Chest X-ray Interpretation:

A systematic approach
Notes to Accompany
The Program

BY
Theresa M. Campo, DNP, FNP-C, ENP-BC, FAANP
Associate Lecturer,
Fitzgerald Health Education Associates, LLC, North Andover, MA
Emergency Nurse Practitioner,
Atlantic Emergency Medical Associates/Atlanticare Regional Medical Center
Co-Director Family Nurse Practitioner Track and
Associate Clinical Professor,
College of Nursing and Health Professions Drexel University
Adjunct Assistant Professor,
Case Western Reserve University, Cleveland, OH

© Fitzgerald Health Education Associates, Inc.

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Phone 978.794.8366 | Fax: 978.794.2455 | Email: [email protected] | www.fhea.com
All rights reserved
 STATEMENT OF LIABILITY

The information contained in this work whether written or oral has

been thoroughly researched and checked for accuracy. However, clinical
practice is a dynamic process and new information becomes available
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from this program. Fitzgerald Health Education Associates, Inc. disclaims
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indirectly, from the use and application of any of the contents of this volume
or information given in the presentation.

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ISBN 978-1-57942588-3 (chxr2)

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The goal of this educational program is:

To provide quality continuing education to advance practicing nurses’ to enhance their
knowledge of chest x-ray interpretation.

Objectives:
1. Identify components of a plain radiograph.
2. Differentiate various markings on a normal and abnormal chest radiograph.
3. Analyze a chest radiograph and identify normal from abnormal.
4. Identify normal from abnormal findings on a chest radiograph.
5. Understand the foundational components of a chest radiograph.
 • Welcome!
• Click on “Resources”
above for a printable
black and white
version of the handout
for this program

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Chest X-ray Interpretation:

• The license grants the purchaser A systematic approach
rights to this learning product for Theresa M. Campo,
DNP, FNP-C, ENP-BC, FAANP
personal use only unless separate Associate Lecturer,
licensing arrangements have been Fitzgerald Health Education Associates,
North Andover, MA
made. Copying this material is a Emergency Nurse Practitioner,
Atlantic Emergency Medical Associates/Atlanticare Regional Medical Center
violation of copyright and is illegal. Co-Director Family Nurse Practitioner Track and
Associate Clinical Professor,
College of Nursing and Health Professions Drexel University
Adjunct Assistant Professor,
Case Western Reserve University, Cleveland, OH

Fitzgerald Health Education Associates 3

Disclosure Objectives

• No real or potential conflict of interest • Upon completion of this program, the

to disclose. participant will be able to:
• No off-label, experimental or – Identify components of a plain radiograph.
investigational use of drugs or devices – Differentiate various markings on a
will be presented. normal and abnormal chest radiograph.
– Analyze a chest radiograph and identify
normal from abnormal.

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 Objectives
Radiographs
(continued)

• Upon completion of this program, the • Used since discovery in 1896

participant will be able to: (cont.) • Revolutionized medicine and improved
– Identify normal from abnormal findings lives with early detection
on a chest radiograph. • Led to the development of more
– Understand the foundational components precise testing modalities
of a chest radiograph. – CT scan
– Nuclear medicine
– MRI
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Image Production
Radiographic Density
Physical Density
• Results from attenuation of x-rays by • Radiographic density is related to the
the material through which they pass physical density of a film.
• Increased density Increased • Different densities produce contrast on
absorption a film and determine the degree of
blackness of a film.
• Decreased density Decreased
absorption • Effect on film occurs paradoxically.
– High physical density produces less
• Atomic number of the substance can
radiodensity and vice versa.
influence absorption
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Radiolucent and Radiopague

• Radiolucent
– Permits passage of rays, low absorbency,
black appearance on film
• Radiopague (radiodense)
– Hinders passage of rays, high absorbency,
light grey to white appearance on film

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 Radiographic Densities

Object Shade
Gas (air) Black
Fat Gray-black
Soft Tissue Gray
Bone (metal) White
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Contrast Between Structures Image Quality

• Motion ~ blurry image

• Scatter ~ “foggy” appearance
• Magnification ~ difference in size
• Thickness ~ more beam is needed to
penetrate object
• Distortion ~ image larger with non-
distinct margins if object is too far

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The Basics What do you see in this picture?

• Anatomy and physiology is key!

• Radiographs are 2-dimensional picture
of 3-dimensional body
• Consistency, consistency, consistency
• Remember your ABCs

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 Strengths of Radiographs

• Evaluate
– Air, fluid, and gas patterns
– Stones
– Gross abnormalities
– Radiopague foreign body identification

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Diagnosis vs. Reading Reading Rules

• Right lower lobe infiltrate • History and physical exam before order
• Right middle and lower lobe consolidation • Order only when necessary
• Pneumonia • Look at the whole radiograph
• Evaluate patient and radiograph
– Reevaluate if incongruity exists

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Reading Rules
Ionizing Radiation
(continued)

• Treat the patient, not the radiograph • High-energy ionizing radiation

• Rule of 2s • Material causes loss of electrons
• Fail-safe measures and become charged upon contact
with a material

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 Ionizing Radiation
Radiation
(continued)

• Damage to genetic material • Radiation exposure researched since

through diminished and the atomic bomb
interrupted cell division (cell DNA) • Significant increase of exposure with
causing mutation increased use
• Sensitive tissue • Recently classified as carcinogenic

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Radiation
Radiation Dose mSv (Millisievert)
(continued)
• Plain radiographs (i.e., CXR Lower GI)
• Statistically significant increase in
– 0.02 – 6.4 mSv
cancer with dose >50 mSv
• CT scan (i.e., Head Pulmonary angiogram)
• Can take 1–2 decades for – 2.0 – 20–40 mSv
cancer development • Nuclear medicine (i.e., Sestamibi scan
– Source: Richardson, L. (2010). Radiation exposure and
diagnostic imaging. Journal of the American Academy of Nurse Dual isotope scanning)
Practitioners. 22, 178–85.
– 9 – 10–25 mSv
– Source: Richardson, L. (2010). Radiation exposure and diagnostic
imaging. Journal of the American Academy of Nurse Practitioners. 22,
178–85.

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Radiation Equivalent Anatomy

Test mSv Years of Estimated Soft tissue
background lifetime risk of Airway
radiation fatal cancer
Chest x-ray 0.1 6 months Minimal Edges Edges
Spine 1.5 6 months Very low
CT head 2 8 months Very low Bird cage
Cardiac/
CT abdomen and 20 7 years Moderate
circulation
pelvis with and
without contrast Diaphragm
PET/CT 25 8 years Moderate
Coronary CTA 12 4 years Low
Source: Mahesh, M. Computed Tomography Dose (CT Dose) retrieved from
http://www.radiologyinfo.org/en/info.cfm?pg=safety-xray Fitzgerald Health Education Associates 30
 Anatomy Anatomy

Heart
border Edges
Heart Airway
border
Bird cages
Edges
Right hemi- Left hemi- Cardiac
diaphragm diaphragm

Diaphragm

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Interpretation ABCs Adequacy

• Adequacy, airway • Positioning

• Breathing • Inspiration
(bird cages)
• Penetration
• Circulation
• Diaphragm
• Rotation
• Edges
• Skeleton, soft tissue

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Positioning Normal PA and Lateral

• Heart no bigger than ½ width of the
• Posterior anterior (PA)
space within the cage
– Facing cartridge
• Supine anterior posterior (AP)
– Supine
• Lateral
• Lateral decubitus

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 PA vs. AP
Posterior Anterior vs. Anterior Posterior
(continued)
PA AP
• Smaller heart • Heart larger
than normal
• Clavicles
superimposed • Shallow
over lung apices lung volumes
• Vertebrae • Clavicles higher
more visible
• Distinct
lung markings

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Lateral Decubitus Lateral Decubitus

• Pleural effusion –
Assess volume,
mobility or loculation
• Dependent lung should
have density due to
atelectasis from
Air
mediastinal pressure –
Air trapping if not Fluid

present

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Normal Inspiration Poor Inspiration

Diaphragm at the level of the 8–10 posterior rib or
5–6 anterior rib
1
2
3
1
4
5
2
6
3
7

4
Anterior
Posterior
8

5
9

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 Penetration
Expiration
Under Over
• Evaluate suspected
– Pneumothorax
• Balloon deflates shows space
– Foreign body in bronchus
• Shifting of structures due to obstruction

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Rotation Airway
• Bronchogram can be normal or sign of
inflammation/fluid
– Outline of airway
• Causes
– Normal expiration
– Lung consolidation
– Pulmonary edema
– Nonobstructive pulmonary disease
– Severe interstitial disease
– Neoplasm
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Bronchogram Breathing, Circulation, Diaphragm,

Edges, Skeleton/Soft tissue

Breathing/
bird cages

Cardiac/circulation
heart <1/2
Diaphragm
diameter of
chest cavity

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 Pediatric Considerations

• Can be challenging
Edges
Airway – Changes with age
Bird cages
– Thymus can cause confusion.
Edges – Different diseases
Cardiac – Patient cooperation

Diaphragm

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Adult vs. Child Differences

Heart Thymus
• Larger, wider heart • Increases in size
• Inspiration • Variable in size and
– Poor can change appearance
the look and • Child and thymus
position of heart
grow but disappears

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Atelectasis Atelectasis − Causes

• Volume loss in portion of lung
• Obstructive
• Subsegment, segment, lobe, or
– Most common
entire lung
– Bronchus obstructed by mucous plug,
– Subsegment and segment – Linear,
neoplasm, or FB
curvilinear, wedge-shaped
• Compressive
• Increased density usually linear
– Lung compressed by tumor,
• Collapse or incomplete expansion emphysematous bulla, or heart
of lung
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 Atelectasis – Causes Atelectasis – Causes
(continued) (continued)

• Cicatrization • Passive
– Organized scar tissue – Normal compliance of lung with
– Most often granulomatous disease pneumothorax or pleural effusion
(TB), pulmonary infarct, or trauma – Airway remains patent
• Adhesive
– Inactivation of surfactant

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Pulmonary Edema
Pulmonary Edema
(continued)
• Cardiogenic • Noncardiogenic (NOT CARDIAC) (cont.)
– Near-drowning
– Increased hydrostatic pulmonary – Oxygen therapy
capillary pressure – Transfusion or trauma
• Noncardiogenic (NOT CARDIAC) – CNS disorder
– ARDS, aspiration, or altitude sickness
– Altered capillary membrane permeability – Renal disorder or resuscitation
or plasma oncotic pressure – Drugs
– Inhaled toxins
– Allergic alveolitis
– Contrast or contusion
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 Cardiogenic Cephalization of Vessels
• Cephalization of pulmonary vessels
• Kerley A and B lines
– Linear opacities caused by interstitial fluid
• Peribronchial cuffing/bronchogram
• “Bat wing” pattern
– Perihilar and medullary consolidation of
both lungs
• Heart enlargement
• Pleural effusion
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Bat Wing Pattern

Kerley lines

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Pneumonia
• Airspace disease and consolidation
– Air spaces fill with bacteria or other
microorganisms and pus.

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 Types of Pneumonia
Types of Pneumonia
(continued)
• Lobar • Interstitial
– Classically pneumococcal pneumonia
– Viral or Mycoplasma pneumoniae
– Entire lobe consolidated and
air bronchograms – Latter starts perihilar and can become
confluent and/or patchy as disease
• Lobular
progresses, no air bronchograms
– Often Staphylococcus aureus (not MRSA)
– Multifocal, patchy, sometimes without
air bronchograms

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Types of Pneumonia Types of Pneumonia

(continued) (continued)
• Aspiration pneumonia • Diffuse pulmonary infections
– Follows gravitational flow of – Community acquired
aspirated contents – Mycoplasma
• Resolves spontaneously
– Anaerobic • Nosocomial
• Bacteroides – Pseudomonas aeruginosa
• Fusobacterium • High mortality rate
• Patchy opacities, cavitation, ill-defined nodular
• Immunocompromised host
– Bacterial, fungal, Pneumocystis carinii
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Where is consolidation?

• Look at your edges

– Heart borders
– Diaphragm
Right heart border=Middle lobe
Left heart border=Upper lobe
Right diaphragm=Right lower lobe
Left diaphragm=Left lower lobe

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Pleural Effusion
• Causes
– CHF
– Infection
– Trauma
– Pulmonary embolus
– Tumor
– Autoimmune disorders
– Renal failure

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Right
Left

Blunted Costophrenic
Angle

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 Pneumomediastinum

• Streaky lucencies over the

mediastinum that extend into the
neck, and elevation of the parietal
pleura along the mediastinal borders

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Pneumomediastinum
(continued)
• Causes
– Asthma
– Surgery
– Traumatic tracheobronchial rupture
– Abrupt changes in intrathoracic pressure
(vomiting, coughing, exercise, parturition)
– Ruptured esophagus
– Barotrauma
– Smoking crack cocaine
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Pneumothorax X-ray
Air Inside Thoracic Cavity but Outside the Lung
• Spontaneous • Pneumothorax • Air without lung
Pneumothorax – Most are iatrogenic. markings in the
– Causes • Caused by a provider least dependent
• Idiopathic during surgery or part of the chest
central line placement
• Asthma • Best demonstrated
• COPD – Trauma
• MVA, blunt
on expiration film
• Pulmonary infection
force trauma
• Neoplasm
• Marfan syndrome
• Smoking cocaine

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Tension Pneumothorax Emphysema

• Loss of elastic recoil of the lung with
destruction of pulmonary capillary bed
and alveolar septa

Source: https://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease

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 Emphysema
Radiographic Findings
(continued)
• Diffuse hyperinflation with flattening of • “Pruned” vascularity
diaphragms, increased retrosternal – Most reliable sign
space, bullae (lucent, air-containing – Decreased vascularity
spaces that have no vessels that are • Hyperlucency
not perfused) and enlargement of
• Increased retrosternal clear space
PA/RV (secondary to chronic hypoxia)
an entity also known as cor pulmonale. • Increased lung volume

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Radiographic Findings
(continued)
• Depression/flattening diaphragmatic
curve
• ↓ diaphragmatic excursion
• Prominent central pulmonary artery
with rapid tapering

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Traumatic Injuries

Source: https://upload.wikimedia.org/wikipedia/commons/c/c6/Crushed_Saturn.jpg

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End of Presentation
Thank you for your time and attention.

Theresa M. Campo,
DNP, FNP-C, ENP-BC, FAANP

www.fhea.com [email protected]

Fitzgerald Health Education Associates 101 Fitzgerald Health Education Associates 102
 References
References
(continued)
• Brant, W.E. & Helms, C.A. (2012). • Daffner, R.H., & Hartman, M.S. (2014).
Fundamentals of Diagnostic Radiology Clinical Radiology: The Essentials 4th
4th edition. Wolters Kluwer/LWW: edition. Lippincott, Williams, & Wilkins:
Philadelphia, PA. Philadelphia, PA.
• Collins, J. & Stern, E.J. (2008). Chest • Goodman, L.R. (2015). Felson’s Principles
Radiology: The Essentials 2nd edition. of Chest Roentgenology: A Programmed
Lippincott, Williams, & Wilkins: Test 4th edition. Elsevier Saunders:
Philadelphia, PA. Philadelphia, PA.

Fitzgerald Health Education Associates 103 Fitzgerald Health Education Associates 104

References
(continued)
• Richardson, L. (2010). Radiation • Images/Illustrations: Unless
exposure and diagnostic imaging. otherwise noted, all images/
Journal of the American Academy of illustrations are from open sources,
Nurse Practitioners. 22, 178–85.
such as the CDC or Wikipedia or
property of FHEA or author.
• All websites listed active at the time
of publication.

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www.fhea.com/testinstructions.htm

This program is intended for individual use.

No reproduction or institutional use is
permitted without a specific license from
Fitzgerald Health Education Associates

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 Copyright Notice Statement of Liability
Copyright by Fitzgerald Health Education Associates • The information in this program has been thoroughly
All rights reserved. No part of this publication may be reproduced or transmitted researched and checked for accuracy. However, clinical
in any form or by any means, electronic or mechanical, including photocopy,
practice and techniques are a dynamic process and new
recording or any information storage and retrieval system, without permission
from Fitzgerald Health Education Associates information becomes available daily. Prudent practice
dictates that the clinician consult further sources prior to
Requests for permission to make copies of any part of the work applying information obtained from this program, whether
should be mailed to: in printed, visual or verbal form.
Fitzgerald Health Education Associates • Fitzgerald Health Education Associates disclaims any
85 Flagship Drive liability, loss, injury or damage incurred as a consequence,
North Andover, MA 01845-6184 directly or indirectly, of the use and application of any of
the contents of this presentation.

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North Andover, MA 01845-6154
978.794.8366 Fax-978.794.2455
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