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CHAPTER
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41
he chest x-ray is the most commonly performed
T
diagnostic x-ray examination. It is performed to
evaluate the lungs, heart, and chest wall. A chest image is typically the rst imaging test used to help diagnose symptoms such as shortness of breath, persistent cough, trauma, chest pain, and fever. Chest images
are also used to diagnose and monitor conditions
such as pneumonia, lung cancer, and congestive heart
failure.
Chest X-Ray
DIAGNOSTIC REASONING: VIEWING
THE CHEST IMAGE
What are the rst steps in reviewing an image?
Key Questions (to self)
l
Do the images being examined belong to the correct
patient?
l
Do I have two views of the area being examined?
l
Is the image correctly displayed on the view box?
l
Are the images of good quality?
l
Do I have any old x-rays available?
l
Do I know the anatomy of the chest?
Identification of Image and Patient
Before viewing an image it is important to verify that
the image being viewed is from the patient being
evaluated. Pertinent information about the patient
should be found on the image in the upper corner and
should be veried.
Views
Frontal and Lateral Views
Generally, two images are taken when a chest x-ray is
requested. One is a frontal view; it is usually a posteroanterior (PA) view, where the patient is standing
6 feet from the cassette and the image is taken from
back (posterior) to front (anterior) (Figure 41-1, A).
A second image is the lateral view (Figure 41-1, B),
where the patient is standing with the hands held
above the head and the lateral thorax is against the
cassette. A left lateral view (where the left thorax is
against the image cassette) is usually ordered instead
of a right lateral view because it provides a better view
of the area behind the heart and the bases of the lower
lungs. Additional views are occasionally ordered for
specic reasons.
Anteroposterior (AP) Chest Image
The AP view is created when the beam passes from
the anterior to the posterior surface of the chest
and then onto the image. These images are usually
ordered for patients who are conned to bed or who
cannot stand. Infants have a single supine AP image and
EVIDENCE-BASED PRACTICE
The National Lung Screening Trial, a randomized trial conducted under the auspices of the National Cancer Institute,
compared annual screening by low-dose chest computed tomography (LDCT) scanning with chest x-ray for 3 years in 53,454
high-risk persons at 33 medical centers in the United States.
The results showed that LDCT screening was significantly more
Data from National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al: Reduced lung-cancer mortality with low-dose computed
tomographic screening, N Engl J Med 365:395, 2011.
Is a Chest X-Ray a Good Screening for Lung Cancer?
sensitive than chest x-ray for identifying small, asymptomatic
lung cancers. Chest x-ray screening does not reduce mortality
from lung cancer, although the data in women are limited.
The authors concluded that plain chest x-ray screening is
ineffective for lung cancer screening and is not recommend
for such screening.
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Chapter 41 • Chest X-Ray
R
A
FIGURE 41-1 A, A patient positioned for a posteroanterior projection of the chest. B, Proper patient position for a left lateral chest view.
Note the left side of the patient is placed against the image receptor. (From Ballinger PW, Frank ED: Merrill’s atlas of radiographic posi-
tions and radiographic procedures, ed. 10, vol 1, St. Louis, 2003, Mosby.)
an erect AP is used with toddlers. Once a child is old
enough to cooperate, a PA image is also taken. When
viewing the AP images, the heart and mediastinum
L
B
used for examining the trachea. Oblique images can be
right or left obliques. In a right oblique, the patient’s
anterior right side is against the image cassette.
appear larger because they are located in the anterior
chest, and in this position the chest is farther from the
image cassette.
Lordotic Image
The lordotic image identies right and left middle lung
elds. The x-ray machine is tilted to a 45-degree angle.
Expiration Image
An expiration image is ordered when a pneumothorax is suspected. A maximum expiration by the
This position offers a better view of lung apices that
can otherwise be obscured by clavicles and upper ribs
on the PA view.
patient will cause the lung tissue to compress. The
lung tissue is then compared with the pleural air.
With a pneumothorax, the pleural air will occupy
more space.
Image Box Placement
Place the PA image on the lighted view box with the
patient’s left side facing the reader’s right side. The
image is labeled with an R or L. If there is no labeling,
Lateral Decubitus Image
The lateral decubitus view is used to assess uid and
air levels in the pleural spaces. The patient is lying on
his or her side with the image cassette upright against
the patient’s chest. The beam is sent perpendicular
to the image cassette. Air rises and uid falls to the
dependent area.
look for the aortic arch. The arch is the rst bump seen
on the image and is on the patient’s left or the viewing
clinician’s right. In the rare patient with dextrocardia,
the reverse is true. The left lateral image should be
placed on the view box such that the left side of the
patient is facing the reader.
Digital imaging is being increasingly used to obtain
x-rays. The advantage of digital images is the ability to
Oblique Image
The oblique image is used to distinguish anterior from
posterior lesions by avoiding bony structures. It is also
manipulate the images. The technique also allows for
easier storage and the ability to send electronic images
to consultants.
SCAPULA
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AXILLARY
FOLD
Chapter 41 • Chest X-Ray
7
481
A
FIGURE 41-2 Normal PA image. A, Unlabeled. B, A diagrammatic overlay showing the normal anatomic structures numbered or labeled:
1, trachea; 2, right main bronchus; 3, left main bronchus; 4, left pulmonary artery; 5, right upper lobe pulmonary artery; 6, right interlobar artery; 7, right lower and middle lobe vein; 8, aortic arch; 9, superior vena cava; 10, azygos vein. (From Fraser R: Fraser and Paré’s
diagnosis of diseases of the chest, ed. 4, vol. 1, Philadelphia, 1999, Saunders.)
Image Quality
The number of x-rays beamed through the patient onto
the image affects the details seen on the image. If not
enough beams were delivered, the image will be under-
B
Previous X-Rays
Comparison x-rays are often important when viewing
newer images side by side. View the older PA x-ray
rst, then the newer image.
exposed and appear lighter than normal. If too many
beams were delivered, the image will become overexposed and will be darker than normal. On the PA view,
thoracic vertebral bodies should be barely visible
through the heart shadow; on the lateral view, the spinal bodies should be visible.
To obtain a good chest image, the x-ray is taken
with the patient in full inspiration. If the image is taken
on expiration or poor inspiration, the heart appears
larger and the lungs look cloudy. The 10 posterior
Reviewing Anatomy
Reviewing the normal anatomy of the structures of the
chest is helpful when learning how to interpret a chest
image.
Superimposing the anatomy onto a chest image will
help to correlate the normal structures to the shadows
(Figure 41-2). An infant’s chest is more triangular shaped
and deeper when seen on the AP lm. As the child grows,
the chest will take on a more adult appearance.
ribs above the diaphragm should be evident in a good
quality image.
What approach should be used when viewing an image?
The angle of the beam should be direct and the
patient should be positioned properly. If the patient is
at an improper angle, the beam will be more scattered
and details will be lost. To determine if the patient is
Key Questions (to self)
l
What is your initial impression?
l
Are you using a systematic examination technique?
positioned correctly, note the clavicles. The medial
heads of the clavicles should be positioned over the
spine. If the heads are not centered, alignment may not
be correct, causing the image to be slightly oblique.
The costophrenic angle and the lateral lung elds
should be visible.
Children frequently rotate when being x-rayed,
which may cause the lm to be misinterpreted. Note
that both clavicles are equal in length and the trachea
is straight.
Initial Impression
Most clinicians view images initially by standing 6 to
8 feet from the image and giving the image a once-over
glance. This is to observe for any obvious abnormality
as well as to obtain an overall impression of the thorax
for size, shape, and symmetry.
Systematic examination of the image after an initial overview is mandatory. All parts of the chest
anatomy are evaluated at 2 to 4 feet from the image,
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Chapter 41 • Chest X-Ray
concentrating on one part of the image at a time, to
observe any abnormalities. A suggested systematic
examination follows.
DIAGNOSTIC REASONING: SYSTEMATIC
EXAMINATION
How do I assess the PA view?
Soft Tissue
Examine the periphery of the image to evaluate the
amount of soft tissue present (for obesity or cachexia),
calcications, or gas collections indicating subcutaneous emphysema. Note the presence of breasts in female
patients. Be aware that breast tissue may cover the
lower lung elds.
Trachea
Located in the anterior mediastinum, the trachea should
be checked for size and position. The trachea will appear
deviated in a rotated patient. Abnormal pathological
deviations may be a result of pressure on the mediastinum, including tumors, pneumothorax, or emphysema.
A mass will push the trachea away from midline. The
trachea will deviate toward a large pneumothorax and
away from a tension pneumothorax. Thickening of the
trachea may indicate lymph node enlargement or an
upper mediastinal tumor.
Clavicles
The clavicles should be present and symmetrical and
located at the second and third intercostal spaces. Scrutinize for fracture lines, which appear black on the
image because of air space surrounded by white bone
and tissue.
Bony Thorax
Note the size and shape of the thorax. Scoliosis is visible on the frontal image, whereas kyphosis and funnel
chest are best seen on the lateral view. Examine individual shoulder girdles for shape, size, and contour.
Bony structures are evaluated for deformity, mineralization, density, and cortical thickness, as well as for
fractures.
Scapulae
The distance between the scapulae is increased when
the shoulders are rotated forward in the PA image. This
position also ensures that the scapulae will be out of
the way so the lung elds can be observed. Observe for
fractures and symmetry.
Thoracic Spine
Look through the mediastinum and lungs to view the
spine and observe for symmetry of the rib cage. Vertebral evaluation is best done on the lateral image. Look
for compression fractures, height of vertebral bodies,
disk spaces, and density of bones.
Ribs and Intercostal Spaces
Count the posterior ribs; 10 should be visible. If eight or
fewer ribs are visible, this is either a poor image or an
expiratory image. Be careful to begin the rib count at the
rst thoracic vertebra. Locate the anterior end of the rst
rib just below the medial end of the clavicles, follow
it back to its posterior end, and start counting ribs
(Figure 41-3). The posterior ribs are more superior than
the anterior ribs. Check ribs side to side and completely
to the lateral end. Most fractures occur on the lateral
parts of the ribs. Normal ribs appear sloped at the edges;
ribs that are horizontal or attened indicate emphysema
or chronic obstructive pulmonary disease (COPD).
Describe abnormalities using ribs or interspaces as
location markers horizontally and chest lines as vertical markers. Interspaces are numbered using the posterior rib and according to the rib above. Observe the
widths of the intercostal spaces, which should be equal
bilaterally.
Decreased lung volume narrows the intercostal
spaces. Conditions that cause this include interstitial
brosis (bilateral) or a foreign body (unilateral).
1
2
3
4
5
6
7
8
9
10
11
FIGURE 41-3 Respiratory lung movement. Full expiration with the
ribs numbered. The anterior ribs are labeled with a suffix. (From
Ballinger PW, Frank ED: Merrill’s atlas of radiographic positions
and radiologic procedures, ed. 10, St. Louis, 2003, Mosby.)
2A
3A
4A
5A
6A
7A
8A
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Increased lung volume increases the intercostal spaces
in such conditions as asthma and COPD.
Diaphragm
The diaphragm separates the abdominal contents from
the pleural cavity. Any changes in these areas can be
seen radiographically to affect the diaphragm. Count
down the posterior ribs near the spine; the diaphragm
should be at the tenth or eleventh rib. The diaphragm
should have a curve that is shaped upward. The right
side is usually higher (1 to 2 cm) than the left because
the liver is located under the right hemidiaphragm; this
will be more visible on a lateral image of the diaphragm. Note if the diaphragm is elevated or attened.
In an infant the diaphragm is higher.
Suspect hepatomegaly in patients who have marked
asymmetry of the right diaphragm. A unilateral elevation of the diaphragm is seen with a pneumothorax.
Patients who do not take a deep breath, who have
ascites or intestinal obstruction, or who are in the third
trimester of pregnancy will have elevated diaphragms.
A diaphragm that is low and at indicates enlarged
structures within the thorax, as seen in COPD.
Note any free air in the peritoneum visible below
the right lower diaphragm edge. The air appears as
lucency (decreased opacity) under the crescent of the
hemidiaphragm, typically as result of a perforated
viscus.
Costophrenic Angle
The edge of the diaphragm curves downward at the
costophrenic junction, meeting the ribs and forming an
angle that is sometimes referred to as the letter “V” on
its side. This angle should be sharp. Blunting of the
angle is caused by pleural effusion, pneumonia, neoplasm, or bros (Figure 41-4). In an infant the costophrenic angles are shallower.
Air-filled
trachea
Apex
Aortic
arch
Lung
Heart
Diaphragm
Costophrenic
angle
FIGURE 41-4 Normal costophrenic angle. (From Ballinger PW,
Frank ED: Merrill’s atlas of radiographic positions and radiologic
procedures, ed. 10, vol. 1, St Louis, 2003, Mosby.)
A prominent structure is the aortic arch (Figure 41-5).
The arch is the rst prominent bulge along the left mediastinal border. Assess for size and length. As patients
age, the aorta increases in thickness and length. An increase in size is also seen in an aortic aneurysm.
The ascending aorta is the small bulge on the right.
The infant has a large thymus gland, which is seen as a
shadow called the “sail.” The shadow is caused by the
margins of the thymus tissues in the intercostal space.
The thymus appears less as the child ages (Figure 41-6).
Hilar Area
The hilar area contains the roots of the lungs and is
where the major bronchi and pulmonary vessels project outward.
Gastric Air Bubble
The gastric air bubble should always be on the examiner’s right side as the image is viewed (the patient’s
left side). The stomach lies close beneath the left diaphragm. The liver, spleen, and kidneys are occasionally visible and should be noted for size.
Mediastinum
The mediastinum is located between the sternum anteriorly, the vertebral bodies posteriorly, and the lungs
laterally. It encompasses a number of structures including the heart and its large vessels, as well as the trachea, thymus, and lymph nodes.
FIGURE 41-5 The normal cardiac-thoracic ratio is 1:2.
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FIGURE 41-6 The classic thymic sail sign (arrows). (From Alves
N, Sousa M: Images in pediatrics: The thymic sail sign and thymic wave sign. Eur J Pediatr 172:133, 2013.)
Chapter 41 • Chest X-Ray
Note the size of the hilar area. Increased fullness or
size generally indicates lymphoma, metastatic carcinoma, tuberculosis, or fungal (Histoplasma sp.) adenopathy.
Pulmonary Vasculature
Pulmonary arteries become smaller as they progress
out to the chest periphery, ending approximately
1.5 cm from the pleural surface. Normal markings
extend approximately one third of the way into the
lung elds.
Increased pulmonary pressure causes engorgement
of the pulmonary vessels, and increased markings that
resemble a branching tree are seen. When engorgement
occurs, a buttery appearance is seen. Pulmonary
edema causes blurred borders and hilar clouding.
Pleura
Follow the pleura around the lungs and note any thickening, calcication, effusion, or pneumothorax.
Pleural thickening is seen as increased soft tissue
around the periphery of the lung. An effusion will blunt
the costophrenic angle. A pneumothorax will pull the
visceral pleura into the lung eld, away from the chest
wall.
Lungs
Examine the lungs from central to peripheral. The
lungs will appear whiter when looking from top to bottom because of the increasing thickness of the chest
areas. The lung markings will decrease by thirds as the
viewer goes from central to peripheral. The markings
are also more prominent in the bases of the lungs than
in the upper lung elds.
Compare right and left lung elds, starting at the
top and continuing across and down. Do this in small
lesions, lung markings, and density changes such as
areas of opacity (seen in white), which represent consolidation, nodules, and calcications. Note the lung
volume. Decreased volume is seen with atelectasis.
Large-volume lungs with a narrow mediastinum and a
at diaphragm are typically viewed in the patient with
emphysema.
Final Look
Research has shown that there are three high-risk locations where pathology is often missed: the upper lobes
of the lungs, costophrenic areas, and peripheral lung
margins. Take one more look at each of these areas.
Heart
Measure the size of the heart using a ruler. The heart
should be less than 50% of the transverse diameter of the
thorax. The measurement should be compared with the
widest thoracic diameter (found below the diaphragm
and between the ribs), resulting in the cardiac/thoracic
(C-T) ratio. The normal ratio is 1:2 (see Figure 41-5).
The heart size appears enlarged in supine and AP images.
Left ventricular hypertrophy extends the heart
border to the left, increasing the size of the heart and
increasing the C-T ratio.
Look for the silhouette sign, which occurs when
two structures have the same density and are in contact
with each other, resulting in a loss of borders on the
x-ray. Because the right and left borders of the heart
are air-lled, lesions in the lung cause the differentiation of the heart border to be lost.
How do I assess the lateral view?
Key Questions (to self)
l
In what position is the patient?
l
How do I know the image quality is good?
l
What are the indications for a lateral image?
l
Am I using a systematic approach to reviewing the
image?
The common position for the lateral view is with the
patient’s left chest against the image cassette. The
beam passes from right to left through the patient.
Remember that the right side of the patient is closer to
the beam and therefore structures are magnied on the
right side compared with the left. The left lateral position is preferred because the heart is less magnied and
the bases of the lungs are more easily seen.
Chapter 41 • Chest X-Ray
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A B
FIGURE 41-7 Lateral chest image. A, Unlabeled. B, A diagrammatic overlay showing the normal anatomic structures numbered or la-
beled: 1, tracheal air column; 2, right intermediate bronchus; 3, left upper lobe bronchus; 4, right upper lobe bronchus; 5, left interlo-
bar artery; 6, right interlobar artery; 7, confluence of pulmonary veins; 8, aortic arch; 9, brachiocephalic vessels. (From Fraser R: Fraser
and Paré’s diagnosis of diseases of the chest, ed. 4, vol. 1, Philadelphia, 1999, Saunders.)
A right lateral image is ordered when the right side
of the lung needs to be less magnied and sharper, such
as when a tumor is suspected. In the lateral position,
the ribs will seem to be superimposed on each other
and the sternum will appear thin.
A good quality lateral image shows lung markings,
ssures (the septa that divide the lobes of the lung),
and good visualization of the spine.
A lateral image can help localize a lesion seen on
the PA view or it may verify lobar consolidation. In
addition, the lateral image allows the viewer to see
behind the sternum and cardiac shadow. The lateral
image is often used to detect subglottic narrowing, as
seen in croup, as well as foreign body investigation.
Use a systematic approach when viewing the lateral
image, similar to the PA review.
Anatomy
Review the anatomy of the lateral chest (Figure 41-7).
Vertebral Bodies
The amount of soft tissue is greater at the lung apices
than at the lung bases; therefore the vertebral bodies appear darker as they approach the diaphragm. Kyphosis is
noticeable on the lateral image. Examine each vertebra
for fractures, and scrutinize the intervertebral disk spaces.
Diaphragm
The right diaphragm is visible and is higher than the
left because of the heart. On the left, the latter two
thirds of the diaphragm should be visible. The gastric
bubble is below the left diaphragm.
Costophrenic Angle
The angle is seen in the most dependent part of the
lung. Both angles should be visible and sharp.
Fissures
Fissures are septa that divide the lobes of lungs. The
major oblique ssure separates the left upper lobe from
the left lower lobe. The right major ssure separates
the right upper and middle lobes from the right lower
lobe. The right minor ssure separates the right upper
lobe from the right lower lobe. Fissures are generally
not seen on plain images because their small surface
provides no shadow or interface. However, these ssures may be seen when a pathological disorder occurs
in the lung.
Pleura
Follow the pleura around the lungs from the posterior
costophrenic area to the posterior sternal margin and
posterior ribs.
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Chapter 41 • Chest X-Ray
Retrosternal Area
The retrosternal space is usually dark because of the
presence of air. It is the lower one third of the sternum
and appears in contact with the right ventricle. When
this area is seen as opaque, air has been replaced with
solid material, and anterior mediastinal disease should
be considered. The area is enlarged when pulmonary
overination occurs, as in emphysema. The retrosternal space will not be visible with an enlarged heart.
Heart/Retrocardiac Area
Identify the right ventricle, left ventricle, and left
atrium. The retrocardiac area of the lateral chest image
is normally dark, caused by air. If the space is opaque,
then the air has been replaced with an effusion, consolidation, or mass.
Lungs
The scapulae make visualizing the upper lobe difcult
in the lateral image. Lung lesions are often hidden by
the heart on the PA view. Localizing a lesion in the left
lung is best accomplished with the lateral image.
Final Look
Take a last look at each of the areas where lesions are
often missed: the upper lobes, peripheral lung margins,
retrocardiac area, and costophrenic area.
What other imaging studies should I consider?
Key Questions (to self)
l
What other common imaging studies are available
for the chest?
l
What imaging studies would give me the best infor-
mation for a particular complaint?
Computed Tomography
Computed tomography (CT), sometimes called computed axial tomography, provides a cross-sectional
slice of the area examined. Unlike plain images, which
superimpose structures onto an image, a CT scan gives
only one slice. The beams of x-rays pass through the
body in an axial plane as the x-ray tube moves in a
continuous arc around the patient. Detectors are placed
opposite the beam to catch the electrical pulses. The
image is the result of the x-rays that are not absorbed
by the tissues between the beam and the detectors.
Detectors pick up the electrical impulses that are fed
into a computer that provides the “picture.” CT is used
to distinguish overlapping shadows from the chest image. It is also very useful in showing ne details of the
pulmonary parenchyma and hilum. Low-dose computed tomography (LDCT) is used to screen for lung
cancer in adults over 55 years who have a 30-pack year
history of smoking.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) produces a computer-based sectional image that does not use ionizing
radiation. MRI uses the hydrogen molecules in the
body to produce the image. A radiofrequency pulse
transmitted through coils causes some of the hydrogen
molecules to absorb energy and spin in a different direction from the other hydrogen ions (resonance).
When the radiofrequency pulse stops, the hydrogen
molecules stop spinning and release their excess stored
energy. A gradient magnet located inside the main
magnet, which provides the slicing capability of the
image, picks up the change. The results are sent to the
computer system, providing a two-dimensional image.
MRI of the chest is used to view lesions of the chest
wall and is less useful for examining the lungs.
Positron Emission Tomography
Positron emission tomography (PET) scans provide information on the biochemical metabolism of an organ or
tissue. Positrons come from the nucleus of a proton as it
decays to a neutron. When released, the positron eventually collides with an electron, resulting in the release of
two high-energy gamma photons. These gamma photons are released at 180 degrees from each other. The
patient is given a radiotracer that follows the destruction
of the positron and the resulting gamma photons. PET
scans are built with hundreds of detectors on circular
rings that are located directly across from each other.
The detectors allow the localization, in three- dimensional
space, of the decay of the gamma photons. PET scans
show the chemical function of an organ or tissue rather
than its structure; very highly active metabolism is seen
with cancer cells. PET scans are ordered for evaluating
the effects of lung cancer therapy.
Echocardiogram
High-frequency sound waves are directed into the
body, which are then recorded as they deect off organs and structures. These deections are transmitted
back to a transducer that records the difference in
acoustic impedance. This recording is changed into an
electrical signal, which is then analyzed by a computer
to produce an image. Echocardiograms are useful to
evaluate heart size, valvular function, and presence of
pericardial effusion.
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DIFFERENTIAL DIAGNOSIS OF
The Chest Image
WHAT TO LOOK AT NORMAL FINDING ABNORMAL FINDING SUGGESTED CAUSE
Clavicles Midline, symmetrical, intact Dark lines; clavicles not centered Fracture; patient rotated; image
Chest wall Chest wall has rounded
contour
Inspiration Adequate inspiration Less than 10 ribs identified Inadequate inspiration
Vertebral
column
Ribs All ribs intact
Trachea Midline Deviation from midline
Hilar region Normal size, centrally
Gastric air
bubble
Diaphragm Right higher than left; right
Costophrenic
angle
Visceral pleura Traced around chest wall Hairline shadow, dark black with
Heart size
Heart borders Presence of heart borders Loss of border Infiltrates
Lungs
COPD, Chronic obstructive pulmonary disease; PA, posteroanterior.
Straight, equal disk spaces Curved Kyphoscoliosis (lateral view);
Able to count 10 ribs
Ribs sloped at edges Ribs horizontal or flattened Hyperinflated lungs, acute asthma,
located
Vascular markings extend
,1/3 out into lung field
Bronchi invisible because
air-filled bronchi have
same density as air in
lungs
Present on right Not visible Image placement error; image label
at level of sixth rib
Present, sharp edges Blunted edges or absent Pneumonia, pleural effusion
Cardiac ratio ,50% Cardiac ratio .50%
Translucent Fluffy appearance Engorged vasculature
Sternum pushed outward (lateral
image)
Sternum pushed inward (lateral
image)
Collapsed disk spaces Degenerative disk disease
Rib fractures present
Less than 10 ribs identified
Widening of trachea
Area enlarged Pulmonary artery congestion; lymph
Vascular markings .1/3 into lung
field
Bronchograms present (bronchi
become visible when lung tissue filled with fluid is contrasted with air-filled bronchi)
Infiltrates or consolidation of lung
tissue
Elevated Collapsed lobe or multisegmental
Radiolucent line present that fol-
lows curvature of diaphragm
Flattened diaphragm Emphysema, asthma, tension pneu-
Elevation on left Perforated ulcer or gas distention of
Bilateral elevation Pregnancy, obesity, peritoneal fluid
no lung markings
Honeycomb appearance Acute respiratory distress syndrome
Butterfly appearance Pulmonary edema
Density changes to consolidation Bacterial pneumonia
Web-shaped density Pulmonary embolism
taken off center
Pectus carinatum
Pectus excavatum
scoliosis (PA view)
Trauma
Inadequate inspiration
COPD
Atelectasis: trachea deviated toward
area of atelectasis; pneumothorax: air, fluid, tumor, lymph node
enlargement push trachea away
from center; rotated image
Chronic cough, cystic fibrosis
node enlargement
Bronchopneumonia or pulmonary
congestion
Infiltration; pulmonary edema
Pneumonia
error
collapse; pleural effusion
Free air present
mothorax
stomach
Pneumothorax
Enlarged heart, patient rotated
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Chapter 41 • Chest X-Ray
References and Readings
Fraser R (ed.): Fraser and Paré’s diagnosis of diseases of the chest,
ed. 4, vol. 1, Philadelphia, 1999, Saunders.
Gaber KA, McGavin CR, Wells IP: Lateral chest x-ray for physi-
cians. J R Soc Med 98:310, 2005.
Kersten L: Comprehensive respiratory nursing, Philadelphia, 1989,
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