Intro To CXR Reading

Introduction to
CXR
Dr. Ramish Riaz

Introduction
Chest X-Ray is one of the most frequently requested hospital

investigations.
It is readily available and inexpensive in comparison to other

imaging studies.
The basic interpretation is of utmost importance in answering

several clinical questions at hand.
It is an important tool to complement both history and initial

clinical examination.
A. Name of
Patient the
details patient
BASIC CHEST
X-RAY
INTERPRETATI
ON
Age Date
B. Quality
Image quality influences interpretation
Quality is influenced by radiographic

technique and patient factors.
First determine if the clinical question

can be answered.
Check the image for – Projection,

rotation, inspiration, penetration and
artefacts.
1. Projection
Look to see if the film is antero-posterior (AP) or postero-

anterior (PA) view
With an AP view the X-ray beam is in front the patient and the
X-Ray placed at the back, and the other way round for PA.
The standard CXR is PA but many emergency CXRs are AP.
The CXR projection has an important bearing on the

interpretation of the structures.
2. Orientation
 Identify the left/right
markings
 Identify the anatomical
structures, erect/supine.
 Do not always assume that
the heart will always be on
the left because certain
pathologies can result with
mediastinal shift,
dextrocardia can also be a
possibility.
 You do not have to solely
rely on just the CXR
markings.
3. Rotation
 Identify the medial ends of the clavicles
and select one of the thoracic vertebra

spinous processes that falls between
them.
 The medial ends of the clavicles should be
equidistant from the spinous process, if

that’s not the case then the X-Ray is
rotated.
Rotation
4. Inspiration (Degree of inspiration)
 To judge the degree of inspiration, count the number
of ribs above the diaphragm.
 The midpoint of the right hemi-diaphragm should be
between the 5th and 7th ribs anteriorly.
 The anterior end of the 6th rib should be above the
diaphragm as should the posterior end of the 10th rib.
 If more ribs are visible the patient is hyperinflated
 If fewer it indicates inadequate inspiration
 Poor inspiration will make the heart look larger, give
appearance of basal shadowing and cause the trachea
to appear deviated to the right
5. Penetration
• To check the penetration, look at the
lower part of the cardiac shadow
• The vertebral bodies should be
barely visible through the cardiac
shadow at this point.
• If they are clearly visible then the film
is over penetrated and you may miss
low density lesion.
• If you cannot see them at all then the
film is under penetrated and the lung
fields will appear falsely opaque
(white).
• The left hemidiaphragm should be
visible to the edge of the spine
• When comparing X-Rays first
determine if the level of penetration
is similar.
CHEST X-RAY ANATOMY
1. TRACHEA
 It should be central or slightly deviated to the right.
- In case of deviation decide if is due to rotation or
pathology
 View the carina, angle should be between 60 –100
degrees.
 Because it contains air, it appears darker
(blacker/radiolucent).
 Trachea normally narrows at the vocal cords (T3/T4)
2. HILAR STRUCTURES
• Also called lung root, consists of the major
bronchi and pulmonary vessels
(veins/arteries).
• The hila are not symmetrical but consist of the
same basic structures.
• The lymph nodes are also present but no
visible unless abnormal.
3. LUNGS
• The lungs occupies the largest portion of the thoracic
cavity.
• The lungs are assessed and described by dividing them
into upper, middle and lower zones.
• The lung zones do not equate to lung lobes e.g. The
lower zone on the right consists of middle and lower
lobes.
• Compare left with right.
• Compare an area of abnormality with the rest of the
lung on the same side.
• If there is any asymmetry decide which side is abnormal
4. PLEURA AND PLEURAL SPACES
• The pleura are only visible when there is an
abnormality present.
• This can be due to pleural thickening and fluid
or air accumulating in the pleural spaces.
• Lung markings should reach the thoracic wall
5. COSTOPHRENIC ANGLE AND RECESS
• The costophrenic recesses are formed by
hemidiaphragms and chest wall.
• They contain the rim of the lung bases which
lie over the dome of each hemidiaphragm.
• These angles are known as the costophrenic
angles.
• Costophrenic angles should form acute angles
that are sharp to the point.
6. HEMIDIAPHRAGM
7. HEART
• The heart lies more to the left of the thoracic
cavity.
• The heart is assessed by means of the cardio-
thoracic ratio (CTR).
• CTR = Cardiac width : Thoracic width
• CTR > 50% is abnormal – PA view only
• The left hemidiaphragm should be visible behind
the heart.
• The hemidiaphrams do not represent the lowest
point of the lungs.
8. THE MEDIASTINUM
• The mediastinum contains the heart and great vessels
(Middle mediatinum) and potential spaces in front of the
heart (anterior mediastinum), behind the heart (Posterior
mediastinum) and above the heart (superior mediastinum).
• These potential spaces are not defined on a normal CXR,
but their awareness can help in describing location of
disease processes.
• There are several structures in the superior mediastinum
that should always be checked. These include aortic
knuckle, aorto-pulmonary window and the right para-
tracheal stripe.
9. SOFT TISSUE
• Normal fat planes are clearly defined in the soft
tissues.
• They appear as smooth layers of low density (black),
between layers of relatively dense (whiter) muscles.
• Irregular low density within soft tissues may be as a
result of tracking air as a result of injury to the
airways or pleura.
• This is known as surgical emphysema and produces
the distinctive clinical sign of palpable subcutaneous
‘bubble wrap’.
10. BONES
• The most dense tissue visible on CXR.
• Look for fractures, dislocation, subluxation,
osteoblastic or osteolytic lesions etc.

APPROACH TO CXR PATHOLOGY
a. The CXR is an important tool to complement both
history and initial clinical examination.
b. Low density structures appear
dark(black/radiolucent) and high density are
whitish (opaque).
c. Abnormalities need to be described in detail.
d. Identify the most striking abnormality first.
However, once you are done with this, it is vital to
check the rest of the image.
•Lung
abnormalities
mostly present
as areas
of increased den
sity, which can
be divided into
the following
patterns:
•Consolidation
•Atelectasis
•Nodule or mass -
solitary or
multiple
•Interstitial
•Less frequuently
areas
of decreased
density are seen
as in emphysema
or lungcysts.
Describing abnormalities
Pneumonia
•The retracted visceral pleura is seen (blue arrow) which indicates that there is a pneumothorax.
•There is a horizontal line visible (yellow arrow).
Normally there are no straight lines in the human body unless when there is an air-fluid level.
This means that there is a hydro-pneumothorax.
•When a pneumothorax is small, this air-fluid level can be the only key to the diagnosis of a
pneumothorax.
Solitary Pulmonary
Nodule
•Idiopathic Pulmonary Fibrosis:
The findings on the chest film comprise volume loss and fibrotic changes in the basal lung area.
The radiographic appearance of honeycombing comprises reticular densities caused by the thick
walls of the cysts.
Whenever you see a chest film with long standing reticulation with a lower lobe and peripheral
preference also think 'UIP'.
THANK YOU

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Introduction to

Dr. Ramish Riaz

Chest X-Ray is one of the most frequently requested hospital

It is readily available and inexpensive in comparison to other

The basic interpretation is of utmost importance in answering

It is an important tool to complement both history and initial

Image quality influences interpretation

Quality is influenced by radiographic

First determine if the clinical question

Check the image for – Projection,

Look to see if the film is antero-posterior (AP) or postero-

The standard CXR is PA but many emergency CXRs are AP.

The CXR projection has an important bearing on the

and select one of the thoracic vertebra

equidistant from the spinous process, if

osteoblastic or osteolytic lesions etc.

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