1. CHEST X-RAYS
SWATI VARA

2. Contents How X-rays work Radiation Indications DR. ABCDEFGHI
Common conditions
References

3. How do X-rays work? X-rays are electromagnetic waves
Bone, fat, muscles and tumours absorb X-rays at different levels
Dense structures = white e.g. bone
Air filled = black e.g. lungs
Fluid = shades of grey

4. Radiation
A single chest x-ray exposes the patient to about mSv – equivalent to three days of natural background radiation
A mammogram exposes a woman to 0.4 mSv – equivalent to ~7 weeks of natural background radiation
Benefit of detecting breast cancer outweighs the risk of problems from radiation exposure
A CT scan of the abdomen and pelvis exposes a person to about 10 mSv; this goes up to 20 mSv if the test is done twice (once with and once without contrast) – equivalent to 3 years and 7 years natural background radiation respectively
CXR -
Mammogram -
CT -

5. Indications for a CXR Difficulty breathing Persistent Cough
Suspected infection
Chest injury
Chest pain
Signs of suspected lung cancer/lung disease
Suspected heart failure
CONTRAINDICATIONS
Pregnancy – take more of the radiation dose

6. IRMER RCR Ionising radiation medical exposure regulation
Before requesting an X-ray, must comply with IRMER regulations
RCR
Royal college radiologists have guidelines on requesting X-rays

7. First and foremost… IDENTIFY THE PATIENT FILM TYPE NAME, D.O.B, M/F
Date and time
Type of film - AP or PA

8. 2) Technical assessment
RIPE
R= Rotation
Find the spinous processes and medial end of the clavicles
I= Inspiration
X-ray taken during inspiration
Sign of full inspiration = diaphragm is at level of 6th rib anteriorly
P= Posture/picture
Posture = Patient should be standing so that gas rises and fluid sinks
Picture = Vertebrae should be visible through the heart
E= Exposure
If OVER-EXPOSED – structures will look dark and difficult to see the lung markings
If UNDER-EXPOSED – structures will look pale and hard to see soft tissue

9. A=Airways: Tracheal deviation? Look for the carina
B=Bones and soft tissues:
Ribs – 7 in midclavicular line, 8/9 posteriorly
Fractures, dislocations?
Change in density – if white= bone metastases, if dark= osteoporosis
Lymph nodes, swellings?
C=Cardiac
Normal site and size – no more than 50% cardiothoracic ratio
Borders – Right atrium, Left atrium and ventricle
Vessels – calcification?

10. D=Diaphragm E= Effusions & edges
Normal level: R. side slightly higher than left
Appearance: smooth and dome shaped
Angles: cardiophrenic and costophrenic
E= Effusions & edges
Lung apices and bases
Behind the heart
Under the diaphragm
Pericardial effusion/pleural effusion

11. F= Fields G= Gases Divide into zones Upper = above 2nd rib
Middle = between ribs 2-4
Lower = 4th rib to diaphragm
Any asymmetry?
G= Gases
Gas under L. hemidiaphragm – normal
Gas under R. hemidiaphragm
Pneumoperitoneum
Bowel herniation through ruptured diaphragm

12. H = Hilum and mediastinum
L. hilum higher by ~ 2cm
Normal hilum levels T6-T7
Changes in density and size?
Mediastinum – Hodgkins lymphoma – mediastinal mass
I= Instruments
Pacemakers
Metal work
Chest drains
CVP lines
NG tube
ECG electrodes

13. Common conditions Pericardial effusion Pneumothorax Pleural effusion
Pneumonia
Pulmonary fibrosis
Lung tumour

14. Pneumothorax Abnormal collection of air/gas in pleural space Causes
Lung collapses so the edges are visible
Causes
Spontaneous – e.g tall males, Marfan syndrome
Secondary to chronic lung disease – e.g. asthma, COPD
Iatrogenic – central line insertion, lung biopsy, mechanical ventilation
Infections – pneumonia
Trauma
TENSION PNEUMOTHORAX – requires immediate treatment!!

15. Pleural effusion A collection of fluid in the pleural space Causes:
Exudates (high protein) e.g. infection and malignancy
Transudates (low protein) –e.g. cardiac, renal and hepatic failure, pancreatitis
Empyema
Can be a sign of underlying disease so investigate this!
Meniscus appearance and blunting of costophrenic angle

16. Pericardial effusion Abnormal fluid present in pericardial space
Causes:
Trauma
Inflammation
Malignancy
Autoimmune conditions
Can lead to cardiac tamponade
Water bottle shaped heart

17. Pneumonia Symptoms: Signs: Dyspnoea Productive cough Haemoptysis Fever
Pleuritic chest pain
Signs:
Local consolidation – coarse crackles, bronchial breathing and increased vocal resonance

18. References
Au-Yong I, Au-Yong A, Broderick N. On-call x-rays made easy. Edinburgh: Churchill Livingstone/Elsevier; 2010.
Kumar PJ, Clark ML. Clinical medicine. 5th ed. Edinburgh: Saunders; 2002.
Longmore JM. Oxford Handbook of clinical medicine. 9th ed. Oxford: Oxford University Press; 2014.
NHS. Radiation. 29/01/2015; Available at:  Accessed 09/23, 2015.