Chest X-ray (CXR)

Interpretation
Khalil Fathi Alsharef R1
Confirm Details
Begin chest X-ray interpretation by checking the following details:
Patient details: Name, date of birth and MRN
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
Inspiration
Projection
Exposure
Rotation
The medial aspect of each clavicle should be equidistant from the
spinous processes.
Inspiration
The 5-6 anterior ribs, lung apices, both costophrenic angles and
the lateral rib edges should be visible.
Projection
Anterior – Posterior view ( AP )
Posterior – Anterior view ( PA )
Lateral view

How to differentiate between AP and PA ??

Exposure
The left hemidiaphragm should be visible to the spine and the
vertebrae should be visible behind the heart.
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.
 Carina and bronchi
The carina is cartilage situated at the point at which
the trachea divides into the left and right main bronchus.
Hilar structures
The hilar consist of the main pulmonary vasculature and
the major bronchi.
The hilar point is also a very important landmark; anatomically it
is where
the descending pulmonary artery intersects the superior pulmona
ry vein.
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.
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
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.
Pleura
Inspect the pleura for abnormalities:
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.
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).
Assess the heart’s borders
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.
Costophrenic angles
The costophrenic angles are formed from the dome of each
hemidiaphragm and the lateral chest wall.
Loss of this acute angle, sometimes referred to as costophrenic
blunting, can indicate the presence of fluid or consolidation in the
area
Everything else
Aortic knuckle
The aortic knuckle is located at the left lateral edge of the
aorta as it arches back over the left main bronchus.

Aortopulmonary window
The aortopulmonary window is a space located between the arch
of the aorta and the pulmonary arteries.
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
Thank You