Intensive Care Nursing/Chest X-Ray Interpretation
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
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.
X-Ray Densities
- Bone= white
- Tissue= grey
- Gas (Air)= black e.g. trachea or stomach
Key Learning Points (no matter which approach you take):
- Difference between posterioranterior (PA) vs anteriorposterior (AP) view
- Basic anatomy seen on the CXR
- Inspiration
- Signs of COAD
- 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.
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)