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1 of 37 1/5/2011 4:27 PM
Chest X-ray Interpretation http://www.scribd.com/doc/11537684/Chest-Xray-Interpretation

AACN1904_444–473 21/10/08 09:26 PM Page 444

AACN Advanced Critical Care


Volume 19, Number 4, pp.444–473
© 2008, AACN

Chest Radiograph Evaluation


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

ABSTRACT
Chest imaging is an important tool in manag- learning some basic skills in interpreting and
ing critically ill patients. Basic chest radiology evaluating chest radiographs, nurses can
is still used to quickly detect abnormalities in recognize and localize gross pathologic
the chest. Critical care nurses are often the changes visible on a chest radiograph. This
ones who first read the radiologist’s report of article provides basic chest radiograph inter-
chest radiograph results and provide their pretation information that allows readers to
interpretation to a physician. Oftentimes, review relevant anatomy and physiology,
chest radiographs are obtained routinely on summarize normal and abnormal findings
a daily basis for every critical care patient, on chest radiographs, and describe radi-
with the goal of effective clinical manage- ographic findings in common pulmonary
ment. Critical care nurses can confirm car- and cardiac disorders.
diopulmonary assessment findings by also Keywords: APN, chest imaging, chest radi-
evaluating their patient’s chest radiographs ograph, chest radiograph evaluation, chest
and reviewing the radiologist’s report. By radiograph interpretation, critical care nurses

hest imaging is an important tool in findings, and 20% have new major findings
C managing critically ill patients. Basic that are clinically unsuspected and are seen
chest radiology is still used to quickly detect only on the radiograph.4
abnormalities in the chest. Critical care nurses Other research supports discontinuing daily
are often the ones who first read the radiolo- routine chest radiographs for critically ill
gist’s report of chest radiograph results and patients because subtle changes may not be
provide their interpretation to a physician. clinically significant and because of the use of
Oftentimes, chest radiographs are obtained resources and cost.5–7 Some consensus exists
routinely on a daily basis for every critical for routine but not daily chest radiographs
care patient with the goal of effective clinical depending on the nature of the acute illness.8
management. Many of these studies1,3,9 suggest using clinical
Debate exists about the efficacy of daily or assessment to guide the need to obtain confir-
routine chest radiology for critically ill matory chest radiographs whether or not they
patients. It has been suggested that daily or are daily or routine.
routine serial chest radiographs are not needed. Critical care nurses can confirm cardiopul-
Some research supports obtaining daily routine monary assessment findings by also interpreting
chest radiographs for critically ill patients to be
able to identify even subtle changes.1–3 Mettler4
supports daily chest radiographs in critically ill
Debra Siela is Assistant Professor, Ball State University
patients. Mettler reports that in daily chest School of Nursing, and ICU Clinical Nurse Specialist, Ball
radiographs, 60% do not disclose either new Memorial Hospital, 2000 University Ave, Muncie, IN 47306
major or minor findings, 20% have new minor (dsiela@bsu.edu).

444

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AACN1904_444–473 21/10/08 09:26 PM Page 445

VOLUME 19 • NUMBER 4 • OCTOBER–DECEMBER 2008 C HE S T RA D IOG RA P H EV A LU A T IO N A N D I N TE RP RE T AT I ON

their patient’s chest radiographs and review- heart, blood vessels, muscle, and diaphragm;
ing the radiologist’s report. This process can and
aid in planning appropriate nursing care. This • bone (or metal), which appears all white or
article provides information on basic chest completely radiopaque; examples are bones,
radiology interpretation that will allow calcium deposits, prostheses, and contrast
the reader to review relevant anatomy and media.
physiology, summarize normal findings on Figure 1 provides a review all of the chest
chest radiographs, and describe radiographic tissues and structures basic radiodensities in a
findings in common pulmonary and cardiac chest radiograph, and Figure 2 identifies each
disorders. chest structure or tissue on a frontal chest radi-
ograph (note that all figures appear at the end
Basic Chest Radiography of the article).
X-rays are very short wavelengths of electro- If 2 structures of equal density are adjacent
magnetic radiation that penetrate matter.4,10–12 A to each other, the border of neither structure
traditional radiograph is created when x-rays can be detected. This phenomenon, the silhou-
penetrate a structure and produce images on a ette sign, is used to identify normal chest struc-
piece of photographic film usually contained in tures and diagnose and localize lung
a cassette. However, in most hospitals and med- diseases.4,10–13 The silhouette sign may be used
ical centers, the traditional x-ray film has been to distinguish anterior from posterior struc-
replaced with digital images. Special detectors tures on a chest radiograph.4,10–13 For example,
are used to replace the film in the cassettes and a silhouette sign would be expected in an area
convert the x-ray energy into digital signals to of consolidation in the left upper lobe of the
construct a digital radiograph. The digital lung because this lobe borders the left sides of
images are stored on and distributed on a pic- the atrium and the mediastinum. Because both
ture archiving and communications system the area of consolidation and the heart are
(PACS).4,10–13 A PACS allows viewing access far water densities, the left border of the atrium
from the radiology department at any computer cannot be distinguished from the border of the
workstation at any time. Digital radiographs left upper lobe of the lung (Figure 3).
can be manipulated to alter contrast and bright-
ness or magnify images to see any abnormality. Views of the Chest
Every sample radiograph included in this docu- Two of the most common radiographs are pos-
ment is from a digital format. teroanterior (PA) and anteroposterior (AP) or
Each radiograph has a continuum of shades frontal views of the chest.4,10–13 For PA views, the
from black to white in its images due to the x-ray beam passes through the chest from the
way the body structures or tissues absorb the back to the front. For AP views, the beam
x-ray beam.4,10–13 X-rays penetrate body tissues
passes through the chest from the front to the
back. For acutely ill patients who cannot stand
that have minimal tissue density, such as air or
up for a PA view, AP views are obtained with a
air-filled structures, and produce black or dark
portable x-ray machine. Ketai and coworkers13
areas on the radiograph; these areas are referred
to as radiolucent. Areas or body tissues that report that more than half of all chest radi-
cannot be penetrated by x-rays are radiopaque ographs in hospitals are performed at the
and appear light or white on the radiograph. bedside. Many of the sample radiographs in this
Thus, each body tissue or structure has article are AP views.
different radiodensity. The next most common view of the chest
The 4 basic roentgen densities or radioden- after the frontal view is the lateral view.9 Lateral
sities4,10–13 are views of the chest enable detection of lesions
behind the heart, near the mediastinum, or near
• gas (air), which appears black or radiolu- the diaphragm.10,12 The lateral view also allows
cent; examples are gas or air in trachea, for visualizing the tracheal air column, inferior
bronchi, or stomach; vena cava, retrosternal space, posterior margin
• fat, which appears gray or less radiolucent of the heart, and diaphragmatic contour.10,11 A
than air; an example is lipid tissue around patient’s frontal and lateral view radiographs
muscle; allow the viewer to have a vision of the chest in
• water (soft tissue), which appears white 3 dimensions so that the viewer can more easily
with slight radiopacity; examples are the localize infiltrates and lesions.

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SIELA A A C N A d v a n c e d Cr it i c a l C a r e

In addition, if ventricle enlargement is sus- above the diaphragm, it is an excellent inspira-


pected on the frontal chest image, a lateral view tory film.10 When less than 10 ribs can be
may help confirm the finding. Portable lateral counted above the diaphragm, it is either poor
view chest images are also used to evaluate inspiratory effort or a sign of low lung volume.
presence of pleural effusions that cannot be Low lung volume from a poor inspiration
seen on frontal views because they are small in effort can crowd and compress the lung mark-
size.10 It takes 250 mL of fluid to blunt a lateral ings, producing the impression that a lower
costophrenic sulcus on a frontal radiograph, lobe pneumonia is present.
but only 75 mL to blunt the posterior
costophrenic sulcus on a lateral radiograph.10 Rotation
Sometimes, a lateral decubitus view radiograph In AP radiographs, patient malposition or
(patient lying either on one side or on the rotation may appear to indicate abnormalities
other) is obtained to evaluate possible pleural in cardiac, vascular, or mediastinal contours
effusions and their fluid levels.13 Figure 4 shows when, in fact, they may not exist.11,13 The posi-
lateral view chest structures and tissues. tion of the clavicles help identify a patient’s
rotation.11,13 If one clavicle appears to be
Technical Factors of Viewing shorter in length than the other, then one side
Chest Radiographs of the chest may be rotated close to or away
It is necessary to consider whether each of the from the detector cassette, producing what
following factors are adequate or appropriate appear to be abnormalities.11,13 Figure 9 shows
to accurately assess and evaluate normal and a difference in clavicle length. Comparing the
abnormal chest radiograph findings.10–13 length of the clavicles in addition to compar-
ing the symmetry of the distance between the
Penetration spinal pedicles and clavicle heads as a method
X-rays must adequately penetrate body struc- of identifying chest rotation is an important
tures to visualize the structures. For example, part of the radiograph examination. If one
one should be able to faintly see the thoracic identifies asymmetry in the distance between
spine through the heart shadow.10 If you cannot, the pedicles (outer edge of spinal vertebra) and
the chest radiograph is underpenetrated or too the clavicle heads, the chest is likely
light. In this situation, the left hemidiaphragm rotated.10,13 Figure 9 shows an example of
may not be visible because the left lung base can asymmetry between the spinal pedicles and the
appear opaque, which may hide or mimic true clavicle heads due to chest rotation.
disease in the left lower lung field.10 A lateral view
will be necessary to confirm any abnormalities Magnification
in the left lower lung field. In addition, the pul- Anteroposterior views obtained with a
monary markings may appear more prominent portable machine have some disadvantages.
then they really are and may be interpreted as Structures in the anterior part of the chest are
interstitial pulmonary edema or pulmonary magnified on AP views, so structures such as
fibrosis.10 Again, a lateral view will be neces- the heart are not as distinct as on PA views and
sary to confirm the interstitial findings. may even be distorted.4,10–13 The heart and the
If the chest radiograph is overpenetrated or mediastinum appear about 15% wider than
too dark, the lung markings may appear to be on the PA view.13 This phenomenon occurs on
absent or decreased.10 It is then possible to an AP view mainly because of the shorter dis-
make the judgment that the patient has tance between the x-ray tube and the patient
emphysema or pneumothorax when in reality than occurs in a PA view.4,10,11
this pathophysiology does not exist.10 One
could also miss a pulmonary nodule when the Angulation
chest radiograph is overpenetrated.10 Posteroanterior views are sharper and more dis-
tinct with less chest rotation and have consis-
Inspiration tent clavicle placement because they are always
A full-inspiration chest radiograph can be obtained with the patient upright and 2 m (6 ft)
reproduced from one time to the next to elimi- away from the source of the x-rays and at a
nate the possibility of artifacts that may con- 90 angle to the beam, whereas angles less
fuse the viewer to think that disease is than 90 are often used for AP radiographs
present.10 If one can count 10 posterior ribs because of inability of critically ill patients to

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tissue shadowing
airspace

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