Chest X-ray Interpretation

By: Lacey Burke, RN, BSN,

FNP-S

Know the Normal.

To have the ability to interpret chest
xrays, knowing whats normal will
help you to see when its not.

Steps to Analyze a Chest Xray

Side Marker
Projection
Patient Positioning
Rotation
Penetration
Lung Volume
Artifacts

Side Marker
Ensure correct orientation.
There have been reports of chest
drain insertion on the opposite side
to a pneumothorax because of
mislabeling.

Projection
Most films are from posterior to
anterior (PA).
X-ray source situated 1.5-1.8 m
posterior to the patient
X-ray plate positioned immediately
anterior to patients chest.

Film may be taken anterior to

posterior if the patient has difficulty
due to acute illness or general
immobility.

Patient Positioning
PA films taken with patient standing
AP films taken either standing or
sitting position
All films other than those taken PA
should be labeled with the position
Positioning is significant due to the
appearance of air, fluid and blood
vessels within the chest.

Air
Air tends to rise to the highest point
within the chest cavity.
A pneumothorax is most commonly
seen at the lung apex in the erect
position.
When the patient lies on the side
opposite to the suspected
pneumothorax, any air in the pleural
cavity will rise along the lateral chest
wall.

Fluid
Pleural fluid usually collects in the
lung base and appears dense and
opaque, obscuring adjacent
structures.
Fluid usually reaches a higher point
along the lateral chest wall than
along the mediastium= meniscus
sign.

Pulmonary Vessels

Rotation
Rotation should
be minimal.
Assessed by
looking at the
medial ends of
the clavicles.
Distance should
be equal from
the medial ends
of the clavicles
and the thoracic
spinous
processes.

Penetration
End plates of the lower thoracic
vertebral bodies should be just
visible through the cardiac shadow.
Under-penetrated: film looks diffusely
opaque
Over-penetrated: film looks diffusely
lucent. Lungs appear blacker than
usual and vascular markings are
poorly seen.

Lung Volume
To detect abnormalities-Full
inspiration
Diaphragm should be seen at the
level of the 8th-10th posterior ribs or
the right 6th anterior rib with good
inspiration
Poor inspiration- cause increased
opacification of the lungs because of
atelectasis

Artifacts
Common artifacts:
ECG stickers
Patients hair and clothing
Hospital bedding

Normal Chest X-ray

Systematic Approach

Airway
Bones
Circulation
Diaphragm
Review Areas

Airway- Large Airways, Lung,

and Pleura
Check whether trachea is midline or
deviated.
Carina lies at the T4 level on
expiration and will move to T6 on
inspiration
Right main bronchus has a steeper
angle than the left- in adults.
Lungs divided into lobes by fissures:
right lung has 3 lobes, left lung has 2
lobes.

Bones- Clavicles, Ribs, and

Spine
Assess for fractures and bone
destruction
Ribs
Clavicles
Scapulae
Spine

Ribs and intercostal spaces should be

symmetrical.

Circulation-Heart, Mediastinum, and

Vascular Markings
Knowledge of the normal anatomical
structures that form the mediastinal and
cardiac outline helps to detect abnormality.
Left: Superior to inferiorly by the left
brachiocephalic vein, aortic knuckle, left
main pulmonary artery, left atrial
appendage, and left ventricle.
Right: right brachiocephalic vein, superior
vena cava and right pulmonary artery,
right atrium and interior vena cava.

Diaphragm
Check the shape, height, and angles.
Right diaphragm: approx. 1-3 cm
higher than the left.
Look through diaphragmatic shadow
for pathology of lung bases and
pleural reflections for evidence of
pleural fluid.

Review Areas
Lines and Tubes: Chest position for complications, ex:
pneumothorax
Central Lines: pass to lower superior vena cava. Should
not enter right atrium
Pulmonary Artery Catheters: should not be wedged into
small branches
Endotracheal Tubes: Tip at least 3 cm above the carina.
Gastric Tubes: pass below the diaphragm and into
stomach
Chest drains: Check position. Tip of the tube should lie
in an effective position and not be displaced into lung
tissue.

Key Points
Silhouette Sign: Describes loss of normal lung/soft
tissue interface applied to the heart, mediastinum,
chest wall and diaphragm.
Air Bronchogram: Commonly signifies alveolar
disease and also atelectasis.
Consolidation: Result of filling of the alveoli by any
cause (Ex: fluid, pus, blood, tumor)
Pleural Effusion: Greater than 150ml must be
present for pleural effusion to be detected on chest
X-ray.

Air Bronchogram
If area of lung is consolidated, it becomes dense
and white.
If the larger airways are spared, they are
relatively low density blacker
Characteristic sign of consolidation

What is this?

Answer:

Pneumonia

What is this?

Answer:

Pneumothorax

What is this?

Answer:
Tuberculosis in the right upper
lobe

What is this?

Answer:
Total Atelectasis on RT side.

What is this?

Answer:

Pulmonary Embolism

What is this?

Answer:

Cardiomegaly

What is this?

Answer:

Pleural Effusion

What is this?

Answer

Free Air
under the diaphragm
seen in
bowel perforation

What is this?

Answer:

Congestive heart failure

Notice the numerous small
circular doughnuts that
represent fluid in bronchial walls.

Coi
n

And sometimes

O.R.
Instruments

13-cm steak
knife

Earring
Back

Resources
http://www.medscape.com/viewarticl
e/560163_3