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Prelims.indd 1 21-01-2014 19:53:17
 Interpretation of
Chest X-ray

AL GRAWANY
Prelims.indd 2 21-01-2014 19:53:17
 Interpretation of
Chest X-ray
An Illustrated Companion

G Balachandran MD DNB DMRD

Associate Professor
Department of Radiology
Sri Manakula Vinayakar Medical College and Hospital
Puducherry, India

Jaypee Brothers Medical Publishers (P) Ltd

New Delhi • London • Philadelphia • Panama

AL GRAWANY
 Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]
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Phone: +44-2031708910 Phone: +1 507-301-0496
Fax: +02-03-0086180 Fax: +1 507-301-0499
Email: [email protected] Email: [email protected]
Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd
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Phone: +977-9741283608
Email: [email protected]
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2014, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily
represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of
their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the
subject matter in question. However, readers are advised to check the most current information available on procedures included
and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula,
method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all
appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage
to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice
or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright mate-
rial. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first
opportunity.
Inquiries for bulk sales may be solicited at: [email protected]
Interpretation of Chest X-ray: An Illustrated Companion
First Edition: 2014
ISBN 978-93-5152-172-3
Printed at

Prelims.indd 4 21-01-2014 19:53:18

Preface
This book is meant for all those doctors who want to gain an inside knowledge about how X-rays
are interpreted. The book is written in simple medical language so that even medical students
would be able to understand the principles of chest X-ray interpretation. There has never been
an Indian radiology book devoted exclusively to the principles of chest X-ray interpretation
and, meant for medical students.The unique feature of this book is that almost all chest X-rays
are accompanied by corresponding line diagrams, some in color, in order to make the salient
findings easy to understand. This book contains over 100 chest X-rays and similar number of
line diagrams. The book is lavishly studded with tables to enhance the knowledge of the reader.
Every effort has been made to ensure that only common diseases are dealt with. I hope and trust
that this book will cater to the needs of all medical (MBBS) students belonging to all the Indian
medical universities. The postgraduate medical students like MD general medicine and residents
in radiology will also find this book very useful.

G Balachandran

AL GRAWANY
Prelims.indd 6 21-01-2014 19:53:18
Contents

1. Introduction 1
General Introduction 1
Basic Radiography 2
Basic Principles of Chest X-ray Interpretation 9
2. Normal Chest X-Ray 12
Normal Structures Seen in Chest X-ray—A Brief Description 12
Introduction 12
The Lungs and Fissures 12
Some Useful Signs in Chest X-ray Interpretation 22
3. Lung Opacity and Lung Lucency 29
Lung Opacity 29
Introduction 29
Unilateral Lung Opacity 30
Lobar Collapse Series 37
Collapse/Atelectasis 37
Collapse of Individual Lobes 43
Hilum Based Opacity 57
Bilateral Lung Opacity 60
Lung Lucency 64
Lung Lucency—Unilateral Involving Whole Lung 64
Lung Lucency—Unilateral Involving Part of Lung 65
Bullous Emphysema 70
Bronchiectasis 70
Lung Lucency—Bilateral Copd 72
4. Diseases of the Heart 75
Criteria for a Normal Heart in Chest X-ray 75
Method of Measuring Ctr in Chest X-ray 76
How to Read X-ray Chest in Cardiology? 79
Cardiac Shape—A Guide to Congenital Heart Disease 84
Cardiac Situs—A Guide to Chd 87
Coarctation of Aorta 88
Patent Ductus Arteriosus (Pda) 89
Ventricular Septal Defect (Vsd) 90
Atrial Septal Defect (Asd) 91
Primary Pulmonary Hypertension 92
Bicuspid Aortic Valve 93
Mitral Regurgitation 95
Rheumatic Mitral Stenosis 96
Left Atrial Enlargement 98

AL GRAWANY
 viii Interpretation of Chest X-ray: An Illustrated Companion

Pericardial Effusion 98
Calcific Pericarditis 99
Dilated Cardiomyopathy 100
Congestive Heart Failure—Chf/Ccf 101
Pulmonary Edema 102
Aortic Aneurysm 103
5. Miscellaneous Lesions 105
Rib Fracture 105
Cervical Rib 106
Complete Eventration of the Right Hemidiaphragm 106
Diaphragm Rupture 108
Diaphragmatic Hernia in a Child 110
Gas Under Diaphragm 111
Chilaiditi Syndrome 112

Index 117

Prelims.indd 8 21-01-2014 19:53:18

 1
cHAPTER

Introduction

Chapter Outline

‰‰ General Introduction ‰‰ Basic Principles of Chest X-ray Interpretation

‰‰ Basic Radiography

‰‰ GENERAL INTRODUCTION
There are no great textbooks for young doctors, medical students (and, for that matter, interns)
who want to learn the basics of chest film interpretation. Radiology is not a part of curriculum,
even at medical postgraduate level. Nobody is there to teach radiology to budding doctors.
Most of the doctors just have a bird’s eye view during the rounds. As medical students and
interns you will be caring for a great number of patients on whom you will be ordering chest
X-rays. While most films will ultimately be interpreted by a radiologist, you will nevertheless
be expected to look at any film you order and you should have some comfort in making general
diagnoses in these films without having to wait for the “official read”. Many chest films are
obtained even at night, both in the Emergency Department and in the hospital. These films may
have abnormalities that are immediately life-threatening (e.g. Tension pneumothorax). Your
responsibility is to the patient, and the sooner you can make the diagnosis, the better of the
patient will be.
The goal of this book, therefore, is to attempt to simplify the process of looking at and
interpreting chest films. I will ignore some of the technical jargon and subtle details in the
interest of compacting the information into an easily-digested format. In addition, I will focus
primarily on those findings which you may encounter at night or as an emeregency or when
a radiologist may not be available to you, and on those findings which are particularly time
sensitive. Only cases which are important in day-to-day practice, of a young doctor, is included.
Chest X-ray (CXR) is one which any medical doctor would come across in his day-to-day
practice, irrespective of his speciality, designation or seniority. In casualties and emergencies,
CXR have to be interpreted by duty doctors. Chest imaging is an important tool in managing
critically ill-patients. In ICU chest radiographs are obtained routinely on a daily basis for every

AL GRAWANY
 2 Interpretation of Chest X-ray: An Illustrated Companion

critical care patient, with the goal of effective clinical management. Such is the importance of
a CXR. By learning some basic skills in interpreting and evaluating chest radiographs, junior
doctors can recognize and localize gross pathologic changes visible on a chest radiograph.
Sometimes X-rays have to be interpreted, in life-threatening situations, in which immediate
decision have to be taken. Traditionally, GPs rarely see and interpret X-rays. Learning to
interpret X-rays is a skill learned as a junior hospital doctor that should not be lost. There may
be occasions when a GP has to make decisions based on an unreported film.

‰‰ BASIC RADIOGRAPHY
X-rays have very short wavelengths of electromagnetic radiation that penetrate matter. A
traditional radiograph is created when X-rays penetrate body structure and produce images
on a piece of photographic film usually contained in a cassette. However, in most hospitals
and medical centers, the traditional X-ray film has been replaced with digital images. The
basics of chest X-ray interpretation is the same irrespective of whether it is a digital image or
conventional X-ray film.

Black and White Principles

• White color indicates lack of exposure and black color indicates intense exposure.
• Dense substances absorb all the rays and appear white on the film – radiopaque.
• Soft tissues and air absorb part of the beam and appear gray (tissues) or black (air) –
radiolucent.

Basic Chest X-ray Views

A chest X-ray is a 2D projection of a 3D thoracic viscera. Therefore, what we see in a chest
X-ray is a summated and compressed image.
Two of the most common chest radiographs are posteroanterior (PA) and anteroposterior
(AP), both taken in frontal projections.
For PA views (Fig. 1.1), the X-ray beam passes through the chest from the back to the front.
For AP views (Fig. 1.2), the beam passes through the chest from the front to the back.
By convention most of the PA views are taken with patient in erect posture and most of the
AP views are taken with patient in supine posture. For acutely ill patients who are bedridden
and who cannot stand up for a PA view, AP views are obtained with a portable X-ray machine.

Posteroanterior (pa) View vs Anteroposterior (ap) View

There are certain findings that can distinguish a supine AP from erect PA view (Table 1.1). For
e.g. PA view shows the scapulae clear of the lungs whilst in AP view they always overlap. The
clavicles are overlie the lung fields in PA view, while in AP they are usually projected above the
lung apices. The level of the diaphragm is lowest in PA view, while in AP view they are placed
higher up. Further the heart looks bigger on an AP view because of the technical magnification
In an erect film, the gastric air bubble is clearly seen in the fundus with a clear fluid level just
below the left dome of diaphragm. In a supine film, blood will flow more to the apices of the

Ch-1.indd 2 21-01-2014 18:48:13

 Introduction 3

Fig. 1.1: Patient positioning for a typical erect chest X-ray in pa view

Fig. 1.2: Patient positioning for a typical supine (bed side)

chest X-ray in ap view

lungs than when erect. Failure to appreciate this will lead to a misdiagnosis of pulmonary
congestion. The recognising a chest X-ray film as AP or PA view is of very important as the
normal anatomy significantly changes (Fig. 1.3). Therefore, doctors have to be careful about
this aspect before interpreting any abnormality.

AL GRAWANY
 4 Interpretation of Chest X-ray: An Illustrated Companion

Table 1.1 PA view and AP view in chest X-ray—a comparison

Parameter PA view (Posteroanterior) AP view (Anteroposterior)

1. Patient posture Erect (standing) Supine (lying on back)
2. Scapulae Away from lung fields Ovelie lung fields
3. Clavicle Project over lung zones Project above lung apices
4. Distinct ribs end Posterior end Anterior end
5. Patients hands Placed on hips On the sides of thorax
6. Heart magnification Minimal, negligible Moderate, significant
7. Cardiothoracic ratio Normal 1:2 Spuriously increased
8. Diaphragm Lowest level Highest level
9. Gastric air/fluid Seen Not seen, only gas seen
10. Respiratory phase Deep inspiration Mid inspiration or expiration
11. Lung expansion Maximal Restricted
12. Lung markings Normal, only lower zone vessels Crowded, upper zone vessels
prominent due to gravity unduly prominent
13. Lung volume Normal Apparently reduced

Chest Pa view erect Chest Ap view supine

Note the low diaphragm Note the highly placed diaphragm
Air-fluid level in stomach No air-fluid level in stomach
Narrow superior mediastinum Widened superior mediastinum
Normal cardiac silhouette Enlarged cardiac silhouette
Scapula away from lung zones Scapula over lung zones
Fig. 1.3: Chest X-ray for demonstrating effects of various patient positioning

Ch-1.indd 4 21-01-2014 18:48:14

 Introduction 5

Technical Factors of Viewing for Chest Radiographs

It is necessary to consider whether each of the following radiographic factors are adequate or
appropriate for proper assessment of chest radiograph findings.

Penetration
X-rays must adequately penetrate body parts to visualize the structures. Ideally, one should be
able to faintly see the thoracic spine, beyond fourth thoracic level, through the heart shadow, if
proper penetration is employed. There are two types of improper penetration—underpenetration
and overpenetration.
If you cannot clearly visualize the structures (as if it is fogged) in the chest X-ray then the
radiograph is underpenetrated or too light (Fig. 1.4A). A poorly penetrated film looks diffusely
bright and soft tissue structures are readily obscured, especially those behind the heart. In
addition, the pulmonary markings may appear more prominent than they really are and may be
interpreted as interstitial pulmonary edema or pulmonary fibrosis.
On the other hand if all thoracic vertebrae are seen, it is overpenetrated, too dark. The lung
markings may appear to be absent or decreased. It is then impossible to make the judgment that

C
Figs 1.4A to C: Chest X-ray showing differerent types of penetration
(A) Underexposure, “Too white” all vertebral bodies, not visible chances of misdiagnosis
(B) Optimal exposure, vertebral bodies just visible through the heart
(C) Overexposure, “Too dark” all vertebral bodies seen, chances of misdiagnosis

AL GRAWANY
 6 Interpretation of Chest X-ray: An Illustrated Companion

the patient has emphysema or pneumothorax. One could also miss a pulmonary nodule when
the chest radiograph is overpenetrated. An overpenetrated film looks diffusely dark and features
such as lung markings are poorly seen (Fig. 1.4C).
Both under and overpenetrated X-ray film not good for reporting.
Figure 1.4B shows optimal penetration. These man made errors of X-ray technique are
largely overcome by modern day computerized radiography (CR). Further in modern day CR
no film processing in a dark room is done. It is a filmless and dry technique.
The computer can adjust the shortcoming in radiographic technique.

Respiration
Ideally CXR should be taken with the patient in full inspiration.
The anatomical findings changes in various phases of respiratioinare shown in Table 1.2.
A CXR in full inspiration should have the diaphragm as low as possible, atleast at the level
of the sixth rib anteriorly and eighth rib posteriorly (Fig. 1.5). If one can count 10 posterior ribs
above the diaphragm, it is an excellent inspiratory film.

Fig. 1.5: Chest X-ray to assess depth of inspiration.

The X-ray shows the right dome of diaphragm at anterior
seventh rib and posterior tenth rib, indicating good
respiratory effort. (Note the medical ends of clavicles
are equidistant from midline indicating that the patient
has not been rotated.)

Ch-1.indd 6 21-01-2014 18:48:14

 Introduction 7

Table 1.2 Anatomical changes in chest in various respiratory phases seen normally

Anatomical part Inspiration Expiration

1. Superior mediastinum Normal Magnified
2. Trachea Straight May be buckled
3. Heart Normal size Magnified
4. CTR Normal Increased
5. Lungs Fully expanded Partially expanded
6. Bronchovascular markings Well spread out Crowded
7. Diaphragm Lowest Highest
8. Rib cage Anterior ends lower Anterior and posterior ends almost same level
9. Lung volume Normal Reduced

Inspiratory film Expiratory film

Fig. 1.6: Chest X-ray to show rib levels during breathing

When less than 10 ribs can be counted above the diaphragm, it is either poor inspiratory
effort or a sign of low lung volume. Low lung volume from a poor inspiration effort can crowd
and compress the lung markings, producing the impression that a lower lobe pneumonia is
present (Fig. 1.6).

Patient Rotation
While positioning the patient, any rotation patient is to be avoided. Ideally the patient is to
positioned straight with spine in midline. It can be assessed by comparing the medial ends of
the clavicles. They should be equidistant from midline as shown in Figure 1.7.
Patient rotation changes the normal thoracic anatomy, especially the mediastinum producing
spurious enlargement. Rotation means that the patient was not positioned flat on the X-ray

AL GRAWANY
 8 Interpretation of Chest X-ray: An Illustrated Companion

No patient rotation Patient rotation seen

The medical ends of clavicle are equidistant from the The medical ends of clavicle are not equidistant from
midline spinous process the midline spinous process
Fig. 1.7: Chest X-ray to show patient rotation

film, with one plane of the chest rotated compared to the plane of the film. It causes distortion
because it can make the lungs look asymmetrical and the cardiac silhouette distorted. Look
for the right and left lung fields having nearly the same diameter, and the heads of the ribs
(end of the calcified section of each rib) at the same location to the chest wall, which indicate
absence of significant rotation. If there is significant rotation, the side that has been lifted
appears narrower and denser (whiter) and the cardiac silhouette appears more in the opposite
lung field.

Patient Movement
X-rays are usually taken without any movement of patient including breath holding. Movement
blurring mars the image quality and loss of details.
Criteria for a technically good quality chest X-ray are shown in Table 1.3. The normal adult
chest X-ray findings expected are shown in Table 1.4.

Table 1.3 Criteria for a good quality chest X-ray in adults

Parameter Criteria for a good quality Comments

1. X-ray beam direction PA (posteroanterior) In all ambulant patients
2. Patient body position Erect Gravity helps lung expansion
3. Patient rotation Nil Clavicle equidistant, spine midline
4. Respiratory phase Deep inspiration Diaphragm at lowest position
5. Depth of respiration Diaphragm level Eight anterior or ten posterior ribs seen
6. Technical factors X-ray penetration/exposure Adequate so that the lower thoracic spine is
(Radiographic density) just seen through the heart shadow
7. Artifacts No blurring of image Movement artifacts mars the image quality

Ch-1.indd 8 21-01-2014 18:48:15

 Introduction 9

Table 1.4 Normal adult chest X-ray

Parameter Criteria Comments

1. Penetration Should be adequate Overpenetration – too black film
Underpenetration – too white film
Buckled indicates expiration
2. Trachea Straight, in midline, spine to be seen Altered in expiration/supine films
through it
3. Mediastinum Only 1/3 of heart seen in right of midline Altered in expiration/supine films
side and 2/3 to the left of midline
4. CTR Normally 1:2 Altered in expiration/supine films
5. Lung zones Well aerated in fully expanded lungs Altered in expiration/supine films
6. Diaphragm Right dome 2–3 cm higher than left dome. Because of heart lying on left dome
Height Anterior 8th rib or posterior 9th rib, dome Altered in expiration/supine films
Level shaped Altered in expiration/supine films
Shape
7. CP angles Sharp, acutely angled in both sides Altered in expiration/supine films

‰‰ BASIC PRINCIPLES OF Chest X-ray Interpretation

Radiographic Density
When referring to radiographic shadowing, the term ‘density’ refers to the radio-opacity of a
lesion and this will be influenced fundamentally by the degree of exposure of the film. What we
see in radiography is a measure of the optical density.
The four basic radiographic densities are (Table 1.5):
• Gas (air), which appears black or radiolucent; examples are gas or air in trachea, bronchi,
or stomach
• Fat, which appears gray or less radiolucent than air; an example subcutaneous fat
• Water (soft tissue), which appears white with slight radiopacity; examples are the heart,
blood vessels, muscle, and diaphragm
• Bone (or metal), which appears all white or completely radiopaque; examples are bones,
ribs, clavicles, etc.
Each radiograph has a continuum of shades from black to white in its images due to the way
the body structures or tissues absorb the X-ray beam. X-rays penetrate body tissues that have

Table 1.5 Basic radiographic densities as seen in cxr

Structures Radiographic appearance Examples—normal tissues Examples—abnormal tissues

1. Air Dark-black (radiolucent) Air in lungs, trachea Surgical emphysema
2. Fat Gray, less dark (less Fat in subcutaneous plane Mediastinal lipomatosis
radiolucent)
3. Water Fluid, light-white (less Muscles, blood in heart Pleural efusion
radiopaque)
4. Bone Bright-white (radiopaque) Clavicles, ribs Calcific focus

AL GRAWANY
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