Various systems may be used. The illustrative approach we have chosen is an A B C review, similar to the method taught in Advanced Trauma Life Support (ATLS).
A: Airway–Large Airways, Lung, and Pleura
Check whether the trachea is midline or deviated. The carina lies at the T4 level on expiration and will move inferiorly to T6 on inspiration. In adults, the right main bronchus has a steeper angle than the left, but the angles are symmetrical in children.
Check whether the trachea is midline or deviated. The carina lies at the T4 level on expiration and will move inferiorly to T6 on inspiration. In adults, the right main bronchus has a steeper angle than the left, but the angles are symmetrical in children.
The lungs are divided into lobes by fissures; the right lung has three lobes and left has two lobes.
The oblique fissures, separating the upper from the lower lobes, are not usually seen as they are positioned facing the toward X-ray beam. Part of the horizontal fissure, separating the right upper and middle lobes and lying tangential to the beam, is seen in about 50-60% of patients. Most commonly, the lateral portion is seen in contact with the chest wall at the level of the right 6th rib.
B: Bones–Clavicles, Ribs, and Spine
Review of the ribs, clavicles, scapulae, and spine is needed to look for fractures and bone destruction. The ribs and intercostal spaces should be symmetrical.
Review of the ribs, clavicles, scapulae, and spine is needed to look for fractures and bone destruction. The ribs and intercostal spaces should be symmetrical.
C: Circulation–Heart, Mediastinum, and Vascular Markings
Knowledge of the normal anatomical structures that form the mediastinal and cardiac outline is essential to detect abnormality. On the left, the outline is formed from superiorly to inferiorly by the left brachiocephalic vein, the aortic knuckle, the left main pulmonary artery, the left atrial appendage, and left ventricle. Similarly, the right is formed by the right brachiocephalic vein, the superior vena cava and right pulmonary artery, and the right atrium and inferior vena cava.
Knowledge of the normal anatomical structures that form the mediastinal and cardiac outline is essential to detect abnormality. On the left, the outline is formed from superiorly to inferiorly by the left brachiocephalic vein, the aortic knuckle, the left main pulmonary artery, the left atrial appendage, and left ventricle. Similarly, the right is formed by the right brachiocephalic vein, the superior vena cava and right pulmonary artery, and the right atrium and inferior vena cava.
D: Diaphragm
Check the shape, height, and angles. The right diaphragm should be ≈1-3 cm higher than the left. Look through the diaphragmatic shadow for pathology in the lung bases and the pleural reflections for evidence of pleural fluid.
Check the shape, height, and angles. The right diaphragm should be ≈1-3 cm higher than the left. Look through the diaphragmatic shadow for pathology in the lung bases and the pleural reflections for evidence of pleural fluid.
E: Review Areas
Lines and Tubes. Check position and look for complications, e.g. pneumothorax
Lines and Tubes. Check position and look for complications, e.g. pneumothorax
*Central lines should pass to the lower superior vena cava, and should not enter the right atrium.
*Pulmonary artery catheters should not be wedged into small branches.
*Endotracheal tubes should have the tip at least 3 cm above the carina, optimally midway between the carina and thoracic inlet.
*Gastric tubes should pass below the diaphragm and into the stomach.
*Chest drains–check the position. The tip of the tube should lie in an effective position, and not be misplaced or displaced into lung tissue.
*Pulmonary artery catheters should not be wedged into small branches.
*Endotracheal tubes should have the tip at least 3 cm above the carina, optimally midway between the carina and thoracic inlet.
*Gastric tubes should pass below the diaphragm and into the stomach.
*Chest drains–check the position. The tip of the tube should lie in an effective position, and not be misplaced or displaced into lung tissue.
Areas Where Pathology is Commonly Missed:
>Apices. Avoid missing masses, consolidation, or a small pneumothorax.
>Behind the Heart. Look for lobar collapse and hiatus hernia
>Apices. Avoid missing masses, consolidation, or a small pneumothorax.
>Behind the Heart. Look for lobar collapse and hiatus hernia
>Hila. Look for masses or lymphadenopathy. The left hilum will be 1-2 cm higher than the right.
>Below the Diaphragm. Look specifically for tubes and free gas.
>Soft Tissues. Look specifically for breast shadows or mastectomy, and surgical emphysema.
>Below the Diaphragm. Look specifically for tubes and free gas.
>Soft Tissues. Look specifically for breast shadows or mastectomy, and surgical emphysema.
Cont Edu Anaesth Crit Care & Pain. 2007;7(3):71-75.
