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Chest X-Ray Review. SYMPTOMS : Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath S/P fall. Why order a CXR?. Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB. Lung cancer Chest pain (MI?)

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why order a cxr

Bad or persistent cough

Chest pain

Chest injury

Coughing up blood


Shortness of breath

S/P fall

Why order a CXR?
why order a cxr3
Pleural effusion



Pulmonary embolus


Monitoring chest drainage


Lung cancer

Chest pain (MI?)






Why order a CXR?
normal chest x ray
Normal Chest X-Ray

Compare symmetry

Review organs (bones, lungs, heart) in sequence

Left to Right then… Top to Bottom

Random free search

Recognition of abnormal first requires knowledge of normal. Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.

chest x ray findings
Chest X-RayFindings
  • Is heart enlarged or normal?
  • Signs of heart failure and fluid overload?
  • Does patient have pneumonia or collapsed lung?
  • Is there evidence of emphysema?
  • Are there findings of an aortic aneurysm?
  • Is there fluid in the sac that surrounds the lung?
  • Is there free air under the diaphragm?
  • Is there a tumor in the lung that could represent cancer?
the normal chest x ray
Systematically evaluate chest wall, mediastinum, lungs, pleural space, heart, large arteries, ribs & diaphragm.

Also evaluate neck, axilla, thyroid gland & abdomen

The Normal Chest X-Ray

What does air under diaphragm signify?

What is best position for this diagnosis?

the normal chest x ray7
You can recognize air, water & bone density on chest x-ray

Lung fields appear dark because of air.

99% of the lung is air.

The Normal Chest X-Ray
the normal chest x ray8
The pulmonary vasculature, interstitial space, constitutes 1% of the lung

Gives a lacy lung pattern.

Most disease states replace air with a pathological process which usually is a liquid density and appears white.

The Normal Chest X-Ray
poor quality cxr
Supine position

Decreases lung volume, increased heart size

Basilar infiltrates & interstitial spaces accentuated

Increases venous return to the heart

Semi-upright position

Enlarges normal structures

Changes air-fluid levels

Failure to hold breath

Lung structures & diaphragm blurred

Expiration film

Basilar infiltrates & interstitial spaces accentuated

Increased heart size

Poor Quality CXR
missed diagnoses
What is wrong with this lung tissue???Missed Diagnoses

10% of all x-ray interpretations have errors


But the clavicle is fractured!

Especially if there are multiple problems, don’t focus on the most obvious abnormality!

systematic cxr interpretation

Correct patient

Correct date & time

Correct examination

Right vs. Left side

Comparison film


Complete exam?

All views

Entire anatomical area included?


Is the film AP or PA?

The width of heart & mediastinum larger on AP film


Systematic CXR Interpretation
systematic cxr interpretation12


Over-penetrated dark films can obscure subtle pathologies

Under-penetrated white films may given impression of diffuse increased density

Systematic CXR Interpretation
  • TECHNIQUE, cont.
    • Inspiration
      • Normal, erect, inspiratory CXR shows 9.5-10.5 ribs.
      • Less inspiration appears diffusely denser
      • Diaphragms elevated causing heart & mediastinum to appear enlarged
systematic cxr interpretation13
Systematic CXR Interpretation
  • Order of exam is important.
  • Start with "less significant"
  • Tendency to stop looking as soon as find pathology
  • Identify atelectasis behind heart shadow!
  • Don’t notice tip of ET tube is in right main stem bronchus, causing the atelectasis!
systematic cxr interpretation14
Systematic CXR Interpretation
  • TECHNIQUE, cont.
    • Rotation
      • Determined by distance between spinous process & medial clavicle
      • Affects heart size & shape, aortic tortuosity, mediastinal widening, density of lung fields
systematic cxr interpretation15
Systematic CXR Interpretation
    • Extraneous material
      • Contrast
      • Lines, tubes, clips
      • All properly located?
    • Soft tissues
      • Asymmetry
      • Calcifications
    • Diaphragms & Below
      • Free air
      • Dilated bowel
      • Abnormal position
    • Bones
      • Fracture, dislocation
      • Mineralization
    • Lung fields
      • Asymmetry
      • Consolidation
      • Nodules, lesions
    • Heart
      • Size & shape
      • Cardiothoracic ratio
systematic cxr interpretation16
Systematic CXR Interpretation
    • Pulmonary vascularity
      • Taper at periphery
      • Narrow toward upper lobes with erect film
      • Asymmetry
    • Interstitial markings
      • Very fine
      • If indistinct, prominent suspect edema, fibrosis
    • Mediastinum
      • Width
      • Masses
      • Contour
    • Hila
      • Asymmetry
      • Vessel aneurysm
      • Trachea & carina
  • Alveolar space filled with inflammatory exudate
    • WBC, bacteria, plasma, and debris
congestive heart failure
Congestive Heart Failure
  • Increased heart size: cardiothoracic ratio >0.5
  • Large hila with indistinct markings
  • Fluid in interlobar fissures
  • Pleural effusions, alveolar edema
  • Congestion
  • Interstitial and alveolar edema
  • Collapsed or distended alveoli
  • Bilateral
  • Granulomatous Inflammation
  • Bilateral & symmetrical hilar & mediastinal LAD
  • Generalized fibrosis
  • No ventilation to lobe beyond the obstruction
  • Trapped air absorbed by pulmonary circulation
  • Segmental/lobar density
  • Compensatory hyper-inflation of normal lungs.