INTERPRETATION OF

CHEST X-RAY

 Adapted from
source
SYSTEMATIC INTERPRETATION
 Label
 Orientation
 Quality
 Skeletal structures
 Soft tissue structures
 Densities
The big two densities are:

(1) WHITE - Bone

(2) BLACK - Air

The others are:

(3) DARK GREY- Fat

(4) GREY- Soft tissue/water

And if anything Man-made is on the

film, it is:

(5) BRIGHT WHITE - Man-made

Techniques - Projection
P-A (relation of x-ray beam to patient)
Techniques - Projection (continued)
Lateral
Techniques - Projection (continued)
Lateral Decubitus
Rotation
Rotation (continued)
Penetration
Inspiration/Expiration
Lateral CXR (continued)
Lateral CXR (continued)
Soft Tissue Structures
Neck and Esophagus Symmetry, masses

Trachea Deviation, ID bifurcation, should not be

able to ID airways further out because
they are thin walled.
Breasts Symmetry, nipples may be visible

Diaphragm Right usually higher

Costophrenic Angles Should be sharp and clear (no fluid

density)
Cardiophrenic Angles Should be fairly clear

Vasculature Check for position and calcification

Hilum- L side generally higher and looks
smaller than R
Heart Size (1/2 width of thorax), Ventricles
Skeletal Structures
 Skeletal Structures  Assessment
 Scapulae  Check for
 Humeri & Shoulder symmetry, spacing,
Joints and fractures.
 Clavicles  Check for linearity
 Ribs (9+ = good of the spine.
inflation)
 Spine
Ribs
Lungs

Start at the top and compare the R

and L
 Trachea should be midline over the
thoracic vertebrae and air filled
 Lung parenchyma becomes lighter as
you go down the lung. If not, it may
indicate a lower lobe or pleural effusion
 Lobes
 Right upper lobe:
 Lobes (continued)
 Right middle lobe:
 Lobes (continued)
 Right lower lobe:
 Lobes (continued)
 Left lower lobe:
 Lobes (continued)
 Left upper lobe with Lingula:
 Lobes (continued)
 Lingula:
 Lobes (continued)
 Left upper lobe - upper division:
 Heart Size

 Cardio-Thoracic Ratio
* Up to 50%- adults
* Up to 55%- 1-24 mths
* Up to 60%- neonates
 Cardiomegaly
* Mild
* Moderate
* Severe
Heart Size of heart
Abnormal CTR > 0.55
Size of individual chambers
of heart

Size of pulmonary vessels

Evidence of stents, clips,

wires and valves

Outline of aorta and IVC and

SVC
Heart

1.Right border: Edge of Rt. Atrium

2. Left border: Lt. Ventricle + Lt.Atrium

3. Posterior border: Left Ventricle

4. Anterior border: Right Ventricle

RA ENLARGEMENT
LA ENLARGEMENT
LA & LAA enlargement
LV enlargement
RV enlargement
Heart (continued)
 Valves
Hilum

Made of:

1. Pulmonary Art.+Veins
2. The Bronchi

Left Hilus higher (max 1-2,5 cm)

Identical: size, shape, density

Hilum
Mediastinum:
 Width
 Contour
 AP window

Hila:
 Size
 Location
ABNORMAL CHEST X RAY
 Radiopacity (whiteness) means increased
density
 Radiotranslucency (blackness) means
decreased density
 Radiopacity - Alveolar/Interstital
 Alveolar pattern – fluffy, soft, poorly demarcated
opacifications < 1 cm in diameter
 Possible causes:
 Pulmonary edema
 Viral pneumonia
 Pneumocystis
 Alveolar cell carcinoma
 Interstitial pattern
 Consolidation of interstitial tissue
(alveolar walls, intralobular vessels,
interlobar septa and connective tissue)
 Looks like branching lines radiating
toward the periphery of the lung
 Possible causes:
 Interstitial pneumonitis
 Pulmonary fibrosis
Left Hilum is always higher than Right

 Vascular pattern – assessment of the

pulmonary arteries and capillaries
 Increase in the size of the pulmonary
arteries – pul. HTN
 Decrease in size, truncation, or
obliteration – Embolus
 Lack of vascular making in the periphery
– Pneumothorax
Rules for detecting Concealed
Consolidation
 Assess Heart borders and domes of
diaphragm-Clearly visible/well
defined

 If Border is ill defined – Precise site of

Concealed consolidation can be
deduced.
Silhouette Sign: When a margin or
structure is masked by another density

Right Side of heart masked by a RML pneumonia

RUL pneumonia
RML pneumonia
LLL pneumonia
Multiple Masses
Cephalisation
Enlarge
pulmonary
veins with
perivascular
fluid
collection
Pleural Effusion
ARDS
Pneumothorax
RUL collapse
Air under the diaphragm
Emphysema
COPD
Cervical Rib
Cavitating lesion
Miliary shadowing
Chest Tube, NG Tube, Pulm. artery cath
Hemothorax
 Mnemonic about the items you should
look at in a CXR :
A: Airways
B: Bones
C: Cardiac shadow
D: Diaphragm
E: Empty spaces
F: Fields of the lung
G: Hilar regions
What is the abnormality seen in this
pediatric AP chest x-ray?