How to read chest e-rays

 

working as an Intensiveness, ICU consultant  
is actually based on the request from all of  you guys, from my juniors from my colleagues  

and this is all about reading and interpreting  chest x-rays in a simplified manner and in this  

video I have discussed around 25 x-rays and that  too starting from the basics which you need to  

know. So do watch this video till the end to  become a chest x-ray expert. So let's begin

Before you start reading or interpreting the  x-ray, you need to know which is the right  

and the left side in this x-ray. This  is the right side and this one is the  

left side and this is usually marked on the  x-rays. A good way to remember is that you  

imagine that the patient is always facing towards  you, this is true for both PA and AP films now  

I will tell you the structures which are normally  seen on chest x-ray. I'll just mark and name the  

structures, will discuss in detail in the later  part of this video. So this is the trachea,  

this is the carina, right bronchus and this one  is left bronchus this is divided into right and  

the left bronchus then this is the lung field  this one is the clavicle then this is aortic  

knuckle this is the hilum over here is the heart  this one is a diaphragm the right hemidiaphragm  

these are the ribs and this one as you can see  below the left hemidiaphragm is a gastric bubble  

now this x-ray looks like a perfect x-ray right  and before moving further you need to check the  

patient detail this is very important  and it is always mentioned on the x-ray  

now the name is Chirag Madaan. Oh, I know this  guy okay okay that's me . So check the name  

the age of the patient the unique id number  and the date on which it is taken next is  

to assess the quality of the image it can be  remembered by mnemonic RIPE where R stands for  

rotation so as to see whether the film is rotated  or not the spinous processes should lie halfway  

between the medial ends of the clavicle  that means in between the middle ends of  
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the clavicle if the patient is rotated then  interpretation of the x-ray becomes difficult  
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firstly it may be difficult to know  if the trachea is deviated to one side  

by a disease process and it also becomes difficult  to comment actually uh upon the heart size  

and the changes in the lung density due  to asymmetry of the overlying soft tissue  

may be incorrectly interpreted as lung disease  so now let's see what happens to the heart size  

with respect to the rotation so this is a person  standing over
and this is a normal the rays are coming from  the back so this is most likely a pa film and  

if the patient is rotated towards the left let's  see the second second image. Second image shows  

patient is rotated towards the left so as you  can see the xray beams are going like this  

and heart size looks greater or  magnified or exaggerated whereas  

if you see the third image the patient is  rotated towards the right in this the true  

size of the heart may be underestimated.  Now next in RIPE is inspiration ideally  

chest x-ray should be done in inspiratory phase if  the x-ray taken during a good inspiratory effort  

diaphragm should be intersected by five to  six anterior ribs or eight to ten posterior  

ribs in the mid clavicular line. Less is a sign of  incomplete inspiration whereas if more than seven  

anterior ribs then it suggests hyper inflation  now let's count in this x-ray. So these are the  

posterior ribs whereas these one are anterior  one let's count the anterior ones this is first  

second and third so there are three anterior ribs  intersecting the diaphragm in mid clavicular area  

that means this is either expiratory film or poor  inspiratory effort also heart appears bigger and  

there seems to be consolidation on left base now  let's see the next x-ray so the number of anterior  

ribs in this x-ray are you can calculate one  this one is second then third then fourth fifth  

and sixth heart seems to be normal and there  is no consolidation at the base. now don't get  

surprised my friends these two x-rays are  of the same patient one in the expiratory  

phase the first one and the second one in the  inspiratory phase now why such a big difference,  

first of all diaphragm pulls the under surface of  the heart down during a good inspiratory effort  

which is absent in expiratory phase so heart  appears bigger in transverse diameter whereas  

the second reason is the failure to distance the  lungs fully can cause crowding the vessels