Chest X-ray Systematic Approach
Image quality

Key points

  • Assess the image quality
  • Comment on the presence of medical artifacts
  • Can the clinical question still be answered?

Image quality should always be assessed because it may not be possible to answer the clinical question if the image is inadequate.

The chest X-ray should be checked for rotation, inspiration, and penetration. The tutorial on chest X-ray image quality covers this in more detail.

Image quality - Rest In Peace

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Image quality - Rest In Peace

  • Mnemonic - RIP - Rest In Peace
  • R - Rotation - Spinous processes at midpoint between medial ends of the clavicles?
  • I - Inspiration - 5 to 7 anterior ribs intersecting the diaphragm in the mid-clavicular line?
  • P - Penetration - Spine visible behind the heart?

Artifact

When you present a chest X-ray it is good practice to comment on the presence of any artifact. Here is an example.

Central line position?

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Central line position?

  • The left jugular line tip (red circle) is in the left subclavian vein
  • It should take the course of the dotted line to lie in the region of the superior vena cava (red oval)
  • Usually a central line is placed on the right side (green line)
  • External oxygen tubing is also visible on the left (highlighted)

Many chest X-rays are performed to assess the position of medical equipment such as a naso-gastric tube or central line. When you are assessing a chest X-ray for this purpose, do not forget to look at the entire image systematically.