1) Documentation
2) Technical factors-adequacy, AP/PA, supine/erect:
-Assess rotation-look at Google docs picture
-Assess inspiration-The diaphragm should be intersected by the 5th to 7th anterior ribs in the mid-clavicular line. Less is a sign of incomplete inspiration.
-Assess penetration-the left hemidiaphragm should be visible to the edge of the spine.
**Pro tip-if PA or AP film has shown pathology on the right side, then a right lateral view should be requested (Default is left lateral view).
For assessment of lung apices, get a lordotic view of the chest x-ray.
3) Extra objects such as lines, NG tube, etc.
**NG tube placement- The tube tip should be below the level of the diaphragm and ideally should be at least 10cm beyond the gastro-oesophageal junction.
This tube is only just in the stomach and so was advanced and the position rechecked prior to using it for feeding.
The tip of a naso-gastric tube should also lie on the left. If it crosses the midline it has entered the duodenum.
**Pro tip-if PA or AP film has shown pathology on the right side, then a right lateral view should be requested (Default is left lateral view).
4) Mneumonic:ABCDE; Apices-Pneumothorax (Diagnosing pneumothorax requires an expiration film, look for asymmetry in the apices and edge of the lungs and paucity of the markings); Bones/soft tissues-Fractures/density; Cardiac shadow-Consolidation/mass; Diaphragm-Pneumoperitoneum; Edge of the image-Unexpected findings.
https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_06
Chest x-ray interpretations:
Air-least dense-lungs- black
Heart-gray
Bones-white
Soft tissue (heart) and pleural fluid (water) have the same density on X-rays.
Pulmonary vessel branches not visible 1 cm from the pleura. In CHF, upper vessels are just as visible as lower vessels.
You cannot determine the spatial location on the PA film alone.
Central mass and tracheal shift-think mediastinum
Air bronchograms-think lungs
Rib destruction-think chest wall
Silhouette sign-think lungs
For collapse, look at the lateral CXR.
Left upper lobe collapse-diffuse veil-like opacification of the left hemithorax. You can see volume loss by the elevated left hemidiaphragm.
For white-out of the lung-check position of the mediastinum, pleural effusion-shift of the mediastinum away from effusion, collapse-shift of the mediastinum to the side of the collapse.
Ideal position of the ETT tube—5 cm above carina
Correct position of a NG tube is below the diaphragm and Dobhoff tube can be identified by metallic endpoint (correct position-region of the antrum of the stomach, or in the duodenum).
