5 CHESTX{AY INTERPNFTANON

thcsc results in a subopt;mal X-ray and may produce appearanccsthat

sinrulatelung pathology.
Hff:;::interPretation
NORMAL LOAARANATOMY
. The right lung containsthreelobes,upper (RUL), middle (RML) and
lowcr (RLL) (Fig. s.2A-B).
. On the right sidc, thc obliquc fissuresepararesthe RUL from the RLI-
Thc cmphasisof this chaptcris rhc X ray appcarance of common con- abovc thc horizontal fissureand thc RML from the RLL bclow it.
clitions that you will see when on call. As the majority of patients . The horizontal fissurcscparatcsthc RUL from rhc RML.
rcquiring cmergencyphysiotherapyare short of breath or havc sub-
optimal gas exchange,only abnormalitiesof the lungs and pleural
Remember:
sp:rccsarc demonstratcd.Only frontal X-rays (posteroantcrior(PA)
When lookinS at a frontal CXR:
and anteropostcrior(AP)) arc uscd es thesearc thc oncs that you will
. RUL is at the top abovethe horizontal fissure
bc rcquireclto intcrprct.

n\
. RML is at the baseanteriorly below the horizontal fisslre
Rcmcnrbcrthet a pcrfcctchcstX rer,(CXR; Fig.5.1)requircscorrccr
. RLL is posterior.
peticnr positioningand rhc corrccr X r.ry dosc. I)cficicrrcyin any of

Horizontal

F iture 5.2A
Frontalplane.

Figure 5.1 Normal chestX-ray.

Ke/:1 trachea;2horizontalfissure;3costophrenicangle:4ritht hemidiaphragm; Figure 5.2B
5 left hemidiaphraSm;6
hearrshadow7 aortic arch;8riShthilum;9left hilum. Rightlun8,lateral.

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CH€'' X.MYINTXT.PRSTATION

HOWTO INTERPRETABNORMALITIESINTHE LUNG

FIELDSONTHE CXR

theyappeareither:
theseareasare abnormalbecause
Essentially,
. too white
or
. too black.

Too \A/hite
Figure 5,2C Le't
in thc on callse$ingarcarcasthat
Thc r'.rsrrnajorityof abnormalitics
lunt,lateral.
arctoo whitc andthc commonest causes arc:
. collapseor.itelec(asis
. consol;dation
. plcural cffusion
r pulrronary oedcma.

Too Black
\fhen there are arcaswhich appcar too black, the most important

Lowerzone Figure 5.2D Lung

fleld zones.
. The left lung consists of two lobcs, uppcr (LUL) arld lowcr
(l. t . l-) (lig.5 .2C). T he lingula is t he m os t inf c r io r p a r t o f
the LUL.
. 'l hc obliquc fissureon the left side separatcsthc LUL and LLL.
Remember:
The LUL is anterior and t}|e LLL is posterior.
For dcscriptivc purposcs, the lungs on the CXR are dividcd into
thirds or zones(Fig. 5.2D):
. uPper zonc
. mid-zone
Thcsc arc NOT ANATOMICAL divisions.For example,the apex of
the lower lobe on eachside is in thc mid-zonc.
. Pncumothorax
. c()Pl).
L.achof thcscis dcscribcd
below.
ATELECTASIS/COLLAPSE
Atelcctasisor collapscrefcrsto an areaof lung which is airlcssand the
lung collapscsin this reg;on.A!clcctasismav involvc an ent;rc lobc or
cvcn an cntirc lung.
'l'hc cbcst X-ray will show a loss of lung volume. This meansthat
thc lung field will bc smallcr than expccted.OdTer structurcs mav
movc to fill up the space,so thcrc may bc:
. shift of the rnediastinalstructurcssuch as the heart or trachc;l
. eleuationof rhc hcmidiaphragmconpared ro rhc othcr sidc.
The arca of collapscdlung appcarses a whitc or'dcnsc'area and this
rcprcscntsairlesslung rissuc.\flhen this affectsa small volumc of thc
lung, thc appcaranceis of a white line and this is often seenat thc lung
bascsin postoperativcplticnts. Whcn a wlrole lobe collapscs,cach
producesa spccificappcarance(Tablc5.1):

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X"RAYINTERPRETATION 5 CHEST
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Table 5 . 1 A p p e a r a n c eo f lo b e co lla p se

Lob€ collapse Presentation

RUL c o l l a p s e . There is increaseddensity high in the riSht l!n8 down to

t h e h o r izo n ta lfssu r e
. This fissure swingsupwards and can adopt an almost
vertical position (Fig.5.3)
Rl'11c o l l a p s e . The Rl"lL collapsesdown againstthe right heart border
which becomes indistinct (Fig.5.4)
. The right hetrrt borde s clearly seen on a normal CXR
b€causeit li€s adjacentto the air-filledmiddle lobe
RLL collapse . There is a trianSulard€nsity low in the right lung but the
riSht heart border can still be cl€arly seen (Fig.5.5)
LUL c o l l a p s e . The left lunS is slightlywhiter than the right
. The LUL is ant€rior and so collapsesagainstthe anterior
c h e stwa ll.T h u s,yo use etr ir in th e L L L th r o ughthe
d e n seco lla p se dL UL ( F i8 .5 .6 )
LLL c ol l a p s e . A t r i an Su ladr e n sityis se e nb e h in dth e h e a r t (Fi g.5.7)
. The part of the heart sh:dow to the left of the spine is
whiter rhan thar to the right of che spine

Fi 8ure 5.4 R i tht mi ddl e l obe co l aps e.The ri 8ht heart border i s i ndi s ti nc t
and there i s a vaguew hi te appearanc eto rhe adj ac entl un8.

flr

Figure 5.3 Rightupperlobecollapse. The horizonral fissureis now

Figure 5.5 Rightlower lobecollapse. Thereis abnormalwhiteness with
orientatedobliquely.
The tracheais deviated
to the rightwhichis evidence
a straightouter border(arrow)low in the rightlun8.The riShtheartborder
of mediastinal
shift.
is stillvisible.
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X-RAYINTERPRETATION 5 CHEST
X-RAYINTERPRETATION

w- #
3
#4
.#

Figure 5.6 Leftupperlobecollapse.Therets a hazyincreasedwh teness

over the lefthemithorax.
The lefrhearrborderis indistinct.

Figure 5.8 LeftlunScollapse. Thereis abnormal whirenessover rhe left

hemithorax.The heart is shifredto the left within the abnormalarea.

Vhen a rvholc lung collepscsthcrc is incrersed(lensitvof rhc cnrirc

hcrnithor-ex (l;igs 5.ll ud 5.9).This.rppcrrenccis sonrctinrcscallerl.r
'rvhitc out', rlthough thcrc.lrc ()ther ciluscsfor dris. A pncunrorc.
torrrr is in eflcct an cxtrcmc fornr o[ cornplctc lung collirpsc.rnrl so
u ill look thc s.rmcon (lXR but vou nral scerib irrcgul.rritr nrerl'inq
tllc sitc ()f !he thorrcotornv.

Remember:
When you see complete collapseof the left lung associaredwirh RUL
collapsein a ventilated patienr alwayscheck rhe position of the
endotrachealtube. lf the tube has been advanceddown the right main
bronchusthen only the RML and RLLwill be aerated(Fi9.5.10).

CONSOLIDATION

F igure 5 . 7 L e f t l o w e r l o b e co lla p se .In cr e a se wh

d ite n e ssis seen behrnd Consolid.rtionoccursrvhcn.rir in lung is rcpleccdbt fluid. l hc distri
the heart with a straight outer edge (arrows). bution of this consolidit;orr rner bc patchv or nr.rv.rffect:rn cntirc

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X-RAYINTERPRETATION 5 CHEST
X.RAYINTERPRETATION

sciamcntor lobc.'fhe composirionof this fluid dcpcndson thc c,rusc:

. infccte'cl fluicl,as in pncumonia(the corlrnloncstceuscthrt \'()u
rvill scc)
. srliva or liistric contcnts,sccnin cescsof rspiretion
. l '1 , , , , J i, l c . r . c . , , l r r . r u r r . r r i .L r r r o ( i ,n l u \i ,,n
. sclous transutlltc, sccnin alvrolar pulmonarv ocdcmx.

Although thc distribution nray hc'lpto clicit thc ceusc,the ricliologi-

cll lppcaranceof consolid,rrionis thc s.rrnefor rll of thcsc:

Radiological Appearance
. The whiteness or shadowing in thc lung is poorly defined. It is
clifficult to scc the edgcsof thcsc arcrs. The shadowing has bccn
dcscribedas'flufff in appcirr:rncc.
o lhcrc is no loss of volunTe,unlikc atclcctasis,es drcrc is no lung
c o l h p s c '( F i g .5 . 1l ) .

Figure 5 . 9 P n e u m o n e c to m y.Ab n o r m a l wh ite n e ssis se e n in t he l eft

hemithorax. The trachea and heart are shifted to the left.

Figure 5,'l'l Traumaticconsolidation of the rishtupperlobe.Thereis

abnormalwhitenessin the right upper lobe.The horizontalfissureis in its
Figure 5.10 Collapse of the leftlunt andrightupperlobe.Note the tip of normalposition,so thereis no volumeloss.Note the shraPnel in the
the ETrubewhichliesin the rishtinte.lobarbronchus.
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X.RAYINTERPRETATION 5 CHEST
X-MY INTERPR€TATION

. An air bronchogram mav tre sc'en,particularlv when thcrc is

crrcnsiveconsolidation.This is causcd[rl consolidationof lung tis
suc:rdjaccntto an ait-fillcd brorrchuswhich thus stirndsout es r
bl.rcktube anid thc consolidrtivc shadorving(Irig.5.t2).

Krrorvlcdgeof lobar anatomv hclpsto locelizcconsolidationesit clocs

rvith etclcctasis(Fig. S.13).lt is important in tcrrns of how vou trcat
vour paticrlt;rnd nral also provide clucs:rsto thc causc:
. Aspirerion rcnclsto particulerly ir{fectthc right lowcr lobc rvhcn
thc peticnt is crcct asthc right nrainrnd lorvcr lobc bronchi irc thc
rrost vcr!icxl (Fig. 5.1,+).
Aspir:rtion is particularlvsccr,in thc apical scgrncntso| thc lower-
lobcs whcn thc paticnt is supinc as thescbronchi arc dirccrcd pos-
tcriorlv and erc thus thc nrostdcpcnclcntin l patient lving flit.
l.urrg contusion tcnds to occur in thc sctting of traunra so thcre
mal b c skin bru isin g. r nc l\ { ) u nr r v s c e r ib f r r c t ur c s o n t h c C X R
(tris.s.l5). Figure 5.13 Middlelobeconsolidation. The poorlydeflned'fluffy'
increasedwhitenessabutsthe horizontalfissureand rhere is no volumeloss.

Figure 5.t2 RiShtlower lobe consolidation.The abnormalwhitenessin the

right lower andmid-zonesis poorlydefinedand'cloudy. There is a trident- Figure 5.14 Rightlowerlobeconsolidatio n.The upperlimitof this
shapedlucencywhich is an air bronchogram(arrows).The right hean border abnormalwhitenessshowsthe locationof the apicalsetment of the right
remainsvisible. lower lobe.whichis in the mid-zone.
 5 CHEST
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X.MY INTERPR$ATION
Figure 5.15 Traumatic
righrlowerlobeconsolidation.
Note the rib
fractures(arrows).
. In alvcolarpulmonary ocdcma,thc consolidationappcarenccrcnds
to bc situatedin thc mid-zoncs around thc hila.
ln children, infcctivc consoliderionis oftcn circular in shapc.This is
t Lrnrcd ,1r^ u nd p ncum , , nia{ Ft t s .5. lo) .
Remember:
In real life,consolidationand atelectasiscommonly occur together,
but by analysingthe abnormal white areasoo the CXR you will find
that one of these tends to predominareand thus is probably the
most important when it comes to treating the patient.
PLEURAL EFFUSION
This rcfersto fluid in thc plcural spacc.It occupicsthc dcpendentpart
of thc plcuralspaccdue to gravitv so whcn the paticnt is crcct or scmi-
crcc! ;t occupiesthc lowcr zone on CXR initially. However, if thc
paticntis supinc,;r occupicsthc postcrior surfaceo{ thc plcural space.
5 CHEST
X.MYINT€RPRFTATION
Figure 5.i6 Roundpneumonia.The roundedparchywhiteareain the
ritht lower zone representsconsolidation.
Radiological Appearance
Thc characrcristicfeature of tbe abnormal whitcnessin plcural ef{u
sion is that it is uniform throughout. It is not patchy.
Most paticntsthat vou will sccwill havc rhcir X rar'srakenerccror
scrii crect:
. A small cffusion prcscntsas blunting of the costophrcnicanglc,thc
rcgion on thc CXR betwecnthc hcmidixphragmend rhc chestrvirll.
. In a modcratc-sizcdcffusion, rhe top of thc fluid is sccnas :r hori-
zontll line and therc is a mcniscusar thc poinr where $e fluid
touchesthc chcstwall. Thc hcmidiaphragmis obscured(Fig.5.17).
. Virh a very large effusion thcrc miy bc shifr of the mediastinu,n
ewav from thc sideof the ef{usion.A largccffusion is anothcr causc
1or a'whitc out'appcarancc but thc position of the mediastinurn
tclls vou if ir is due to atelectasis
or effusion(Iig. 5.18).
If thc paticnt is supinc thc fluid adopts a posterior location. Thus
therc rvill bc a generalizcdincrcascdwhitcnessof the lung field. Thc
lung can still bc secn lnd is cffcctivclv bcing vicwcd through a rhin
layer of fluid.
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Figure 5.18 Left pleuraleffusion.There is uniformwhiteness

over the left
hemithoraxand the heart and mediastinumare displacedto
the ritht. Thus
there is'too muchvolume'on the left due to a massave
pleuralefirsion.
Figure 5.17 Ritht pleuraleffusion.There is uniform whitenessat the base
ofthe right hemithoraxwith a horizontalupper surfaceand a meniscusseen
at the chestwall.

PULMONARY OEDEMA

The majoriryofcasesaredueto left ventricularfailure.The fcaturesare:

. The heartis usuallyenlarged.
. There may be consolidationaround thc hila as dcscribcdabovc
(Fi g . 5. 1e) .
. Thcrc may bc tiny, thin horizontallineswhich areseenin the lower
zonesvrhere the lung touchesthe chest wall. Thcse are due to
ocdcmain the lung substance or interstitiumratherrhanthe alveoli
and areknown asKerley B lines(Figs5.20and 5.21).
r Thcrc arc largc distended veins seen in the upper zones Figure 5.19 Heart failureand alveolarpuhonary oedema.
The heart is
(Fig.s.20). enlargedand there is bilateralconsolidationaroundthe hila,the
. Theremay be pleuraleffusions. so-called
'bat! wing'appearance. Note the smallleft pleuraleffusion.

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5 CH€sfX,R Y lNft$[FtAnON

L!

Figure 5.20 Interstitialpulmonaryoedema.The heart is enlarged.There

is prominenceof the upper lobe veins(arrow),representinglpper lobe
blood diversion.KerleyB linesare seenat the riShtbaseandthere is a small Figure S,21 KerleyB lines.Thin horizontalwhite linesare seenreachint
riSht-sidedpleuraleffusion. the pleuralsurfaceat the costophrenicangle.

PNEUMOTHORAX oppositc side (Fig.5.2l). This can causecardiacarrcsr and is rhus a

surgical emcrgency.
'Ihis is an important causcof a lung ficld appearingtoo black and
rcfcrs to air in the pleural space.Thc fcatures on thc CXR are:
. Ihc lung cdgc is sccn as a whire Jine parallel ro the chesr wall Hazard:
(| ig.5.2 2). Youshouldnot usepositivepressur€ventilation(e.g.CpABlppBor
. Lung markingsdo not cxtcnd out beyond this white line. NlV) in a patient with a pneumothoraxasyou mayturn it into a
o I hc arcaoutsidethis lung cdgcis blackcrthan the areainsidethe linc. tensionDneumothorax.

A pncumothorlx may involve the entire hemithorax and in this case

rlrclc will bc no lung markings visible ar all. In a rension pneumo- Occasionally, the air in the pleural caviry may be locatcd anteriorly,
tlrorrrr thc irir in thc plcural spacc stcadily incrcascsand can build particularly when the parienr is supine. This makes it more dif{icult to
rrp rignilic.rnrprcssurc,pushing the mediastinumxway towards thc scc as therc may not bc a visiblelung edge.Bc suspiciousif the CXR

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X.MYINTERPRETATION
@ 5 CH€STX-RAYINTERPRETATION

a. I

b cl

I { |
Fi gure 5.23 Lefi tensi on pneumothorax .The l eft hemi thorax c ontai nsno
l ung marki nS sat al l .The hearr and medi as ti numare s hi fted ro the ri ght.

L -

Figure5.22 Rightpneumothorax.A blackareain the ritht hemithorax

riShtlung,whoseedgeis clearlyseenasa white line (arrows).
LungmarkinSsdo not extendinto this blackarea.

of r vcntilatcd patient shows onc lung to be blackcr than thc odrer,

with otherwiseuncx-
particularlyin the lowcr zonc, and is ass.rciatcd

nn
plainedsuboptimalgasexchangc.

COPD
I
Thc lungs appcar hypcrinflated ar,d blacker in cmphyscma duc tcr
the dcstruction of lung rissuc. Thin wrllecl sacs or bullae n,av
dc"clop and appcar as particularly bleck arcas,often at thc top of
thc lung. ln thcse cases,unlikc pneumothorax, thcrc is no visible Figure 5.24
4 COPD BothI lunSslunSsare normal,pa
€r than nol particuiarly
arlyin the
lung cdge and lung markings are seen rceching the chest wall uPPerzones.
s.No> lung
lunt edte iis visi
s vi si ble.
e., n P ecton
C l os e iIns ton shows
vs lungmar
markings
(Irig.5 .2a ). reachinSallt way ror t h e P reurarsu tt wallon
n eachside
side.

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 5 CHEST
X.RAYINTERPRETATION

Hazard:
lf you use positive pressureventilation in these patients,be aware lhat
POTENTIAL
there is a risk of creating a pneumothorax by burstinSone of the
thin-walled bullae.Usuallyrhe benefitsto the patien! outweigh this
PROBLEMS
small risk but it is important to discussthis with a doctor.

This ch.rptcris e guidc to hclp r ou irrtcrprctrbrrormel(lXlls whcn on

c,rll. Ilorvcvcr',it is impor t . r nt t o c lc v c lop. r s v s t c nr r r ic , l p p r o r . h i o
rcacling:r CX R so es to ,rbt.rinlll thc infor mation ar.rilrbleto r ou.

ArknowledsernPnfs

I .rrr gr:rtclulto Dr D.l. Dcl.rnr .rndI)r L\\i llrorvl for thc uscol thcir
cxtcrrsircfilnr collccti,rnand to I)r .f.l). Arqcnt 1or su;)phing thc iilnr
of rouncipncunronie.

Further readinp
CorncJ, C;rrrollM, BrorvnI, Delanr D (2002)(lhcstX rrv nrclct.rr.
.lnLlcJn.I oncl,n:ChurchillI-irinqsronc.

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