Part II Anaesthesia Refresher Course – 2016

6 University of Cape Town

Approach to Interpretation of a Chest X-Ray

(mainly in the ICU)
Dr Richard Raine
Departments of Medicine & Critical Care
UCT & Groote Schuur Hospital

This should be approached in a systematic way and there are some questions that need to be
answered:

 Why (do a CXR)?

– Medical condition
– Therapeutic/ monitoring devices
 What (to look for)?
– Systematic approach
– Patterns
 When (to do it)?
– Routine radiography
» Is it justified?
– Change in condition
» Medical
» Intervention

The general principles of X-ray interpretation apply to all X-rays - whether taken pre-operatively or in
the ICU.

There are a number of technical considerations before any interpretation occurs:

 Identification
Is it the right patient and date?
 Position
– Side
– Rotation
– Angle
 Penetration
 Depth of inspiration
 Associated devices obscuring structures

After this, a systematic review of the X-ray is undertaken, not jumping straight to the obvious
abnormalities:

 Bones
 Soft tissues
 Vascular structures
 Heart
 Pleura
 Lung fields

There are some regions that often hide abnormalities and careful looking into the film can reveal
surprises so always check:

 Airways + oesophagus
 Behind heart
 Costophrenic angles
 Mediastinum
 Hilar regions
 Apices
 Approach to CXR interpretation
Dr R Raine

Apart from X-rays taken as part of pre-operative evaluation, a clinician’s request for an X-ray is usually
prompted by one of the following questions:

 Why sudden onset of distress?

– Pneumothorax, atelectasis, oedema, embolism
 Why fall in PaO2?
– Fluid, infiltrate, atelectasis, pneumothorax, effusion
 Change in airway pressures?
– Barotrauma, collapse, plugging
 Source of fever?
– Infiltrate, collapse, atelectasis, effusion
 Changes caused by intubation
– Expansion, barotrauma, aspiration, resolution
 Changes caused by extubation
– Fluid, aspiration, atelectasis

Lung segments as seen on PA and lateral CXR

X-rays in the ICU are often prompted by invasive procedures and the need to check for position
or complications:

Where is the device?

 ETT
– 4-5 cm from carina (at level of aortic knuckle)
– Cuff < width trachea
 Central venous catheter
– Within thorax, outside RA
– No pneumo- or hydrothorax
 Nasogastric tube
– In stomach or post-pyloric
 Chest drain
– Tip in area to be drained
– Side holes in pleural cavity
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 Approach to CXR interpretation
Dr R Raine

Apart from X-rays taken to answer the questions above, the value of daily routine chest X-rays in ICU
patients is controversial:

 Does routine daily radiography

– Save or waste money?

– Detect sufficient clinically inapparent problems to justify expense and radiation exposure?

Routine CXR in medical ICU1

 221 routine CXR reviewed

– 72 had significant changes
» 44 important
» 18 prompted management changes
 Management change
– Reduced LOS 2.1 days
 Estimated savings per routine CXR
– $98

 “Policy of obtaining routine CXR is effective and results in net savings”

Efficacy of daily routine CXR in intubated MV patients2

 Prospective review
– 74 patients, 538 CXR
– 354 no change
– 163 minor findings (40% clinically suspected)
 13 patients had CXR with major finding

 “While a large percentage will not disclose new findings, routine daily studies have a substantial
impact on the management of intubated ventilated patients”

Overall – probably depends upon ICU population and ease of obtaining urgent X-rays. Ill patients with
ARDS or other major respiratory difficulties merit daily radiography. Routine post-operative patients or
long-term ventilated patients in stable condition do not need routine radiography and X-rays should
only be requested if specific question as above needs to be addressed.

References
1. Brainsky A, Fletcher RH, Glick HA, et al. Routine portable chest radiographs in the medical intensive care unit: Effects and
costs. Critical Care Medicine 1997;25(5):801.
2. Hall JB, White SR, Karrison T. Efficacy of daily routine chest radiographs in intubated, mechanically ventilated patients.
Crit Care Med 1991;19(5):689-93.

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 Approach to CXR interpretation
Dr R Raine

Notes

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