Chest X-ray: Introduction and Approach

Summary

This video serves as an introduction to interpreting chest X-rays, emphasizing the importance of understanding normal anatomy and adopting a systematic approach to both frontal and lateral X-rays. Key takeaways include recognizing normal appearances and a step-by-step method for analyzing X-rays, from assessing lines and tubes to examining the heart, mediastinum, lungs, and pleura. The video also discusses radiation doses and the significance of identifying abnormalities, such as lung cancer, through regular practice and case review.

Takeaways

• 📚 **Learning Normal Anatomy**: The video emphasizes the importance of familiarizing oneself with what normal chest x-ray anatomy looks like.
• 🔍 **Solid Approach**: It introduces a systematic approach to analyzing both frontal and lateral chest x-rays, which is crucial for identifying common and critical findings.
• 🌐 **Simplicity Overwhelm**: The speaker advises to keep the approach simple, avoiding getting lost in a laundry list of details that can be overwhelming for beginners.
• ⚠️ **Technical Aspects**: A few technical aspects like patient rotation and film quality are mentioned, but the focus is on the basics rather than minor details.
• 📈 **Radiation Awareness**: The video discusses the radiation dose of chest x-rays, comparing it to background radiation to provide perspective.
• 📊 **Radiographic Densities**: It explains the basic radiographic densities (air, bone, fat, water, soft tissue) and how they appear on x-rays.
• 👀 **Visual Cues**: The script provides visual cues for identifying different anatomical structures and abnormalities on chest x-rays.
• 🔎 **Detailed Examination**: It outlines a detailed method for examining various parts of the chest x-ray, including the heart, mediastinum, lungs, pleura, and bones.
• 📖 **Practice Makes Perfect**: The video concludes by encouraging practice and experience as the best way to improve at interpreting chest x-rays.
• 🔍 **Case Studies**: The next video in the series will focus on applying the learned approach to illustrative cases to help viewers improve their skills.

Q & A

What are the two most important things to take away from the first video on chest x-rays?

The two most important things are learning normal anatomy and getting used to what normal looks like, and developing a solid approach to both frontal and lateral chest x-rays.

Why is it important to understand the radiation dose of a chest x-ray?

It is important to understand the radiation dose to know how much radiation a patient is exposed to and to be able to explain this to patients. A chest x-ray uses about 0.1 millisieverts of radiation, which is very low and comparable to about 10 days of background radiation.

What is the difference between a PA and an AP chest x-ray?

In a PA (posterior-anterior) view, the x-ray beams come from the posterior side of the patient to the anterior side, while in an AP (anterior-posterior) view, the x-rays come from the anterior side to the posterior side. The PA view generally provides a better quality image with more visible lung detail.

What does the cardiothoracic ratio represent on a PA chest x-ray?

The cardiothoracic ratio represents the ratio of the size of the heart to the size of the entire chest, measured horizontally from pleura to pleura. It is normally less than 0.5 on a PA film.

How can you tell if a patient has rotated during a chest x-ray?

You can tell if a patient is rotated by looking at the medial aspects of the clavicles in comparison to the spinous processes; the spinous processes should be roughly halfway between the medial aspects of the clavicles.

What is the normal appearance of the AP window on a chest x-ray?

The AP window, which is the space between the aorta and the pulmonary artery, should normally be concave. If it is convex or filled in, that is abnormal.

What is the significance of the retrosternal airspace on a lateral chest x-ray?

The retrosternal airspace should appear relatively dark on a lateral chest x-ray. If it is not, it can indicate pathologies such as an anterior mediastinal mass.

Why are lateral chest x-rays more sensitive to small pleural effusions than frontal chest x-rays?

Lateral chest x-rays are more sensitive to small pleural effusions because they allow for better visualization of the costophrenic angles, where fluids collect in cases of small effusions.

What are the five main things to look for in a simplified approach to a lateral chest x-ray?

The five main things to look for are the retrosternal airspace, the retro cardiac area, the spine sign, the hilar anatomy for lymphadenopathy, and the costophrenic angles for pleural effusions.

How can you determine if a patient has had a good enough inspiration on a chest x-ray?

You can determine if a patient has had a good enough inspiration by checking if at least six anterior ribs or ten posterior ribs are projecting over the lungs, indicating adequate inhalation.

Outlines

00:00

📘 Introduction to Chest X-Rays

This paragraph introduces the video as an educational resource for learning chest X-rays systematically. It emphasizes the importance of understanding normal anatomy and adopting a structured approach to interpreting both frontal and lateral chest X-rays. The speaker intends to simplify the learning process by focusing on the basics and avoiding overwhelming details. Technical aspects like patient positioning and the significance of the radiation dose used in X-rays are briefly mentioned, with a comparison to background radiation levels to highlight the safety of chest X-rays. The video also covers different types of chest X-ray views, with a focus on the PA view, which is commonly used for outpatients and mobile patients in emergency departments.

05:02

🔍 Understanding Radiographic Densities

The second paragraph delves into the concept of radiographic densities, explaining how different tissues appear on X-ray images based on their density. It outlines the four principal radiographic densities: air, soft tissue, fat, and bone. The paragraph uses the example of a normal chest X-ray to illustrate these densities, pointing out how the lungs appear dark due to air, while bones and dense tissues like the heart appear brighter. The speaker also discusses the importance of recognizing normal anatomical structures and the potential for abnormalities, such as pneumomediastinum, which can be identified by gas in the neck soft tissues. The focus is on developing a visual understanding of what constitutes a normal chest X-ray and what variations might indicate a medical issue.

10:03

👨‍⚕️ Approach to Reading Chest X-Rays

Paragraph three introduces a systematic approach to analyzing chest X-rays, starting with the lateral view and discussing the normal anatomy that should be familiar to radiologists. It highlights key structures such as the trachea, bronchi, pulmonary arteries, and cardiac borders. The speaker emphasizes the importance of recognizing normal patterns and being aware of potential signs of lymphadenopathy, such as a 'donut sign'. The paragraph also touches on other aspects of a normal lateral chest X-ray, including the retrosternal airspace, retro cardiac space, spine sign, costophrenic angles, and hemidiaphragm levels. The goal is to establish a foundation for identifying abnormalities by understanding what constitutes a normal chest X-ray in terms of both anatomy and radiographic presentation.

15:04

🔎 Detailed Examination of Chest X-Ray Components

This paragraph provides a detailed approach to examining the various components of a chest X-ray, starting with the frontal view. It outlines the steps to check for correctly positioned lines and tubes, assess the heart's borders and size, and look for abnormalities such as calcifications or gas. The mediastinum is also scrutinized for size, position, and any bright or dark areas that might indicate issues. The lungs are examined for asymmetry and abnormalities like consolidation, masses, and reticulation. The pleura is checked for pneumothoraces and pleural effusions, with special attention to the costophrenic angles. The abdomen is briefly examined for free gas under the diaphragm, and the bones and soft tissues are screened for any obvious issues. The speaker also mentions four common areas where abnormalities might be missed: the apices, hila, retro cardiac region, and retro diaphragmatic regions.

20:06

📝 Reviewing Chest X-Ray Quality and Pitfalls

The fifth paragraph discusses the importance of assessing the quality of a chest X-ray, including patient rotation, inspiration depth, and exposure levels. It provides tips on how to determine if a patient is rotated by comparing clavicles to spinous processes and how to judge the depth of inspiration by counting visible ribs. The speaker also explains how to identify overexposed and underexposed films and their appearances. The paragraph reinforces the need to be vigilant about potential blind spots and to develop a keen eye for detail when reading X-rays. It concludes with a brief mention of the upcoming video, which will focus on identifying abnormalities in chest X-rays.

25:07

👨‍🏫 Applying the Approach to a Real Case

In the final paragraph, the speaker applies the previously discussed approach to a real chest X-ray of a 60-year-old smoker. The analysis includes checking for lines and tubes, assessing the heart, mediastinum, lungs, pleura, and abdomen, and examining the bones and soft tissues. The speaker also reviews the checkpoints for common oversights. The paragraph concludes with the identification of a lung cancer in the X-ray, underscoring the importance of meticulous examination. The speaker encourages continued practice and familiarity with common pathologies to improve chest X-ray interpretation skills.

Keywords

💡Chest X-ray

A chest X-ray is a diagnostic imaging procedure that uses radiation to generate images of the chest, particularly the heart, lungs, and bones. In the video, chest X-rays are the primary focus, with an emphasis on learning to interpret normal and abnormal findings. The script mentions different views like PA (posterior to anterior) and AP (anterior to posterior), highlighting their importance in medical diagnosis.

💡Anatomy

Anatomy refers to the structure of the body and its parts. The video script stresses the importance of understanding normal anatomy when interpreting chest X-rays. It mentions various anatomical structures visible on X-rays, such as the trachea, bronchi, and heart borders, which are crucial for identifying abnormalities.

💡Radiation Dose

The radiation dose is the measure of ionizing radiation energy absorbed by the body during an X-ray. The script explains that chest X-rays use a very low dose of radiation, approximately 0.1 millisieverts, which is comparable to 10 days of background radiation. Understanding the radiation dose is important for patient safety and informed consent.

💡PA View

PA stands for 'posterior to anterior,' which is a common view in chest X-rays where the X-ray beam moves from the back through the body to the front. The script describes the PA view as the most common view for outpatients and mobile patients, noting that it provides a clearer image of the heart and lungs due to the positioning of the X-ray beams.

💡Lateral Chest X-ray

A lateral chest X-ray is a view taken with the patient's body positioned sideways, allowing a different perspective of the chest structures. The script mentions that lateral views are particularly useful for detecting smaller pleural effusions and are more sensitive to them than frontal views.

💡Radiographic Density

Radiographic density refers to how much an object or body part attenuates X-rays, which affects how dark or light it appears on the image. The script explains that less dense things like air in the lungs appear darker, while denser things like bones appear brighter. Understanding these densities is key to interpreting chest X-rays correctly.

💡Pneumomediastinum

Pneumomediastinum is a condition where air is present in the mediastinum, the area between the lungs. The script uses this term to illustrate the importance of recognizing abnormal gas locations on X-rays, which could indicate a serious condition like esophageal perforation.

💡Cardiothoracic Ratio

The cardiothoracic ratio is a measurement used in radiology to determine the size of the heart relative to the chest cavity. It is calculated on a PA chest X-ray by measuring the heart's width divided by the chest's width. The script mentions that a normal cardiothoracic ratio is less than 0.5, and it's an important tool for identifying heart enlargement.

💡Pleural Effusion

A pleural effusion refers to the abnormal accumulation of fluid in the pleural space, the area between the lung and the chest wall. The script describes how to identify pleural effusions on chest X-rays by looking for blunting of the costophrenic angles, which is a sign of fluid buildup.

💡Abdomen

Although the video's main focus is on chest X-rays, the abdomen is briefly mentioned in the context of looking for free air or gas under the diaphragm, which could indicate a bowel perforation. The script emphasizes the importance of not missing such signs, as they can be critical for patient diagnosis and treatment.

💡Approach

The term 'approach' in the script refers to a systematic method for analyzing chest X-rays. It includes steps like looking at lines and tubes, assessing the heart and mediastinum, examining the lungs and pleura, and checking the bones and soft tissues. The approach is designed to ensure that the radiologist does not miss any critical findings.

Highlights

Introduction to systematic approach for chest x-rays

Importance of learning normal anatomy in chest x-rays

Overview of the two most important takeaways from the video

Simplification of the approach to chest x-rays by focusing on basics

Technical aspects to consider while interpreting chest x-rays

Understanding radiation doses in chest x-rays

Comparison of radiation doses between chest x-rays and other imaging studies

Different chest x-ray views and their applications

Explanation of PA and AP views in chest x-rays

Importance of x-ray beam orientation in image interpretation

Basic radiographic densities and their appearance on x-rays

Identification of normal anatomy on chest x-rays

Approach to reading a frontal chest x-ray systematically

Importance of checking for lines, tubes, and their positions

How to assess the heart on a chest x-ray

Mediastinum assessment techniques on chest x-rays

Lung assessment for abnormalities on chest x-rays

Pleura assessment for effusions and pneumothoraces

Abdominal assessment on chest x-rays for free air

Bone and soft tissue assessment on chest x-rays

Checkpoints to avoid common mistakes in reading chest x-rays

Simplified approach to lateral chest x-rays

Practical example of reading a chest x-ray and identifying abnormalities

Conclusion and encouragement for practice to improve chest x-ray interpretation

Transcripts

this video is an introductory video

designed to give you a solid systematic

approach to chest x-rays in part 2 we're

gonna practice applying this approach by

looking at a few illustrative cases of

common things that you're gonna see and

things that you shouldn't miss the two

most important things to take away from

this first video are 1 learning normal

anatomy while really getting used to

what normal looks like and then to a

solid approach to both frontal and

lateral chest x-rays there are a few

things that we're gonna cover first

but the anatomy and the approach are the

main things that I want you to take away

from this video so let's get started

this is a chest x-ray when most

resources try to teach you an approach

the first thing that they tell you to do

is to look at a bunch of quality things

like patient name date a few technical

things about film quality I'm gonna skip

over most of this a lot of basic chest

x-ray resources give you a laundry list

of things to think about when you're

looking at chest x-rays and to be honest

it can be a little bit overwhelming at

first so let's keep it simple and focus

on the basics with that being said I'm

gonna mention a few technical things

that I actually do think are important

once you know the basic anatomy things

like how you can tell if the patient is

rotated but again for this video don't

get tied down with little details here

and there focus on the basic principles

and the big picture as you know chest

x-rays use x-rays a form of ionizing

radiation and it's probably important

that you know about how much radiation

that is and how to explain the radiation

dose to patients this bar graph shows

typical effective radiation doses for

different imaging studies in

millisieverts it's important to know

that the background radiation dose that

we are exposed to by just living on

earth from just background radiation

which is very low is about 3

millisieverts per year this helps us put

these doses into perspective a chest

x-ray uses about 0.1 millisieverts of

radiation a very small amount this is on

the order or about 10 days of background

radiation a body CT for comparison is on

the order of a few years of low-level

background radiation still a relatively

low dose for a single exam don't get too

bogged down with any of the numbers here

the key is that you know that yes chest

x-rays do use radiation but the dose is

very low and it's on the order of days

of background radiation there are a

number of different chest x-ray views

that you're commonly going to see

including PA when the x-rays come from

posterior to anterior through the body

ApS which are usually performed portably

is the opposite so the x-rays are coming

from anterior to posterior these can

either be done in a supine position with

the patient lying flat or upright if the

patient is sitting or standing we also

have lateral chest x-rays that we'll

show you and then other special views

like a lateral decubitus views where the

patient's on their side and we'll talk

about applications in the next video

the most common view that you're

probably going to order and probably

gonna see for outpatients and relatively

mobile patients in the emergency

department is a PA view and again that

means that the x-ray beams are going

from the posterior side of the patient

to the anterior side of the patient the

film is on the anterior aspect of the

patient and is exposed by beams that

make it through things that are closer

to the film are going to look smaller

and anything further away from the film

is going to look relatively magnified so

with that in mind we can see why the

orientation of the x-ray beams matter

here we have two films one is a P and

the other is PA the one on the left is

the AP view and the

on the right is the PA view the film is

usually labeled but you can usually tell

by just looking at the pictures things

closer to the film are going to look

smaller and sharper and things further

away from the film are going to look

relatively magnified on the PA view you

can see that the heart is smaller you

can see the anterior ribs which I've

outlined here are relatively sharper and

the overall quality of the film is

better on the PA film here as a result

of all of these things we're gonna see

more of the lungs on the PA film and

we're also gonna be able to pick up more

abnormalities the PA and lateral films

are the two standard chest x-rays that

you're gonna see most commonly in

practice for eMobile patients like

patients from the ICU who often get

films daily they are often taken

portably by the patient's bed in AP so

back to our chest x-ray we mentioned

that x-ray beams that make it through

the patient can be detected on the other

side and those that don't make it

through obviously cannot on an x-ray

areas that don't attenuate the x-rays as

much I II the x-rays that make it

through easily show up as darker this

means that in general less dense things

look darker like the lungs and more

dense things look brighter

we covered the basic radiographic

density's in the introduction to CT

video and abdominal x-ray video so we

won't belabor the point but it's

important to remember the main

radiographic density's remember on CT we

can quantify densities on a scale called

the Hounsfield unit scale this is also

covered in other videos like the

introduction to CT video in more detail

but for x-ray things are a little bit

more simple so don't worry about the

stuff for now in general we can simplify

this to four principal radiographic

densities we have air that is very low

density we have bone and metal that are

higher in density are going to show up

as brighter and then in between we

fat water and soft tissue remember fat

is less dense than water if we mix oil

and water oil floats because it's less

dense and it's gonna show up as slightly

darker than soft tissue and water and if

we look at a normal chest x-ray we can

immediately apply this basic knowledge

although these structures are

overlapping and any point on the image

or on the x-ray is a reflection of all

of the materials between the x-ray

source and the film at that particular

location you can still identify the

radiographic density's the lungs are

filled with air and show up as very dark

the bones are denser and show up

relatively brighter soft tissues are

slightly less dense and there are even a

few places on the x-ray where you just

see fat and are relatively low density

so for example you have subcutaneous

fatty tissue that you see part of here

that's darker than the soft tissues

adjacent you also see between the

musculature planes of fatty tissue here

that are relatively darker and again

this is a normal chest x-ray another

location where you commonly will see fat

normally is up here in the neck this is

important to know because when you have

pneumomediastinum or air in the

mediastinum it can track up into the

neck and gas in the neck soft tissues is

often a sign for pneumomediastinum for

inexperienced readers they might look at

the fat here and wonder if it's gas so

remember what this normally looks like

okay now that you understand the basic

densities let's go through the normal

anatomy and we're gonna go into order

here so number one here shows where the

trachea is on a normal plane film number

two the right mainstem bronchus number

three the left mainstem bronchus number

four is the left pulmonary artery number

five is the right upper lobe pulmonary

vein number six is the right inter low

bar artery

number seven is the right pulmonary vein

for number four to seven it's not as

important when you're starting out to be

able to distinguish them individually

instead just get used to what the normal

high-low look like and we'll talk about

that and show examples of it in a bit

number eight is the normal a or tech

arch number nine is the SVC number ten

is where the as igus arches or as a kiss

vein is number eleven is the right heart

border which is made of the right atrium

remember the right ventricle is an

anterior structure and number twelve is

the left heart border which is mainly

the left ventricle and a little bit of

left atrium I'll also draw your

attention to the space between the aorta

here or the air-duct notch and the

pulmonary artery here this here is

called the AP window for a for aorta P

for pulmonary artery this should be

concave this is convex or filled in

that's AB if this is convex or filled in

that's abnormal this is a labeled

lateral film and we're gonna go through

the anatomy here and shortly go through

an approach number one here is the

trachea number two is bronchus

intermedius number three is the left

upper lobe bronchus number four is the

right upper lobe bronchus number five is

the left pulmonary artery and number six

is the right pulmonary artery from one

to six the only important things I think

you need to know are you have a trachea

here you have Lucent circles which are

the upper lobe bronchi on both sides and

then anteriorly you have a density that

is the right pulmonary artery and

posterior superior lis you have the left

pulmonary artery density as well okay so

you're gonna see a lucency down the

middle a density anteriorly and a

density posterior superior Lee

you're gonna have a relative paucity of

densities in this inferior region here

and this is normal if you have densities

that are surrounding the entire bronchus

here that is often a sign of lymph

adenopathy called the doughnut sign so

get used to this normal pattern at the

Hilah lucency down the middle density

anterior to it is the right pulmonary

artery and density posterior superior

li7 is the pulmonary vein confluence h

is the aortic arch 9 is the SVC 10 or

the anterior heart border is the border

of the right ventricle 11 and 12 are the

posterior border of the heart here made

up of the eleven left atrium and twelve

part of the left ventricle I also want

to point out a few other things about a

normal lateral chest x-ray this lucency

posterior to the sternum here is called

the retrosternal airspace this should

usually be relatively dark this region

here behind the heart is called the

retro cardiac space you'll notice that

as you go down the spine and the spinal

elements are outlined here the lung gets

more and more Lucent this is called the

spine sign the lungs should get more

loosened as you go more inferiorly down

the spine on the lateral you have the

costophrenic angles here and this is

where fluids gonna collect when you have

small pleural effusions blunting of this

is the sign of pleural effusion the

lateral chest x-rays are much more

sensitive to smaller pleural effusions

than the frontal chest x-rays the right

and left hemidiaphragm ZAR marked off

here as well in telling which ones which

there are a few different ways you can

do that the one that I caught most

commonly uses that the right

hemidiaphragm you're gonna see extend

very clearly from posterior to anterior

where the left hemidiaphragm you often

lose it when it

touches the heart also the right

hemidiaphragm is usually higher than the

left and this can be confirmed in the

frontal okay now that we've gone through

the anatomy we're gonna go through a

basic approach to chest x-ray this is

something that's gonna be systemic and

something that you're gonna practice

over and over and over again and it's

gonna become second nature so let's

start with a frontal x-ray so this is a

PA film I generally start by looking for

lines and tubes and making sure that

they're appropriately positioned things

that you're commonly gonna see include

chest tubes mediastinal drains

endotracheal tubes in the trachea and

central lines we're gonna talk about

specific positioning of these tubes in

another video I then look at the heart

when I'm looking at the heart I start by

looking at the borders of the heart and

the size of the heart when I'm looking

at the size I'm looking for enlargement

radiologists commonly use a

cardiothoracic ratio on PD on PA films

namely the ratio of the size of the

heart in horizontal distance to the size

of the entire chest here from pleura to

pleura the cardiothoracic ratio is

normally less than 0.5 on a PA film I

then look at the position of the heart

this is a normal position seeing if it's

shifted one way or the other I then look

for anything that's very bright namely

calcifications or metal in the valves or

in the pericardium and then look for

anything that's very dark namely gas so

looking for gas around the heart in the

setting of pneumopericardium so to

review when I'm looking at the heart I'm

looking at borders size position thing

that's things that are very bright and

things that are very dark when I look at

the mediastinum I'm doing the exact same

thing I'm looking at the borders we see

a normal AP window here we see normal

contours the size the position looking

for a shift of the mediastinum anything

that's very bright like calcifications

metal foreign bodies etc anything that's

very dark namely pneumomediastinum when

we have pneumomediastinum ER

pneumopericardium what's the difference

well pneumo just means gas or air and if

it's pneumopericardium it's gas in the

pericardial sac that stays in the

pericardial sac and the reflection of

the pericardium ends at the base of the

great vessel so you're only gonna see

gas below that level and your mo

pericardium pneumomediastinum you have

gas throughout the mediastinum which

often two sex more superiorly in the

mediastinum and then up into the neck

commonly as well as a general point

whenever you see air anywhere where it's

not supposed to be you need to figure

out why it's there I like to break this

down simply by breaking it down into

three categories one air from outside

the body two air from inside the body

and three air from gas forming infection

in this setting of numa numa mediastinum

for example air can come from outside

the body for example if they had a

recent surgery or open procedure in line

placement or trauma it can come from

inside the patient for example from

esophageal perforation or it can come

from a gas forming infection which is

relatively rare so remember when you're

trying to figure out why there is gas in

an abnormal location think is it coming

from outside the patient

somewhere inside the patient or gas

forming infection I then look at the

lungs and I'm comparing both sides to

look for asymmetry normally it's

symmetric and then I look at each lung

more closely by zigzagging up the lungs

for more subtle abnormalities again

remember that there's lung behind the

diaphragm as well as behind the heart

here as well

what I'm looking for abnormalities in

the lung the main things you're looking

for include consolidation which are

going to look like fluffy brighter

opacities cloud like opacities or other

words that are used to describe

consolidation you're gonna look for

masses which are more rounded

abnormalities and you're also gonna look

for abnormal reticulation in other words

too many lines in order to pick up a

reticular abnormality it's good to know

what the normal vasculature looks like I

generally split the lungs into thirds we

have the medial third the middle third

and the peripheral third as you move out

peripherally you're gonna have less and

less markings as you can see from normal

vessels in the peripheral third you

should have next to no or no markings in

a normal situation if you see too many

lines here peripherally that's abnormal

once I've looked at the lungs I look at

the pleura so I follow the pleura around

in both lungs mainly looking for

pneumothoraces aka gas in the pleural

space and pleural effusions the most

sensitive locations in an upright film

are gonna be the costophrenic angles for

a pleural effusion you're gonna see

blunting of the costophrenic angle here

it's very sharp

remember lateral films are more

sensitive than frontal films for pleural

effusions and I'm also gonna look in an

upright patient for small pneumo

authorities at the apex of the lung you

can also look for pleural calcifications

I then look at the abdomen and you can

watch the abdominal x-ray video for more

details the main thing you don't want to

miss is free gas or free air under the

diaphragm

and a patient who hasn't recently had

surgery this is often seen with bowel

perforation which is something you don't

want to miss I then look at the bones

and soft tissues starting with the spine

looking at each of the particular bodies

I look at the ribs both the anterior

ribs and the posterior ribs

I generally screen

he's quickly looking screening the

clavicles the scapula here in any parts

of the shoulders we can see as well as

the soft tissue is taking a quick look

for any obvious gas or high-density

material once I've looked at all of

these things I have four checkpoints at

places where people commonly miss things

the first is the apices small

pneumothoraces and small masses are

often missed here two is the hila get

used to what these normal hila look like

I look at the retro cardiac region again

again a common place for Mis pathology

and then the retro diaphragmatic regions

of the lungs as a brief aside I did

mention that I would briefly touch on a

couple of quality things first to tell

if the patient is rotated I look at the

medial aspects of the clavicles in

comparison to the spinous processes here

the spinous processes should be more or

less halfway between the medial aspect

the clavicles in order to determine if

the patient had a good enough

inspiration we generally want to see six

anterior ribs or ten posterior ribs

projecting over the lungs so here we

have one two three four five six at

least anterior ribs and several

posterior ribs as well so this is a good

inspiration lastly when someone says a

film is overexposed it means that too

many x-rays got through and were

detected on the film so if a film is

overexposed it generally means that it

looks too dark and an underexposed film

usually looks brighter so it's the

opposite of what we usually think with

photography to review this approach

again we have lines and tubes we have

the heart remember borders size position

things that are too bright things that

are too dark mediastinum same thing

borders size position things that are

too bright namely classifications and

metal things that are too dark

looking for gas looking at the lungs

making sure to compare and not remember

the blot and not forget the blind spots

looking at the pleura looking at the

upper abdomen the bones and soft tissues

screening them and then looking for our

check points again the apices the hila

the retro cardiac region and the retro

diaphragmatic region

this is a normal lateral film there are

a lot of different things that you can

look at and we talked about the anatomy

and I'll briefly orient you again so

this is the spine here there's the

trachea here that you can see very well

you see lucency and you see the right

pulmonary artery here that's lighter

anteriorly and the left pulmonary artery

posterior superior lis remember there's

a relative paucity of density in this

inferior region here get used to what

that normal high-low looks like because

the lateral can be very helpful to

determine if there is true adenopathy

because beginners are usually a little

bit worse at looking at the lateral

films compared with the PA films I'm

gonna give you a very simplified

approach to the lateral chest x-ray

we're gonna look at five main things

that I'll mention a few others but if

you remember those five things you're

well ahead of the curve okay

I look at the retrosternal airspace

which should be loosened here it's

brighter that's up at the top because

the patient's arms are here but in

general this should be loosened and if

it's not I can indicate pathologies such

as most commonly an anterior mediastinum

mass I look at the retro cardiac area

which should be loosened here I then

look at the spine signs so I'm looking

at the spine itself but also looking at

the lungs over line so the lungs should

get more and more loosen as you move

more inferior lis oftentimes if you have

consolidation in either of the lower

lobes you're gonna see that that does

not happen and there is something here

that makes it look brighter I then look

at the hila and we talked about that

Anatomy again just now looking for

evidence of lymph adenopathy mainly and

then looking at the cost over neck

angles remember that the lateral film is

more sensitive for plural

fusions than the frontal film so again a

simplified lateral chest x-ray includes

looking at the retrosternal air space

the retro cardiac air space looking at

the spine sign and the spine itself

looking at the hilar anatomy and making

sure there's not lymph adenopathy and

looking at the costophrenic angles now

that we've gone through the normal

anatomy and you have a basic approach

you're getting to know what normal looks

like when you go through your approach

you're gonna need to pick up things that

are abnormal this is gonna come with

practice we're gonna go through an

example now in the next video is

exclusively dedicated to picking up

those abnormalities in my experience

when people first start reading x-rays

they're more often oversensitive but

calling things that are normal abnormal

but the more you practice and the more

you see the better and more confident

you're gonna get you're also gonna get

to know what the most common pathologies

look like so in the next video we're

gonna apply our approach to several

bread-and-butter

cases and things that you shouldn't miss

let's finish off this video by reading

this chest x-ray this is a 60 year old

smoker so I'm gonna start looking for

lines and tubes there's no lines or

tubes looking at the heart this is a

portable film but it's not unlocked it's

in normal position the borders are okay

I don't see anything bright I don't see

any gas the mediastinum size position

contours are okay ap window is normal

there is calcification in the aorta

suggestive or in keeping with calcified

a fish aquatic disease and then look at

the lungs comparing both sides and then

zigzagging up each of the lungs looking

for more subtle abnormalities I look at

the pleura

there's no pleural effusion or

pneumothoraces there's some scarring at

the apices here no pneumothorax no

pleural effusion look at the abdomen

nothing to comment on bones and soft

tissues look okay I then look at my

checkpoints so the apices the hila these

are normal Hilah the

retro cardiac region and the retro

diaphragmatic region okay for those of

you that were paying attention you'd

pick up on this abnormality here this

ended up being a lung cancer so it's

obviously very important that it was

picked up on this chest x-ray okay so

that's the end of this video the main

things I wanted you to take away are the

basic anatomy a basic approach to

frontal and lateral chest x-rays and

really getting used to what normal looks

like the best way to get better at chest

x-rays is to keep practicing and keep

looking at cases the next video as I

mentioned a couple times is going to

review several cases to help you

practice your chest x-ray skills