Reading a Chest Xray

You should feel confident reading a chest x-ray (CXR). It is one of the few films that will follow you from rotation to rotation. It doesn't matter if it is pediatrics, internal medicine, or surgery - You need to know how to read a CXR. Below are a couple sources to choose from because not everyone teaches or learns this in the same way. Here are a couple tips that I learned during my rotations from studying, my preceptors, or just plain screwing up!

  • The first thing you should check is the name/date/type of film! (On one of my rotations, an intern (1st yr resident) was asked to read a chest X-ray for one of our patients who had just gotten a chest tube placed. He did a great job with lung pathology and describing the fluid - and he was also able to pick out that the chest tube was perfectly placed. I was impressed until the chief resident said "great job, you just harmed your patient." The chief had purposefully put up a CXR from 2 years ago when the pt had rec'd another chest tube. He then pulled up the current CXR to reveal that the tube was improperly placed. )
  • Read every film in the same order every time. 
  • Learn the anatomy of what you are reading. 

University of Washington's Method
1. PA or AP, supine or upright
2. Pt rotated? Check for vertebral and clavicle symmetry.
3. Lung volumes
4. Tube & line placement
- ETT 3-5 cm above carina
- NGT in stomach
- FT in stomach/duodenum
- Central line in SVC/R atrium
- Swan in PA
5. Pneumothorax: check apices on upright film, deep sulcus sign at bases
6. Pleural effusion, pleural thickening
7. Mediastinum: normal contour, wide
8. Heart: normal size, cardiomegaly
9. Lung parenchyma: masses, opacites, look for silhouette sign
10. Soft tissues: foreign bodies, SQ air, breast shadows
11. Bones: fractures, osteopenia, abnormalities

Silhouette Sign = obscuring of normal borders on radiograph caused by intrathoracic lesion.
Obscured R heart border = R middle lobe
Obscured L heart border = Lingula
Obscured diaphragm = Lower lobe