Chest X-ray Interpretation
A Clinicians Perspective
Jeff Wilson MD
OVERVIEW
Goal – to show how you can read chest x-ray
Technique – brief, for clinicians
Interpretation system – You should have one
Beyond the Chest X-ray
Lessons learned
Some highlights:
![Window_2020-07-08_12-45-13.png](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594230352824-8SXG6L3HPO8YO5E2RG4D/Window_2020-07-08_12-45-13.png?ssl=1)
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Airways you can are the trachea and the main-stem bronchus. Left main-stem comes out at sharper angle than the right. This is why people aspirate to the right lower lung and ET tubes are often placed in the right main-stem bronchus if advanced too far.
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Tracheal deviation away from pathology indicates positive pleural pressure shifting the trachea contralaterally. This may occur with large pleural effusion or tension pneumothorax
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Tracheal deviation towards pathology indicates negative pleural pressure that deviates the trachea towards pathology. This may occure from collapse, lug resection, or scarring of the lung or pleura.
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On inspiratory film, you should be able to count 9-10 ribs
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Smoothness or contour of the enlarge mediastinum may point you towards various pathology. See below the smooth contour in pulmonary hypertension in contrast to the irregular borders seen in sarcoidosis.
![Window_2020-07-08_12-52-57.png](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594230803768-90IY4QUDIKC4KYU1PR7R/Window_2020-07-08_12-52-57.png?ssl=1)
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Lateral films can give lots of added information and should be obtained when able. The mediastinum can be broken down into three compartments: anterior, middle, and posterior.
![Window_2020-07-08_12-54-50.png](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594230958600-VBJO6R5IH4B156LX94IR/Window_2020-07-08_12-54-50.png?ssl=1)
![Diaphragm is usually 1-2 cm higher on the right side. Upright chest films are sensitive to note free air under the diaphragm; seen in perforated viscus, abdominal surgery, peritoneal dialysis. This is still not a perfect test with roughly 70% sensit…](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594231181675-YQPAF9WA16FXQA19FK0W/Window_2020-07-08_12-58-24.png?ssl=1)
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Diaphragm is usually 1-2 cm higher on the right side.
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Upright chest films are sensitive to note free air under the diaphragm; seen in perforated viscus, abdominal surgery, peritoneal dialysis. This is still not a perfect test with roughly 70% sensitivity, just because you do not see it does not mean it is not there.
![Air sacs are all filled with something, have different density than the airways do. Normally do not see the airways out in the periphery.](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594232466637-JND2X1BCOOQ5XBWKM6YF/Window_2020-07-08_13-20-46.png?ssl=1)
Air sacs are all filled with something, have different density than the airways do. Normally do not see the airways out in the periphery.
![You can see fluid in the minor fissure on the right side. Blunting of costophrenic angles.](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594231699735-XU8BHI6XPKAJQP25ZK1N/Window_2020-07-08_13-05-27.png?ssl=1)
You can see fluid in the minor fissure on the right side. Blunting of costophrenic angles.
![There are plenty of times when a CT scan is needed. From personal clinical experience. Always start with a cheaper and easier to obtain chest x-ray and you will be amazed what you can find with clinical context.](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594231319839-PTJKPMUV8I0Y9R3FS7ZV/Window_2020-07-08_13-01-38.png?ssl=1)
There are plenty of times when a CT scan is needed. From personal clinical experience. Always start with a cheaper and easier to obtain chest x-ray and you will be amazed what you can find with clinical context.
![Window_2020-07-08_13-00-59.png](https://i0.wp.com/images.squarespace-cdn.com/content/v1/5ef0b0903a01b954bad39733/1594231279765-R2K1J24B3IDYLMVKZEI2/Window_2020-07-08_13-00-59.png?ssl=1)
Post by Roger D. Struble Jr. MD MPH