Assessment of Chest X-ray Images for Advanced Practice Providers

00:01 Before we take a look at our first image, I want to remind you that getting good at any skill requires practice, and for this particular skill, it requires practice, practice, practice.

00:13 Spend time. Practice looking at images and talking about them with experienced providers is really useful. Make sure to read any radiology reports you can get your hands on.

00:25 So I am here and you are here.

00:27 So let's get started. As we look through these images, we are going to make some assumptions.

00:34 First that for every image we have already checked for the patient identification to make sure it's correct.

00:41 The image quality is satisfactory, but rarely do we find it being perfect.

00:48 There is proper positioning so we know posterior versus anterior and so forth.

00:55 Here is an image of a normal x ray.

01:00 One of the first images we're going to take a look at is an adult chest.

01:05 First, let's look at what we would consider a normal chest x ray.

01:09 I want to use the mnemonic PIPER ABCDE.

01:14 This is a systematic approach to reviewing your x rays.

01:19 P stands for patient identification and patient Information.

01:23 And I want to remind you here history and physical exam is very important to correlate to your image. I stands for inspiration.

01:32 We want to make sure that this is a good film.

01:35 So we want to make sure we can see at least six anterior ribs and 8 to 10 posterior ribs.

01:42 Note that if the seventh rib should be under the diaphragm, it would mean that we have a hyperinflated lung.

01:50 So we might be looking at a patient with COPD.

01:54 P stands for penetration.

01:56 And you should be able to see the thoracic vertebrae.

02:00 E is for exposure. You want to make sure you can visualize all the lung zones.

02:06 And we refer to this as upper, middle and lower lobes.

02:11 R stands for rotation.

02:13 We want to look at the medial edges of the clavicle and make sure they are equal distance on both sides.

02:19 The way you would do this is to draw a line between the medial edges and see if down both sides this is equal distance.

02:28 A stands for airway. We're going to be looking at the trachea.

02:33 Sometimes you may have a shift in the trachea which we call a deviation.

02:38 So you want to follow the trachea down the midline to see if it bifurcates at the corona into the left and the right bronchus.

02:46 We do sometimes have abnormal deviation of the trachea away from the affected side.

02:53 We see this with pleural effusions, tension pneumothorax and large tumors.

02:59 Another trachea deviation would be toward the affected side.

03:04 We see this more with marked atelactasis.

03:07 Collapsed lung and fibrosis.

03:10 B stands for breathing.

03:12 Scan all lung zones. Normal is going to appear black.

03:17 However, white would mean a collapse.

03:20 This is going to be a uniform opacity.

03:23 And you may see tracheal deviation to the affected side.

03:27 However, this does not always occur.

03:30 If fusion is going to show uniform opacity.

03:34 And tracheal deviation pushed away from the affected side.

03:38 Whereas consolidation will appear localized with patchy opacities.

03:43 This is usually suggestive of infection such as pneumonia.

03:48 Dark is going to mean COPD.

03:51 This is hyperinflation.

03:53 This is a flat diaphragm stretched heart border.

03:56 Or you may have a pneumothorax which will show radiolucency shrunken lung markings.

04:04 You may also have lines which may be an indicator of fibrotic lung.

04:09 Diffuse reticular shadowing with tiny opacities noted as nodules.

04:14 Think of connective tissue disorders, drug induced causes, or idiopathic reasons.

04:22 Pulmonary edema may show up as diffuse pulmonary shadowing with cardiomegaly or pleural effusion. In the hilum area, you have pulmonary vessels and lymph nodes.

04:34 The left hilum is going to be higher than the right.

04:37 Abnormalities may include differentials such as sarcoidosis, tuberculosis, and lymphoma.

04:45 C is going to stand for circulation.

04:48 Review the heart silhouette.

04:50 Notice the aortic notch and the left and right borders.

04:54 So if the heart is less than half of the chest wall width, this is considered normal.

05:00 If it's greater than half the chest wall width, then this would be suggestive of Cardiomegaly.

05:06 D stands for diaphragm, the right superior to the left due to the liver placement. You also have the costophrenic angles.

05:15 You may see small blunting noted with pleural effusions and pneumothorax.

05:20 And you also want to know the gas bubble in the stomach.

05:25 E stands for everything else.

05:27 So this is going to be your soft tissue swelling, subcutaneous air, breast shadows, foreign bodies or poor images.

05:35 You also want to take note of the bones looking at the clavicle, the scapula, the humerus, the anterior and posterior ribs.

05:43 Looking for any fractures or dislocations.

05:47 And of course, you could have medical implants such as pacemakers.

05:50 Or if you're in the acute care setting, you may have things such as Ng tubes.

05:56 Now that you have a clear view of a normal chest view, let's take a look at what a pleural effusion looks like in an adult patient.

06:05 This one has some obvious quality issues in how it was taken.

06:10 You can see the patient is tilted.

06:12 However, this sometimes happens in practice.

06:15 Fluid accumulation in the pleural cavity is noted.

06:19 Multiple causes such as heart failure, kidney disease, inflammation, tumors, eye disease can cause this.

06:27 Your maximum expression means that there could be some partial blunting up to complete white lung, such as what we have in our image here today.

06:36 Adjacent atelectasis may be possible and tracheal deviation.

06:42 It also can be called mediastinal shift.

06:45 This would be to the unaffected side of the pleural effusion because pleural effusion push this away from the trachea.

06:54 You are likely to see pneumonia across the lifespan.

06:57 So knowing your anatomy and physiology, landmarks and age related pathophysiological changes are important when interpreting scans.

07:08 In this scan, we're seeing a classic pneumonia.

07:11 It's going to have confluent spot shadows, also called patchy opacities.

07:17 There may be focal and non-segmental involvement.

07:22 A really startling thing to see on a radiologic image is cancerous mass.

07:27 I have three images here to show you the scans and the defining characteristics of the different types of findings.

07:35 You will note on the cancer scans unilateral enlargement of the hiler shadow, blurred border of the hilum, streaks spread out from the tumor, and active likenesses due to bronchial stenosis.

07:49 Just a note here. This can be real difficult to give this news to a patient.

07:56 Unfortunately, you are likely to see patients with emphysema and chronic obstructive pulmonary disease as well.

08:03 Signs of this damaged condition on radiological images are going to be increased transparency, reduction of the density of the peripheral vascular pattern, diaphragm domes, flattened barrel thorax, enlarge retrosternal space, formulation of bullae, and the seventh anterior rib will be below the diaphragm as we discussed before.

08:32 Seeing a pneumothorax in practice can be really scary, but once you know what to look for, you will feel more confident.

08:41 Here are some keys you will see on a pneumothorax image: distance from the chest walL lung, increased transparency, missing vascular drawings, flattening of the diaphragmatic dome, mediastinum shift, which could also be tracheal deviation, pulling toward the affected side where the pneumothorax is located and small blunting at the costophrenic angle.