Introduction
Rapid interpretation of chest x-rays by intensive care physicians and xsurgeons is essential when treating critically ill patients You should be able to recognize the common normal and pathological appearances of portable chest x-rays in the postoperative or medically xill patient as well as common complications of mechanical lines and their correct positioning

Routine chest films are obtained in the radiology department in a posteroanterior (PA) direction to minimize magnification of the heart The optimal ICU chest x-ray is obtained in the (AP) view at a target-tofilm distance of 72 inches with the patient in the upright position at maximum inspiration. Alternatively a distance of 40 inches is used in the supine patient. Due to the decreased mobility of patients in the ICU. . chest films are often taken while the patient is supine.

and the degree of inspiration . supine positioning.The appearance of the chest film is affected by the AP positioning.

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PA AP .

     Have a structured method! Be consistent with that method Don¶t take short cuts LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!) PRACTICE«PRACTICE« PRACTICE .

SHADOW .

Identification! Correct patient ƒ Correct date and time ƒ Correct examination ƒ Š Š Are old films available? DO THIS EVERYTIME ± It buys you time and is vitally important. .

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Š Š Š Projection ± PA or AP Position ± Upright or Supine (Supine folks are sick) Inspiratory effort ƒ 9-10 posterior ribs thoracic intervertebral disc space just visible medial clavicle heads equidistant to spinous process Š Penetration ƒ Š Positioning/rotation ƒ .

Maximum x-ray xTransmission (least dense tissue) Maximum x±ray x± Absorption (densest tissue) .

1 3 5 9 10 .

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11 Note bilateral flattening of the diaphragms and significant hyperinflation as demonstrated by visualization of 11 posterior ribs. .

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where the air will accumulate first. . This is the key sign of a pneumothorax as this is the highest point in the supine patient.An inferior anteromedial pneumothorax may be evidenced by delineation of the heart border and a lucent cardiophrenic sulcus.

The anteromedial and subpulmonary locations are the initial areas of air collection in the supine patient. Subpulmonic pneumothorax occurs when air accumulates between the base of the lung and the diaphragm. An apical pneumothorax in a supine patient is a sign that a large volume of air is present. intrapleural air rises anteriorly and medially. Anterolateral air may increase the radiolucency at the costophrenic sulcus. Other signs of subpulmonic pneumothorax include a hyperlucent upper quadrant with visualization of the superior surface of the diaphragm and visualization of the inferior vena cava. . often making the diagnosis of pneumothorax difficult. This is called the deep sulcus sign.In the supine patient.

Bilateral pleural effusions in a supine patient. This film demonstrates fluid in the posterior basilar space without loss of normal bronchial markings.

A large pleural effusion has wrapped around the lateral and apical lung surfaces

Even an effusion this size may be difficult to detect in a supine film .This PA chest film of an erect patient shows a large pleural effusion on the right.

Pleural fluid (arrows) layers out on this left lateral decubitis film .

The pneumoperitoneum outlines the inferior border of the diaphram. diaphram. This facilitates identification of the large subpulmonary plueral effusion .This is a sitting AP film of a patient who underwent abdominal surgery resulting in pneumoperitoneum (arrow).

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Supine radiograph: Sharp diaphragmatic and mediastinal outline .

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Three mechanisms lead to pulmonary edema. over hydration. These are: 1. Diminished oncotic pressure 3. It is the most common cause of decreased oxygenation in the ICU patient. Increased hydrostatic gradient 2. or from endothelial injury as in the patient with ARDS. The radiographic manifestations of cardiogenic edema (much more common) are shon on the next several pages . Poor cardiac function will cause nonincreased hydrostatic pressures in the pulmonary capillary bed resulting in cardiogenic pulmonary edema. or from diminished oncotic pressure in the liver failure patient. Non-cardiogenic pulmonary edema can result Nonfrom volume overload due to renal failure. Increased capillary permeability due to endothelial injury Any one or more often a combination of these mechanisms will cause fluid to enter the alveolar space.Pulmonary edema occurs when fluid traverses capillary membranes and enters the alveolar space. The causes of pulmonary edema are broadly catogorized as cardiac versus non-cardiac.

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This is a patient with pulmonary edema with typical bilateral "batwing" increased pulmonary vasculature .

This chest film demonstrates cephalization of the pulmonary vessels .

. Notice the Kerley's B lines in the closeup view (right).congestive heart failure resulting in interstitial edema (left).

Air bronchograms are visible ( normally invisible) in he right upper lobe.Haziness of the pulmonary hila are due to vessel enlargment in a patient with CHF. .

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Chest Xray PA view on admission shows sharply marginated biconvex opacity in the right interlobar fissure .

5 Vasular phase Cephalization: Vessels in upper chest is more prominent as a manifestation of pulmonary venous hypertension. Cardiothoraccic rartio >0. .Cardiac width is larger than half trans-thoracic diameter.

Hilar fullness with haziness: Enlarge pulmonary veins with perivascular fluid collection leads to full hazy hilum .

Interstitial phase Kerley lines: 2-3 cm long lines in bases perpendicular to pleural surface. Due to increased lymphatic flow and fluid in interstitium .

air bronchograms and soft coalescing densities .Alveolar phase Basal congestion Pulmonary edema: Bilateral diffuse alveolar findings with butterfly distribution.

Pleural effusions .

Rapid changes in CXR .

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In ARDS the heart is normal in size and there are no pleural effusions. . cases. While cardiogenic pulmonary edema typically begins centrally in the bilateral perihilar areas. while air bronchograms can be found in both. Clinical setting and the wedge pressure are necessary in some cases. ARDS usually causes more uniform opacification. Pleural effusions are not typical of ARDS but often present in CHF. Kerley B lines are common in CHF but not in ARDS.

The progression of this patients pulmonary disease is consistent with ARDS .

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abrupt changes in intrathoracic pressure (vomiting. exercise. In pneumopericardium. and parturition). asthma. and smoking crack cocaine. traumatic tracheobronchial rupture. air can be present underneath the heart. coughing.Causes of pneumomediastinum include. surgery (post-op complication). ruptured esophagus. but does not enter the neck . Pneumomediastinum should be distinguished from pneumopericardium and pneumothorax. barotrauma.

Air density within the pericardium (arrows) after aspiration of a large pericardial effusion .

A lucent stripe along the inferior border of the cardiac silhouette which crosses the midline is also diagnostic for pneumopericardium. pneumopericardium. .

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.Right mainstem bronchus intubation (arrow) leading to left lower lobe collapse (arrow heads).

This patient had a large right pleural effusion (left) which had been evacuated 12 hours later (right) by a pigtail thoracostomy tube .

This chest tube failed to remove the pleural effusion due to anterior placement .

Central venous catheter tip (small arrow) at junction of left subclavian vein and superior vena cava (arrow).

Intracardiac placement of a central venous catheter (arrow). The tip (small arrow) is within the right ventricle..

.Close up view of chest x-ray showing catheter tip in the external jugular vein. xEach catheter should be followed to its tip so that an abnormality like this one on the edge of the film is not missed.

Single lead pacer with tip in the right ventricle.) .the tip should be at the apex with no sharp angulations throughout its length tip should be imbedded within the cardiac trabeculae( it appears 3 to 4 mm beneath the epicardial fat stripe.

Š Š Š Š Š Š Š Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB Š Š Š Š Š Š Š Lung cancer Chest pain (MI?) Hypertension Screening Pneumonia COPD Asthma .

heart) in sequence Left to Right then« Top to Bottom Random free search Recognition of abnormal first requires knowledge of normal. lungs.Š Š Š Š Compare symmetry Review organs (bones. . Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.

        Is heart enlarged or normal? Signs of heart failure and fluid overload? Does patient have pneumonia or collapsed lung? Is there evidence of emphysema? Are there findings of an aortic aneurysm? Is there fluid in the sac that surrounds the lung? Is there free air under the diaphragm? Is there a tumor in the lung that could represent cancer? .

large arteries. thyroid gland & abdomen What does air under diaphragm signify? What is best position for this diagnosis? . lungs. pleural space. axilla. mediastinum. ribs & diaphragm. heart. Also evaluate neck.Š Š Systematically evaluate chest wall.

ƒ 99% of the lung is air. . water & bone density on chest x-ray Lung fields appear dark because of air.Š Š You can recognize air.

interstitial space.Š Š Š The pulmonary vasculature. . Most disease states replace air with a pathological process which usually is a liquid density and appears white. constitutes 1% of the lung Gives a lacy lung pattern.

Š Supine position ƒ ƒ ƒ Decreases lung volume. increased heart size Basilar infiltrates & interstitial spaces accentuated Increases venous return to the heart Enlarges normal structures Changes air-fluid levels Lung structures & diaphragm blurred Basilar infiltrates & interstitial spaces accentuated Increased heart size Š Semi-upright position ƒ ƒ Š Š Failure to hold breath ƒ ƒ ƒ Expiration film .

10% of all x-ray interpretations have errors What is wrong with this lung tissue??? Nothing!! But the clavicle is fractured! Especially if there are multiple problems. don·t focus on the most obvious abnormality! .

Left side Comparison film ƒ Š TECHNIQUE ƒ Complete exam? All views Entire anatomical area included? ƒ Projection Is the film AP or PA? The width of heart & mediastinum larger on AP film ƒ Position .Š IDENTIFICATION Correct patient ƒ Correct date & time ƒ Correct examination Right vs.

cont.  Penetration Over-penetrated dark films can obscure subtle pathologies Under-penetrated white films may given impression of diffuse increased density Inspiration  Normal.Š TECHNIQUE. inspiratory CXR shows 9.5 ribs.  Less inspiration appears diffusely denser  Diaphragms elevated causing heart & mediastinum to appear enlarged .5-10. cont. erect. ƒ  TECHNIQUE.

Start with "less significant" Tendency to stop looking as soon as find pathology Identify atelectasis behind heart shadow! Don·t notice tip of ET tube is in right main stem bronchus.     Order of exam is important. causing the atelectasis! .

mediastinal widening. density of lung fields . aortic tortuosity.  Rotation  Determined by distance between spinous process & medial clavicle  Affects heart size & shape. TECHNIQUE. cont.



INTERPRETATION 

Extraneous material  Contrast  Lines, tubes, clips  All properly located? 

INTERPRETATION 

Bones  Fracture, dislocation  Mineralization 

Soft tissues
Asymmetry  Calcifications  

Lung fields
Asymmetry  Consolidation  Nodules, lesions  

Diaphragms & Below
Free air  Dilated bowel  Abnormal position  

Heart
Size & shape  Cardiothoracic ratio 



INTERPRETATION  

INTERPRETATION 

Mediastinum  Width  Masses  Contour

Pulmonary vascularity  Taper at periphery  Narrow toward upper lobes with erect film  Asymmetry 

Hila
Asymmetry  Vessel aneurysm  Trachea & carina  

Interstitial markings
Very fine  If indistinct, prominent suspect edema, fibrosis 

Alveolar space filled with inflammatory exudate
WBC, bacteria, plasma, and debris
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alveolar edema .5 Š    Large hila with indistinct markings Fluid in interlobar fissures Pleural effusions.Increased heart size: cardiothoracic ratio >0.

Š Š Š Š Congestion Interstitial and alveolar edema Collapsed or distended alveoli Bilateral .

Š Š Š Granulomatous Inflammation Bilateral & symmetrical hilar & mediastinal LAD Generalized fibrosis .

Š Š Š Š No ventilation to lobe beyond the obstruction Trapped air absorbed by pulmonary circulation Segmental/lobar density Compensatory hyperinflation of normal lungs. .

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