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Daniel Ward and Dr Lewis Potter · Radiology ·

Last updated: November 12, 2021

Chest X-ray (CXR) Interpretation

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Table of Contents 

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This guide provides a structured approach to

chest X-ray interpretation and includes
examples of relevant pathology.

You may also be interested in our

chest X-ray documentation guide.

Confirm details

Begin chest X-ray interpretation by checking

the following details:

Patient details: name, date of birth and

unique identification number.
Date and time the film was taken
Previous imaging: useful for comparison.

Assess image quality

Next, you should assess the quality of the

image: a mnemonic you may find useful is
‘RIPE’.

Rotation

The medial aspect of each clavicle should be

equidistant from the spinous processes.

The spinous processes should also be in

vertically orientated against the vertebral
bodies.

Inspiration

The 5-6 anterior ribs, lung apices, both

costophrenic angles and the lateral rib edges
should be visible.

Projection

Note if the film is AP or PA: if there is no

label, then assume it’s a PA film (if the
scapulae are not projected within the chest,
it’s PA).

Exposure

The left hemidiaphragm should be visible to

the spine and the vertebrae should be visible
behind the heart.

You might also be interested in our

OSCE Flashcard Collection which
contains over 2000 flashcards that
cover clinical examination,
procedures, communication skills and
data interpretation.

ABCDE approach

The ABCDE approach can be used to carry

out a structured interpretation of a chest X-
ray:

Airway: trachea, carina, bronchi and hilar

structures.
Breathing: lungs and pleura.
Cardiac: heart size and borders.
Diaphragm: including assessment of
costophrenic angles.
Everything else: mediastinal contours,
bones, soft tissues, tubes, valves,
pacemakers and review areas.

Airway

Trachea

Inspect the trachea for evidence of

deviation:

The trachea is normally located centrally

or deviating very slightly to the right.
If the trachea appears significantly
deviated, inspect for anything that could
be pushing or pulling the trachea. Make
sure to inspect for any paratracheal
masses and/or lymphadenopathy.

Causes of true and apparent

tracheal deviation

True tracheal deviation:

Pushing of the trachea: large pleural

e!usion or tension pneumothorax.
Pulling of the trachea: consolidation
with associated lobar collapse.

Apparent tracheal deviation:

Rotation of the patient can give the

appearance of apparent tracheal
deviation, so as mentioned above,
inspect the clavicles to rule out the
presence of rotation.

Pleural e!usion with tracheal deviation 2

Carina and bronchi

The carina is cartilage situated at the point

at which the trachea divides into the left
and right main bronchus.

On appropriately exposed chest X-ray, this

division should be clearly visible. The carina
is an important landmark when assessing
nasogastric (NG) tube placement, as the NG
tube should bisect the carina if it is correctly
placed in the gastrointestinal tract.

The right main bronchus is generally wider,

shorter and more vertical than the left main
bronchus. As a result of this di!erence in
size and orientation, it is more common for
inhaled foreign objects to become lodged in
the right main bronchus.

Depending on the quality of the chest X-ray

you may be able to see the main bronchi
branching into further subdivisions of
bronchi.

Carina and bronchi (normal CXR)

Hilar structures

The hilar consist of the main pulmonary

vasculature and the major bronchi.

Each hilar also has a collection of lymph

nodes which aren’t usually visible in healthy
individuals.

The left hilum is often positioned slightly

higher than the right, but there is a wide
degree of variability between individuals.

The hilar are usually the same size, so

asymmetry should raise suspicion of
pathology.

The hilar point is also a very important

landmark; anatomically it is where the
descending pulmonary artery intersects the
superior pulmonary vein. When this is lost,
consider the possibility of a lesion here (e.g.
lung tumour or enlarged lymph nodes).

Causes of hilar enlargement or

abnormal position

Hilar enlargement can be caused by a

number of di!erent pathologies:

Bilateral symmetrical enlargement is

typically associated with
sarcoidosis.

Unilateral/asymmetrical enlargement
may be due to underlying
malignancy.

Abnormal hilar position can also be

due to a range of di!erent
pathologies. You should inspect for
evidence of the hilar being pushed
(e.g. by an enlarging soft tissue mass)
or pulled (e.g. lobar collapse).

Breathing

Lungs

Inspect the lungs for abnormalities:

When interpreting a chest X-ray you should

divide each of the lungs into three zones,
each occupying one-third of the height of
the lung.
These zones do not equate to lung lobes
(e.g. the left lung has three zones but only
two lobes).
Inspect the lung zones ensuring that lung
markings are present throughout.
Compare each zone between lungs, noting
any asymmetry (some asymmetry is normal
and caused by the presence of various
anatomical structures e.g. the heart).
Some lung pathology causes symmetrical
changes in the lung fields, which can make
it more di"cult to recognise, so it’s
important to keep this in mind (e.g.
pulmonary oedema).
Increased airspace shadowing in a given
area of a lung field may indicate pathology
(e.g. consolidation/malignant lesion).
The complete absence of lung markings
should raise suspicion of a pneumothorax.

Right-sided pneumonia
1

Lung tumour 2

Pleura

Inspect the pleura for abnormalities:

The pleura are not usually visible in

healthy individuals. If the pleura are visible
it indicates the presence of pleural
thickening which is typically associated
with mesothelioma.
Inspect the borders of each lung to ensure
lung markings extend all the way to the
edges of the lung fields (the absence of
lung markings is suggestive of
pneumothorax).
Fluid (hydrothorax) or blood (haemothorax)
can accumulate in the pleural space,
resulting in an area of increased opacity on
a chest X-ray. In some cases, a
combination of air and fluid can
accumulate in the pleural space
(hydropneumothorax), resulting in a mixed
pattern of both increased and decreased
opacity within the pleural cavity.

Tension pneumothorax

A tension pneumothorax is a life-

threatening condition which involves
an increasing amount of air being
trapped within the pleural cavity
displacing (pushing away) mediastinal
structures (e.g. the trachea) and
impairing cardiac function.

If a tension pneumothorax is
suspected clinically (shortness of
breath and tracheal deviation) then
immediate intervention should be
performed without waiting for imaging
as this condition will result in death if
left untreated.

Pleural thickening in
Right-sided the context of
pneumothorax 2 mesothelioma 2

Cardiac

Assess heart size

In a healthy individual, the heart should

occupy no more than 50% of the thoracic
width (e.g. a cardiothoracic ratio of less than
0.5).

This rule only applies to PA chest X-rays (as

AP films exaggerate heart size), so you
should not draw any conclusions about heart
size from an AP film.

Cardiomegaly is said to be present if the

heart occupies more than 50% of the
thoracic width on a PA chest X-ray.
Cardiomegaly can develop for a wide variety
of reasons including valvular heart disease,
cardiomyopathy, pulmonary hypertension and
pericardial e!usion.

Assess the heart’s borders

Inspect the borders of the heart which

should be well defined in healthy individuals:

The right atrium makes up most of the

right heart border.
The left ventricle makes up most of the
left heart border.

The heart borders may become di!cult to

distinguish from the lung fields as a result
of pathology which increases the opacity of
overlying lung tissue:

Reduced definition of the right heart

border is typically associated with right
middle lobe consolidation.
Reduced definition of the left heart border
is typically associated with lingular
consolidation.

Diaphragm

The right hemidiaphragm is, in most cases,

higher than the left in healthy individuals
(due to the presence of the liver). The
stomach underlies the left hemidiaphragm
and is best identified by the gastric bubble
located within it.

The diaphragm should be indistinguishable

from the underlying liver in healthy
individuals on an erect chest X-ray, however,
if free gas is present (often as a result of
bowel perforation), air accumulates under
the diaphragm causing it to lift and become
visibly separate from the liver. If you see
free gas under the diaphragm you should
seek urgent senior review, as further imaging
(e.g. CT abdomen) will likely be required to
identify the source of free gas.

There are some conditions which can result

in the false impression of free gas under the
diaphragm, known as pseudo-
pneumoperitoneum, including Chilaiditi
syndrome. Chilaiditi syndrome involves the
abnormal position of the colon between the
liver and the diaphragm resulting in the
appearance of free gas under the diaphragm
(because the bowel wall and diaphragm
become indistinguishable due to their
proximity). As a junior doctor, you should
always discuss a scan that appears to show
free gas with a senior colleague
immediately.

Chilaiditi syndrome 4

Pneumoperitoneum3

Costophrenic angles

The costophrenic angles are formed from

the dome of each hemidiaphragm and the
lateral chest wall.

In a healthy individual, the costophrenic

angles should be clearly visible on a normal
chest X-ray as a well defined acute angle.

Loss of this acute angle, sometimes referred

to as costophrenic blunting, can indicate the
presence of fluid or consolidation in the
area. Costophrenic blunting can also develop
secondary to lung hyperinflation as a result
of diaphragmatic flattening and subsequent
loss of the acute angle (e.g. chronic
obstructive pulmonary disease).

Everything else

Mediastinal contours

The mediastinum contains the heart, great

vessels, lymphoid tissue and a number of
potential spaces where pathology can
develop. The exact boundaries of the
mediastinum aren’t particularly visible on a
chest X-ray, however, there are some
important structures that you should assess.

Aortic knuckle
The aortic knuckle is located at the left
lateral edge of the aorta as it arches back
over the left main bronchus. Reduced
definition of the aortic knuckle contours can
occur in the context of an aneurysm.

Aortopulmonary window
The aortopulmonary window is a space
located between the arch of the aorta and
the pulmonary arteries. This space can be
lost as a result of mediastinal
lymphadenopathy (e.g. malignancy).

Bones

Inspect the visible skeletal structures

looking for abnormalities (e.g. fractures, lytic
lesions).

Soft tissues

Inspect the soft tissues for obvious

abnormalities (e.g. large haematoma).

Tubes, valves and pacemakers

Tubes
Nasogastric tube placement is something
you’ll often be asked to assess on a chest X-
ray to confirm safe placement for feeding.
See our NG tube placement guide for more
details.

Lines
Various tubes and cables will be visible as
radio-opaque lines on the chest X-ray (e.g.
central line, ECG cables).