II. Approach: General

  1. Compare findings from side to side
  2. Determine film adeqaucy
    1. Alignment
      1. Note if patient is lordotic or kyphotic
    2. Rotation
      1. Spinous processes should be midway between clavicle heads
    3. Penetration
      1. Thoracic Spine should be visible through the heart
    4. Inspiratory film
      1. Diaphragm should be at or below the 10th rib on an adequate inspiratory film

III. Approach: Systematic Review

  1. Soft tissues
    1. Evaluate for subcutaneous air, swelling
  2. Bones
    1. Evaluate clavicles, Vertebrae and ribs for Trauma, lesions
  3. Cardiovascular Structures and mediastinum
    1. Hilum is higher on the left
    2. Evaluate aorta, trachea and hilar masses
    3. Evaluate heart for cardiomegaly
  4. Diaphragm
    1. Hemidiaphragm is lower on the left (may be variable in older patients)
    2. Right hemidiaphragm sharply outlined
    3. Left hemidiaphragm sharply outlined lateral to cardiac apex
    4. Evaluate infradiaphragmatic areas for free air
  5. Pleural spaces
    1. Evaluate for Pneumothorax, Pleural Effusion or Hemothorax
  6. Lung parenchyma
    1. Evaluate for infiltrates, Nodules
    2. Localize any lesion on both lateral and AP films
  7. Lines and Tubes
    1. Endotracheal Tube should be above carina (Usually overlies 5-6th Vertebrae)
    2. Trace intravenous lines along entire course
    3. Trace Nasogastric Tubes along entire course

IV. Approach: Findings

  1. Widened Mediastinum (>6-8cm)
    1. Aortic Dissection
  2. Pneumomediastinum
    1. Esophageal Rupture
  3. Silhouette Sign
    1. Infiltrate, fluid or air
  4. Air Bronchogram
    1. Lung consolidation
    2. Atelectasis
  5. Lobar Collapse (Atelectasis)
    1. Bronchial obstruction
  6. Lung Nodule
  7. Hilar Node Enlargement
  8. Straight Pulmonary Lines
  9. Pulmonary Infiltrates (distinguish between the 2 patterns)
    1. Interstitial Infiltrate (pulmonary vessels are visible with fuzzy margins, "Trees in fog")
    2. Alveolar Infiltrate (obscured pulmonary vessels)
  10. Pulmonary Edema
  11. Pleural Space

V. References

  1. Marini (1987) Respiratory Medicine, Williams & Wilkins

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