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Daniel Ward and Dr Lewis Potter · Radiology Interpretation

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.

OSCE Stations
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’. PSA Question Bank

Rotation
APP

The medial aspect of each clavicle should be equidistant from the spinous processes.
Reading
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Chest X-ray (CXR) Interpretation
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.

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 the context of
Right-sided 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).

Artificial heart valves

Artificial heart valves typically appear as ring-shaped structures on a chest X-ray
within the region of the heart (e.g. aortic valve replacement).

Pacemaker
Pacemakers typically appear as a radio-opaque disc or oval in the infraclavicular
region connected to pacemaker wires which are positioned within the heart.
:
 Review areas

Finally, before completing your assessment of a chest X-ray, make sure you’ve looked
at the ‘review areas’ where pathology is often missed. These areas include:

the lung apices

the retrocardiac region
behind the diaphragm
the peripheral region of the lungs
the hilar regions

This ensures you’ve comprehensively assessed the X-ray and reduces the risk of
missing subtle pathology (e.g. a small nodule).

Reviewer

Dr Kunal Patel
Radiology Registrar

References

1. James Heilman, MD. Right-sided pneumonia. Licence: CC BY-SA 3.0. 

2. James Heilman, MD. Cardiomegaly. Licence: CC BY-SA 3.0. 
3. Hellho". Pneumoperitoneum. Licence: CC BY-SA 3.0.
4. Steven Fruitsmaak. Chilaiditi syndrome. Licence: CC BY-SA 3.0.

 
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