The document provides guidance on evaluating chest x-rays. It discusses reading chest x-rays concentrically from the periphery towards the center and outlines key areas to examine, including the airway, breathing, circulation, diaphragm, soft tissues, bones, and tubes/lines. Technical factors like positioning, inspiration, and exposure quality are also reviewed. The document emphasizes examining specific zones like the retroclavicular, hilar, retrocardiac, and subdiaphragmatic areas for abnormalities and comparing findings to normal lung anatomy.

1. IN THE NAME OF GOD

2. Chest X-Ray
In Emergency Department
kavous Shahsavari Nia. MD
Emergency Medicine Specialist
Assistant professor of Emergency Medicine
Faculty of Medicine Tabriz University of Medical Sciences
Tabriz , Iran

3. Introduction
CXR: 1) Adult
2)Childeren
 Reading → Pathologic Finding → Diagnosis
 Every doctor will have a different approach to reading
chest X-rays
CXR: 1) TRUMA → ATLS → ABCDEFG
2) Internal Medicine
Chest radiographs are read « concentrically » from
the periphery towards the center

4. A B C D E F G
• OVERVIEW
• A = Airway
• B = Breathing
• C = Circulation
• D = Diaphragm
• E = Emphysema (Soft Tissues)
• F = Fracture (Bones)
• G = Tube & Lines

5. OVERVIEW
1- Name & AGE & Sex
2- Date
- important for comparing prior exams
- Serial image
3- Position markers right(R) vs. left(L)
- Gastric bubble should be on the left
- Cardiac Anatomy
4- Patients position : sitting , standing , supine
1-P-A view
2-A-P
3-A-P supine
4-Lateral (Lt/Rt)
5-Lateral decubitus (Lt/Rt)
6-Lordotic
7-Oblique(Rt/Lt; post/anterior)
‫در‬
‫انجام‬ ‫ايستاده‬ ‫حالت‬ ‫در‬ ‫سينه‬ ‫قفسه‬ ‫راديوگرافى‬ ‫بايد‬ ‫حاد‬ ‫شکم‬ ‫موارد‬ ‫تمام‬
‫شود‬
. -
5- Technical quality

6. Position
 Special position for special purpose
- PA : Anatomy reading
- AP view
- AP supine : Ambulatory limit
- Lateral (Lt/Rt)
- Lateral decubitus : Effusion or thickening
- Lordotic : Apical lesion
- Oblique :
helpful localize lesions and eliminate superimposed structures
Right anterior oblique for left side lesion
-
‫بررسی‬
‫شامل‬ ‫استاندارد‬
:
1
)
‫دو‬
‫خلفی‬ ‫عکس‬
–
‫هم‬ ‫با‬ ‫تفسيرهردو‬ ‫و‬ ‫لترال‬ ‫و‬ ‫قدامی‬
&
‫مقايسه‬
‫جديد‬ ‫با‬ ‫قديمی‬ ‫های‬ ‫عکس‬

7. PA
‫شود‬ ‫مي‬ ‫ها‬ ‫كناره‬ ‫به‬ ‫كتف‬ ‫هاي‬ ‫استخوان‬ ‫چرخيدن‬ ‫باعث‬ ‫لگن‬ ‫روي‬ ‫بر‬ ‫ها‬ ‫دست‬ ‫پشت‬ ‫دادن‬ ‫قرار‬
‫اين‬ ‫كه‬
‫هاي‬ ‫استخوان‬ ‫داخلي‬ ‫هاي‬ ‫كناره‬ ‫كه‬ ‫شود‬ ‫مي‬ ‫باعث‬ ‫كار‬
‫كتف‬
‫در‬ ‫يا‬ ‫نيفتد‬ ‫ها‬ ‫ريه‬ ‫روي‬
‫كمتري‬ ‫حد‬
‫بيف‬
‫تد‬
.

8. Lat

9. AP
AP views are less useful and should be reserved for very
ill patients who cannot stand erect (trauma, LOC, …..)

11. ‫تفاوتهای‬
PA
‫و‬
AP
•
‫بزرگی‬
‫قدامی‬ ‫ساختارهای‬ ‫ساير‬ ‫و‬ ‫قلب‬ ‫سايه‬
(
‫مدياستينوم‬
)
•
‫تشخيص‬
‫افيوژن‬ ‫و‬ ‫پنوموتوراکس‬
‫تر‬ ‫مشکل‬ ‫ريوی‬ ‫واحتقان‬
•
‫های‬ ‫سايه‬
‫مزاحم‬
(
‫مانيتور‬ ‫سيم‬
،
Back Board
)
•
‫کمتر‬ ‫نفوذپذيری‬ ‫و‬ ‫دم‬ ،‫چرخش‬
≈ 2 m

14. PA versus AP

15. Lat. decubitus
‫بررسی‬ ‫برای‬ ‫دکوپيتوس‬ ‫لترال‬ ‫وضعيت‬
:
‫پلور‬ ‫مايع‬ ‫حجم‬
‫يا‬ ‫بودن‬ ‫متحرک‬
‫لوکاليزه‬
‫بودن‬
‫افزايش‬
‫جاذبه‬ ‫اثر‬ ‫علت‬ ‫به‬ ‫گرفته‬ ‫قرار‬ ‫پايين‬ ‫ريه‬ ‫دانسيته‬

16. Technical quality
 Well centered: (Rotation?)
- Spinous process of T4 should be between the heads of the clavicle
 Exposure (penetration):
- It is affected by both the duration of exposure and the power of the beam
 Good expose: You will be able to see the thoracic vertebrae
 Over expose film looks diffusely dark and features such as lung markings
are poorly seen
 Under (poorly) expose film looks diffusely light (an x-ray is a negative)
and soft tissue structures are readily obscured (especially those behind the
heart)
 Full inspiration

18. Well centered

19. Rotation

20. Good exposure(penetrate)

21. Under exposed/Over exposed
‫آيد‬ ‫مي‬ ‫وجود‬ ‫به‬ ‫اشعه‬ ‫كم‬ ‫نفوذ‬ ‫دليل‬ ‫به‬ ‫كه‬ ‫اشكاالتي‬
:
1
-
‫شود‬ ‫نمي‬ ‫ديده‬ ‫خوبي‬ ‫به‬ ‫چپ‬ ‫ريه‬ ‫قاعده‬ ‫و‬ ‫چپ‬ ‫ديافراگم‬ ‫همي‬
.
2
-
‫نظر‬ ‫به‬ ‫تر‬ ‫برجسته‬ ‫واقعيشان‬ ‫شكل‬ ‫به‬ ‫نسبت‬ ‫ريه‬ ‫ساختاري‬ ‫عالئم‬
‫رسند‬ ‫مي‬
.
3- Soft tissue structures are readily obscured (especially those behind
the heart)

23. Good expose
small pneumothorax

24. Over expose
small pneumothorax

25. Full inspiration

26. (PA) ‫ها‬ ‫دنده‬ ‫شمارش‬

27. 
‫د‬ ،‫فيلم‬ ‫به‬ ‫خلفي‬ ‫هاي‬ ‫دنده‬ ‫به‬ ‫نسبت‬ ‫قدامي‬ ‫هاي‬ ‫دنده‬ ‫بودن‬ ‫نزديك‬ ‫دليل‬ ‫به‬
‫ر‬
‫يك‬
‫نماي‬
PA
‫سايه‬
‫تر‬ ‫شارپ‬ ً‫ال‬‫معمو‬ ‫و‬ ‫شده‬ ‫بزرگنمايي‬ ‫دچار‬ ‫كمتر‬ ‫ها‬ ‫آن‬
‫هستن‬
‫د‬
.

‫هاي‬ ‫دنده‬
1
‫و‬
2
‫عرضي‬ ‫رائده‬ ‫امتداد‬ ‫در‬
1
T
‫افتند‬ ‫مي‬ ‫هم‬ ‫روي‬
.

28. • Different tissues in our body absorb X-rays at different
extents:
• Bone - high absorption (White)
• Air - low absorption (Black)
• Tissue - somewhere in the middle absorption (Grey)
- GREY- Soft tissue/water
- DARK GREY- Fat

29. A = Airway
Trachea & Bronchi

‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬ ‫آيا‬

30. B = Breathing
Pleural Space & Lung Parenchyma

31. Pleural
 Layers: Parietal
Visceral
 Check the costophrenic angles
Margins should be sharp
‫پلور‬
:
‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬
 ‫پلور‬
:
‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬

32. Lungs
Density
Symmetry
Lesions

33. If you see nothing abnormal on the x-ray, and yet clinical
examination or history suggests otherwise, what do you do?

34. Before taking an x-ray off the monitor
you must say:
AH HA !!!

36. With your eyes, you define the 4 following target zones

37. The first target is: the retroclavicular zone
(foci of pulmonary tuberculosis, lung neoplasms, Pancoast’s tumour)

38. Right retro clavicular opacity

39. The second target is : the hilum
(density, size, abnormal opacity, lymph nodes)

40. Dermoid cyst (hilum overlay sign)

41. Bilateral hilar and mediastinal enlargement

42. The third target is: the retrocardiac region
(bronchopneumonia, atelectasis, neoplasm)

43. Bronchopneumonia in the posterior and lateral basal segments of the
LLL

44. Large hiatus hernia

45. The fourth target is: the subdiaphragmatic zone
(abdominal and abdomino-thoracic diseases)

46. Gastric ring

47. ‫آناتومی‬
‫طبيعی‬
‫ها‬ ‫ريه‬
-
‫ريه‬
‫راست‬
3
‫چپ‬ ‫ريه‬ ‫و‬ ‫لوب‬
2
‫لوب‬
-
‫ريه‬
‫مايل‬ ‫فيشر‬ ‫دو‬ ‫راست‬
(
‫اصلی‬
)
‫افقی‬ ‫و‬
(
‫کوچک‬
)
‫ماي‬ ‫فيشر‬ ‫يک‬ ‫چپ‬ ‫ريه‬ ‫و‬
‫ل‬
(
‫اصلی‬
)
-
‫ريه‬
‫راست‬
10
‫چپ‬ ‫ريه‬ ‫و‬
9
‫سگمان‬
‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫عرضي‬ ‫يا‬ ‫مينور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬
.
‫شود‬ ‫مي‬ ‫جدا‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫ريه‬ ‫تحتاني‬ ‫لوب‬
.
‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫چپ‬ ‫تحتاني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬
.
-
‫شكاف‬
،‫شود‬ ‫مي‬ ‫گسترده‬ ‫ناف‬ ‫محل‬ ‫از‬ ً‫ا‬‫دقيق‬ ‫عرضي‬ ‫يا‬ ‫مينور‬
‫به‬
ً‫ال‬‫اص‬ ‫يا‬ ‫شود‬ ‫مي‬ ‫ديده‬ ‫سختي‬
‫ديده‬
‫نمي‬
‫شود‬
.

48. Lobes
Right upper lobe:

49. Right middle lobe:
‫مياني‬ ‫لوب‬
‫مجاورت‬ ‫در‬ ‫راست‬
‫كناره‬
‫راست‬
‫قرار‬ ‫قلب‬
‫دارد‬

50. Right lower lobe:

51. Left lower lobe:

52. Lingula:

53. Left upper lobe - upper division:

54. ‫ريه‬ ‫ناف‬ ‫طبيعی؛‬ ‫آناتومی‬
•
‫ای‬ ‫مجموعه‬ ‫ريه‬ ‫ناف‬
‫از‬
:
‫ريوی‬ ‫اصلی‬ ‫های‬ ‫شريان‬
،
‫وريدهای‬
‫ها‬ ‫برونکوس‬ ‫و‬ ‫ريوی‬
•
، ‫شکل‬ ،‫سايز‬ ‫کردن‬ ‫مشخص‬
‫ريه‬ ‫ناف‬ ‫دانسيته‬
•
‫شاخه‬
‫تا‬ ‫ريوی‬ ‫شريان‬ ‫تحتانی‬ ‫لوب‬
2
-
4
‫دارد‬ ‫ادامه‬ ‫سانتيمتر‬
•
‫های‬ ‫شاخه‬ ‫حاصل‬ ‫ريه‬ ‫بافت‬ ‫طبيعی‬ ‫نمای‬
‫و‬ ‫عروقی‬
‫تا‬
1
‫جداره‬ ‫سانتيمتری‬
‫توراکس‬

55. Left Hilus higher (max 1-2.5 cm)

56. C = Circulation
Heart & Medistinum

58. Apical pleural cap
• An apical pleural cap refers to a curved density at lung apex
seen on chest radiograph
• It has relatively narrow differential diagnosis:
 Pleural thickening / scarring
secondary to previous apical infection - typically pulmonary tuberculosis
radiation fibrosis
may be present in upto 10% of radiographs
 Pancoast tumour
 Haematoma
thoracic aortic injury
fractured first rib
 Lymphoma : extending from neck or mediastinum
 Abscess within the neck / mediastinum

60. ‫مدیاستینوم‬ ‫طبیعی؛‬ ‫آناتومی‬
Define:
- Area between the lung
- Water density
Surrounded two air filled lungs and
Intersected by the air filled trachea and major bronchi
Anatomy dividing region:
1- SUPERIOR MEDIASTINUM
Begins - root of the neck and
Ends - line drawn T-4 vertebrae --- sternomanebrum junction
line skims the top of the aortic arch
2- INFERIOR MEDIASTINUM
Begins - this line End - diaphragm
Further divided into three regions:
1- Anterior
2- Middle
3- Posterior

62. Superior Mediastinum
 Retrosternal: Great vessels and branches
Thymus
 Prevertebral: Trachea
Esophagus
Thoracic duct
Sympathetic trunks
Vagus nerves

63. Inferior Mediastinum
 Anterior: Thymus, fat, lymph nodes
 Middle: Pericardium
Phrenic nerves
Pericardiacophrenic artery
Heart and great vessels
 Posterior: Esophagus
Thoracic duct
Aorta and branches
Vagus nerves
Sympathetic trunks
Azygos system of veins

64. 1- Overall size and shape
2- Trachea: position
 Mediastinum : 3- Margins (Cardiac)
4- Lines and stripes
5- Retrosternal clear space
1
-
‫توده‬ ، ‫انحراف‬ ، ‫شدن‬ ‫پهن‬
2
-
‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬
‫اگر‬
‫كنيد‬ ‫بررسي‬ ‫را‬ ‫ها‬ ‫آبنورمالي‬ ،‫نيست‬ ‫وسط‬ ‫خط‬ ‫در‬ ً‫ا‬‫دقيق‬ ‫هوايي‬ ‫راه‬
.
،‫افيوژن‬ ‫پلورال‬ ‫مثل‬
،‫پنوموتوراكس‬ ‫تنشن‬
‫آتلكتازي‬
.
‫اگر‬
‫بايد‬ ‫آن‬ ‫محل‬ ‫بايد‬ ‫دارد‬ ‫تراشه‬ ‫لوله‬ ‫بيمار‬
cm 3-4
‫باالتر‬
‫کارينا‬ ‫از‬
‫باشد‬
.
‫اصلی‬ ‫برونش‬ ‫و‬ ‫تراشه‬ ‫اطراف‬ ‫در‬ ‫آزاد‬ ‫هوای‬ ‫وجود‬
(
‫مدياستن‬ ‫پنومو‬
)
‫كارينا‬
:
‫محاذات‬ ‫در‬
T6 - T7
‫آن‬ ‫زاويه‬ ‫و‬ ‫گرفته‬ ‫قرار‬
60
‫تا‬
70
‫باشد‬ ‫می‬ ‫درجه‬
.
‫اگر‬
‫از‬ ‫بيش‬ ‫زاويه‬ ‫اين‬
90
‫باشد‬ ‫داده‬ ‫رخ‬ ‫است‬ ‫ممكن‬ ‫علت‬ ‫سه‬ ‫به‬ ،‫باشد‬ ‫درجه‬
:
1
-
‫كارينا‬ ‫زير‬ ‫در‬ ‫چپ‬ ‫دهليز‬ ‫بزرگي‬
2
-
‫وجود‬
Lymphadenopathy
3
-
‫وجود‬
‫در‬ ‫توده‬
‫مدياستن‬

66. 3-Margins

67. ‫آناتومی‬
‫و‬ ‫قلب‬ ‫طبیعی؛‬
‫آئورت‬

68. Venography

72. Cardiothoracic Ratio
‫نسبت‬
‫داخ‬ ‫لبه‬ ‫از‬ ‫سينه‬ ‫قفسه‬ ‫عرضی‬ ‫قطر‬ ‫بيشترين‬ ‫به‬ ‫قلب‬ ‫قطر‬ ‫بيشترين‬
‫دنده‬ ‫لی‬
 Greater than 50% suggests cardiac enlargement (usually CHF or
pericardial effusion)
 Remember: AP views make heart appear larger than it actually is Cardiac margins
should be sharp

73. Widened mediastinum
• Widening of the mediastinum is most often due to technical
factors such as patient positioning or the projection used.
Rotation, incomplete inspiration, or an AP view, may all
exaggerate the width of the mediastinum, as well as heart
size
• In the setting of trauma, patients are positioned supine
while a chest x-ray is acquired, very often causing the
mediastinum to appear wide spuriously
• Is a mediastinum with a measured width greater than 6 cm
on an upright PA chest X-ray or 8 cm on supine AP chest
film(at the level of the aortic knob on the best film)
• Use of cross-sections from CT and MRI will supplement
this section

74. 4- Lines and stripes:
Para tracheal /Para spinal/Para esophageal(azygo esophageal)/Para aortic
 Lines typically measure less than 1 mm in width and are
formed by air, typically within the lung, outlining thin
intervening tissue on both sides
Lines present on chest radiographs include the anterior and
posterior junction lines
 Stripes are thicker lines formed by air outlining thicker
intervening soft tissue
Stripes are seen on chest radiographs including:
L&R paratracheal stripes
posterior tracheal stripe

75. 5-Retrosternal clear space
•
‫دارد‬ ‫وجود‬ ‫چپ‬ ‫بطن‬ ‫شدن‬ ‫بزرگ‬ ‫احتمال‬ ،‫باشد‬ ‫كم‬ ‫خيلي‬ ‫فاصله‬ ‫اگر‬
.
•
‫اگر‬
‫انسدادي‬ ‫بيماري‬ ‫احتمال‬ ،‫باشد‬ ‫زياد‬ ‫خيلي‬ ‫فاصله‬
‫ريه‬
COPD
‫دارد‬ ‫وجود‬
.

76. D = Diaphragm

78. ‫قله‬
‫ديافراگم‬ ‫هاي‬
:
•
‫است‬ ‫متفاوتي‬ ‫هاي‬ ‫موقعيت‬ ‫داراي‬ ،‫تنفس‬ ‫مختلف‬ ‫مقادير‬ ‫با‬ ‫ديافراگم‬
.
•
‫كمي‬ ً‫ال‬‫معمو‬ ‫راست‬ ‫ديافراگم‬ ‫همي‬
‫باالتر‬
‫ازهمي‬
‫است‬ ‫چپ‬ ‫ديافراگم‬
(.
2
‫تا‬
3
‫متر‬ ‫سانتی‬
)
‫قلب‬ ‫آناتوميکی‬ ‫موقعيت‬ ‫و‬ ‫کبدی‬ ‫اثر‬ ‫خاطر‬ ‫به‬
•
‫شود‬ ‫می‬ ‫ديده‬ ‫راست‬ ‫ديافراگم‬ ‫تمام‬
‫چپ‬ ‫ديافراگم‬ ‫ولی‬
‫بدليل‬ ،‫خير‬
‫قلب‬ ‫اينکه‬
‫قرارمی‬ ‫ديافرگم‬ ‫روی‬
‫گيرد‬
.
•
‫زيرديافراگم‬ ‫هوای‬ ‫بررسی‬
(
‫پريتوين‬ ‫پنومو‬
)
penetrating trauma, peritonitis, recent surgery
Laparoscopy, hallow viscus perforation
•
‫ديافراگم‬ ‫رويت‬ ‫عدم‬
:
‫مايعات‬ ‫نفوذ‬ ‫يا‬ ‫افيوژن‬
•
‫ديافراگم‬ ‫دوسطح‬ ‫بيشتربين‬ ‫وت‬ ‫تفا‬
:
‫ديافراگم‬ ‫فلج‬ ، ‫کالپس‬ ، ‫افيوژن‬
•
‫کوستوفرنيک‬ ‫زاويه‬ ‫شدن‬ ‫محو‬
:
‫تومور‬ ،‫اسکار‬ ،‫هموتوراکس‬ ،‫افيوژن‬ ‫پلورال‬

80. E = Emphysema
Soft Tissues

81. Soft tissue:
• Look for subcutaneous emphysema (suggestive of trauma)
• Soft tissue swelling
• Axillary line
• Calcification
• Foreign body
• Breasts shadow

82. F = Fracture
Bones

84. Skeletal structures
Overall size, shape, contour of each bone:
- Density( mineralization)
- Compare cortical thickness to medullary cavity, trabecular pattern
- Erosions, fractures, any lytic or blastic regions
Joints:
- Articular relationships
- Joint spaces narrowed, widened
- Calcification in the cartilages
- Air in the joint space, abnormal fat pads
 Note calcified anterior cartilages may obscure or mimic
underlying lung lesions
 Compare side to side

85. Anatomy of Shoulder

89. G = Tube & Lines

90. Chest Tube, NG Tube, Pulmonary artery cath

91. ‫؟‬