The Normal Chest X-Ray

Introduction
• Most of the chest x-rays you will see
will be normal
• In order to recognise abnormality, you
need to know what a normal CXR looks
like

The CXR on the next slide is normal. How

would you interpret it?
 General Principles
• Have a systematic approach
• Interpret the CXR in conjunction with
the clinical findings
• Always compare with previous CXR if
available to assess for change
• Ask yourself “does my interpretation
make sense?”
Systematic Approach
•Name/marker/rotation/
penetration

•Lines/metal work

•Heart

•Mediastinum

•Lungs
•Zones
(upper/middle/lower)

•Bones

•Diaphragm

•Soft Tissues
Systematic Approach
•Name/marker/rotation/
penetration

clavicles equidistant
from spinous
processes of thoracic
spine

can just see lower

thoracic spine
Systematic Approach
•Lines/metal work

Look for:

•Sternal wires (implies

previous thoracic
surgery)
•Tip of endotracheal
tube (2cm above
carina)
Systematic Approach
•Lines/metal work

Tip of central venous

lines at origin of
superior vena cava. See
tubes and lines
presentation.
Systematic Approach
•Heart

•Occupies up to 50% of
the maximum internal
thoracic diameter on a
standard PA erect view
•Cannot comment on
heart size on AP view
because of magnification
of heart
Systematic Approach
•Mediastinum

•Hilar vascular
structures should be
crisply defined
•No widening of
mediastinum
•Trachea should be
central
 Systematic Approach
•Lungs

upper zone
•Compare upper, mid
and lower zones
middle zone •Look between ribs for
lung detail
•Remember to look
“behind” the heart
lower zone
Systematic Approach
•Bones

•Look at each rib in turn

•Clavicles
•Scapulae and humeri if
visible
•Lower cervical and
thoracic spine
Systematic Approach
•Diaphragm

•Both diaphragms
should form a sharp
margin with the lateral
chest wall
•Both diaphragm
contours should be
clearly visible medially
to the spine

Position of stomach
gas bubble (not
present on this CXR)
Systematic Approach
•Soft Tissues

•Supraclavicular fossae
(enlarged nodes)
•Lateral chest wall
(surgical emphysema)
•Under diaphragm
(pneumoperitoneum)
How would you summarise this?
“This is an erect chest X-Ray of an adult male. The
heart is not enlarged, the mediastinal contours are
normal and the lungs are clear”
 Take Home Points
• Be systematic
• Review with history and physical
examination in mind