CXR Interpretation

Chest X-ray Interpretation

https://litfl.com/drsabcde-of-cxr-interpretation/

Details - Before you even begin interpreting a CXR you should have the correct details. This includes;

  • Patient name, age / DOB, sex

  • Type of film – PA or AP, erect or supine, correct L/R marker, inspiratory/expiratory series

  • Date and time of study

RIPE - Next up, how “ripe” is the image. That is, what is the technical quality of the film?

  • Rotation – medial clavicle ends equidistant from spinous process

  • Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?, hyperexpanded?

  • Picture – straight vs oblique, entire lung fields, scapulae outside lung fields, angulation (ie ’tilt’ in vertical plane)

  • Exposure (Penetration) – IV disc spaces, spinous processes to ~T4, L) hemidiaphragm visible through cardiac shadow.

Soft Tissue and Bones - In CXR interpretation it is common to leave soft tissues until the end.

  • Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density

  • Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses

  • Breast shadows

  • Calcification – great vessels, carotids

Airway and Mediastinum - Trachea – central or slightly to right lung as crosses aortic arch

  • Paratracheal/mediastinal masses or adenopathy

  • Carina & RMB/LMB

  • Mediastinal width <8cm on PA film

  • Aortic knob

  • Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.

  • Check vessels, calcification.

Breathing - Lung Fields:

  • Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices

  • Pneumothorax – don’t forget apices

  • Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae

  • Horizontal fissure on Right Lung

  • Pulmonary infiltrates – interstitial vs alveolar pattern

  • Coin lesions

  • Cavitary lesions

Pleura

  • Pleural reflections

  • Pleural thickening

Circulation - Heart position –⅔ to left, ⅓ to right

  • Heart size – measure cardiothoracic ratio on PA film (normal <0.5)

  • Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium

  • Heart shape

  • Aortic stripe

Diaphragm -

  • Hemidiaphragm levels – Right Lung higher than Left Lung (~2.5cm / 1 intercostal space)

  • Diaphragm shape/contour

  • Cardiophrenic and costophrenic angles – clear and sharp

  • Gastric bubble / colonic air

  • Subdiaphragmatic air (pneumoperitoneum)

Extras - ETT, CVP line, NG tube, PA catheters

  • ECG electrodes, PICC line, chest tube

  • PPM, AIDC, metalwork