How to Read a Chest X-ray : Steps

Reading Chest X-ray is a systematic and orderly way of interpreting Roentography of Chest. Describing it in various steps makes the Doctor or student, less likely to miss findings in the X-ray.

Moreover it is also a part of MBBS / Medical course curriculum for Students around the Globe both in Basic science and Clinical Sciences.

On all X-rays check the following:

  1. Patient details-  Name , age and Complaints in Brief ( If available)
  2. Orientation, position and side description- Left, right, erect, AP -anterioposterior , PA- poserioanterior, supine, prone
  3. Additional information- inspiratory, expiratory film
  4. Rotation-  Rotated or not , Measure the distance from the medial end of each clavicle to the spinous process of  the vertebra at the same level, which should be equal in Good Xray.
  5. Adequacy of inspiration- Nine pairs of ribs should be seen posteriorly in order to consider a chest x-ray adequate in terms of inspiration
  6. Penetration- Good/Inadequate- one should barely see the thoracic vertebrae behind the heart
  7. Exposure- Adequate /Inadequate- One needs to be able to identify both costophrenic angles and lung apices.

Read the X ray in Order Either Outside to Inside or Vice-versa. Most Prefer Out to in.

8. Soft tissue

  • Look  for subcutaneous air, foreign bodies and surgical clips
  • Caution with nipple shadows, which may mimic intrapulmonary nodules
  • Compare side to side, if on both sides the “nodules” in question are in the same
  • position, then they are likely to be due to nipple shadows

 9. Bony Cage and structures

  • Check for fractures, dislocation, subluxation, osteoblastic or osteolytic lesions in clavicles, ribs, thoracic spine and humerus.

10. Trachea and Bronchi-

  • Ensure trachea is visible and in midline
  •  Trachea gets deviated away from abnormality- eg pleural effusion or tension pneumothorax
  •  Trachea gets deviated towards abnormality- eg atelectasis
  •  Trachea normally narrows at the vocal cords
  •  View the carina, angle should be between 60 –100 degrees
  •  Check for tubes, pacemaker, wires, lines foreign bodies
  •  If an endotracheal tube is in place, check the positioning, the distal tip of the tube should be 3-4cm above the carina

11.Diaphragm and Angles

  • See Costophrenic angles and Cardiophrenic angles- Normally should be sharp. Bluting denotes effussions.
  • Right hemidiaphragm- Should be higher than the left. If much higher, think of effusion, lobar collapse, diaphragmatic paralysis. If you cannot see parts of the diaphragm, consider infiltrate or effusion
  • If film is taken in erect or upright position you may see free air under the diaphragm if intraabdominal perforation is present

12.Lung Fields-

  • Normal or Hyperinflated- Count Ribs- Anterior Ribs if 7 or more visible -Hyperinflated, Posterior ribs more than 9 than hyperinflated.
  • Check for infiltrates-Identify the location of infiltrates by use of known radiological phenomena, eg loss of heart borders or of the contour of the diaphragm,Remember that right middle lobe abuts the heart, but the right lower lobe does not
  • Identify the pattern of infiltration-
    • o Interstitial pattern (reticular) versus alveolar (patchy or nodular) pattern
    • o Lobar collapse
    • o Look for air bronchograms, tram tracking, nodules, Kerley B lines
    • o Pay attention to the apices
  • Check for granulomas, tumour and pneumothorax

13.Cardia sillouhete and Mediastinum-

  • Heart size and heart borders-Appropriate or blunted, Thin rim of air around the heart, think of pneumomediastinum, Cardiomegaly – Calculate Cardiothoracic Ratio
  • Aorta- Widening, tortuosity, calcification
  • Heart valves- Calcification, valve replacements
  • SVC, IVC, azygos vein- Widening, tortuosity
  • Check for a widened mediastinum-  Mass lesions (eg tumour, lymph nodes), Inflammation (eg mediastinitis, granulomatous inflammation), Trauma and dissection (eg haematoma, aneurysm of the major mediastinal vessels)

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