CHEST XRAY (CXR)

Basics of Chest Radiography

 Basics of CXR reading

 Patient Details
❑ Name
❑ Date of birth
❑ Gender
❑ Hospital number
❑ Date of Xray
❑ Previous films
Normal CXR Anatomy
Normal CXR Anatomy

1 Trachea
2 Carina (division of trachea into R+L bronchi)
3 1st Rib
4 Right hemidiaphragm
5 Left hemidiaphragm
6 Posterior rib
7 Anterior rib
8 Aortic notch
9 Descending aorta
10 Left ventricle
11 Costocardiac angle
12 Costphrenic angle
13 Right atrium
14 Clavicle
15 Hilum
Level of carina??
What do the different shades
represent in an Xray?

 A – Black → Air
 B – Dark grey → Fat
 C – Light grey → Soft tissue
 D – White → Bone/fluid
 E - Bright white → Metal
Lung Zones – not the same as lung lobes
How does the diaphragm appear in X-ray?
Cardio-thoracic ratio
Systematic Approach – Image Quality

 Image quality should always be

assessed because it may not be
possible to answer the clinical
question if the image is inadequate.
 The chest X-ray should be checked for
rotation, inspiration, and penetration.
Systematic Approach – Image Quality

Image quality - Rest In Peace

 Mnemonic - RIP - Rest In Peace
 R - Rotation - Spinous processes at
midpoint between medial ends
of the clavicles?
 I - Inspiration - 5 to 7 anterior ribs
intersecting the diaphragm in the
mid-clavicular line?
 P - Penetration - Spine visible
behind the heart?
What is the basic orientation of most
X-rays and why?

 PA = Preferred - most common

 Can accurately comment on size of
heart

 AP = used for patients who are unwell,

unable to stand.
 Problem is heart appears larger (thus
unable to accurately determine
cardio-thoracic ratio, scapula appear
over lung field and clavicles appear
horizontal
What is the normal patient rotation in X-rays?

Spinous processes of thoracic vertebrae

should be:
 STRAIGHT and lie in the MIDLINE at
back of chest

 equidistant from the medial heads of

the 2 clavicles.
If patient is rotated, these processes will
lie more towards one clavicle vs the other
Rotated CXR
 Why are X-rays done in inspiration?

 Chest X-rays are generally done in inspiration

 Lung density increased in expiration as less air (lungs

appear consolidated) and diaphragm is also raised -
leads to exaggeration of heart size and obscuration of
lung bases.
How do we assess inspiration from X-rays?

SHOULD BE ABLE TO:

 Count to 10th rib posteriorly

 Count to 6th or 7th rib anteriorly

What about Exposure/Penetration?
What are the features assessed to define
whether an X-ray is good/poor coverage?

 Good: MUST have apices of lungs AND

costophrenic angles visible
 First ribs as well as lateral edges of ribs
should also be visible - need to be
able to see the entire thoracic cage
 Refer to the link below

 https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_03
 https://www.radiologymasterclass.co.uk/gallery/chest/quality/normal-chest-x-ray-male