what's up future respiratory therapists hey let's talk about some chest x-rays let's look at normal and let's compare them to abnormal let's dive in [Music] all right so as i said we're going to be talking about chest x-ray interpretation let's look at a chest x-ray here all right so i'm going to tell you right now this is a normal chest x-ray you're going to want to take some notes here because i'm not going to reprogram you you've probably all been taught ways to interpret chest x-rays from your professors at your school i'm not trying to reprogram that i'm just going to point out a few things here of value as we look at this x-ray first thing is this when i look at this x-ray the first thing i notice is that i can see the vertebral column behind the heart that tells me that my exposure is good it's not excessively visible it's not glowing it's not it's not highlighted but it's also not invisible so i can see it that's an exposure that's step one when you're looking at an x-ray is the exposure of good quality the next element of quality that we need to ask ourselves is is our patient rotated is are they not rotated we want our patients to be straight because any rotation will impair our ability to find and identify potential problems to do so we look at the end of the clavicle heads here and we see that they both meet equally and symmetrical at the cervical vertebrae that's a good thing the other thing we can look at is the point of the costing angle to the vertebral column and when we look at that we see that these spaces are essentially equal that tells us we're not rotating now the last thing we're going to look for in terms of quality of a chest x-ray is is this an inspiratory film did did we take this film during a full inspiration because if we did it then we know that it's an expiratory film and an expiratory film is going to be an image of empty lungs and that's obviously going to appear more dense more radio opaque and and blur our vision in interpreting the chest x-ray so what we do is we count our ribs and we see one two three four five six seven eight nine and ten we've got ten ribs visible within the lung fields on this chest x-ray that means this is an inspiratory film and that's a good thing the number you're looking for or is nine plus ribs in the lung fields and what that tells you is this the patient took in a deep breath the diaphragm dropped and the x-ray image is going to capture nine plus ribs you want to remember that those are the three elements of a quality chest x-ray exposure inspiration and rotation those are all good on this chest x-ray now without spending too much time here because this could easily be an hour long video i don't want it to be that let me just point out a couple of other things that i notice here first of all i see two lung fields that appear well aerated and i see lung markings that go out to the periphery so this is good i see lung markings over here that extend outward this is important because i don't see areas of radiolucency that might indicate a pneumothorax so this is good the second thing i noticed is my diaphragms down here are nice and rounded they're very dome shaped and i've got these nice pointy claustrophobic angles this is all good stuff okay so these are this is normal when i look at the size of the heart i can trace it here and i see that our heart border is within normal size well what's within normal size less than 50 percent of the total width of the thoracic cavity this right here is less than 50 of the total width of the thoracic cavity so all of this equates to a normal chest x-ray and yes there's other things the right hemi-diaphragm is slightly higher than the left for sure because the liver sits right there 100 so we can spend time talking about what makes a normal chest x-ray i want to show you an abnormal one and see if you can figure out what it is here we go this is an abnormal chest x-ray the question is what's the diagnosis based off of the chest x-ray now i know this isn't really fair because i didn't tell you to take notes on the normal you can probably remember it but i really want you to compare this abnormal film to the normal one i showed you so i'm gonna make it super easy for you i'm gonna put them side by side so here's what i want you to do pause this video right now tell me this x-ray on the right what do you notice that makes it abnormal compared to normal okay now let's look at these and let's compare these remember this is normal this is abnormal what's the first thing we notice oh these lungs look long and skinny versus these lungs that look healthy and well aerated two different images here okay so the first thing is to notice the hyperinflation and the hyperlucency that is happening on the right side of your screen on this x-ray over here now get rid of those the second thing we're going to notice here is that let's look at the spacing between the ribs this is what we call intercostal spacing when we look over here look at the spacing between these ribs it is very increased compared to the spacing here this is key because what we know is that with diseases that cause air trapping we see that the the lungs become hyperinflated and the ribs get spread further apart this is called an increased intercostal spacing this is a finding that we see associated with these chest x-rays right now now the next thing we notice is that look at the diaphragms remember we talked about the diaphragms over here how they were very nice and pointy look at the diaphragms here they do have a curvature to them but they are not dome-shaped you see how these come up and then back down this is a dome-shaped diaphragm but these don't do that these come up and kind of flatten out this is called a flattened diaphragm or a depressed diaphragm two different words here same thing it's indication of the same thing the lungs are hyperinflated they are pushing the diaphragm down that flattens the diaphragm and it results in flattened or depressed imaging when looking at a chest x-ray now because these diaphragms are flattened what we notice here is when we look at the heart we see this kind of kind of bicycle seat appearance it looks very elongated looks very long and skinny i'll take that away so you can look at it again look how long and narrow that heart looks compared to over here when we come over here and draw an image around the heart here so i'll draw just draw it again here so you can kind of see it you can see the difference in the heart or the cardiac silhouette this is much more elongated than this one those are the key differences in these x-rays now the question is is what is the diagnosis of this x-ray over here on your right the answer is you are looking at an infrasomatic chest x-ray right here now think about emphysema for just a second remember it is a obstructive lung disease which means destruction to the alveoli and the distal airways leads to excessive air trapping which leads to chronic hyperinflation which leads to the lungs getting bigger which means they move downward they depress on the diaphragm and it leads to all of these findings we're gonna see right here here's what they are the four key findings associated with emphysema first things first increased elongated lung volumes and increased radiolucency more black because there's more air in the lungs the second point increased intercostal spacing remember we talked about this look at the spacing between the ribs they are increased why because when the lungs become hyperinflated the ribs do this and they get forced outward and they spread apart so you have increased intercostal spacing you have flattened or depressed diaphragms you see where the diaphragms are no longer dome-shaped they are more flattened associated with chronic hyperinflation due to the air trapping the diaphragms get pushed down and it flattens them on appearance and then the last one is that elongated heart that we talked about right here looks like a bicycle seat these are all classic signs of emphysema you want to be able to pick up on them and and recognize them and go boom my patient has a history here and this all supports it all right so that is the infosomatic chest x-ray abnormal compared to a normal chest x-ray if you would like access to my cheat sheet based off of radiographic interpretations send me an email i will send you this cheat sheet so that you have it it's not going to have images but it's going to have words that help you associate these findings with these ab normalities now if you want to reach out to me you want to contact me you want to follow me in any way which i would love for you to do so hit me up on instagram respray coach tick tock respiratory coach twitter at coach rrt you can always send me a gmail respiratory coach at gmail.com this is where you need to request your chest x-ray cheat sheet guideline provided by myself if you are interested send me a text to 817-968-7035 this will sign you up to be a part of my texting platform where i simply send out occasional inspirational educational motivational content tell me your birthday i'll tell you happy birthday it's not a group text you will not be overly bugged i just want to be staying in touch and promoting and enhancing and motivating the respiratory therapy community do me a favor right now if you found any value in this video share it amongst different platforms comment like and subscribe to the channel if you haven't already done so we need your support here this is the fastest growing respiratory therapy community on all of the interwebs and i want you to be a part of it okay so remember this when you want to join we have a saying here average is easy don't be it