Introduction
Patient: name, DOB, hospital number, age, sex
Previous films for comparison
Radiograph detail
Date
Type (anteroposterior or posteroanterior; erect or supine)
Adequacy (RIPE)
R otation: medial borders of clavicles should be equidistant from nearest spinous process
I nspiration: at least 5-6 anterior ribs should be visible above diaphragm
P icture area: lung apices and costodiaphragmatic recesses should be visible; scapulae should be out of the way
E xposure: vertebral bodies should be just visible through the lower part of the cardiac shadow (overexposure = too black; underexposure = too white)
Interpretation (ABCDE)
Briefly mention obvious abnormalities first
Airway
Tracheal deviation (away from a pneumothorax or large effusion; towards a collapse )
Breathing
Lung fields (compare in thirds) β see notes on analysing lung field abnormalities below
Air (pneumothorax )
Fluid (effusion )
Consolidation (e.g. due to infection )
Lobar collapse
Lesions (e.g. malignancy, abscesses )
Pleura: look for pleural thickening (pleura not normally visible), and at lung borders for a pneumothorax
Hilar region: look for lymphadenopathy, masses (malignancy ), calcification, bilateral enlargement (sarcoidosis )
Circulation
Heart size: should be <50% thorax diameter on PA film (cardiomegaly suggests heart failure )
Heart position (may be displaced if there is lobar collapse or a large effusion )
Heart shape and borders (right border = right atrium; left border = left ventricle)
Great vessels: the aortic knuckle should be visible
Mediastinal width: should be <8cm on PA film (widening may indicate aortic dissection )
Diaphragm
Position and shape: right usually slightly higher due to liver (flat in COPD )
Costophrenic angles (blunting indicates effusion )
Air below diaphragm (abdominal viscus perforation )
Extra things
Bones and joints: trace around ribs for fractures if clinically suspicious
Soft tissues: look for swelling, subcutaneous air, masses, calcification of aorta
A patient presents to ED with chest pain and this trace. What would you do?
Interpretation management
Covered in OSCE Stations
To complete
βTo complete my analysis, I would examine previous films and ascertain the clinical history.β
Summarise and suggest differentials
Analysing lung field abnormalities
Background knowledge
Four densities to note on a chest radiograph:
Wherever a density changes, a silhouette will be seen
Consolidated/unaffected lobes may be identified by determining if consolidation is contiguous with:
Diaphragm = lower lobes
Cardiac border = middle lobe (right)/lingula (left)
Describing the abnormality
Density
Bone/soft tissue/fat/air density
Uniform (i.e. same shade throughout) or non-uniform (i.e. blotchy)
Radiograph position
Left or right
Zone
Upper (above 2nd anterior rib)
Mid (between 2nd and 4th anterior rib)
Lower (lower than 4th anterior rib)
Anatomical position (lung parenchyma/pleural space)
Size
Borders
For example: βThere is a non-uniform soft tissue density in the left lower zone. Anatomically, this is in the lower lobe because the left hemi-diaphragm is not visible.β
Diagnosing the abnormality
Consolidation
Non-uniform soft tissue density (i.e. blotchy white)
βAir bronchogramβ = visible bronchioles penetrating the consolidated areas (hence, it cannot be collapsed)
Collapse
Uniform soft tissue density (i.e. pure white)
Affected lobe is smaller
Other structures move towards it into empty space (e.g. heart, other lung lobes, trachea)
Effusion
Uniform soft tissue density (i.e. pure white)
Meniscus sign
Fluid at lung bases if erect or along posterior thorax if supine
Pneumothorax
Normal lung lobes, but they are partially deflated
Uniform air density (usually at top if erect)
Seen better on an expiration film
Look very carefully around pleura!
Test your knowledge
What are the chest radiographic changes seen in COPD?
Oops! This section is restricted to members. Click here to signup!
What are the chest radiographic changes seen in heart failure?
Oops! This section is restricted to members. Click here to signup!
Interpret the following radiographs
This patient presented with breathlessness. Click the image to enlarge.
Systematically interpret the above radiograph
Oops! This section is restricted to members. Click here to signup!
This patient presented with weight loss and night sweats. Click the image to enlarge.
Systematically interpret the above radiograph
Oops! This section is restricted to members. Click here to signup!
How would you further investigate this patient?
Oops! This section is restricted to members. Click here to signup!
Pleural fluid is aspirated. How would you determine if a pleural effusion is due to an exudate or transudate? List some causes of each.
Oops! This section is restricted to members. Click here to signup!
Boost your productivity with an OSCEstop membership
π All OSCE Lerning
π OSCE stations
π Qbank
π‘ Conditions
Try some OSCE stations with chest radiographs in
COPD data interpretation
HAP data interpretation
Diabetic ketoacidosis
Find lots more stations here