies on the side
opposite to the suspected
pneumothorax, any air in the pleural
cavity will rise along the lateral chest
wall.
Fluid
Pleural fluid usually collects in the
lung base and appears dense and
opaque, obscuring adjacent
structures.
Fluid usually reaches a higher point
along the lateral chest wall than
along the mediastium= meniscus
sign.
Pulmonary Vessels
Rotation
Rotation should
be minimal.
Assessed by
looking at the
medial ends of
the clavicles.
Distance should
be equal from
the medial ends
of the clavicles
and the thoracic
spinous
processes.
Penetration
End plates of the lower thoracic
vertebral bodies should be just
visible through the cardiac shadow.
Under-penetrated: film looks diffusely
opaque
Over-penetrated: film looks diffusely
lucent. Lungs appear blacker than
usual and vascular markings are
poorly seen.
Lung Volume
To detect abnormalities-Full
inspiration
Diaphragm should be seen at the
level of the 8th-10th posterior ribs or
the right 6th anterior rib with good
inspiration
Poor inspiration- cause increased
opacification of the lungs because of
atelectasis
Artifacts
Common artifacts:
ECG stickers
Patients hair and clothing
Hospital bedding
Systematic Approach
Airway
Bones
Circulation
Diaphragm
Review Areas
Diaphragm
Check the shape, height, and angles.
Right diaphragm: approx. 1-3 cm
higher than the left.
Look through diaphragmatic shadow
for pathology of lung bases and
pleural reflections for evidence of
pleural fluid.
Review Areas
Lines and Tubes: Chest position for complications, ex:
pneumothorax
Central Lines: pass to lower superior vena cava. Should
not enter right atrium
Pulmonary Artery Catheters: should not be wedged into
small branches
Endotracheal Tubes: Tip at least 3 cm above the carina.
Gastric Tubes: pass below the diaphragm and into
stomach
Chest drains: Check position. Tip of the tube should lie
in an effective position and not be displaced into lung
tissue.
Key Points
Silhouette Sign: Describes loss of normal lung/soft
tissue interface applied to the heart, mediastinum,
chest wall and diaphragm.
Air Bronchogram: Commonly signifies alveolar
disease and also atelectasis.
Consolidation: Result of filling of the alveoli by any
cause (Ex: fluid, pus, blood, tumor)
Pleural Effusion: Greater than 150ml must be
present for pleural effusion to be detected on chest
X-ray.
Air Bronchogram
If area of lung is consolidated, it becomes dense
and white.
If the larger airways are spared, they are
relatively low density blacker
Characteristic sign of consolidation
What is this?
Answer:
Pneumonia
What is this?
Answer:
Pneumothorax
What is this?
Answer:
Tuberculosis in the right upper
lobe
What is this?
Answer:
Total Atelectasis on RT side.
What is this?
Answer:
Pulmonary Embolism
What is this?
Answer:
Cardiomegaly
What is this?
Answer:
Pleural Effusion
What is this?
Answer
Free Air
under the diaphragm
seen in
bowel perforation
What is this?
Answer:
Coi
n
And sometimes
O.R.
Instruments
13-cm steak
knife
Earring
Back
Resources
http://www.medscape.com/viewarticl
e/560163_3