Chest X-ray Interpretation


  • Details
    • Patient name, age/DOB, sex
    • Type of film (most PA erect, but some will be AP, supine, expiratory etc. Check also L/R marker is correct for PA/AP view)
    • Date and time of CXR (in relation to patient history/condition if available)
      • Compare to previous films if possible
  • RIPE
    • Rotation- medial clavicles are equidistant from the spinous process
    • Inspiration- should be able to visualise 5-6 anterior ribs in mid-clavicular line and 8-10 posterior ribs above the diaphragm (?poor inspiration if less; hyperexpansion if more)
    • Picture- straight vs oblique, entire lung fields, scapulae out of lung fields, angulation (excess lordosis/kyphosis)
    • Exposure (penetration)- IV disc spaces, spinous processes to T4 and L hemidiaphragm (through cardiac shadow) should all be visible
  • Soft tissues and Bones (in reality, this is commonly left until the end- but DON’T FORGET if you do leave it til later)
    • Ribs, sternum, spine, clavicles (look for symmetry, fractures, dislocations, lytic lesions, density)
    • Soft tissues (symmetry, masses, subcutaneous air/swellings
    • Breast shadows
    • Calcification e.g. of the great vessels, carotids, masses
  • Airway (& mediastinum)
    • Trachea – should be central or slightly rightly deviated as it crosses the aortic arch
    • Paratracheal/mediastinal masses/lymphadenopathy
    • Carina, right and left main bronchi
    • Mediastinal width <8cm on PA film
    • Aortic knob and Hilum (T6/7, left side usually higher and squarer than right (triangular))
  • Breathing
    • Lung fields
      • Vascularity normally extends to ~2cm of pleural space
      • Look for any pneumothorax (don’t forget apices)
      • Look for any lesions, opacities, atelectasis (collapse), consolidation, bullae
      • Remember the apices, the bases/angles
    • Pleura
    • Effusions
  • Circulation
    • Heart position and size (2/3 left and 1/3 right; total <1/2 of chest diameter)
    • Heart borders (right atrium and left atrium/ventricle)
    • Heart shape
  • Diaphragm
    • Hemidiaphragm levels (Right higher than left)
    • Shape/contour
    • Cardio/costophrenic angles (clear/sharp)
    • Gastric bubble/colonic air
  • Extras
    • E.g. lines, tubes, catheters, electrodes, metalwork, stents etc

Some tips

  • Collapse is uniform, consolidation is non-uniform (consolidation will also have air bronchograms (visible air in the bronchial tree))
  • In an effusion, look for a meniscus sign (fluid level)
  • Structures are pulled towards a collapse and away from an effusion
  • A sail sign is suggestive of left lower lobe collapse
  • Loss of the silhouette of the heart on the right border of the heart suggests right middle lobe disease (NB If the R heart border is still visible but there is an opacity adjacent to it, this may be lower lobe disease)
  • Some features of
    • COPD
      • Hyperinflation; flat hemidiaphragms; decreased lung markings; black lesions (bullae); prominent hila
    • Heart failure (ABCDE)
      • Alveolar shadowing; B-lines (interstitial oedema); Cardiomegaly; Diversion of blood to upper lobe; Effusion

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