II. Approach: General
- Compare findings from side to side
- Determine film adeqaucy
- Alignment
- Note if patient is lordotic or kyphotic
- Rotation
- Spinous processes should be midway between clavicle heads
- Penetration
- Thoracic Spine should be visible through the heart
- Inspiratory film
- Diaphragm should be at or below the 10th rib on an adequate inspiratory film
- Alignment
III. Approach: Systematic Review
- Soft tissues
- Evaluate for subcutaneous air, swelling
- Bones
-
Cardiovascular Structures and mediastinum
- Hilum is higher on the left
- Evaluate aorta, trachea and hilar masses
- Evaluate heart for cardiomegaly
- Diaphragm
- Hemidiaphragm is lower on the left (may be variable in older patients)
- Right hemidiaphragm sharply outlined
- Left hemidiaphragm sharply outlined lateral to cardiac apex
- Evaluate infradiaphragmatic areas for free air
- Pleural spaces
- Evaluate for Pneumothorax, Pleural Effusion or Hemothorax
-
Lung parenchyma
- Evaluate for infiltrates, Nodules
- Localize any lesion on both lateral and AP films
- Lines and Tubes
- Endotracheal Tube should be above carina (Usually overlies 5-6th Vertebrae)
- Trace intravenous lines along entire course
- Trace Nasogastric Tubes along entire course
IV. Approach: Findings
- Widened Mediastinum (>6-8cm)
- Pneumomediastinum
-
Silhouette Sign
- Infiltrate, fluid or air
-
Air Bronchogram
- Lung consolidation
- Atelectasis
-
Lobar Collapse (Atelectasis)
- Bronchial obstruction
- Lung Nodule
- Hilar Node Enlargement
- Straight Pulmonary Lines
-
Pulmonary Infiltrates (distinguish between the 2 patterns)
- Interstitial Infiltrate (pulmonary vessels are visible with fuzzy margins, "Trees in fog")
- Alveolar Infiltrate (obscured pulmonary vessels)
- Pulmonary Edema
- Pleural Space
V. References
- Marini (1987) Respiratory Medicine, Williams & Wilkins