Chest X-ray Interpretation

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Chest Radiograph Evaluationand Interpretation

Debra Siela, RN, PhD, CCNS, ACNS-BC, CCRN, CNE, RRT

Chest imaging is an important tool in manag-ing critically ill patients. Basic chest radiologyis still used to quickly detect abnormalities inthe chest. Critical care nurses are often theones who first read the radiologist’s report ofchest radiograph results and provide theirinterpretation to a physician. Oftentimes,chest radiographs are obtained routinely ona daily basis for every critical care patient,with the goal of effective clinical manage-ment. Critical care nurses can confirm car-diopulmonary assessment findings by alsoevaluating their patient’s chest radiographsand reviewing the radiologist’s report. Bylearning some basic skills in interpreting andevaluating chest radiographs, nurses canrecognize and localize gross pathologicchanges visible on a chest radiograph. Thisarticle provides basic chest radiograph inter-pretation information that allows readers toreview relevant anatomy and physiology,summarize normal and abnormal findingson chest radiographs, and describe radi-ographic findings in common pulmonaryand cardiac disorders.

Keywords:

APN, chest imaging, chest radi-ograph, chest radiograph evaluation, chestradiograph interpretation, critical care nurses

ABSTRACT

findings, and 20% have new major findingsthat are clinically unsuspected and are seenonly on the radiograph.

4

Other research supports discontinuing dailyroutine chest radiographs for critically illpatients because subtle changes may not beclinically significant and because of the use of resources and cost.

5–7

Some consensus existsfor routine but not daily chest radiographsdepending on the nature of the acute illness.

8

Many of these studies

1,3,9

suggest using clinicalassessment to guide the need to obtain confir-matory chest radiographs whether or not theyare daily or routine.Critical care nurses can confirm cardiopul-monary assessment findings by also interpreting

C

hest imaging is an important tool inmanaging critically ill patients. Basicchest radiology is still used to quickly detectabnormalities in the chest. Critical care nursesare often the ones who first read the radiolo-gist’s report of chest radiograph results andprovide their interpretation to a physician.Oftentimes, chest radiographs are obtainedroutinely on a daily basis for every criticalcare patient with the goal of effective clinicalmanagement.Debate exists about the efficacy of daily orroutine chest radiology for critically illpatients. It has been suggested that daily orroutine serial chest radiographs are not needed.Some research supports obtaining daily routinechest radiographs for critically ill patients to beable to identify even subtle changes.

1–3

Mettler

4

supports daily chest radiographs in critically illpatients. Mettler reports that in daily chestradiographs, 60% do not disclose either newmajor or minor findings, 20% have new minor

Debra Siela is Assistant Professor, Ball State UniversitySchool of Nursing, and ICU Clinical Nurse Specialist, BallMemorial Hospital, 2000 University Ave, Muncie, IN 47306(dsiela@bsu.edu).

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VOLUME 19 • NUMBER 4 • OCTOBER–DECEMBER 2008 CHEST RADIOGRAPH EVALUATION AND INTERPRETATION

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their patient’s chest radiographs and review-ing the radiologist’s report. This process canaid in planning appropriate nursing care. Thisarticle provides information on basic chestradiology interpretation that will allowthe reader to review relevant anatomy andphysiology, summarize normal findings onchest radiographs, and describe radiographicfindings in common pulmonary and cardiacdisorders.

Basic Chest Radiography

X-rays are very short wavelengths of electro-magnetic radiation that penetrate matter.

4,10–12

Atraditional radiograph is created when x-rayspenetrate a structure and produce images on apiece of photographic film usually contained ina cassette. However, in most hospitals and med-ical centers, the traditional x-ray film has beenreplaced with digital images. Special detectorsare used to replace the film in the cassettes andconvert the x-ray energy into digital signals toconstruct a digital radiograph. The digitalimages are stored on and distributed on a pic-ture archiving and communications system(PACS).

4,10–13

A PACS allows viewing access farfrom the radiology department at any computerworkstation at any time. Digital radiographscan be manipulated to alter contrast and bright-ness or magnify images to see any abnormality.Every sample radiograph included in this docu-ment is from a digital format.Each radiograph has a continuum of shadesfrom black to white in its images due to theway the body structures or tissues absorb thex-ray beam.

4,10–13

X-rays penetrate body tissuesthat have minimal tissue density, such as air orair-filled structures, and produce black or darkareas on the radiograph; these areas are referredto as

radiolucent.

Areas or body tissuesthatcannot be penetrated by x-rays are

radiopaque

and appear light or white on the radiograph.Thus, each body tissue or structure hasdifferent radiodensity.The 4 basic roentgen densities or radioden-sities

4,10–13

are•gas (air), which appears black or radiolu-cent; examples are gas or air in trachea,bronchi, or stomach;•fat, which appears gray or less radiolucentthan air; an example is lipid tissue aroundmuscle;•water (soft tissue), which appears whitewith slight radiopacity; examples are theheart, blood vessels, muscle, and diaphragm;and•bone (or metal), which appears all white orcompletely radiopaque; examples are bones,calcium deposits, prostheses, and contrastmedia.Figure 1 provides a review all of the chesttissues and structures basic radiodensities in achest radiograph, and Figure 2 identifies eachchest structure or tissue on a frontal chest radi-ograph (note that all figures appear at the endof the article).If 2 structures of equal density are adjacentto each other, the border of neither structurecan be detected. This phenomenon, the silhou-ette sign, is used to identify normal chest struc-tures and diagnose and localize lungdiseases.

4,10–13

The silhouette sign may be usedto distinguish anterior from posterior struc-tures on a chest radiograph.

4,10–13

For example,a silhouette sign would be expected in an areaof consolidation in the left upper lobe of thelung because this lobe borders the left sides of the atrium and the mediastinum. Because boththe area of consolidation and the heart arewater densities, the left border of the atriumcannot be distinguished from the border of theleft upper lobe of the lung (Figure 3).

Views of the Chest

Two of the most common radiographs are pos-teroanterior (PA) and anteroposterior (AP) orfrontal views of the chest.

4,10–13

For PA views, thex-ray beam passes through the chest from theback to the front. For AP views, the beampasses through the chest from the front to theback. For acutely ill patients who cannot standup for a PA view, AP views are obtained with aportable x-ray machine. Ketai and coworkers

13

report that more than half of all chest radi-ographs in hospitals are performed at thebedside. Many of the sample radiographs in thisarticle are AP views.The next most common view of the chestafter the frontal view is the lateral view.

9

Lateralviews of the chest enable detection of lesionsbehind the heart, near the mediastinum, or nearthe diaphragm.

10,12

The lateral view also allowsfor visualizing the tracheal air column, inferiorvena cava, retrosternal space, posterior marginof the heart, and diaphragmatic contour.

10,11

Apatient’s frontal and lateral view radiographsallow the viewer to have a vision of the chest in3 dimensions so that the viewer can more easilylocalize infiltrates and lesions.

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In addition, if ventricle enlargement is sus-pected on the frontal chest image, a lateral viewmay help confirm the finding. Portable lateralview chest images are also used to evaluatepresence of pleural effusions that cannot beseen on frontal views because they are small insize.

10

It takes 250 mL of fluid to blunt a lateralcostophrenic sulcus on a frontal radiograph,but only 75 mL to blunt the posteriorcostophrenic sulcus on a lateral radiograph.

10

Sometimes, a lateral decubitus view radiograph(patient lying either on one side or on theother) is obtained to evaluate possible pleuraleffusions and their fluid levels.

13

Figure 4 showslateral view chest structures and tissues.

Technical Factors of Viewing Chest Radiographs

It is necessary to consider whether each of thefollowing factors are adequate or appropriateto accurately assess and evaluate normal andabnormal chest radiograph findings.

10–13

Penetration

X-rays must adequately penetrate body struc-tures to visualize the structures. For example,one should be able to faintly see the thoracicspine through the heart shadow.

10

If you cannot,the chest radiograph is underpenetrated ortoolight. In this situation, the left hemidiaphragmmay not be visible because the left lung base canappear opaque, which may hide or mimic truedisease in the left lower lung field.

10

A lateral viewwill be necessary to confirmany abnormalitiesin the left lower lung field. In addition, the pul-monary markings may appear more prominentthen they really are and may be interpreted asinterstitial pulmonary edema or pulmonaryfibrosis.

10

Again, a lateral view will be neces-sary to confirm the interstitial findings.If the chest radiograph is overpenetrated ortoo dark, the lung markings may appear to beabsent or decreased.

10

It is then possible tomake the judgment that the patient hasemphysema or pneumothorax when in realitythis pathophysiology does not exist.

10

Onecould also miss a pulmonary nodule when thechest radiograph is overpenetrated.

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Inspiration

A full-inspiration chest radiograph can bereproduced from one time to the next to elimi-nate the possibility of artifacts that may con-fuse the viewer to think that disease ispresent.

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If one can count 10 posterior ribsabove the diaphragm, it is an excellent inspira-tory film.

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When less than 10 ribs can becounted above the diaphragm, it is either poorinspiratory effort or a sign of low lung volume.Low lung volume from a poor inspirationeffort can crowd and compress the lung mark-ings, producing the impression that a lowerlobe pneumonia is present.

Rotation

In AP radiographs, patient malposition orrotation may appear to indicate abnormalitiesin cardiac, vascular, or mediastinal contourswhen, in fact, they may not exist.

11,13

The posi-tion of the clavicles help identify a patient’srotation.

11,13

If one clavicle appears to beshorter in length than the other, then one sideof the chest may be rotated close to or awayfrom the detector cassette, producing whatappear to be abnormalities.

11,13

Figure 9 showsa difference in clavicle length. Comparing thelength of the clavicles in addition to compar-ing the symmetry of the distance between thespinal pedicles and clavicle heads as a methodof identifying chest rotation is an importantpart of the radiograph examination. If oneidentifies asymmetry in the distance betweenthe pedicles (outer edge of spinal vertebra) andthe clavicle heads, the chest is likelyrotated.

10,13

Figure 9 shows an example of asymmetry between the spinal pedicles and theclavicle heads due to chest rotation.

Magnification

Anteroposterior views obtained with aportable machine have some disadvantages.Structures in the anterior part of the chest aremagnified on AP views, so structures such asthe heart are not as distinct as on PA views andmay even be distorted.

4,10–13

The heart and themediastinum appear about 15% wider thanon the PA view.

13

This phenomenon occurs onan AP view mainly because of the shorter dis-tance between the x-ray tube and the patientthan occurs in a PA view.

4,10,11

Angulation

Posteroanterior views are sharper and more dis-tinct with less chest rotation and have consis-tent clavicle placement because they are alwaysobtained with the patient upright and 2 m(6 ft)away from the source of the x-rays and at a90



angle to the beam, whereas angles lessthan 90



are often used for AP radiographsbecause of inability of critically ill patients to

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