[Music] hello everyone I'm Olivia from geeky Medics today I'm going to take you through how to interpret a chest x-ray if you haven't already make sure you subscribe to the geeky Medics YouTube channel so you can be the first to know about our latest videos in this video I'll take you through a structured approach to interpreting any chest x-ray at the end of the the video there are several cases for you to put these skills into practice and test your understanding remember when interpreting any chest x-ray the clinical context is key to effective x-ray interpretation let's start by discussing the basic principles behind obtaining an x-ray an x-ray uses high energy electromagnetic radiation composed of photons to create two-dimensional images of threedimensional structures structures that are less dense are penetrated more easily by the photons and appear dark or black on film an example of a structure that has a low density are the lungs in contrast denser structures are much less easily penetrated and appear as a white color on film examples of these structures include bones and dense tumors such as metastases some structures for example soft tissues only allow some of the photons to pass through and will normally appear as Shades of Gray before interpreting a chest x-ray you should check the following details firstly confirm the name date of birth and Hospital number of the patient and check this matches the details on the X-ray check the date and time the X-ray was performed and finally check for any previous Imaging as this is useful for comparison as previously mentioned it's important to understand the clinical context as to why the chest x-ray is being performed for example does the patient have any symptoms such as shortness of breath or a cough knowing these details will assist with your overall interpretation and differential diagnosis the first step in our approach to interpreting a chest x-ray is to assess the quality of the image poor image quality can obscure important film findings and so ensuring the image quality is appropriate is essential a useful pneumonic to assist with this is ripe this pneumonic corresponds to R for rotation I for inspiration P for projection and E for exposure let's look at how to assess each of these in more detail if the patient is rotated it can become very difficult to appreciate any abnormal Anatomy or pathology when the patient is correctly positioned the vertebral bodies and spinous processes will be vertically aligned you must also assess the medal aspect of each clavicle which should be equidistant from the spinous processes when capturing an x-ray image patients are asked to inspire and hold their breath whilst the film is taken to ensure appropriate and accurate anatomical features of visualized to assess whether there was appropriate inspiration the following structures should be visualized firstly you should be able to identify at least five to six anterior ribs which can be distinguished from the posterior ribs as they appear to slope downwards next ensure you can visualize both lung Apes both costophrenic angles and the lateral rib edges the standard x-ray is usually a posterior anterior projection this refers to the X-ray beams passing post posteriorly through the patient before reaching the detector this contrasts with anterior posterior films where the X-ray beam is passed anteriorly through the patient an AP projection is often preferred when the patient is very unwell and unable to tolerate being mobilized look out for a mobile label on a film as this is likely to indicate an AP film alternatively any plain film which does not mention AP assume this was performed in a PA projection PA projection is the standard as this allows the most accurate assessment of the cardiac size and produces the highest quality image in contrast an AP film often gives a lower quality image avoid drawing any conclusions about the heart size when using an AP film as the heart size will appear exaggerated to summarize some factors to look for to distinguish a PA versus an AP film the first is the heart size as EA mentioned the cardiac size is usually exaggerated in an film additionally if a patient has not been asked to cross their arms over their chest when taking the film the edges of the scapula are often visible within the lung fields of an AP film finally e stands for exposure it's important for a film to be correctly exposed to allow for visualization of the pulmonary vessels lung fields and bony Anatomy Overexposed films appear darker whilst the bones and heart are easy to appreciate in an Overexposed film the lungs and Pulmonary vessels are difficult to visualize underexposed films appear more white and make visualization of the retrocardiac region and spinal Anatomy difficult as a general rule to check for appropriate exposure the left Hemi diaphragm should be visible to the spine and the vertebrae should be visible behind the heart now it's time to systematically interpret the Imaging and identify any findings to do this we use the ABCDE approach broadly this corresponds to Airway including inspection of the tracha Kina broni and hila structures breathing including inspection of the lungs and plura cardiac including inspection of the heart size and borders diaphragm including inspection of the hemid diaphragm and costophrenic angles and finally everything else which includes inspection of the medeia styal Contours bones soft tissues tubes valves pacemakers and having a final check of important areas to review remember when interpreting an x-ray the images are laterally inverted let's now look at each area in more depth the first area for inspection is the airway when assessing the airway the following structures should be examined the trachea Kina and broni and hiler structures the first thing to consider when inspecting the trachea is whether there are any signs of deviation broadly this can be broken down into true deviation and apparent deviation true deviation that is deviation caused by pathology can be the result of a large plural affusion a tension pneumothorax and lowbar collapse in the case of a large plural affusion and tension pum thorax the trachea will deviate away from the site of pathology in contrast with lowbar collapse the trachea will be pulled towards the side of the collapse in any case tral deviation suggests serious underlying pathology and should be immediately escalated apparent deviation is much less concerning as this is usually due to the rotation of the patient to confirm this refer back to the rip pneumonic to assess whether the medial aspect of the clavicles are equidistant from the spinus processes it's also worth noting that the trachea is normally located to the right of the aorta and so what may appear as a very mild deviation to the right is actually normal in this film we can see a large plural Fusion in the left middle Zone and lower Zone as a result of this the trachea which should be Central appears deviated to the right away from the affusion the Karina refers to the division of the trachea into the right and left main bronchus the right and left bronchi Supply Air to the lungs entering at the right and left hilum the right main broncus is wider and more vertical than the left because of this it's often the sight of an inhaled foreign body and should always be considered in pediatric patients Pres presenting with signs of acute respiratory distress the hiler of the lungs contain the pulmonary vessels and major broni pulmonary ligament and the lymph nodes which are normally not visible they are normally of a similar size and Symmetry and therefore asymmetry can be suggestive of pathology when assessing for enlargement it's important to note whether this is unilateral or bilateral symmetrical bilateral enlargement is often indicative of sarid dois and in these cases a lymph no biopsy will often be needed to confirm a diagnosis in this image here we can see that both the left and right lung hilum appear enlarged in these cases a lymph node biopsy will often be needed to confirm a diagnosis unilateral or asymmetrical enlargement should always raise the suspicion of malignancy and will usually require further investigations such as a bronchoscopy and tissue biopsy to assist with the diagnosis here we can see a PA film with the left and right highum highlighted the left highum is often up to 2 cm higher than the right this is a normal variant moving on to assessing the breathing the following should be examined the lungs and the plura when inspecting the lungs it's important to divide these up into three zones inspecting closely for any abnormalities and asymmetry as shown in this film we can divide the zones up into the upper Zone middle Zone and lower Zone there are many abnormalities that may be found within the lungs symmetrical changes in the lungs are often seen in pulmonary edema increased shadowing within the lung Fields may be indicative of consolidative changes or malignancies and finally the complete absence of lung markings with possible tral deviation may be indicative of a numo thorax in pulmonary edema there are some common signs that you may see on film this includes airspace opacification classically in a Batwing distribution curly bee lines plural affusions which may cause costophrenic angle blunting and fluid in the interlobular fishes looking more closely at the previously mentioned pathologies the first film shows pulmonary edema whilst all features aren't apparent there is widespread airspace opacification resulting in a hazy appearance of the lung Fields with fluid visible in the interlobular fishes common causes of pulmonary edema in include left heart failure mital regurgitation and fluid overload consolidation is a term used to describe the replacement of air in the alvioli by materials such as pus and blood in this image there is clear consolidation of the right upper lob borded inferiorly by the horizontal fure one of the most common causes of this is pneumonia however malignancy can also cause this presentation and so further investigations must be undertaken in this film there is an area of rounded consolidation in the left lobe with a clear Border in this example this is likely to indicate an underlying malignancy when considering a diagnosis of a puma thorax it's important to consider whether it has a primary or secondary cause the term primary pnea thorax is used when the patient has no history of respiratory disease such as seen in the left image here the right lung appears to have completely collapsed resulting in a dark right lung field when the patient has a known respiratory condition such as COPD that may have contributed to the collapse of the lung this is termed a secondary pneumothorax sometimes the collapse of the lung can lead to a deviation of the trachea which is pushed away from the side of the collapse lung this can be seen in the right image where the collapse of the left lung has resulted in the trachea being pushed to the right notice again the surrounding darkened lung Fields as a result of the lung collapse when this happens this is turned termed attention pneumothorax which requires immediate emergency decompression with a large B canular this should be inserted into the second intercostal space in the midclavicular line the plura refers to the membrane surrounding the lungs which is not usually visible in healthy individuals but can become visible when thickened one of the most common causes of plural thickening is a cancer called amoel which is usually preceded by a history of asbestos exposure the plura should extend to the thoracic wall and therefore a visible plural line should raise the suspicion of a numa thorax however it's not only air that can become trapped in the plural space a collection of fluid and Air in the plural space is known as a hydrothorax and a collection of blood is known as a hemothorax a collection of p is called an empa other findings that may be visualized when inspecting the plura include plural plaques which are often mistaken for malignancies these are normally secondary to asbestos exposure and don't use usually require any treatment moving on to assessing the heart the following two elements should be examined the cardiac size and the cardiac borders when assessing the size of the heart a cardiac size of greater than 50% of the thoracic window is abnormal as the cardiothoracic ratio should be less than 0.5 remember the cardiac size can only be accurately determined when using a PA film due to an AP film exaggerating the size of the heart there are many different causes of card omegal including valvular heart disease coronary artery disease pulmonary hypertension and congenital heart disease when measuring the size of the heart a horizontal line should first be drawn between the two widest points of the heart this measurement is then compared to a horizontal line drawn between the two widest points of the rib cage the left picture depicts a PA film of a normal chest x-ray the two horizontal lines represent the width of the heart and the width of the thoracic window when these are measured the cardiac size is less than 50% of the thoracic window and so this is normal the film on the right clearly shows a patient with cardio megali as the heart occupies a much larger area of the thoracic window in healthy individuals the borders of the heart should be clearly visible and well defined the right heart border is made up mostly by the right atrium loss of this border is usually due to right middle lobe consolidation often secondary to an infection the the left heart border is made up mostly by the left ventricle and a loss of this border is associated with lingular consolidation which is also often secondary to an infective cause moving on to assessing the diaphragm it's important to examine the following structures firstly the left and right Hemi diaphragm followed by the costophrenic angles in healthy individuals the right Hemi diaphragm often sits higher than the left due to the presence of the liver below the stomach is found under the left Hemi diaphragm and so visualization of a gastric bubble is often possible a key finding that cannot be missed and should be immediately escalated to a senia is a pneumoperitoneum which refers to the accumulation of air under the diaphragm resulting in the separation of the diaphragm from the liver this is often secondary to a bowel perforation looking more closely at this finding on film we can see here that the diaphragm appears to have peeled away from the liver with free gas accumulating under the diaphragm left untreated pumar carries a very poor prognosis and therefore prompt treatment often with an emergency laparotomy is required the costophrenic angles reflect the Dome shape of the Hemi diaphragm as it meets the lateral chest wall in healthy patients this is well defined with a clear angle the loss of this angle is termed costophrenic blunting which is often secondary to the accumulation of fluid consolidation or hyperinflation of the lungs which is often seen in chronic obstructive pulmonary disease this film is particularly Ed F to compare a normal costophrenic angle to a blunted one on the right although consolidation can be seen in the right upper lobe there is a clearly defined right costophrenic angle comparing this to the left the costophrenic angle is completely obscured possibly due to a left lower L pneumonia there is also a loss of the left cardiac border finally it's important to examine everything else which focuses on reviewing the media styal Contours including the atic knuckle and atic pulmonary window the bones and soft tissues tubes valves and pacemakers and final review areas let's focus first on examining the media stal Contours the two structures here that need to be scrutinized include the aortic knuckle and the aoro pulmonary window the aortic knuckle refers to the lateral edge of the distal aortic Arch which curves to form the descending thoracic aorta a loss of this may suggest an aortic aneurysm the aort pulmonary window refers to the space between the atic knuckle and the pulmonary vessels within the lung hilum this can be lost in medor stal lymphadenopathy which is often secondary to malignancy moving on to assessing the bones and soft tissues you should inspect the bones including the ribs and clavicles for any visible fractures litic or sclorotic lesions the presence of these may be suggestive of bony metastases the soft tissues should also be inspected for any abnormalities such as a hematoma being mindful of normal variants such as breast asymmetry there are many pieces of medical equipment you may see on the chest x-ray some of the most common pieces seen in exams include nasogastric tubes Central lines ECG leads artificial heart valves and Pacemakers in this film you can clearly see ECG leads that have been clipped onto the patient in this film you can see a pacemaker on the right hand side this is usually placed under Under the Skin and will often be connected to one two or three leads corresponding to an atrial and or ventricular electrode in this film we can see a correctly placed nasogastric tube for further information on assessing the placement check out our geeki Medics article there are a few final areas to check to avoid missing any pathology these include the lung Apes the retrocardiac region behind the diaphragm and Fin finally the lung peripheries the last thing you need to do after you've interpreted the chest x-ray is to document your findings to do this you'll need to ensure you include the patient details the date and time the chest x-ray was performed the indication and clinical context necessitating the X-ray the findings from the X-ray your overall impression your plan for managing the patient and finally your name grade signature professional registration number and contact or bleep number now we've worked through our a approach for interpreting chest xrays it's time to put our skills to the test and work through some case studies our first case study concerns a 71-year-old patient who has presented to A&E they are feeling feverish and complaining of a new productive cough pause this video to have a go at working through this x-ray before the answers are revealed starting with rotation the clavicles are difficult to visualize SI making it challenging to identify any rotation moving on to inspiration there are five to six anterior ribs that can be visualized alongside the lung apes and costophrenic angles looking at the projection the scapula do not appear visible and so this is likely to be a PA projection finally the left Hemi diaphragm is visible to the spine and the vertebrae are visible behind the heart suggesting adequate exposure moving on to assessing the airway the trachea is visible and does not appear to be deviated the Kina and broni appear normal as does the right lung highum the left highum is difficult to visualize looking at the lungs there is il defined opacification bilaterally particularly in both the right and left middle and upper zones the plura appear unremarkable looking at the heart the Contour of the heart is clearly visible and the Heart size appears slightly enlarged occupying greater than 50% of the cardio icic window the Hemi diaphrag are clearly visible with no costophrenic blunting and finally there doesn't appear to be any bony fractures soft tissue injuries or any medical paraphernalia putting the symptoms together of feeling feverish with a new productive cough it's likely that this patient is suffering from pneumonia and should be managed according to the curb 65 score moving on to our next case study an 18-year-old presents to Ane with shortness of breath after a severe motorcycle accident the the medial aspect of the clavicles are equidistant from the spin's processes and so there is no rotation there are over 5 to six anterior ribs visible so inspiration is adequate this is a PA projection as there are no visible scapula and heart size appears normal the Hemi diaphragm are clearly visible and the vertebrae visible behind the heart indicating adequate exposure assessing the airway the trachea is visible but deviated towards the right hand side with media stal shift the Corina is difficult to appreciate due to the displaced tra but the bronchi are clearly visible looking at the lungs on the right there are visible lung markings but loss of volume due to mediastinal shift on the left there is an absence of lung markings indicating a numa thorax or a collapse lung the collapse lung in conjunction with the medial shift indicates the presence of ATT tension Puma thorax the cardiac size is normal although shifted to the right the left heart border is less defined which likely reflects compression from the adjacent lung parenchima the right Hemi diaphragm is normal the left Hemi diaphragm is also normal although there is slight Distortion of the plural spaces looking at the bones and soft tissues there are no gross abnormalities visible metallic stickers appear to be visible which are likely used for the attachment of ECG leads putting the symptoms together with the findings of a collapse left lung with tril deviation it's likely this patient has attension pneumothorax secondary to trauma it's worth noting that in patients with clinical signs and a history in keeping with attention pnea thorax treatment should never be delayed in order to obtain x-ray Imaging clinical signs include tracheal deviation distended neck veins shortness of breath and absent breath sounds over the affected lung in these cases the diagnosis should be made clinically an urgent needle decompression should be performed by a senior Clinic well done you've made it to the end of this video tutorial hopefully you now feel more confident interpreting chest x-rays using a structured approach for further information on chest x-ray interpretation check out our guide on the geeky Medics website you can also practice interpreting x-rays using our osy station scenarios [Music]