Normal Chest X-ray and

its Interpretation
PREPARED BY
SUMAIYA BUSHRA
Introduction

 The chest xray is taken with the patient in upright

position, taking a deep breath and holding it for a few
seconds to reduce the possibility of a blurred image.
Routine CXR is taken in a PA view.
 Other views: Lateral view, apical view, lateral
decubitus view
 Why xray is not taken during expiration?
 Because the lung bases appear hazy and the heart
looks enlarged
Points to be noted in a CXR:
1.Position of the patient ( kyphoscoliosis)
2.Side of x-ray (left or right)
3.Soft tissue shadow
4.Bony configuration
5.Position of trachea
6.Outline of diaphragm
7.Costophrenic and cardiophrenic angles on
both sides
8.Borders of heart including upper mediastinum
9.Heart size
10.Lung fields
11.Look for integrity of ribs, Clavicle, scapula and
spine
12.In females look for breast shadow
13.Look for any shadow in the neck ,
subcutaneous tissue in chest wall, any
abnormality in humerus, subcutaneous
emphysema
Points to be observed in an
x-ray:

 Position of the patient: observe the Clavicles in relation to

the pedicures of thoracic vertebra, the medial end of
Clavicle should be equidistant from the spinous process at
level of T4 and T5 thoracic vertebrae.
 Side of the xray: check for dextrocardia or situs inversus,
1. Diaphragm: right dome is 2.5cm above the left dome
2. Fundal gas is on the left side
3. Heart: 1/3rd lies on right side and 2/3rd on the left ;
cardiac apex is on left side
 Soft tissue shadow: in females check for breast shadow
 Bony Configuration:
1. Cervical rib
2. Ribs: normal, crowding, wide spaced, erosion,
notching, fracture or healed fracture
3. Clavicle, spine, vertebral column, scapula, humerus
4. Kyphoscoliosis
 Position of trachea: central or deviated ( Normally
trachea lies midway or slightly deviated to the right)
 Outline of diaphragm: right dome of diaphragm is at the
level of the 6th rib and posterior end of 10th rib. Left dome is
2.5 cm below the right dome.
 Costophrenic angles: angle between the diaphragm and
the rib ( obliterated in pleural effusion)
 Cardiophrenic angles: angle between the diaphragm and
cardiac border
 Presentation of a normal chest xray

 Chest x-ray PA view showing lung fields are clear on both sides, trachea is
centrally placed, both domes of diaphragm are normal in position,
costophrenic and cardiophrenic angles are clear on both sides, the heart
is normal in transverse diameter , bony configuration is normal
Trachea shifted to same side
1. Collapse
2. Atelectasis
3. Fibrosis
Heart size

 The cardiothoracic ratio is used for measuring the

heart size. MAXIMUM TRANSVERSE DIAMETER OF THE
HEART IS SLIGHTLY LESS THAN HALF OF THE MAXIMUM
TRANSVERSE DIAMETER OF CHEST (<0•5)
 From the midline the maximum diameter of the right
and left borders of the heart is measured. The sum of
the two diameters is maximum transverse diameter of
the heart.
 Diameter of the chest is measured from the maximum
distance on both sides ( such as from both
costophrenic angles)
BORDERS OF THE HEART

 Right border is formed by:

From above downwards: upper slightly curved portion:
SVC with ascending Aorta.
Lower more convex part: outer border of the right atrium
 Left border of the heart is formed by:
Prominent aortic knuckle formed by arch of aorta
Straight line due to pulmonary artery
Left atrial appendage
Left ventricle
Chamber of heart Findings of Enlargement of the chamber

LEFT VENTRICULAR ENLARGEMENT Apex is displaced downwards and to

the left
Cardiophrenic angle is obtuse

RIGHT VENTRICULAR ENLARGEMENT Apex is round and elev ated abov e the
diaphragm

LEFT ATRIAL ENLARGEMENT Double border or countour in the right

heart border, widening of carina and
left main bronchus is horizontal

RIGHT ATRIAL ENLARGEMENT Increased curv ature in the right border

of the heart
VALVULAR HEART DISEASE
MITRAL STENOSIS AND ITS CXR PRESENTATION
 Mitral stenosis causes impaired
blood flow to the LV so size of LV
is normal but LA is enlarged

Backflow of blood
through pulmonary
vein into lung

Acute Pulmonary
edema

Pulmonary HTN

RVH

RHF
1. Raised JVP
2. Tender hepatomegaly
3. Bipedal oedema
Clinical Features

 Breathlessness ( pulmonary congestion)

 Fatigue ( low cardiac output)
 Oedema, Ascites ( right heart failure)
 Palpitation (Atrial fibrillation)
 Haemoptysis (pulmonary congestion, pulmonary
embolism)
 Chest pain ( pulmonary HTN)
 Symptoms of thromboembolic complications ( stroke,
ischaemic limb)
Signs

 Face: Mitral facies

 Pulse: Irregularly irregular
 JVP : If right heart failure develops = Raised JVP
 Precordium: Palpation: tapping apex beat,
palpable P2= pulmonary HTN
Auscultation: Loud first heart sound, opening snap, low
pitched rumbling Mid diastolic murmur, Followed by
presystolic accentuation, best heard with bell of stethoscope
when patient is in left lateral position and breath holding after
expiration.
Investigations

 1. ECG: P Mitrale, RVH, Features of AF

 2. CHEST X RAY
 3. Echocardiogram
 4. Doppler
 5. Cardiac catheterization
MITRAL STENOSIS

 Xray findings
1. Cardiomegaly : RV type
2. Straightening of the left
border with fullness and
outwards bulging of the
pulmonary conus
3. Double right border contour
4. Upper lobe diversion