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This guide provides a structured approach to chest X-ray interpretation and includes

examples of relevant pathology.
Diagnostic Thoracentesis
(Pleural Tap) – OSCE Guide
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.

Oropharyngeal Airway (Guedel

Assess image qualityInsertion – OSCE
Airway)
Guide
Next, you should assess the quality of the image: a mnemonic you may find useful is ‘RIPE’.

Rotation

The medial aspect of each clavicle should be equidistant from the spinous processes.

The spinous processes should also be in vertically orientated against the vertebral bodies.

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Inspiration

The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should
be visible.
Nasopharyngeal Airway
Insertion – OSCE Guide
Projection

Note if the film is AP

COMMUNICATION 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).
OSCE st ations
Communication History t aking
Exposure Information
A collection of communication skills
giving 
guides,
The left for common
hemidiaphragm OSCE
should scenarios,
be visible to the spine andContraceptive
the vertebrae should be visible
behindincluding
the heart. history taking and information
counselling
giving. Dia gnosis

 counselling
You might also be interested in our OSCE Flashcard Collection
Drug & which contains over
treatment
2000 flashcards that cover clinical examination, procedures, communication skills and
counselling
data interpretation. Diff icult
circumst ances
Document ation 
Prescribing
ABCDE approach Ot her

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.
Explaining a Diagnosis of
Diaphragm: including assessment of costophrenic angles.
Acne Vulgaris – OSCE Guide
Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and
review areas.

Airway

Trachea
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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
Explaining
lymphadenopathy. a Diagnosis of
Psoriasis – OSCE Guide

Causes of true and apparent tracheal deviation

True tracheal deviation:

Pushing of the trachea: large pleural effusion 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.
Explaining the Use of an
Adrenaline Auto-injector –
OSCE Guide

INTERPRETATION 

OSCE St ations
Interpretation ECG
Interpret ation
A collection of data interpretation guides to
Radiology
help you learn how to interpret various
Interpret ation
laboratory and radiology investigations. Lab tests

 Spirometry
Interpret ation
CTG
Interpret ation
St atistics

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Bundle Branch Block

Haematinics Interpretation

Pleural effusion 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.

OSCE
The right main bronchus Stations
is generally wider, shorter and more vertical than the left main
bronchus. As a result of this difference in size and orientation, it is more common for inhaled
foreign objects to become lodged in the right main bronchus.
MEDICINE 
Depending on the quality of the chest X-ray you may be able to see the main bronchi
branching into further subdivisions of bronchi.
Emergency
Medicine Medicine

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A comprehensive collection of medical Cardiology
Respiratory
revision notes that cover a broad range of
Endocrinology
clinical topics. Gastroenterology

 Renal
Neurology
Rheumatology
Haematology
Infectious
Diseases
Dermatology
Opht halmology
Obs & Gynae
Paediatrics
Psychiatry
Ot her 
Physiology
Immunology
Diagnostic Thoracentesis
Geriatrics
(Pleural Tap) – OSCE Guide Sexual Healt h

Carina and bronchi (normal CXR) Oncology

Palliative care
Public healt h
Hilar structures Research
Toxicology
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 Rash

usually& Non-Pigmented
the Skinshould raise suspicion of pathology.
same size, so asymmetry
Lesion Examination – OSCE
The hilar point is also a very important landmark; anatomically it is where the descending
Guide
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).

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Causes of hilar enlargement or abnormal position

Hilar enlargement can be caused by a number of different 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 different pathologies. You should
Pigmented
inspect for evidence Skin
of the hilar Lesion
being pushed (e.g. by an enlarging soft tissue mass) or
pulled (e.g.Examination
lobar collapse). – OSCE Guide

 
SURGERY 

Breathing Dentistry
Surgery Operating
Theatre
A collection of surgery revision notes covering
Lungs
Anaest hetics
key surgical topics.
Suturing
Inspect the lungs for abnormalities:

 General Surgery
Hepatobiliary
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. Surgery
Ortthree
These zones do not equate to lung lobes (e.g. the left lung has hopaedic
zones but only two
lobes). Surgery
Urology
Inspect the lung zones ensuring that lung markings are present throughout.
Neurosurgery
Compare each zone between lungs, noting any asymmetry (some asymmetry is normal and
ENT
caused by the presence of various anatomical structures e.g. the Surgery
heart).
Pl fields,
Some lung pathology causes symmetrical changes in the lung astic Surgery
which can make it
Gynaecological
more difficult 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 Surgery
may indicate pathology (e.g.
consolidation/malignant lesion). Vascul ar Surgery
Breast
The complete absence of lung markings should raise suspicion Surgery
of a pneumothorax.
Maxillofacial
Wound Healing
Surgery

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Deep Neck Space Infections

Right-sided pneumonia 1

Lung tumour 2

Pleura

Inspect the pleura for abnormalities:

The pleura are Carotid

not usuallyArtery
visible inStenosis
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
ANATOMY 
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
Anatomy
an area of increased opacity on a chest X-ray. In some cases, a combination of air and fluid
Anatomy Fundament als
can accumulate in the pleural space (hydropneumothorax), resulting in a mixed pattern of
Head & Neck
bothAincreased
collection
andofdecreased
anatomyopacity
notes covering
within thethe keycavity.
pleural
Upper Limb
anatomy concepts that medical students need
Back
to learn. Thorax

 Abdomen
Tension pneumothorax
Pelvic anatomy
Lower Limb
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
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imaging as this condition will result in death if left untreated.

External Carotid Artery

Pleural thickening in the context of mesothelioma 2

Right-sided pneumothorax 2

Superior Vena Cava (SVC)

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.
The Ventricular System
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
CASES
heart disease, cardiomyopathy, pulmonary hypertension and pericardial effusion.

Assess the heart’s borders

Cases
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InspectAthe borders of
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history taking, investigations, diagnosis and management. We

The heart borders may become difficult to distinguish from the lung fields as a result of
alsowhich
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a collection of 500+ofOSCE
the opacity cases
overlying with
lung mark schemes
tissue:
and answers to relevant questions.
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.

Cardiomegaly 2

Diaphragm

OSCE Stations
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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

A patient with penile swelling

Pneumoperitoneum3

Costophrenic angles

The costophrenic angles are formed from the dome of each hemidiaphragm and the lateral
chest wall.

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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).

Doc, I’ve felt a lump…

QUIZ

Quiz Costophrenic blunting secondary to pneumonia 2

A collection of free medical student quizzes to put your medical

and surgical knowledge to the test! Check out our brand new
Everything else
medical MCQ quiz platform at https://geekyquiz.com.


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.

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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). OSCE Stations

PSA Question Bank

Aortic knuckle and aortopulmonary window

Bones

Inspect the visible skeletal structures looking for abnormalities (e.g. fractures, lytic lesions).

Soft tissues
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Inspect the soft tissues for obvious abnormalities (e.g. large haematoma).

Tubes, valves and pacemakers

Tubes Medical Student Finals Question Bank

Nasogastric tube placement is something you’ll often be asked to assess on a chest X-ray to
confirm
APP safe placement for feeding. See our NG tube placement guide for more details.

Reading
Lines  SHARE  TWEET
Chest X-ray (CXR) Interpretation
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).

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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. Hellhoff. Pneumoperitoneum. Licence: CC BY-SA 3.0.
4. Steven Fruitsmaak. Chilaiditi syndrome. Licence: CC BY-SA 3.0.

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