Radiographic Findings to Know for the TMC/CSE Exams (2025)

When preparing for the board exams, mastering radiographic interpretation is essential for success. Chest x-rays and other imaging studies provide critical information that guides diagnostic decisions and treatment plans in clinical practice.

These exams often require respiratory therapists to identify key radiographic findings associated with conditions like atelectasis, pneumothorax, pneumonia, and acute respiratory distress syndrome (ARDS).

In this article, we will break down the essential radiographic findings you need to know for the TMC and CSE, focusing on high-yield pathologies, common patterns, and tips for accurate interpretation.

Common Radiographic Findings and Their Clinical Significance

Radiographic imaging is a cornerstone of respiratory therapy, offering valuable insights into a patient’s condition and guiding treatment decisions.

Watch this video and keep reading to learn more about the most critical radiographic findings you need to recognize for the TMC and CSE exams, along with tips to connect these findings to real-world clinical scenarios.

Atelectasis

• Radiographic Appearance: Increased opacity (whiteness) in the affected lung area, often accompanied by air bronchograms (air-filled bronchi visible against collapsed tissue). The trachea, mediastinum, and diaphragm may shift toward the side of collapse.
• Clinical Tip: Atelectasis commonly occurs postoperatively or in patients with mucus plugging or decreased lung expansion. Look for elevated hemidiaphragms and volume loss on the x-ray.

Pneumothorax

• Radiographic Appearance: A visible pleural line with the absence of vascular markings beyond that line, indicating air in the pleural space. In tension pneumothorax, there may be a shift of the trachea and mediastinum away from the affected side, with flattening of the diaphragm.
• Clinical Tip: For suspected pneumothorax, always check for signs of hemodynamic instability. In exams, if patient vitals show a drop in blood pressure and oxygen saturation, immediate needle decompression or chest tube placement is indicated.

Pleural Effusion

• Radiographic Appearance: Blunting of the costophrenic angles and a homogenous opacity that obscures the diaphragm and lung base. In larger effusions, a “meniscus sign” (a curved upper fluid level) may be seen.
• Clinical Tip: Pleural effusions often present in cases of congestive heart failure, infections, or trauma. A lateral decubitus x-ray can help differentiate between free fluid and loculated effusions.

Pneumonia

• Radiographic Appearance: Consolidation in the form of dense, localized opacities, often with air bronchograms. Patterns may be lobar (involving an entire lobe), patchy (as in bronchopneumonia), or diffuse (as seen in atypical pneumonia).
• Clinical Tip: In patient scenarios with fever, elevated white blood cells, and cough, a chest x-ray confirming consolidation helps narrow down the diagnosis. Remember that right middle lobe pneumonia can obscure the heart border, a clue to the affected lobe.

Acute Respiratory Distress Syndrome (ARDS)

• Radiographic Appearance: Diffuse, bilateral opacities (commonly referred to as “white-out” or “ground-glass” appearance) with normal heart size, indicating non-cardiogenic pulmonary edema.
• Clinical Tip: ARDS is associated with low compliance and refractory hypoxemia. In simulation exams, focus on managing oxygenation with high PEEP and avoiding fluid overload.

Congestive Heart Failure (CHF)

• Radiographic Appearance: Enlarged heart silhouette (cardiomegaly), vascular congestion, and “batwing” or “butterfly” patterns of pulmonary edema spreading from the hilar regions outward. Pleural effusions may also be present.
• Clinical Tip: CHF often presents with bilateral fluffy opacities, pleural effusions, and Kerley B lines (thin horizontal lines at the lung bases indicating interstitial edema). Recognize that diuretics and noninvasive ventilation may be indicated.

Airway Complications and Key Radiographic Clues

Airway complications often present unique challenges in both diagnosis and management.

Understanding the radiographic clues associated with these conditions is essential for identifying issues like tube misplacement, obstructions, and structural abnormalities during the TMC and CSE exams.

Endotracheal Tube (ETT) Misplacement

• Radiographic Appearance: The endotracheal tube (ETT) tip should be positioned 4–6 cm above the carina (around the level of the T2–T4 vertebrae). If the tube is placed too low, it may enter the right mainstem bronchus, causing collapse of the left lung.
• Clinical Tip: In TMC and CSE scenarios, if breath sounds are diminished on one side after intubation, suspect right mainstem intubation and adjust the ETT position immediately.

Mucus Plugging and Airway Obstruction

• Radiographic Appearance: Localized lung collapse, often seen as a sharply demarcated opacity affecting one lobe or segment. The mediastinum may shift toward the affected side.
• Clinical Tip: In patient cases involving poor secretion clearance or thick sputum production, a sudden drop in oxygenation with a corresponding x-ray finding of opacity suggests mucus plugging. Treatment involves aggressive airway clearance, including suctioning and bronchoscopy if needed.

Tracheomalacia and Tracheal Stenosis

• Radiographic Appearance: Narrowing of the tracheal lumen may appear as a “hourglass” shape on imaging.
• Clinical Tip: These conditions are often associated with prolonged intubation or tracheostomy. If airway resistance increases and the patient shows signs of difficulty breathing despite adequate ventilator settings, this complication should be considered.

Croup (Laryngotracheobronchitis)

• Radiographic Appearance: The hallmark “steeple sign” on a frontal (anteroposterior) neck x-ray, indicating subglottic narrowing of the airway.
• Clinical Tip: Croup is commonly seen in pediatric patients with a barking cough and stridor. Treatment typically involves humidified oxygen, racemic epinephrine, and corticosteroids.

Epiglottitis

• Radiographic Appearance: The “thumb sign” on a lateral neck x-ray, indicating an enlarged and swollen epiglottis.
• Clinical Tip: Epiglottitis is a medical emergency, often presenting with drooling, dysphagia, and stridor. Intubation should be performed carefully by an experienced provider to avoid complete airway obstruction.

Radiographic Findings in Trauma Cases

Trauma cases often involve complex injuries that require quick and accurate radiographic interpretation.

Recognizing key imaging findings in these scenarios is crucial for diagnosing conditions like rib fractures, hemothorax, and pneumothorax, which are commonly tested on the TMC and CSE exams.

Flail Chest

• Radiographic Appearance: Multiple rib fractures with paradoxical movement of the chest wall during breathing. May show areas of rib misalignment and pulmonary contusion (bruising) with patchy opacities.
• Clinical Tip: Patients with flail chest often present with hypoxemia and require pain control, oxygen, and sometimes mechanical ventilation to stabilize breathing.

Hemothorax

• Radiographic Appearance: Homogenous opacity in the lower lung field with a fluid line, indicating blood in the pleural space.
• Clinical Tip: In trauma scenarios, a sudden drop in blood pressure, diminished breath sounds, and opacity on the affected side indicate a hemothorax. Emergency chest tube placement is typically required.

Tension Pneumothorax

• Radiographic Appearance: Large collection of air in the pleural space with a visible pleural line and shift of the mediastinum away from the affected side.
• Clinical Tip: This is a life-threatening emergency. Needle decompression followed by chest tube insertion is essential for survival.

 

Final Thoughts

Radiographic interpretation plays a vital role in the TMC and CSE exams, as it reflects real-world clinical scenarios where quick and accurate assessments can save lives.

Focus on recognizing key patterns such as increased opacity (suggestive of consolidation or atelectasis), pleural lines (indicative of pneumothorax), and positional abnormalities of airways and devices. Additionally, practice identifying findings unique to pediatric and trauma cases, as they frequently appear in clinical simulations.

To further refine your radiographic interpretation skills, consider using our TMC/CSE exam prep materials, which include detailed patient scenarios, mock exams, and related practice questions. By integrating visual learning with exam-specific scenarios, you’ll gain the confidence needed to ace your board exams and provide exceptional patient care.