This document provides guidance on reading and interpreting chest x-rays. It begins by identifying the different lung zones and providing a stepwise approach to examining a CXR, including assessing technical quality, position, inspiration, exposure, and rotation. It then describes how to systematically examine the image from center to periphery, looking at grey scale, position, size and shape of structures at each step. Common findings are described, such as consolidation, pneumothorax, cardiomegaly, and foreign bodies. Guidance is also provided on interpreting cervical spine x-rays and CT brain images in trauma.

1. CHEST X RAY

2. CONTENTS
1. Identifying lung zones
2. Stepwise approach to describe/read a
CXR.
3. Coming to a diagnosis
4. Hardware/ Equipment

3. CONCEPT OF ZONES
Anterior ribs Zones
2 - 4 UPPER zone
4 - 6 MIDDLE zone
BELOW 6 LOWER zone
Loss of normal silhouettes of structures
aid in identifying lobes involved.
E.g. Right heart border= right middle lobe

4. STEPWISE APPROACH

5. NAME, AGE, SEX & IP NO.
DATE AND TIME OF STUDY
Do this before putting it on screen..
Ramu or Gopal
Sequential improvement
or worsening

6. TECHNICAL QUALITY
P • Position
I
E •Exposure
R • Rotation

7. POSITION
AP v/s PA
ERECT V/S SUPINE
PA AP

8. INSPIRATION
5-6 ant ribs in MCL/ 8-10 posterior
ribs above diaphragm
 Lung bases appear denser
 Apparent cardiomegaly

9. EXPOSURE
Just visible Intervertebral spaces, spinous
process / T4 visible through cardiac
shadow

10. ROTATION
Medial ends of clavicle equidistant
from spinous process
 Distort Mediastinal image
 Lung lesions hidden behind mediastinum
 Lung on rotated side appear denser

11. CENTRE PERIPHERY
 Trachea & Bronchi
 Heart & Mediastinum
 Hila
 Lungs
 Pleura & angles
 Chest wall
- Diaphragm
- Soft tissue
- Bony

12. AT EACH STEP LOOK AT..
• Grey scale
• Too white/Too black?
G
• Position
• Normal/ shifted?
P
• Size/Shape
• Normal/ altered
S

13. GREY SCALE
Bones- Denser – opaque
Tissue – Air – Grey
Air – Lucent - Darker

14. GREY SCALE (LUNGS)
TOO WHITE
• Consolidation
• Collapse
• Lung mass/Nodule
• Pleural mass/fluid/
thickening
• ARDS/ Pulmonary
edema (Ground glass
appearance)
TOO BLACK
• Emphysema
• Pneumothorax

15. TOO WHITE/ TOO BLACK
 Focal/ Diffuse
 Multiple/ Solitary
 Homogenous/ Non homogenous
Signs of any surgery

16. NORMAL
Cardio-phrenic
Costo-phrenic

17. CENTRAL LINES

18. TRACHEAL TUBE POSITION
2-3 cm above the
carina
T4 vertebra
1
3
2
4

19. NASOGASTRIC TUBE
• Remains close to
midline and not
follow the path of
any of the main
bronchi.
• Crosses the
diaphragm in midline
• Tip is well below the
diaphragm

20. PACING WIRES

22. RIGHT UPPER LOBE COLLAPSE
 Opacity
 Focal – R UL
 Homogenous
 Horizontal fissure
pulled up
INDIRECT SIGNS
 Trachea pulled
ipsilaterally
 Compensatory
hyperinflation of RML
 Elevation of
hemidiaphragm

23. CONSOLIDATION RML
Opacity
Non
homogenous(Air
bronchograms)
Focal- RML

24. PNEUMOTHORAX
• Lung field - Too
black
• Visceral pleura –
white line
• No vascular marking
beyond pleural line.
• Trachea pushed to
opposite side
• Widening of the ribs

25. CARDIOMEGALY
A
B
C
A= 6 cm
B= 10 cm 0.61
C= 26 cm
CT Ratio: A+B/C
Normal < 0.5

26. BATWING APPEARANCE

27. CONGESTIVE HEART FAILIURE

28. PNEUMONECTOMY
Hemithorax opacified
Ipsilateral
mediastinal shiftContralateral lung
hyper-inflated
Absent left main
bronchus

30. DR CHARULATHA R MD
Assistant professor MGMCRI

31.  Cervical spine injury in x ray
 Level of foreign body in chest x ray
 Ct brain in trauma

32.  CERVICAL SPINE INJURY IN XRAY

33.  Spinal cord injuries -permanent paralysis
 Missed c spine fracture can lead to death or life
long neurological deficit
 3 standard views – lateral view, AP view,
odontoid peg view or open mouth view
 Lateral view is the most informative image
 Normal c spine xrays do not exclude significant
injuries

34. Step 1
Assess adequacy and
alignment
A. Identify the presence of
all seven cervical
vertebrae
B .Identify the
1. Anterior vertebral line
2. posterior spinal line
3. Spinolaminar line
4. Posterior spinous line

35. Step 2
1. Assess the bone
2. Examine all vertebrae
for preservation of
height and integrity
of bony cortex
3. Examine facets
4. Examine spinous
processes

36. Step3
1. Assess the cartilage
including examining
cartilaginous disc
spaces for narrowing
or widening

38. Step 4
 Assess the dens
 Examine the outline of
the dens
 Examine the
predental space
 Examine the clivus;it
should point to the
dens

40. Step 5
 Examine the
extraaxial space and
soft tissues
 7 mm at C3
 3 cm at C7
 Widening of extra
axial space – possible
fracture

41.  FOREIGN BODY ESOPHAGUS

42.  Nasopharynx is from base
of skull till soft palate.
 Oropharynx extends from
the plane of hard palate
above till the plane of
hyoid.
 Hypopharynx is the
lowest part of the pharynx
and lies behind and partly
on the sides of larynx.
 Cervical esophagus starts
at C6 level. Below this
level F.B is in esophagus.

43.  F.B in esophagus
usually identified as it
lies behind air
column, and there
will be prevertebral
widening.
 In this picture F.B is a
the level of
hypopharynx.

44.  Foreign bodies in
esophagus appear
face on in frontal
projection
 Foreign bodies in
trachea appear end on

46.  Coin – single shadow
 Button battery-
double density
shadow

48.  CT brain in trauma

49.  Is a diagnostic
imaging procedure
 Series of Xray images
taken from different
angles
 Processed to create
cross sectional images
of various tissues
within our body

50.  The internal structure
of an object can be
reconstructed from
multiple images of the
object

51. How to hold the film in
proper orientation ?
 Look at words on the
film
 Uppercase R and L on
the films
It is like looking at a
person from front
Anterior part of the body
on the top and posterior
part on the bottom

52. A. FALX CEREBRI
B. FRONTAL LOBE
C. BODY OF LAT.
VENT
D. CORPUS
CALLOSUM
E. PARIETAL LOBE
F. OCCIPITAL LOBE
G. SUP.SAGITTAL
SINUS

53. Hounsefield units-represents the tissue density
Represented by assigned portion of gray scale
Air ,Fat,
CSF
Black
White
matter,
gray matter
gray
Acute
hemorrhag
white

54.  Check patient and image information
 Check date and time
 Check image quality
 Scalp and skull bones
 Brain volume
 Ischemia and Hemorrhage
 Mass effect

55.  Look at old images and reports
 Check for movement artifacts and medical
artifacts
 Do not view only a single slice in isolation
 If you suspect brain stem pathology ,consider
MRI

58.  Sutures
 found in typical anatomical
locations
 Jagged in appearance and corticated
 Fracture
 passes across both inner and outer
table of the skull in a straight line
 Edges of fractured skull bones are
not corticated

59.  Extradural hematoma
 Subdural hematoma
 Subarachnoid hemorrhage

60.  Post traumatic event
 Injury to an intracranial
artery –middle
meningeal artery
 Leakage of injured
artery –collection of
blood which strips the
dura mater away from
inner table of skull
 Lens shaped collection –
dura is strongly
adherent to the skull in
the region of sutures

62.  Cerebral veins are
fragile
 Risk is increased in
elderly and
anticoagulated patients
 Not limited by
attachment points of
dura to bone
 Crescent shaped
collection
 Arachnoid is intact-so
blood does not pass into
sulci

64. Trauma or intracranial
aneursym
Blood can pass into any
part of CSF spaces-
suci,fissures,basal
cisterns and ventricles

65.  Intra axial hemorrhage -
spontaneous or traumatic
 Area of high density
material (blood)
surrounded by low
density(oedema)

67.  Assess brain volume by
assessing volume of
CSF spaces
 Cerebral oedema-
can cause the brain to
swell – generalised
reduction of CSF
volume and loss of
differentiation between
grey and white matter

68.  Can be caused by
intracranial
masses,hemorrhage and
oedema
 Effacement of sulci,
partial or complete
effacement of adjacent
ventricles
 Displacement of
midline structures
 Effacement of
contralateral ventricles
and sulci