1. The document provides guidance on systematically interpreting a chest x-ray by first examining the bony framework and then soft tissues, lung fields, diaphragm, mediastinum, heart, abdomen and neck. 2. Key aspects to evaluate include the lung fields, hila, diaphragm, heart size and location, mediastinal structures, and presence of any masses, infiltrates or abnormalities. 3. Anatomical structures are also described including lung lobes, fissures, and appearances on PA versus lateral views to aid localization of findings. 4. Examples of common pathologies are shown such as pneumonia, lung cancer, COPD, and cardiomegaly along with

1. Chest X-ray
Interpretation
Bucky Boaz, ARNP-C

2. Introduction
 Routinely obtained
 Pulmonary specialist consultation
 Inherent physical exam limitations
 Chest x-ray limitations
 Physical exam and chest x-ray provide
compliment

3. Essentials Before Getting
Started
 Exposure
– Overexposure
– Underexposure
 Sex of Patient
– Male
– Female

4. Essentials Before Getting
Started
 Path of x-ray beam
– PA
– AP
 Patient Position
– Upright
– Supine

5. Essentials Before Getting
Started
 Breath
– Inspiration
– Expiration

6. Systematic Approach
 Bony Framework
 Soft Tissues
 Lung Fields and Hila
 Diaphragm and Pleural Spaces
 Mediastinum and Heart
 Abdomen and Neck

7. Systematic Approach
 Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder girdle
– Clavicles

8. Systematic Approach
 Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts

9. Systematic Approach
 Lung Fields and Hila
– Hilum
 Pulmonary arteries
 Pulmonary veins
– Lungs
 Linear and fine nodular
shadows of pulmonary
vessels
– Blood vessels
– 40% obscured by other
tissue

10. Systematic Approach
 Diaphragm and
Pleural Surfaces
– Diaphragm
 Dome-shaped
 Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures

11. Systematic Approach
 Mediastinum and
Heart
– Heart size on PA
– Right side
 Inferior vena cava
 Right atrium
 Ascending aorta
 Superior vena cava

12. Systematic Approach
 Mediastinum and
Heart
– Left side
 Left ventricle
 Left atrium
 Pulmonary artery
 Aortic arch
 Subclavian artery and
vein

13. Systematic Approach
 Abdomen and Neck
– Abdomen
 Gastric bubble
 Air under diaphragm
– Neck
 Soft tissue mass
 Air bronchogram

14. Summary of Density
 Air
 Water
 Bone
 Tissue
Tissue

15. Pitfalls to Chest X-ray
Interpretation
 Poor inspiration
 Over or under penetration
 Rotation
 Forgetting the path of the x-ray beam

16. Lung Anatomy
 Trachea
 Carina
 Right and Left Pulmonary
Bronchi
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Alveolar Duct
 Alveoli

17. Lung Anatomy
 Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
 Left Lung
– Superior lobe
– Inferior lobe

18. Lung Anatomy on Chest X-ray
 PA View:
– Extensive overlap
– Lower lobes extend
high
 Lateral View:
– Extent of lower lobes

19. Lung Anatomy on Chest X-ray
 The right upper lobe
(RUL) occupies the upper
1/3 of the right lung.
 Posteriorly, the RUL is
adjacent to the first three
to five ribs.
 Anteriorly, the RUL
extends inferiorly as far as
the 4th right anterior rib

20. Lung Anatomy on Chest X-ray
 The right middle lobe
is typically the
smallest of the three,
and appears triangular
in shape, being
narrowest near the
hilum

21. Lung Anatomy on Chest X-ray
 The right lower lobe is the
largest of all three lobes,
separated from the others by
the major fissure.
 Posteriorly, the RLL extend
as far superiorly as the 6th
thoracic vertebral body, and
extends inferiorly to the
diaphragm.
 Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.

22. Lung Anatomy on Chest X-ray
 These lobes can be separated
from one another by two
fissures.
 The minor fissure separates
the RUL from the RML, and
thus represents the visceral
pleural surfaces of both of
these lobes.
 Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level of
the fourth vertebral body.

23. Lung Anatomy on Chest X-ray
 The lobar architecture
of the left lung is
slightly different than
the right.
 Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper

24. Lung Anatomy on Chest X-ray
 Left lower lobes

25. Lung Anatomy on Chest X-ray
 These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
 The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.

26. The Normal Chest X-ray
 PA View:
1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure

27. The Normal Chest X-ray
 Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space

28. The Silhouette Sign
 An intra-thoracic radio-
opacity, if in anatomic
contact with a border of
heart or aorta, will obscure
that border. An intra-
thoracic lesion not
anatomically contiguous
with a border or a normal
structure will not
obliterate that border.

29. Putting It All Together

31. Understanding Pathological
Changes
 Most disease states replace air with a
pathological process
 Each tissue reacts to injury in a predictable
fashion
 Lung injury or pathological states can be
either a generalized or localized process

32. Liquid Density
Liquid density Increased air density
Generalized Localized
Diffuse alveolar
Diffuse interstitial
Mixed
Vascular
Infiltrate
Consolidation
Cavitation
Mass
Congestion
Atelectasis
Localized airway obstruction
Diffuse airway obstruction
Emphysema
Bulla

33. Consolidation
 Lobar consolidation:
– Alveolar space filled with
inflammatory exudate
– Interstitium and
architecture remain intact
– The airway is patent
– Radiologically:
 A density corresponding to
a segment or lobe
 Airbronchogram, and
 No significant loss of lung
volume

34. Atelectasis
 Loss of air
 Obstructive atelectasis:
– No ventilation to the lobe
beyond obstruction
– Radiologically:
 Density corresponding to a
segment or lobe
 Significant loss of volume
 Compensatory
hyperinflation of normal
lungs

35. Stages of Evaluating an
Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension
 Complex problems
 Introduction of contrast medium
 CT chest
 MRI scan

36. Case 1

37. A single, 3cm relatively thin-walled cavity is noted in the left
midlung. This finding is most typical of squamous cell carcinoma
(SCC). One-third of SCC masses show cavitation

38. Case 2

39. LUL Atelectasis: Loss of heart borders/silhouetting. Notice
over inflation on unaffected lung

40. Case 3

41. Right Middle and Left Upper Lobe Pneumonia

42. Case 4

43. Cavitation:cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.

44. Cavitation

45. Case 5

46. Tuberculosis

47. Case 6

48. COPD: increase in heart diameter, flattening of the diaphragm, and
increase in the size of the retrosternal air space. In addition the
upper lobes will become hyperlucent due to destruction of the lung
tissue.

49. Chronic emphysema effect on the lungs

50. Case 7

51. Pseudotumor: fluid has filled the minor fissure creating a density that
resembles a tumor (arrow). Recall that fluid and soft tissue are
indistinguishable on plain film. Further analysis, however, reveals a
classic pleural effusion in the right pleura. Note the right lateral gutter
is blunted and the right diaphram is obscurred.

52. Case 8

53. Pneumonia:a large pneumonia consolidation in the right lower
lobe. Knowledge of lobar and segmental anatomy is important in
identifying the location of the infection

54. Case 9

55. CHF:a great deal of accentuated interstitial markings,
Curly lines, and an enlarged heart. Normally indistinct
upper lobe vessels are prominent but are also masked
by interstitial edema.

56. 24 hours after diuretic therapy

57. Case 10

58. Chest wall lesion: arising off the chest wall and not the lung

59. Case 11

60. Pleural effusion: Note loss of left hemidiaphragm. Fluid drained
via thoracentesis

61. Case 12

62. Lung Mass

63. Case 13

64. Small Pneumothorax: LUL

65. Case 15

66. Right Middle Lobe Pneumothorax: complete lobar collapse

67. Post chest tube insertion and re-expansion

68. Case 16

69. Metastatic Lung Cancer: multiple nodules seen

70. Case 17

71. Right upper lower lobe pulmonary nodule

72. Case 18

73. Tuberculosis

74. Case 19

75. Perihilar mass: Hodgkin’s disease

76. Case 20

77. Widened Mediastinum: Aortic Dissection

78. A widened mediastinum can be indicative of several pathologies
aortic aneurysm]
aortic dissection]
aortic unfolding
. Ruptured Aorta
hilar lymphadenopathy
anthrax inhalation. A widened mediastinum was found in 7 of the first 10 victims
infected by anthrax (Bacillus anthracis) in 2001
esophageal rupture - presents usually with pneumomediastinum and pleural
effusion. It is diagnosed with water soluble swallowed contrast.
mediastinal mass
mediastinitis
cardiac tamponade]
pericardial effusion
thoracic vertebrae fractures in trauma patients.

80. Primary b cell lymphoma

81. Achalasia

83. 1.Check the rotation of the film. A badly rotated film can make the mediastinum appear
widened.
2.Decide whether the enlargement is at the top, middle or bottom of the mediastinum. If at
the top it is likely to be thyroid, thymus or innominate artery. If in the middle or bottom of
the mediastinum it could be lymphadenopathy, aortic widening, dilatation of the
oesophagus or a hiatal hernia.
3.If the shadowing is at the top then look at the position of the trachea. An enlarged thyroid
will displace or narrow the trachea. This will not happen with a tortuous innominate artery
– a common finding in the elderly.
4.Look at the right side of the trachea. The white edge of the trachea should be less than 2–3
mm wide on an erect film. An increase in its width suggests either an enlarged superior vena
cava or a paratracheal mass. This rule does not apply to supine films.
5.If you suspect an enlarged thyroid then look at the outline of the shadow. A thyroid has a
well-defined outline that tends to become less clear as one moves up the neck.
6.If you suspect widening of the aorta then try and follow its outline, remembering that

87. Caudad displacement of Left Main Bronchus Rightward
deviation of trachea Rightward deviation of NG tube Caudad

89. Bronchus Intermedius Tear Presentation 2 day f/u
pneumomediastinum Chest tube Persistent pneumothorax

94. Case 21

95. Pulmonary artery stenosis with cardiomegally likely
secondary to stenosis.

96.  Look at the x-ray results :
 Diffuse spider webbing ?
 Egg-shell calcifications present ?
 Is the cardiac image obscured ?
 Are there spots on the lungs ?
 Are fractures present ?
 Fluid lines present ?

97. Left Pneumothorax

98. CWP - Black Lung

99. Flail Chest

100. Cancer - Tumor In Right Lung

101.  Chronic Obstructive Disease
 asthma
 bronchitis
 emphysema
 bronchiectasis

102.  Restrictive Lung Disease
 sarcoidosis
 tuberculosis
 pneumonia
 ARDS
 IRDS
 Valley Fever

103.  Occupational Lung Disease
 psiticosis
 byssinosis - white lung
 CWP - black lung
 silicosis
 asbestosis
 pidgeon breeders disease

104. Medical Findings
 CT scan of thorax, pelvis WNL
 CT scan of brain showed atrophy - WNL
 X-Ray of chest showed some diffuse
cloudiness in L > R - no masses