Chest X-ray interpretation: Not just black and white | CE Article | NursingCenter
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Guide to thoracic imaging
Multiple selection allowed. No activity. This module is virtually identical to the module you are currently completing within the research project. Please click the button to continue your practice within the research project. Kerley B lines can also be seen on a CXR in a patient with pulmonary edema. See Kerley B lines. These are thin, horizontal lines of fluid, no more than 2 cm long, which can be seen in the lung periphery near the costrophrenic angles and lateral wall. Pneumonia can best be found on a CXR when a silhouette sign is revealed.
A silhouette sign occurs when two structures of equal density are next to each other but the border of neither structure can be seen.
See Silhouette sign. The silhouette sign is sometimes used to distinguish anterior from posterior structures on a CXR. The silhouette sign can help the practitioner determine which lung lobe is affected. When attempting to decide which lobe the infiltrate occupies, look for the silhouette sign. When the silhouette sign is seen in the anterior structures, the pneumonia is in the left or right upper lobe of the lung.
When the right lower lobe border is lost but the right hemidiaphragm is visible, a right middle lobe pneumonia is present. Atelectasis causes the alveoli to lose their volume and collapse and may lead to pneumonia. It can be prevented or alleviated by having the patient deep breathe and cough, ambulate, and perform incentive spirometry. To distinguish between consolidation in pneumonia and consolidation atelectasis, assess lung volume. If lung volume is reduced, the consolidation indicates atelectasis. If not, it may be due to an infiltrate. Left lower lobe atelectasis, which is very common after surgery, often appears on a CXR as an increase in density.
Close inspection of a consolidation may reveal an air bronchogram sign. This is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates. This will cause the airway to appear black against a white background. Intrinsic obstruction can cause atelectasis and is usually a result of secretions or foreign bodies in the airway.
Extrinsic airway obstruction is usually caused by compression, likely from a tumor. The most common lobe to become atelectatic is the right middle lobe, due to the lung being surrounded by lymph node tissue and the slope and length of the bronchial tube.
This is likely caused by cellular damage due to an inflammatory response or events such as trauma. This tends to happen within a hour time frame after injury to the alveoli-capillary membrane. Pneumothorax is caused by air in the pleural space, which can at times be more difficult to find on a CXR than fluid, especially if only a very small amount of air is present. Look for an increase in radiolucency dark images on the CXR and a decrease in lung vascular markings.
If this is the case, a thin white line would represent the displaced visceral pleura. Examine the apex of each lung in detail, as air will always rise while the patient is in an erect position. Tension Pneumothorax occurs when air leaks from the lung into the pleural space and can't escape, increasing intrapleural pressure. This causes the affected lung to collapse and shifts the mediastinum toward the unaffected side. Usually, mediastinal landmarks such as the trachea, aortic notch, and the right heart border are clearly seen displaced to the unaffected side.
COPD includes emphysema and chronic bronchitis. This type of lung disease causes airway obstruction, air trapping, and increased residual volume. You may also notice that the lungs look very black because of vascular destruction. The black appearance of the lung is called hyperlucency. Hyperinflation of the lungs also cause the lungs to appear larger, darker, and longer.
These bullae are densely black areas of the lung, usually round and surrounded by fine curvilinear shadows. Lung nodules are discrete areas of whiteness within the lung field. They're usually less than 3 cm in diameter and can be singular or found in multiples. If a lesion is larger than 3 cm, it's called a mass. The main worry about finding these lesions is the possibility of carcinoma. Inspect the lesions' edges. A speculated, irregular, or lobulated edge may indicate a malignancy, especially if you see more than one.
If the nodule appears dense and white and appears to be the same density as bone, it's most likely a calcification. Tuberculosis TB is seen as patchy, nodular infiltrates on a CXR located primarily on the upper lobe lung fields. Cavitation of the lung, or a darker gray center over a white lesion on the CXR, is also seen with TB. Perforation of the bowel is seen as free air under the diaphragm on a CXR.
Air should never appear in the peritoneal cavity outside the gastrointestinal tract. If air is found in this location, it's called pneumoperitoneum, which is a medical emergency. It can be caused by a ruptured appendix, perforated ulcer, or ruptured diverticulum. Nurses can use CXRs as an additional tool to confirm physical assessment findings. Acutely ill patients can have a multitude of nonspecific signs and symptoms. Nurses with a basic understanding of CXR interpretation can sharpen their assessment skills, promote patient safety, and optimize care.
Tarrac SE. A systematic approach to chest x-ray interpretation in the perianesthesia unit. J Perianesth Nurs. Siela D. Introduction to Chest Radiology. The content on or accessible through Physiopedia is for informational purposes only.
Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Read more. Search Search. Toggle navigation p Physiopedia. Contents Editors Categories Share Cite. Contents loading Chest X-Rays. Jump to: navigation , search. Our Partners. The trachea should be central or slightly to the right. If it is deviated, check whether it is due to the patient's position or another pathological cause.
Assess the bones visible in the image from top to bottom.
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