Anatomy of the Chest X-ray
Before we dig into an approach for reading chest x-rays, it’s important to know all the things that we’ll looking at. There are typically two views you’ll be looking at PA and lateral. The PA or posterior to anterior shoots a beam from a standing patient’s back through to their front, where the x-ray plate collects it. The lateral shoots the beam through the standing patient’s size through to the other side where the x-ray plate collects it.
For those of you in the M3 CRASH course, here are some useful resources:
I really appreciate the DRS ABCDE approach from Life In The Fastlane, a modification of what I was taught many years ago (ABCDE).
|Details||Are you looking at the right patient? |
Are you looking at the right date?
|RIPE Image||Make sure that the quality of the picture is good. |
Rotation: look at the clavicular heads
Inspiration: did they take a deep enough breath? can you see at least 9-10 posterior ribs?
Position: can you see both costo-phrenic angles on the x-ray? Is the picture capturing everything.
Exposure: can you barely see the intra vertebral disk space in the spine especially down toward the bottom?
|Soft Tissue and Bones||Look for any lesions in the bones. |
Look at the vessels (like the aorta).
Look at the soft tissues, is there any air (black)?
|Airways and Mediastinum||The carina and trachea should be in the midline. And the mediastinum should be less than 8 cm in width.|
|Breathing||Look at the vascularity. They should start to disappear at the periphery, but you can usually still see a few. If it’s all black, consider a pneumothorax.|
Look for infiltrates and fluids in the fissures and the costophrenic angles.
|Circulation||Look at the heart, ⅔ will be on the left side. |
The cardiothroacic ratio should be about half the distance of the thorax.
Heart should have a non-boot shape and be distinct.
|Diaphragm||Right hemidiaphragm is usually higher than the left|
There should be no air underneath but you will see the gastric bubble on the left side.
|Extras||Various tubes have radio-opaque strips in them. |
Common things you will see include an NG tube, chest tube, pacemaker, endotracheal tube and cardiac monitor wires on top of the chest.