How to interpret CXRs for the ICE

1. Dim room lighting

2. Check patient information - name, age, sex, date of radiograph
3. Identify radiographic technique - AP/PA film, exposure, rotation,
patient position (supine, sitting or erect)
4. Identify and check position of lines, tubes and other invasive
devices
5. Soft tissues – foreign bodies (metal), thickness, contours, presence
of gas, masses, mastectomy
6. Lungs (parenchyma)- look for abnormal densities (opacity or
lucency) or Pneumothorax

- Look at lung volumes (hyperinflated in COPD)

- Look at each lobe and compare (esp. apices)
- Linear atelectasis
- If shadowing: look for air bronchograms

7. Hila - position, masses or lymphadenopathy

8. Heart - size and shape
9. Pulmonary vessels - artery or vein enlargement (follow outwards)
10. Bones – density, lesions or fractures. Clavicle, scapula, ribs.
11. Pleura - thickening, calcification, effusion or Pneumothorax
12. Trachea - midline or deviated, wall, lumen diameter
13. Mediastinum - width and contour, discreet masses
14. Check review areas - apices, especially right upper lobe,
retrocardiac area, the peripheral lung margins, posterior
costophrenic sulci, and the diaphragm.

CXR signs of heart failure:

1. Alveolar oedema
2. Kerley B lines
3. Cardiology
4. Distended upper lobe vessels
5. Pleural effusions

Causes of consolidation: infection, pulmonary oedema, sarcoidosis, neoplasm,

infarction (following PE), haemorrhage.
Silhouette signs
Anatomical relationships:
• Right heart boarder and RML
• Ascending aorta and RUL
• Left heart border and lingula
• Left anterior diaphragm and heart
• Aortic knob and LUL
• Right posterior diaphragm and RLL
• Left posterior diaphragm and LLL

Lobar collapse

• Occurs due to proximal occlusion of a bronchus, causing a loss of

aeration. The remaining air is gradually absorbed, and the lung loses
volume. Causes:

1. Proximal stenosing bronchogenic carcinoma, which occludes a bronchus.

Patients are middle aged or elderly, and almost always smokers.
2. Asthma: In a young adult or older child . Collapse occurs secondary to
mucous plugging of the major airways.
3. In an infant consider an inhaled foreign body, such as a peanut.
4. Retention of secretions is a frequent cause of post operative collapse.

Features of collapse on CXR:

• Tracheal displacement towards the side of the collapse.
• Mediastinal shift towards the side of the collapse.
• Elevation of the hemidiaphragm.
• Reduced vessel count on the side of the collapse.
• Herniation of the opposite lung across the midline.
• A hilar mass, which also suggests carcinoma as the cause.
• Other evidence of malignant disease (eg. rib metastases, lymphangitis,
effusion)
• The presence of a foreign body; however these are rarely easy to see.
• The presence of an endotracheal tube; is it sited too low?

Pleural effusions

• Meniscus sign
• Subpulmonic pleural effusion: effusion trapped between lung and
diaphragm (resembles elevated diaphragm)
• Large effusions can cause the mediastinum to shift to opposite side
• Free flowing pleural effusion: use lateral decubitus views to identify
• Loculated pleural effusion: doesn’t shift with a change in position, absence
of air bronchogram, convex border
• “pseudotumor” is fluid trapped in a fissure
• Kerley lines: 2-3 cm long pleural perpendicular to lateral chest, represent
thickened interlobular septa and edematous lymphatics