Intensive Care Nursing/Chest X-Ray Interpretation

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A chest radiograph with the angle parts of the ribs and some other landmarks labeled.
There are many methods of structuring chest x-ray (CXR) interpretation from formal to mnemonics. The daily routine CXR in ICU is changing to a rationale approached intervention to prevent unnecessary exposure.


Some approaches:

  • DRSABCDE
    •   Details, Rotation/Inspiration/Picture/Exposure, Soft tissue and bones, Airway and mediastinum, Breathing, Circulation, Diaphragm, Extras (lines, drains, ETT) 
  • ABCDEF
    • Airways, Breast shadows, Bones, Cardiac silhoutte, Costophrenic angles, Diaphragm, Edges, Extrathoracic tissues, Fields (lung)
  • Airway, Breathing, Circulation
  • Inside Out
    • Heart, mediastinum, hilar region, lungs, thoracic wall, Abdomen then tissues and lines/tubes/drains
  • Water, Air and Bone approach
  • 'Old School' Systematic
    • Name, date, view, exposure, rotation, soft tissues, trachea, lung fields, inspiration, lung volume intercostal spaces, bony thorax/ribs, diaphragm,  heart mediastinum, hilar region, angles, liver, gastric, lines/tubes/drains


X-Ray Densities

  • Bone= white
  • Tissue= grey
  • Gas (Air)= black e.g. trachea or stomach


Key Learning Points (no matter which approach you take):

  1. Difference between posterioranterior (PA) vs anteriorposterior (AP) view
  2. Basic anatomy seen on the CXR
  3. Inspiration
  4. Signs of COAD
  5. Develop a consistent approach (one that will stand up during night shift at 04:30 on a Sunday morning!)


1. AP View

  • AP views are commonly performed for critically ill patient using portable x ray machines.
  • AP- the beam passes through the chest from front to back
  • Posterior ribs are most apparent (closer to the film). Anterior ribs should still be seen on a quality film

2. Anatomy

  • AP view may provide an enlarged image of the heart and mediastinum
  • Heart size should be less than 50% of the thoracic cavity
  • Supine position causes different fluid shifts compared to normal upright position

3. Inspiration

  • Review image (1. PA View) above and count the number of ribs above the diaphragm. On inspiration there should be 10 posterior ribs and may be possible to see 6 anterior ribs.
  • Look for current or old fractures (try 'invert' setting on reviewing your x-ray)

4. Signs of Chronic Obstructive Airways Disease (COAD)

  • Widened intercostal spaces occur in COAD due to increase in lung volume and hyperinflation.
  • Caution: Pneumothorax and pleural effusion may also be causative factors.

5. X-Ray Interpretation as part of daily practice and try different methods until one sticks.

Costal cartilages animation


References

Siela, D. (2008). Chest radiograph evaluation and interpretation. AACN Advanced Critical Care, 19(4), 444-473. http://bmhlibrary.info/18981746.pdf

University of Virginia: Introduction To Chest Radiology. http://www.med-ed.virginia.edu/courses/rad/cxr/

Sparshot, A. (2014) Life in the fastlane. http://lifeinthefastlane.com/drsabcde-of-cxr-interpretation/


ICUnurses (discuss • contribs) 16:26, 3 September 2014 (UTC)

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