II. Protocol: Standard Views
- Standing (Upright Chest XRay)
- Posteroanterior (PA) Film
- Left Lateral XRay
- Request right lateral film if right-sided finding
- Normally more dark in the retrocardiac space and inferior spine approaching the diaphragm
- Increased white density ("spine sign") is seen in Pneumonia, aspiration, mass or Pleural Fluid
- Medjek (2015) Br J Radiol 88(1050): 20140378 +PMID:25827203 [PubMed]
- More sensitive than PA for abdominal free air
- Supine (Portable Chest XRay)
III. Protocol: Special Views
- Inspiration and Expiration Film Indications
- Pneumothorax accentuated on expiration
- Unilateral diaphragmatic paralysis
- Unilateral obstruction of major Bronchus
- Lordotic View Indications
- Posterior Apical Disease
- Middle Lobe disease
- Reverse Lordotic View Indications
- Anterior apical disease
- Oblique Film
- Peripheral small lesions
- Separated from overlying chest shadows
- Lesions poorly seen on lateral Chest XRay
- Rib Fractures (at axillary lines)
- Peripheral small lesions
- Lateral decubitus Film
- Detect small areas of air at uppermost pleural space
- Detect small areas of dependent Pleural Fluid
- Measure size and mobility of fluid collection
- Accessible with sampling needle (>1 cm size)
- Uncover Lung tissue obscured by Pleural Fluid
- Place side of interest up
- Mobility of mediastinal or pleural masses
- Assess mobility of solids and fluids within cavities
- Assist with maximizing inspiration of uppermost lung
- High Penetration Film with moving grid (Bucky Film)
- Obesity
- Dense pleural or pulmonary opacities
- Calcified lesions
- Lesions obscured by heart or diaphragms
- Air Bronchograms in densely infiltrated areas
- Intrathoracic Pressure Maneuvers
- Valsalva Maneuver: shrinks pulmonary vessels
- Muller Maneuver: distends pulmonary vessels
- Indications
- Distinguish blood vessel from Lymph Node
- Distinguish A-V malformation from solid lesion
- Barium Swallow
- Enlarged retro-mediastinal nodes
- Define Posterior intrathoracic mass
- Confirm ruptured diaphragm or Diaphragmatic Hernia
- Impaired Swallowing with aspiration
- Diagnostic Pneumothorax (instill air in pleural space)
- Distinguish peripheral Lung Mass from pleural lesion
- Define Mesothelioma
- Parenchymal disease extending towards chest wall
IV. Evaluation: Circumstances that decrease Chest XRay quality
- Semi-upright position (neither standing nor supine)
- May enlarge normal structures
- Changes air-fluid levels
- Lordosis or vertical axis rotation
- Widens heart and mediastinum
- Inadequate sustained inspiration
- Breathing film
- Lung structures and diaphragm blurred
- Expiration film
- Basilar infiltrates accentuated
- Interstitial structures accentuated
- Vessels
- Pleural Fluid
- Increased heart size
- Breathing film
- Supine Film
- Decreases Lung Volume
- Highlights infiltrates and interstitium
- Increases venous return to heart
- Distends azygous vein and pulmonary vein
- Diaphragm rises and intracardiac pressure increases
- Heart and mediastinal structures enlarge
- Fluid and air migrate
- Pleural Effusions disappear
- Small Pneumothorax disappears
- Air-Fluid levels (e.g. Lung Abscess) disappear
- Pneumothorax signs on supine film
- Deep Sulcus sign
- Costophrenic angle sharply outlined by air
- Diaphragm-mediastinal junction sharply outlined
- Hyperlucency superimposed over liver shadow
- Deep Sulcus sign
- Decreases Lung Volume
V. Images
- Azygous Vein
VI. Resources
VII. References
- Marini (1987) Respiratory Medicine, Williams & Wilkins
- Katz (1999) Clin Chest Med 20(3):549-62 [PubMed]