How to Read a Chest X Ray

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Normal chest x-ray. A=Airway; B=Bone, C=Cardiac silhouette, D=Diaphragm, E=Edge of the heart, F=Field of lung, G=Gastric bubble, H=Hilum of lung.

You have probably seen a chest x-ray (chest radiograph), or might even have had one taken. Have you ever wondered how to read a chest x-ray? Here is a quick and easy approach by following these simple steps and using the mnemonic 'A,B,C,D,E,F,G,H,I'. When looking at a radiograph, remember that it is a 2-dimensional representation of a 3-dimensional object. Height and width are maintained, but depth is lost. The left side of the film represents the right side of the individual, and vice versa. Air appears black, fat appears gray, soft tissues and water appear as lighter shades of gray, and bone and metal appear white. The denser the tissue, the whiter it will appear on x-ray. Denser tissues appear radiopaque, bright on the film; less dense tissues appear radiolucent, dark on the film.
EditSteps

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Check the patient's name. Above all else, make sure you are looking at the correct chest x-ray first.

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Read the date of the chest radiograph. Make special note of the date when comparing older radiographs (always look at older radiographs if available). The date the radiograph is taken provides important context for interpreting any findings. For example, a mass that has become bigger over 3 months is more significant than one that has become bigger over 3 years.

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Note the type of film (while this article assumes you are looking at a chest x-ray, practice noting if it is a plain film, CT, angiogram, MRI, etc.) For chest x-ray, there are several views as follows:

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The standard view of the chest is the posteroanterior radiograph, or "PA chest." Posteroanterior refers to the direction of the x-ray traversing the patient from posterior to anterior. This film is taken with the patient upright, in full inspiration (breathed in all the way), and the x-ray beam radiating horizontally 6 feet away from the film. The anteroposterior (AP) chest radiograph is obtained with the x-ray traversing the patient from anterior to posterior, usually obtained with a portable x-ray machine from very sick patients, those unable to stand, and infants. Because portable x-ray units tend to be less powerful than regular units, AP radiographs are generally taken at shorter distance from the film compared to PA radiographs. The farther away the x-ray source is from the film, the sharper and less magnified the image. (You can confirm this by placing your hand about 3 inches from a desk, shining a lamp above it from various distances, and observing the shadow cast. The shadow will appear sharper and less magnified if the lamp is farther away.) Since AP radigraphs are taken from shorter distances, they appear more magnified and less sharp compared to standard PA films.

It helps to determine whether suspected fluid (pleural effusion) will layer out to the bottom. 4. The A arrow indicates "fluid layering" in the right chest. check a rightlateral decubitus view (to allow the air to rise to the left side). 4 . An oblique view is a rotated view in between the standard front view and the lateral view. It is taken with the beam at 6 feet away.o Lateral chest x-ray. If air is suspected in left lung. o Right lateral decubitus chest x-ray showing pleural effusion. as in the PA view. if pleural fluid is suspected in the left lung. or suspected air (pneumothorax) will rise to the top. For example. The volume of useful lung is reduced because of the collection of fluid around the lung. o The lateral chest radiograph is taken with the patient's left side of chest held against the x-ray cassette (left instead of right to make the heart appear sharper and less magnified. since the heart is closer to the left side). It is useful in localizing lesions and eliminating superimposed structures. The B arrow indicates the width of the right lung. check a left lateral decubitus view (to allow the fluid to layer to the left side). A lateral decubitus view is one taken with the patient lying down on the side.

5 Note the technical quality of film. Look for intervertebral bodies in a properly penetrated chest x-ray. which indicate absence of significant rotation. If detailed spine and pulmonary vessels are seen behind the heart. decubitus. but not the pulmonary vessels. To assess exposure. while an over-penetrated film shows the intervertebral spaces very distinctly. the side that has been lifted appears narrower and denser (whiter) and the cardiac silhouette appears more in the opposite lung field. 'R' for Right. etc. 'AP' for anteroposterior. 6 . If there is significant rotation. If the spine is not visible. Note the position of the patient: supine (lying flat). the exposure is correct. and the heads of the ribs (end of the calcified section of each rib) at the same location to the chest wall.Look for markers: 'L' for Left. 'PA' for posteroanterior. If only the spine is visible. It is hard to find a subtle pneumothorax if there is significant motion. the film is too white (underexposed). 6. It causes distortion because it can make the lungs look asymmetrical and the cardiac silhouette disoriented. the film is too dark (overexposed). lateral. o  o o Exposure: Overexposed films look darker than normal. making fine details harder to see. An under-penetrated chest x-ray cannot differentiate the vertebral bodies from the intervertebral spaces. Rotation: Rotation means that the patient was not positioned flat on the x-ray film. and cause appearance of areas of opacification. underexposed films look whiter than normal. upright. Look for the right and left lung fields having nearly the same diameter. look at the vertebral column behind the heart on the frontal view. Motion: Motion appears as blurred areas. with one plane of the chest rotated compared to the plane of the film. 5.

Left tension pneumothorax. cortical thickness in comparison to medullary cavity. well-demarcated area devoid of lung markings. 8 . abnormal fat pads. Airway: Check to see if the airway is patent and midline. in a tension pneumothorax. where the trachea bifurcates (divides) into the right and left main stem bronchi. 7 Fracture of the left clavicle. shape. Look for thecarina. etc. or defects. fractures. trabecular pattern. The bright metallic spots are snaps for EKG readings. lesions. the airway is deviated away from the affected side. it may appear punched out compared to surrounding bone. Note the large. For example. presence of any erosions. calcification in the cartilages. widening. lytic or blastic areas. A sclerotic bone lesion is an area of bone with an increased density (appearing whiter). 7. air in the joint space. Bones: Check the bones for any fractures. At joints. and contour of each bone. Look for lucent and sclerotic lesions. look for joint spaces narrowing. A lucent bone lesion is an area of bone with a decreased density (appearing darker). Note the overall size. and deviation of the trachea (airway) and the heart away from the affected side. density or mineralization (osteopenic bones look thin and less opaque). 8.

Also look at the costophrenic angle (which should be sharp) for any blunting. Note that the cardiac silhouette takes up more than half of the chest width. suggestive of pericardial effusion. The right diaphragm is normally higher than the left. due to the presence of the liver below the right diaphragm. situated between the lungs). . It takes about 300-500 ml of fluid to blunt the costophrenic angle. A normal cardiac silhouette occupies less than half the chest width. 9. which may indicate effusion (as fluid settles down). A raised diaphragm may indicate area of airspace consolidation (as in pneumonia) making the lower lung field indistinguishable in tissue density compared to the abdomen. Characteristic of aortic dissection here is the enlarged mediastinum (labeled 1) and aortic arched (labeled 2).Enlarged cardiac silhouette in a case of aortic dissection (blood fills the mediastinum). Diaphragms: Look for a flat or raised diaphragm. Cardiac silhouette: Look at the size of the cardiac silhouette (white space representing the heart. A flattened diaphragm may indicate emphysema. and the left diaphragm is raised compared to the right. Get an ultrasound or chest Computed Tomagraphy (CT) to confirm. 9 Left pleural effusion associated with left lower lobe pneumonia: note that the costophrenic angle is blunted. o Look for water-bottle-shaped heart on PA plain film.

B) Q fever pneumonia affecting the lower and middle lobes of the right lung. and other lesions. for example. due to an infiltrate or consolidation surrounding the bronchi. look at the external soft tissues for any abnormalities. Note the prominent air-bronchogram sign: air visualized in the peripheral intrapulmonary bronchi. Edges of heart. Also. . 11. 11 Right lower lobe pneumonia. Note the lymph nodes. External soft tissues: Check the edges of the heart for the silhouette sign: a radioopacity obscuring the heart's border. 10 A) Normal chest radiograph. Note the loss of the normal radiographic silhouette (contour) between the affected lung and its right heart border as well as between the affected lung and its right diaphragm border. look for subcutaneous emphysema (air density below the skin). in right middle lobe and left lingula pneumonia. This phenomenon is called thesilhouette sign.10.

Look for calcified lymph nodes in the hilar. The left pulmonary artery is always more superior than the right. presence of any mass. infiltration. etc. etc. 12 Gastric bubble: Look for the presence of a gastric bubble. blood. 12. bronchial cuffing. in a case of carcinoid tumor. 14. most of the hilar shadows represent the left and right pulmonary arteries. just below the heart. 14 . If fluid. fills the air sacs. mucous. the lungs will appear radiodense (bright). nodules. Assess the amount of gas and location of the gastric bubble. On the frontal view. vascularity. 13 Enlarged lymph node in left hilum. which may be caused by an oldtuberculosis infection. Normal gas bubbles may also be seen in the hepatic and splenic flexures of the colon. making the left hilum higher. note whether it is obscured or absent. or tumor. fluid. with less visible interstitial markings.Fields of the lungs: Look for symmetry. 13. Hila: Look for nodes and masses in the hila of both lungs.

prosthesis. The sternum should be seen edge on and posteriorly you should see two sets of ribs. surgical drains. .Breast implants. Ads by Google The patient should be examined in full inspiration.6th anterior rib on good inspiration. This is due to more air in lung in the lower lobes and less chest wall. IV lines. Instrumentations: Look for any tubes. The diaphragm should be found at about the level of the 8th . EKG leads. On the other hand penetration is sufficient that bronchovascular structures can usually be seen through the heart. the thoracic spine disc spaces should be barely visible through the heart but bony details of the spine are not usually seen. On a good PA film. you can look for proper penetration and inspiration by observing that the spine appears to be darken as you move caudally. etc.10th posterior rib or 5th . This greatly helps the radiologist to determine if there are intrapulmonary abnormalities. On the lateral view. Adequate penetration of the patient by radiation is also required for a good film.

the mediastinum may look very unusual. .Rotation The technologists are usually very careful to x-ray the patient flat against the cassette. This is a normal PA film without any rotation. If there is rotation of the patient. One can access patient rotation by observing the clavicular heads and determining whether they are equal distance from the spinous process of the thoracic vertebral bodies. the mediastinum may look very unusual. If there is rotation of the patient. One can access patient rotation by observing the clavicular heads and determining whether they are equal distance from the spinous process of the thoracic vertebral bodies.Rotation The technologists are usually very careful to x-ray the patient flat against the cassette.

Magnification of clavicular head and spinous process alignment demonstrating a straight film. .Magnification of clavicular head and spinous process alignment demonstrating a straight film.

Notice the skewed positioning of the heads of the clavicles (red arrows) and the spinous processes. Notice the skewed positioning of the heads of the clavicles (red arrows) and the spinous processes.In this rotated film skin folds can be mistaken for a tension pneumothorax (blue arrows). . In this rotated film skin folds can be mistaken for a tension pneumothorax (blue arrows).

there is an abnormal opacity in the left upper lobe.The basic diagnostic instance is to detect an abnormality. In both of the cases above. The case on the right has an opacity that is poorly defined. Infiltrate . It is most useful to state the diagnostic findings as specifically as possible. then try to put these together and construct a useful differential diagnosis using the clinical information to order it. the opacity would best be described as a mass because it is well-defined. This is airspace disease such as pneumonia. Mass vs. In the case on the left. In each of the cases above. there is an abnormal opacity.

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Think of the mediastinal structures that comprise this interface. If the margin were abnormal you could diagnose the cause. the radiologist should be able to identify what part of the lung and what organ within the mediastinum are involved. The margins of the mediastinum are made up of the structures shown below. .Mediastinum and Lungs The radiologist needs to know both the structures within the mediastinum forming the mediastinal margins and the lobes of the lungs forming the margins of the lungs along the mediastinum and chest wall. If a mass or pneumonia "silhouettes" (obscures) a part of the lung/mediastinal margin. Trace the margin of the mediastinum with your eye all the way around the margin.

This image indicates the locations of each lung margin on chest x-ray. .This image outlines the specific anatomy of the PA chest x-ray. Trace the margin of the lung with your eye in the image below thinking about what mediastinal structure and what lobe of the lung is present at this margin.

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The table below shows the segmental bronchi and their designated numbers. Look at the drawing on the left and compare it to the chest x-ray on the right. G2 = Apicoposterior Segmental Bronchus G3 = Anterior Segmental Bronchus H = Lingular Bronchus H4 = Superior Lingular Segmental Bronchus H5 = Inferior Lingular Segmental Bronchus I = Left Lower Lobe Bronchus I6 = Superior Segmental Bronchus I7 = Medial Basal Segmental Bronchus I8 = Anterior Basal Segmental Bronchus I9 = Lateral Basal Segmental Bronchus I10 = Posterior Basal Segmental Bronchus SMALP = "Suppose My Aunt Loves Peaches" is a helpful way to remember the segmental lower lobe bronchi. You can see that the major bronchi are visible if you look carefully. .Bronchi A physician should absolutely know the anatomy of the bronchi. A = Right Main Stem Bronchus B = Right Upper Lobe Bronchus B1 = Apical Segmental Bronchus B2 = Anterior Segmental Bronchus B3 = Posterior Segmental Bronchus C = Bronchus Intermedius D = Right Middle Lobe Bronchus D4 = Lateral Segmental Bronchus D5 = Medial Segmental Bronchus E = Right Lower Lobe Bronchus E6 = Superior Segmental Bronchus E7 = Medial Basal Segmental Bronchus E8 = Anterior Basal Segmental Bronchus E9 = Lateral Basal Segmental Bronchus E10 = Posterior Basal Segmental Bronchus F = Left Main Stem Bronchus G = Left Upper Lobe Bronchus G1. It may be beneficial to practice drawing the bronchi and labeling them until you are entirely familiar with their names and locations.

and anterior portion of the pleural cavity. the silhouette sign can be caused by an opacity in the RML. For the heart. Use the back button on your browser to return here. . In other words. of lower lobes which cause an overlap and not an obliteration of the heart border. and diaphragm. for example. Ben Felson. then the opacity will obscure that border. anterior segment of the upper lobe.Signs Silhouette sign One of the most useful signs in chest radiology is the silhouette sign. aorta. The silhouette sign is in essence elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung. Take a moment to review the makeup of the mediastinal margins and the lobes of the lungs that interface with the mediastinum. lower aspect of the oblique fissure. posterior mediastinum. lingula. This contrasts with an opacity in the posterior pleural cavity. Therefore both the presence and absence of this sign is useful in the localization of pathology. anterior mediastinum. chest wall. The location of this abnormality can help to determine the location anatomically. The sign is commonly applied to the heart. if an intrathoracic opacity is in anatomic contact with. the heart border. This was described by Dr.

This is caused by a pneumonia. can you determine which lobe the pneumonia affects? (click image for answer) .The right heart border is silhouetted out.

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