How to Interpret a Chest X-Ray (Lesson 2 - A Systematic Method and Anatomy)

[@giuseppetardini1424]

TRANSCRIPT LEARNING OBJECTIVES: • to be familiar with the systematic approach to interpreting chest X-rays • to know the correlation between anatomy and normal shadows on the chest X-ray Before just presenting a systematic approach, we should mention a couple of IMPORTANT PRINCIPLES about it: • it is most important for the clinicians least experienced with reading chest X-rays, since it reduces the chance that important findings will be missed • all aspects of chest X-ray interpretation should be included • the individual elements of the approach should be examined in a sequence that is either logical and/or easy to remember • there is no one "best" system, though all should begin with an assessment of the film's technical quality We could informally call such a systematic approach the ABCDEF SYSTEM (each of the letters refers to a specific anatomic structure, but before the A we need to assess the technical quality): • A=AIRWAYS • B=BONES (and soft tissue) • C=CARDIAC SILHOUETTE (and mediastinum) • D=DIAPHRAGM (and gastric bubble) • E=EFFUSIONS (in other words, assessment of the pleura, which actually includes findings beyond just pleural effusions) • F="FIELDS" (i.e. lung fields) • lastly, although it is not explicitly part of the mnemonic, ASSESSMENT OF LINES, TUBES, DEVICES and PRIOR SURGERIES, such as sternotomies and valve replacements Aside from the fact that it is easy to remember, another nice thing about this mnemonic is that the lungs are examined near the end. This is a good idea because normally the lungs are the area of greatest interest and the most likely to be abnormal, therefore once the clinican find an abnormality there, it is very easy to forget examining the rest of the film (for example, overlooking a rib fracture because of a distraction over acute lung pathology) A is for the AIRWAYS. There are three anatomic airway structures that are typically visible on a normal X-ray: • TRACHEA, which is normally in the midline • RIGHT and LEFT MAIN BRONCHUS ○ the left main bronchus tends to take off from the trachea at a slightly more horizontal angle as compared to the right, which is why aspirated foreign bodies, if small enough, are more likely to end up in the right lung than the left, and it is also why endotracheal tubes, if advanced too far, end up in the right main bronchus, blocking off ventilation to the left rather than viceversa The next set of structures is the BONES. There are four types of bones, easily visualized on a PA and lateral X-ray set: • RIBS ○ there are two radiographic components of the rib on the PA film, the POSTERIOR RIB, which is easier to see and is oriented horizontally, and the ANTERIOR RIB, which is harder to see and oriented at a 45 degree angle • CLAVICLE • STERNUM (sometimes visible on the LATERAL film, but is often obscured by soft tissue in the anterior chest wall) • VERTEBRAL BODIES (more easily visible on the LATERAL film, but usually seen on the PA as well, provided that the technical quality is adequate) Then, there are the CARDIAC SILHOUETTE and the MEDIASTINUM, which should logically be evaluated together. There are a lot of anatomic structures that compose the silhouette (on the left side, AORTIC ARCH, LEFT PULMONARY ARTERY, LEFT ATRIUM, LEFT VENTRICLE, while, on the right side, ASCENDING AORTA, RIGHT PULMONARY ARTERY and RIGHT ATRIUM): • we should usually also be able to see another vertical line running just to the patient's left of the vertebral bodies, which corresponds to the LEFT SIDE OF THE DESCENDING AORTA • the one structure on the patient's left called the AORTOPULMONARY WINDOW may be unfamiliar to some: this is an important space between the aortic arch and the pulmonary artery where one will find the recurrent laryngeal nerve and lymphnodes It makes sense to evaluate the DIAPHRAGM and the PLEURA together: • RIGHT and LEFT DIAPHRAGM ○ they are clearly visible on the PA view ○ it is normal for the right hemidiaphragm to be slightly higher than the left, presumably due to the liver being directly beneath it ○ while looking at the diaphragm, it's important to remember that there aren't any truly flat structures in the body: for example, the hemidiaphragms are curved in three-dimensional space; as we might be able to appreciate from comparing the PA to the LATERAL, the hemidiaphragms seen on the PA really just represent the superior most aspect of the diaphragm • PLEURA ○ it is normally invisible due to its thinness ○ however, knowledge that the pleura is there is essential for diagnosing a pneumothorax, pleural plaques from asbestos exposure and pleural thickening • RIGHT and LEFT COSTOPHRENIC ANGLES (although SULCI would probably be more semantically accurate in most circumstances) ○ spaces on either side where the diaphragm meets the thoracic wall ○ these two spaces are usually seen on the PA • POSTERIOR COSTOPHRENIC ANGLE ○ space in the back on the LATERAL film • GASTRIC AIR BUBBLE ○ small pocket of air, visible under the left hemidiaphragm, usually representing air in the stomach ○ occasionally, it can be unclear whether the gas is in the stomach or in the intestines Next, we need to take into consideration the main anatomic structures of the LUNGS: • FISSURES BETWEEN THE LOBES ○ HORIZONTAL FISSURE § there is only one, and it is located on the right side § it is the only one of the three fissures that is commonly visible in normal X-rays, which is because a significant portion of the plain of the fissure is parallel to the direction of the X-ray beams § however, it is only visible on the PA § the right and left oblique fissures are not visible ○ LOBES § RIGHT UPPER LOBE § RIGHT MIDDLE LOBE § RIGHT LOWER LOBE □ because the oblique fissure runs obliquely, as seen in the lateral view, the lower lobe extends almost all the way to the apex of the lung (this will be true on the left side as well) □ as a consequence, if only the PA or AP views are presented without a lateral, it's almost impossible to tell in what lobe a visualized nodule or mass is located, unless it's seen in the uppermost part above the lower lobe's most superior extent § LEFT UPPER LOBE § LEFT LOWER LOBE

[@lawlietlawliet]

You're a savior

[@Mr.C0ffee]

THE MVP!!!

[@jamiebrown5028]

I will be encouraging my students to review this and this available for review while out in clinic. Excellent video and very concise.

[@StrongMed]

Thanks for sharing it! I'm always happy to hear feedback from fellow educators!

[@caseytrammell6673]

You are a wonderful teacher. I'm finding your videos to be great help, in assisting me through PA school. Thank you!!

[@flubu2816]

Love the ABCDEF mnemonic, thank you for this high-yield series! I've seen it extended to G = gastric bubble, H = Hilum, I = instruments (lines, tubes, devices, etc.). A question: any plans to create a interpreting CT series? Would be very useful (and if not - any recommended free resources for med students?)

[@Lsoldier09]

My son is 5 and autistic. He loves human anatomy and xrays. These are the videos we watch together. Awesome video and info.

[@chiefs5822]

Did he take on science?

[@Paschimnepal2025]

Hello sir I am a student of pcl diagnostic radiography in nepal I always watch your video to better understand where I study in my collage 🇳🇵🇳🇵thank you for your information video ❤️❤️❤️❤️always respect and love

[@abulc.4996]

Sir, the quality of your teaching is SUPERB😍

[@mictheoc7301]

Thank you very much for these videos , right from the start you got my attention. You are clear and concise. Most perfect teaching videos that I have watched on you tube.

[@sinclair657]

Thank you very much. I am an RT and it is becoming imperative that I can identify the CXR abnormalities along with my assessments.🧐

[@chipomilambo5878]

Thanks a lot for uploading this it has really helped me.Zambian student

[@Echooffeelings]

nice video... very well described, right diaphragm is higher as left diaphragm is pushed down by heart.. as right diaphragm is lower in patient with dextrocardia with normal situs

[@damonspears7788]

fantastic intro for novice learners, even experienced nurses and laymen

[@carlosjoelgarcia3200]

Phenomenal presentation with super imposing anatomy. Genius!!! Thank you for the clarity of explanation and please continue doing these videos. Disregard the haters....

[@wanyonyisam8445]

I finally landed on what I have been looking for

[@anast9301]

Greetings from Indonesia. This is the first radiolology lesson that's able to make me fully understand a CXR. It is very systematic and doesn't cause confusion

[@tariqalziad3730]

I am very benefited to see this video...

[@abdulazeez.98]

Your videos are defenitely the best.

[@manymarius]

thanks a lot for the video.I just started studing x-rays and at first i was really shocked...all i saw was black and white but you really helped me to understand the basics.Greetings from Romania

[@sunving]

Thanks ,I just learn from you more or less today.

[@skibitom]

Great and helpful Tutorial. Thank you for sharing.

[@drtirthpatel5202]

Very helpful video .... appreciate your efforts.thanks

[@dr.shakya]

As a medical student,i found it very helpful to build my basic concepts. Thanks a lot sir !

[@tapasguha917]

Very good , but just wanted to add that -I think for a fissure to be identified it's plane should be tangential to the beam rather than parallel.

[@StrongMed]

In a mathematical sense, the word parallel should only be applied to true lines (which X-ray beams are) and planes (which fissures are not because they are curved), so you're correct that tangential is the more accurate word.

[@dr.ahmetboran8455]

MAY ALL PRAISES AND GLORY BE UNTO ALMIGHTY CREATOR, VERY GOOD EXPRESSION OF THOUGHTS.

[@mustafamukaram7412]

Very helpful video, thank you.

[@halukozdemir7568]

Many thanks for this excellent video Eric...I just wondered that;the mnemonic ABCDEF + is very useful for not overlooking any particular part since as far as I know the human mind is tend to stop seeking another anomaly when he or she finds out one.Is this mnemonic correlates with the regular checking for parts according to the importance? Namely,in my practice ,I am an anesthesiology and reanimation specialist, I usually check the bones last..

[@StrongMed]

I find that the ABCDEF system works best for trainees, but the more experienced the clinician is, the less superior this system will be over other alternatives. The order in ABCDEF is only dependent on the alphabet, and not based on importance (though I find it beneficial for the "Fields" (i.e. lungs) to be looked at last since this is where pathology is most likely to be found. I suspect many radiologists routinely examine the bones last.

[@gabi.melotti]

So amazing video

[@kylewilson653]

LOVE your Chest Xray interpretation videos! Do you have videos for improving reading CT's or MRI's?

[@tabner100]

I Loved your video. The overlay was very helpful in showing what one is viewing in the X-ray.

[@drsaharabdulkarim8996]

greetings from China 🇨🇳,thank you so much

[@sweetbug]

Dr. Eric I appreciate you taking time out of your busy life in making these very educational videos. I am thankful that there are resources like you because my NP school sucks.

[@AlmaSouthAfrica]

Thank you sooooo much - from South Africa!

[@gregsbox]

Great video. What explains the darker regions on each side of the sternum, just below the clavicle?

[@alialshehry9037]

Thank you doctor .. Please make some vedios about .. MRI and CT .. We really need them .

[@StrongMed]

Thanks for the suggestions. I plan on eventually covering basic CT of the head and abdomen/pelvis, but I'm far behind on requests, so I can't give any estimate as to when it will be. Unfortunately, as I'm not a radiologist, I'm underqualified to speak knowledgably about MRI. I think videos on point-of-care ultrasound are more likely at this point than any on MRIs.

[@mohammadramishammah4977]

Thanks a lot Dr ...really impressive job

[@DucVietNguyenPhD]

Great Thankful Appreciation for valuable lecture.

[@2003121300]

sir ,its very interesting and helpful to gain lot of knowledge from your lecture.i watched ur lecture regularly and eagerly waiting for next video everytime.Sir could you start lecture series on bacteriology ,virology and mycology as it find difficult for me to understand in concise manner.Thanks a lot sir again for such wonderful teaching

[@StrongMed]

I have a video series already posted on antibiotics, which covers a little bacteriology outside of the specific topic of antibiotic therapy, predominantly in lectures 1, 2, and 9. I plan to create a brief 2-3 video series on fungal infection and fungal treatment within the next month or so. I have less clinical experience with most viral diseases, so this will likely come along much later, but I plan to get to it at some point. Thanks for watching!

[@aalaaabduljalil8455]

Very useful,thanks

[@priyankanamishra7290]

Amazing explanation Dr. Strong. Many thanks

[@dr.anilkumar146]

excellent one

[@ashrazterrian8851]

thank you so much! it's so helpful for basic understanding of chest x rays

[@ladyheart5147]

thanks again, these videos are helping me tremendously

[@TheDaoke]

many thx for your great work, Eric. It's very very helpful. I'm wondering if you have any plan to interpret CT anatomies of neck, chest, abdomen and pelvics.

[@StrongMed]

I'm very glad you've found them helpful! Unfortunately, I have so many other topics on my to-do list that I don't anticipate covering CT imaging in the near future. Perhaps much further down the road. For now, if you are wanting to study CT imaging on your own, I recommend www.radiopaedia.org - they have many great examples and mini-tutorials covering all radiographic modalities.

[@StethoscopeStoryTime]

I have seen people add a "G" of "gadgets" (e.g.,Ines and tubes) to the end of the list

[@edwinvilcapajares1975]

Thank you from Peru. I am radiology residen.

[@vd.matheusmacedo]

Thank you so much doctor! I watch all your videos and they are absolutely amazing! Please never stop

[@lovelyroroa]

This is the first video of yours I have watched and it seems like I'll be seeing more of your awesome clear, made simple videos... I just need to say thank you! THANK YOU

[@medicalmumbojumbo5622]

That cardiac overlay was incredibly helpful. Thank you!

[@how8087]

Hello eric strong .... i really want to thank you ....... for your amazing vedios that's helped many of physician around the globe .....

[@boredshrimp9425]

Thank you so much

[@sagarboss2004]

Excellent

[@mdshowkathali7306]

Thank you so much from Bangladesh.

[@pedromaciel3058]

How can i differentiate the pulmonary vessels from the bronquios?

[@yajna-slayduop7138]

Veey interesting and clear explanation. Thank you so much today i got to lern from you. And i recommend those who want to learn please go for it worth watching and very helpful, Thanks.

[@hsyed010]

Absolutely awesome. Thank you for your efforts!!!

[@erciasequeira2380]

Thank you so much for sharing

[@32franss]

thank you for made this video

[@albertrajadevaanbu3400]

Thanks for posting this video. in this video is very useful for me and all medical students also. hope i am become a good radiographer. Once again thanx Mr. Eric's.

[@nadiakharismalita5338]

this is so worth it and a must watch lecture! thank you so much doc. and may i request for another lectures of radiology such as MRI CT or USG please? :3

[@borhanzabaan6024]

How r you

[@doctorusmle1996]

Great work , Go On 😍

[@ANonyMouse627]

Start at 5:17 after MedCram video

[@Maddawg31415]

I’m a paramedic taking ATLS audit in a few weeks. This was very helpful

[@Darusiha6254]

Good well explained chest x.ray thank u for your efforts

[@lelabb4110]

Many thanks..Anatomy prof's are fired! with a pre-med school refund.

[@jsachin3171]

a query abt lat. view ?? when u tell lat view which side lat view right or left side of t chest?

[@mariatileinge2902]

These videos save my life in med school👌

[@pakosenthumoleng9617]

Please recheck your facts about the aorto-pulmonary window.

[@StrongMed]

Can you elaborate?

[@ryuhyobosa2465]

thank u sir for these pernicious lectures, but i have few notes if u allowed me.

[@n1cK059]

Greetings from France, you rock man. Your videos are among the most useful materials I could get ahold of.

[@manu27190]

thanks. This video gives me very use ful information about chest x rays.ABCDEF systems is very useful and easy to remember

[@sonalisubhadarsini2436]

Thank you for helping 😊

[@SonaliguptaSG]

Great work

[@viktoriousextensions394]

Thank you

[@dr.msaqibhissan4370]

A great Video. Thank you so much for effort.

[@maheshkale7387]

Thank you so much!!!

[@dr.bchandra4507]

Want to see lesson 1

[@hardanddiffi]

Very useful and beautiful media. How can I get a permision from the author to translate the whole content to arabic language for tutorial purposes?

[@sonalisubhadarsini2436]

U r so knowledgeable

[@knunniek.9304]

Great thanks

[@ibrahimsarhan4432]

Great! How can I reach the rest of the videos?

[@drrevision964]

👍👍👍👍👏👏

[@drtoladingeta1554]

thank you for this vedio and i hope u do more in the future! i have also seen ur vedio on urine dipstick and i realy found it use full! just i would like to say thanks! From HARAMAYA UNIVERSITY, ETHIOPIA!

[@yirgalemfirisa5064]

Wow you are the only till now continued

[@cywoodie]

Honda x-ray,ctscan physical exam city

[@chirag.vijayvargiya]

Really informative

[@fredastaire6156]

Thank you for such a detailed and thoughtful video. Dr. Strong.

[@ajazhussain7502]

Excellent Work

[@여름사이다]

Thank you so much! From South Korea

[@peterthorne6431]

Third year medical student. Your video series has been a great help for wards. Thank you!

[@ajaynimbalkar8952]

Informative

[@amyflamingo3761]

please what is the basal wall hypoknesis... And in which case it happens... Thanks

[@navinkore]

what is meaning of haziness and congestion in cxr ??

[@zj9338]

Very nice videos keep up doctor 💕

[@jimmyhandle8667]

Hayır

[@AlphabetNumbers]

Thanks

[@AlphabetNumbers]

Thanks

[@guyizhaki1137]

thank u very much dr. eric...would u make some videos about pet scan and scintigraphy...please.???

[@StrongMed]

Thanks for the suggestion. Currently, I'm focusing efforts on those topics on which I feel most qualified to teach. Unfortunately, interpretation of PET scans is something on which I can't speak with nearly as much authority as plain radiographs, and interpretation of scintigraphy falls well outside my usual scope of practice. The bottom line is that I hope to get to these topics some day, but it will likely be in the distant future (and only after I've studied them a bit more myself).

[@saidmo1797]

Thank you.

[@Gymnopediea]

Brilliant.

[@fatimamamdouh866]

Thanks 😊

[@ivanribaric7547]

Thank you