THE BASICS

OF CXR
INTERPRETATION
Mir M. Alikhan, MD
Pulmonary & Critical Care Medicine
drbeen.com

Disclosures
None

All sources and credits for images will be provided at the end of this
presentation

Introduction
CXR is probably the most common imaging test
Few providers (including MDs) are comfortable interpreting
their own films
Clinical decisions are too often made based on reports
from non-clinicians
Having a systematic and repetitive approach is the key

Objectives
By the end of this lecture, the learner will be able to:
Develop an understanding of the normal CXR appearance
Assess the technical quality of a CXR
Utilize a systematic and reliable approach in CXR evaluation
Identify common CXR findings
Correlate basic CXR findings with clinical evaluation in order
to reach a diagnosis

Understanding the
Normal CXR

Is this a normal CXR?

Develop confidence with the
normal appearance
Type of CXR will have an
impact on what is
considered normal
Absence/aberration of
normal findings should raise
red flags
Know which structures
should be present or absent

Different Types of CXR

Postero-anterior (PA; standard)

Antero-posterior (AP; portable)

Patient is usually standing with

anterior chest against the x-ray plate

Patient is usually in bed and leaning

with back against the x-ray plate

X-ray beam originates from 5-6 feet

behind the patient

X-ray beam originates from 2-4 feet

in front of the patient

Beam penetrates from posterior to

anterior chest

Beam penetrates from anterior to

posterior chest

Trachea

Carina

Right PA/hilum

Aortic knob
Left PA/hilum

Heart

Diaphragm

Gastric air
bubble

Utilizing a Systematic
Approach

RIP - ABCDE - LUNGS

Assessing Technical Quality

R - rotation
I - inspiration
P - penetration

Rotation
Ideally CXR beam should be transmitted perpendicular to
the chest
Abnormal angles will distort the image by creating an
oblique view
Clavicular heads should be equidistant from vertebral
spinous processes

Inspiration
Assessment of inspiratory effort and lung volumes
Ideally 7-9 ribs should be visible
< 7 suggests poor effort by the patient and/or low lung
volumes (restrictive lung disease, atelectasis, etc.)
10 or more ribs typically suggests hyperinflation (COPD,
asthma, bronchiectasis)

Penetration
Exposure quality of the film
Over-penetration will make structures more radiolucent
which could lessen significance of opacities
Under-penetration will make structures more radioopaque
which may lead to over-calling certain findings

Evaluation of Structures

A - airway
B - bones (and soft tissues)
C - cardiac silhouette
D - diaphragm
E - everything else (hardware)

Airway
Trachea

Deviation

Caliber

Carina

Typical angle

Splaying

Mainstem and lobar bronchi

Right mainstem is more straightly aligned with trachea

Bones (and soft tissues)

Scan all bony structures

Fractures

Pins/rods/staples/wires

Thoracic cage deformities (scoliosis, etc.)

Look for foreign bodies

Cardiac
Evaluate the size and shape of the cardiac silhouette

Cardiomegaly - width of the silhouette is greater than the thoracic cage width

Can be exaggerated or over-called on AP (portable) films

Aortic knob

Left atrium

Pulmonary arteries

Shift of mediastinal structures

Cardiac borders

Pericardial effusion

Diaphragm
Diaphragmatic line should be clearly demarcated
Evaluate costophrenic and cardiophrenic angles
Retrocardiac space
Elevation or flattening of the hemidiaphragms
Also look at structures immediately beneath diaphragm (liver, gastric bubble,
free air in the abdomen)
Things that obscure the diaphragm:

Pleural effusion

Atelectasis

Lower lobe infiltrates or mass

Everything Else (Hardware)

Endotracheal tube

Tip should be 2-4 cm from the carina

Central line

Tip of catheter should lie in the cavo-atrial junction

Pacemaker or defibrillator

Know how to tell the difference

Leads can be placed in the atria or ventricles

Chest tubes

Always identify the sentinel hole to make sure it is within the pleural space

Lungs
Make a conscious effort to evaluate the lung parenchyma
last!!
Look at each side independently and then compare the
two sides
Point out features that seem abnormal
Always describe before diagnosing!

Lungs
Common descriptive terms

Opacities/Infiltrates

Mass/Nodule

Defining the descriptions

Consolidation

Effusion

Atelectasis

Edema

Fibrosis

Lungs
Opacities

Something which appears relatively radio-opaque compared to normal lung

Alveolar opacity

Interstitial opacity

Mass/Nodule

Discrete appearance with apparent borders

Nodule < 3 cm

Can be pleural-based or parenchymal

Lungs
Consolidation

Focal confluence of alveolar opacities

Air bronchograms
Obliteration of vessels

Atelectasis vs. Effusion

Look for discrete lines or lobar distribution for atelectasis

Effusions are usually dependent which causes gradation from base upwards

Edema

Alveolar vs. Interstitial patterns

Fibrosis

Septal thickening
Honeycombing

Clinical Correlations

A Common Radiology Report ...

The lung fields demonstrate non-specific hazy, discrete
interstitial and alveolar infiltrates or opacities that could
represent any of the following: consolidation, effusion,
atelectasis, or mass. These findings could suggest
pneumonia, lung malignancy, or absolutely nothing.
Please correlate clinically.

Case #1
60 y/o M with recent pneumonia returns with severe shortness of breath and
cough. Also complains of L-sided chest pain when taking a breath.
T 101.3

HR 115

BP 120/70

RR 30

O2Sat 87%

Exam: tachypneic, diminished breath sounds in L hemithorax

Labs: WBC 21.2

BUN 28

Cr 1.4

Case #1
What is the most likely diagnosis?
A) Recurrent pneumonia
B)

Mucus plugging leading to atelectasis

C)

Parapneumonic pleural effusion

D)

Hemothorax

E)

Tension pneumothorax

Case #1
What is the most likely diagnosis?
A) Recurrent pneumonia
B)

Mucus plugging leading to atelectasis

C)

Parapneumonic pleural effusion

D)

Hemothorax

E)

Tension pneumothorax

Case #2
68 y/o male with history of smoking presents with intermittent night sweats, weight
loss, and hemoptysis.
T 99.0

HR 96

BP 118/80

RR 18

O2Sat 98%

Exam: no distress; breath sounds clear bilaterally

Labs:

WBC 11.5

Hgb 9.5

Case #2
What is the most likely diagnosis?
A) Aspergilloma
B)

Tuberculosis

C)

Lung adenocarcinoma

D)

Sarcoidosis

Case #2
What is the most likely diagnosis?
A) Aspergilloma
B)

Tuberculosis

C)

Lung adenocarcinoma

D)

Sarcoidosis

Case #3
42 y/o male with history of CAD presents with sudden onset of chest pain and
severe shortness of breath. The pain radiates to the back and he finds it hard to
take a deep breath. He also was in a car accident 2 days ago and has been under
a lot of stress.
T 98.0

HR 130 BP 85/50

RR 35

O2Sat 80%

Exam: severe resp distress, diminished breath sounds, mild tracheal deviation
Labs: WBC 14.5
EKG: sinus tachycardia, T wave inversions

Case #3
What is the most likely diagnosis?
A) Aspiration pneumonia
B)

Myocardial infarction

C)

Aortic dissection

D)

Hemothorax

E)

Tension pneumothorax

Case #3
What is the most likely diagnosis?
A) Aspiration pneumonia
B)

Myocardial infarction

C)

Aortic dissection

D)

Hemothorax

E)

Tension pneumothorax

Case #4
What do you think of this CXR?
A) Lobar pneumonia
B)

Atelectasis

C)

Pleural effusion

D)

Cardiomegaly

Case #4
What do you think of this CXR?
A) Lobar pneumonia
B)

Atelectasis

C)

Pleural effusion

D)

Cardiomegaly

Case #5
40 y/o male with recent influenza infection presenting with shortness of breath,
recurrent fever, cough, and yellow-green sputum production.
T 102.3 HR 110

BP 105/65 RR 24

O2Sat 93%

Exam: diminished breath sounds and some scattered crackles/rhonchi

Labs: WBC 22.5 BUN 30 Cr 1.6

BNP 45

Case #5
What is the most likely diagnosis?
A) Pleural effusion
B)

Pulmonary edema

C)

Multifocal pneumonia

D)

Atelectasis due to mucus plugging

E)

Interstitial lung disease

Case #5
What is the most likely diagnosis?
A) Pleural effusion
B)

Pulmonary edema

C)

Multifocal pneumonia

D)

Atelectasis due to mucus plugging

E)

Interstitial lung disease

Case #6
70 y/o male with history of ETOH abuse is admitted with acute pancreatitis. He is
admitted to the hospital for aggressive IV fluid resuscitation and pain control. Over
the next 24 hours he develops worsening respiratory distress?
T 100.2 HR 120 BP 160/95

RR 35

O2Sat 86%

Exam: diaphoretic, tachypneic, inspiratory crackles in lower lung fields

Case #6
What is the most likely diagnosis?
A) Hospital-acquired pneumonia
B)

ARDS

C)

Myocardial infarction leading to pulmonary edema

D)

Aspiration pneumonitis

Case #6
What is the most likely diagnosis?
A) Hospital-acquired pneumonia
B)

ARDS

C)

Myocardial infarction leading to pulmonary edema

D)

Aspiration pneumonitis

Summary
Look at all your films - even the normal ones
Use a repetitive & reliable system to avoid missing details
RIP - ABCDE - LUNGS
Describe findings first before considering a diagnosis
Clinical correlation is ALWAYS necessary to arrive at a
diagnosis

Sources

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Extras!!