Mnemonic
PIPER N’ ABCDE
PIPER to assess the quality of chest radiograph
ABCDE to assess the chest radiograph
P= Patient information; I= Inspiration; P= Penetration; E= Exposed areas; R= Rotation
N’= NG tube
A= Airway; B= Breathing; C= Circulation; D= Diaphragm; E= Everything else
Quality Assessment
Patient information
- Name and demographic details
- Review clinical history
- Always compare with previous CXR
Inspiration
- Count 6 anterior ribs above diaphragm
- 7th rib should be penetrating the diaphragm (if above the diaphragm, it suggest hyperinflation)
Penetration (how well x-ray photons penetrate pt thorax)
- Assessed by identifying vertebral bodies through heart shadow
Exposed area
- Make sure all lung fields are visible
Rotation
- Draw a midline through the spinous process
- compare distance from medial end of clavicle to the midline and compare it to each other
NG tube placement
Chest radiograph assessment
Airway
- 3 main presentation: 1) Normal 2) Deviated 3) Narrow
- Deviation away from lesion
- Massive Pleural Effusion
- Tension pneumothorax
- Tumour
Breathing
3 main presentation: 1) Normal density 2) increased density (white aka opacity) 3) Reduced Density (black)
Opacity can be assess by considering these four patterns:
- Consolidation
- Interstitial
- Nodule or masses
- Atelectasis
Consolidation- caused by filled up alveoli by fluid (transudate), pus, cells; it gives rise to three patterns: lobar opacities, diffuse opacity and multiple ill-defined opacity
- Lobar opacity
- Disease spread from one alveolus to another
- ill defined border as not all alveoli is affected
- As the disease reaches a fissure, it creates a sharp delineation as it doesn’t cross fissure
- alveoli surrounding bronchi becomes dense with substance resulting in air-bronchogram
- Diffuse opacity
- Most common cause is pulmonary oedema due to heart failure; heart size is usually used to distinguish between cardiogenic and non-cardiogenic pulmonary oedema; other signs of heart failure includes upper lobe diversion (dilated upper lobe vessels due to pulmonary hypertension), Septal Kerley B lines, Alveolar oedema (acutely in perihilar “bat wing” distribution) and pleural effusion
- Bronchopneumonia: disease affects bronchioles unlike in lobar opacity which affects the alveoli; multifocal ill-defined patchy opacity which involves multiple lobes and as it progress it becomes diffused opacity; disease does not cross fissure
- Multiple ill-defined opacity
- Bronchopneumonia starts its life as multifocal ill-defined patchy opacity
- other causes include vascular (Septic emboli, Wengern’s), and Neoplasm
Interstitial disease- four pattern of interstitial disease are seen on high-resolution CT of the chest mainly: reticular pattern, nodular pattern, high attenuation and low attenuation. However, it is often difficult to assess interstitial disease pattern on chest xray. If suspected of interstitial disease, then consider HRCT
Nodules/masses- discrete with well defined margin. If <3cm, then called solitary pulmonary nodule and if >3cm then called mass and considered malignancy unless otherwise proven
Atelactasis- aka lung collapse