Chest X-Ray INTERPRETATION ALGORITHM

Starting from center and moving OUT:

1 Trachea & bronchi

2 Heart
3 Mediastinum
4 Hila
5 Lungs
6 Pleura
7 Chest wall

How to use the algorithm

If you FIND AN ABNORMALITY, If you DON‘T FIND an abnormality,

GO TO THE APPROPRIATE STEP. EVALUATE THE STEPS IN
Then evaluate the remaining steps. CONSECUTIVE ORDER.

2 Trachea & bronchi 1 Trachea & bronchi

3 Heart 2 Heart

4 Mediastinum 3 Mediastinum

5 Hila 4 Hila

1 Lungs 5 Lungs

6 Pleura 6 Pleura

7 Chest wall 7 Chest wall

 Trachea & Proximal Bronchi Radiological Analysis Checklist

rc 1. TRACHEA & BRONCHI

To confidently state that the trachea and proximal bronchi are normal, all parts of the checklist should indicate a normal
appearance.

GRAYSCALE

1 Is the grayscale of the trachea If YES, then describe.

altered? Too white/too black.

POSITION

If YES, then describe.

2 Is the trachea deviated? Right/left.
Anterior/posterior.

3 Is the carina angle greater than 90 If YES, then describe.

degrees? Give angle measurement.

SHAPE

If YES, then describe.

4 Is the shape of the trachea narrowed?
Focal/diffuse.

5 Is there a visible mass deviating/ If YES, then describe.

narrowing the trachea? Size/position.
X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I

OTHER

6 Are there any radiological signs If YES, then describe.

Air bronchogram.
related to the trachea? Tram line.

7 Is there any evidence of previous If YES, then describe.

surgery to the trachea and/or Type of surgery and location.
bronchi? Compare to previous CXR.

8 Are there any lines or tubes in the If YES, then describe.

trachea? Give location of each relative to the carina.

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 Heart & Pericardium Radiological Analysis Checklist

2. HEART
rc
To confidently state that the heart and pericardium are normal all parts of the checklist should indicate a
normal appearance.

GRAYSCALE

Is the grayscale of the cardiopericardial If YES, then describe.

1 Too white/too black.
silhouette altered?

SIZE

2 Is the size of the If YES, then describe.

cardiopericardial silhouette Too big/too small.
Pathological/magnification effect/pectus excavatum.
altered?

POSITION

Is the position of the If YES, then describe.

3 Up/down.
cardiopericardial silhouette Right/left.
shifted? Anterior/posterior.

SHAPE

4 Is the shape of the If YES, then describe.

cardiopericardial silhouette Name specific contour.
Pathological/normal variant.
distorted?

OTHER

5 Is there any evidence of If YES, then describe.

previous surgery to the heart or Type of surgery and location.
Compare to previous CXR.
pericardium?

CONGESTIVE HEART FAILURE

If YES, then describe.

6 Are there signs of vascular Pulmonary venous hypertension/
redistribution? pulmonary arterial hypertension /
shunt vascularity.

If YES, then describe.

7 Are there signs of edema? Interstitial/alveolar.
Kerley A/Kerley B/cuffing.

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 Mediastinum Radiological Analysis Checklist

rc 3. MEDIASTINUM
To confidently state that the mediastinum is normal, all parts of the checklist should indicate a normal appearance.

GRAYSCALE

If YES, then describe.

1 Is the grayscale of the mediastinum altered? Too white/too black.
Pathology/lipomatosis.

SIZE

If YES, then describe.

2 Is the size of the mediastinum Too big.
altered? Right/left.
Anterior/middle/posterior compartment.

SHAPE

If YES, then describe.

3 Are the mediastinal contours abnormal? Right/left.
Distorted/missing/additional.

POSITION

4 Is the position of the If YES, then describe.

Right/left.
mediastinum shifted?
Anterior/posterior.

OTHER

5 Is the AP window normal? If NO, then describe.

Blurred, obscured.
Too big/too small.

6 Are the lines and stripes normal? If NO, then describe.

Too wide/irregular/missing.

If YES, then describe.

123.
7 Are there any radiological signs hilar overlay.
related to the mediastinum? Iceberg.
Silhouette.

8 Is there any evidence of previous If YES, then describe.

surgery to the mediastinum? Type of surgery and location.
Compare to previous CXR.

9 Are there any lines or tubes in the If YES, then describe.

Give location of each relative to the
mediastinum? carina and SVC.

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 Hilum Radiological Analysis Checklist

4. HILA
To confidently state that the hilum is normal all parts of the checklist should indicate a normal appearance.
rc
GRAYSCALE

If YES, then describe.

1 Is the grayscale of the hilum altered? Too white (too dense)
Right/left/bilateral.

SIZE

If YES, then describe.

2 Is the size of the hilum altered? Too big/too small.
Right/left/bilateral.

POSITION

If YES, then describe.

3 Is the position of the hilum Elevated/depressed.
shifted? Medial/lateral.
Anterior/posterior.
Right/left/bilateral.

SHAPE

4 Is the H-shape of the hila If YES, then describe.

Lobulated/irregular.
distorted on the PA x-ray? Right/left/bilateral.

5 Are one or both of the arches If YES, then describe.

distorted on the lateral x-ray? Aorta narrowed/distended.
LPA narrowed/distended.

X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I
OTHER

If NO, then describe.

6 Is the AP window normal? Blurred/obscured.
Too big/too small.

If YES, then describe.

7 Are there any radiological signs Hilar convergence.
related to the hilum? Hilar overlay.
H-sign.

8 Is there any evidence of previous If YES, then describe.

surgery to the hilum? Type of surgery and location.
Compare to previous CXR.

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Lung Radiological Analysis Checklist

5. LUNGS
To confidently state that the lungs are normal, all parts of the checklist should indicate a normal appearance.

GRAYSCALE
rc
If YES, then describe.
1 Is the grayscale of the lungs altered? Too white/too black/too white AND too black.
Right/left/bilateral.

If TOO WHITE , then describe opacity.

Focal/diffuse.
Multiple/solitary.
Homogeneous/inhomogeneous.

If TOO BLACK , then describe hyperlucency.

Focal/diffuse.
Multiple/solitary.
Pathological/mastectomy/surgery.
Homogeneous/inhomogeneous.

2 Is the normal branching of blood If YES, then describe.

vessels obscured? Right/left/bilateral.

SIZE

3 Is the size of the lungs altered? If NO, then describe.

(Does the blackness of the lungs Right/left/bilateral.
extend all the way to the ribs?) Increased/decreased.

OTHER

If YES, then describe. X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I

4 Are there any radiological signs Air bronchogram.
related to the lungs? Silhouette.
Spine.

5 Is there any evidence of previous If YES, then describe.

Type of surgery and location.
surgery to the lungs? Compare to previous CXR.

If YES, then describe.

6 Are there any lines or tubes in the Give location of each relative to the
lungs? carina, SVC and/or diaphragms.

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 Pleura Radiological Analysis Checklist

rc 6. PLEURA
To confidently state that the pleura is normal, all parts of the checklist should indicate a normal appearance.

GRAYSCALE

1 Do the lungs extend all the If YES, then describe.

way to the ribs? Too white/too black/too white AND too black.
Right/left/bilateral.
If NO, is the grayscale of the
pleura altered?

SIZE

If YES, then describe.

2 Is the size of the pleural Right/left/bilateral.
space altered? Give size of pneumothorax or
pleural effusion.

POSITION

If YES, then describe.

3 Are the fissures shifted? Elevated/depressed.
Medial/lateral.
X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I

SHAPE

4 Is the shape of the lateral If YES, then describe.

or posterior costophrenic Right/left/bilateral.
angles altered? Blunted.

OTHER

5 Are there any radiological signs If YES, then describe.

Pseudotumor.
related to the pleura? Deep sulcus.

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 Chest Wall & Diaphragms Radiological Analysis Checklist

7. CHEST WALL
rc
To confidently state that the chest wall and diaphragms are normal all parts of the checklist should indicate
a normal appearance.

BONY THORAX (Spine, ribs, clavicles, scapulae, sternum)

GRAYSCALE

If YES, then describe.

1 Is the grayscale of the bones Too white/too black.
Bone density.
altered? Cortical outline.
Fractures/bone destruction.

If YES, then describe.

2 Are any abnormal opacities present? Give number and location.
Focal/diffuse.

POSITION

X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I
3 Is the position of the bony thorax If YES, then describe.
Right/left.
(ribs, spine, clavicles, sternum, Anterior/posterior.
scapulae) altered? Elevated/depressed.

OTHER

If YES, then describe.

4 Are there any accessory ribs? Cervical/lumbar
Give number and position.

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rc SOFT TISSUES
7. CHEST WALL

GRAYSCALE

5 Is the grayscale of the soft If YES, then describe.

tissues altered? Too white/too black.

6 Are breast, pectoral folds and/or If YES, then describe.

Right/left/bilateral.
nipple shadows present? If not sure, repeat CXR with nipple markers.

SIZE

If YES, then describe.

7 Is the size of the breasts altered? Right/left/bilateral
Increased/decreased.

DIAPHRAGMS

POSITION
X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I

8 Is the position of the diaphragm(s) If YES, then describe.

altered? Right/left/bilateral.
Elevated/depressed.

SHAPE

9 Is the shape of the If YES, then describe.

diaphragm(s) altered? Right/left/bilateral.
Describe shape.

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 7. CHEST WALL
OTHER

10 Is there a presence of bowel loops If YES, then describe.

or stomach in the thoracic cavity? Right/left.
Anterior/posterior.

11 Are there any external objects that If YES, then describe.

ECG leads/buttons and clips on clothing/
are not part of the normal chest wall?
hair bands and clips/jewellery/coins and
currency in pockets.

12 Is there any evidence of previous If YES, then describe.

surgery to the chest wall or Type of surgery and location.
diaphragms? Compare to previous CXR.

If YES, then describe.

13 Are there any lines or tubes in the Give location of each relative to the carina,
chest wall? SVC and/or diaphragms.

X- R AY I N T E R P R E TAT I O N Chapter 16 S E C T I O N I I I

These normal images are

provided for your use as
reference images so you can
familiarize yourself with what
LATERAL

the normal looks like.

PA

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