CXR Interpretation

By Dr. Iqbal Tariq

 Introduction
 an important aspect of the assessment of the
respiratory patient.
 gives a valuable insight into the pathology
affecting the patient.
 excellent outcome measure.
 check old films for comparisons.
 radiographic improvement may lag behind
clinical improvements by a number of days
 Reading CXR
 Name and date of image
 Orientation – type of film - AP o PA, (R
or L)
 Technical quality (R.I.P)
 Look at the big picture
 Systematic analysis
 Technical Quality of film

 Rotation – medial clavicle ends equidistant

from spinous process
 Inspiration – 5-7 anterior ribs and 8-10
posterior ribs should bisect right
hemidiaphragm in MCL in full inspiration CXR
 Penetration - optimal: intervertebral spaces
are visible in the heart shadows
– Black film (over exposed)
- White film (under exposed)
 Now run through the X-ray systematically
Remember each item alphabetically from A-H as follows:

A= Airway:
Look for the shadow of the
trachea. It is seen as a
vertical radiolucent (black)
shadow located over cervical
spinous process. It should be
in midline. Any deviation is
called a tracheal shift.
 B = Bones and soft tissues

Look at the position of clavicle,

scapulae and ribs
Clavicles: level
Scapulae: retracted off the lung
fields
Ribs:Anterior ribs (red): Curve
downward towards midline
Posterior ribs (yellow):
Are more horizontal
Close together? Far apart?
fractures
Look at the soft tissues e.g for
sub cutaneous empysema
 C = Cardiac Shadow

 On a PA film the diameter of the heart is

usually less than half the total diameter of the
thorax.
 In the majority of cases, 1/3 of the cardiac
shadow lies on the right and 2/3 on the left,
which should be sharply defined.
 The density of both sides of the heart should
be equal
 The heart may appear bigger in an AP film or if
the patient is rotated
 C = Cardiac Shadow
 Sail Sign
• Left lower lobe collapse
• Won’t see curving border of the left side of the
heart and left hemi-diaphragm
 Silhouette Sign
• The absence of an adjacent heart border or hemi-
diaphragm should help indicate which lobe is
affected
 Right heart border pathologies- Right mid lobe
affected
 Right hemi-diaphragm disappears – Right lower lobe
pathology
Sail sign and Silhouette Sign
 D = Diaphragm
 The left and right diaphragm are usually seen as clearly outlined
domes
 The right diaphragm should be ~ 2-3cm higher than the left due
to the position of the liver
 The peripheral margins of the diaphragm are called the
costophrenic angles where the diaphragm meets the ribs. The
cardiophrenic angle is where the heart and the diaphragm meet
 These angles should be sharp on a full inspiratory film, otherwise
it may indicate some pathology
 Meniscal sign - blurred costophrenic angles are indicative of a
pleural effusion
 Free gas under the diaphragm indicates bowel perforation. Note
that this sign is only likely to be seen if an erect film is taken
D = Diaphragm
 E = Edges of the heart

Look for silhouette sign

 Right heart border:
Right middle lobe
 Left heart border: Left
middle lobe
 F = (Lung) Fields
 Compare R to L (upper, middle, lower zones)
 Lung Boundaries:
• should be in contact with the chest wall and diaphragm

 Vascular markings:
• should extend from mediastinum and become progressively more faint toward
the peripheries
 Fissures - only seen with pathology
 Volume loss?
 Homogenious density throughout the lungs?
• Air will be black, fluid will be white
• One shouldn’t be whiter/blacker than the other
F = Lung Fields
 G = Gastric Bubble
 Is it present & on correct (left) side?
Stomach contents are white

 Often air is visible above the contents

of stomach (black pocket) under the left
hemi-diaphragm if the patient is
standing
G = Gastric Bubble
 H = Hardware
• Comment on any lines, lead placements, tubing,
drains etc...
• Are they lying where they should be?
• All man-made equipment will have a radio-
opaque line
H = Hardware
 How to interpret abnormalities in the lung fields on
the CXR

General rule is everything is abnormal that is:

 Too white
 Too black
 Not in place

Too white:
 collapse or atelectasis
 consolidation
 pleural effusion
 pulmonary oedema.

Too black:
 pneumothorax
 COPD.