Chest
Volume 141, Issue 2, February 2012, Pages 545-558
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Postgraduate Education Corner
Chest Imaging Review
Interpretation of Plain Chest Roentgenogram

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Plain chest roentgenogram remains the most commonly ordered screening test for pulmonary disorders. Its lower sensitivity demands greater accuracy in interpretation. This greater accuracy can be achieved by adhering to an optimal and organized approach to interpretation. It is important for clinicians not to misread an abnormal chest radiograph (CXR) as normal. Clinicians can only acquire the confidence in making this determination if they read hundreds of normal CXRs. An individual should follow the same systematic approach to reading CXRs each time. All clinicians must make a concerted effort to read plain CXRs themselves first without reading the radiologist report and then discuss the findings with their radiology colleagues. Looking at the lateral CXR may shed light on 15% of the lung that is hidden from view on the posteroanterior film. Comparing prior films with the recent films is mandatory, when available, to confirm and/or extend differential diagnosis. This article outlines one of the many systematic approaches to interpreting CXRs and highlights the lesions that are commonly missed. A brief description of the limitations of CXR is also included.

Section snippets

The Importance of Dual Readings

There are three reasons for our emphasis on the importance of dual reading of the CXR by the radiologist and the clinician. First, subtle lesions may be missed on the plain CXR either by the clinician or the radiologist. The number may be as high as 19% of early lung cancers.8 Therefore, a dual “backup” and independent reading of the CXR by a radiologist and a clinician may reduce the number of such missed lesions. Quality of care has become the mantra of all medical centers, so a “free second

Clinical History and Physical Examination

The clinical history and physical examination should provide the basis for differential diagnoses before the CXR is obtained.15 Duration and severity of symptoms and signs of infection, risk of lung cancer, or coronary artery disease will help to narrow the differential diagnosis. Social, occupational, and travel history are equally important. For example, a person who lived in an area endemic for histoplasmosis may present with mediastinal and hilar adenopathy (Fig 1). Although the

Advancements in Imaging of Plain Chest Radiographs

There have been remarkable advances in the quality of digital chest images since a letter appeared in this journal by Bennett E. Ojserkis24 that questioned the diagnostic quality of plain film chest images obtained using digital equipment. The present status of plain chest imaging is that digital images have become the norm in many radiology departments, especially in the United States and Europe. The resolution of the images is now equal to or greater than the resolution of hard-copy plain

Summary

Understanding the properties of plain chest radiography, including its advantages and pitfalls, is important to successful interpretation. Skills in interpreting CXR must be maintained, since every pulmonary patient does not need a CT scan of the chest. Pursuing a systematic search for lesions on the CXR will minimize missed lesions. The most difficult film to read is a normal CXR. Confidence in calling a CXR as normal comes from the accrued experience gained after reading hundreds of CXRs.

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Sung was the principal investigator for Broncus Technologies 2007 to 2009. Drs Suhail Raoof, Feigin, Sabiha Raoof, Irugulpati, and Rosenow have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

References (24)

  • G Simpson et al.

    Use of thoracic computed tomography by general practitioners

    Med J Aust

    (2007)
  • S Tigges et al.

    Routine chest radiography in a primary care setting

    Radiology

    (2004)
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