Chest X-ray Analysis for Junior Doctors

A Structured Approach

When analysing a chest X-ray, a systematic approach helps ensure that no important findings are missed. One simple way is to move from image quality → bones/soft tissues → lungs → mediastinum/heart → pleura/diaphragm.

Check patient details and image quality
- Confirm name, date of birth, and study date.
- Check penetration, rotation, and inspiration (ideally 9–10 posterior ribs visible).
Assess bones and soft tissues
- Look for fractures, dislocations, lytic/sclerotic lesions.
- Scan soft tissues for masses, swelling, subcutaneous emphysema, or foreign bodies.
Examine the lung fields
- Consolidation, masses, nodules, cavities.
- Signs of atelectasis (volume loss, shift) or pneumothorax.
- Interstitial markings, fibrosis, reticular/nodular patterns.
Inspect mediastinum and hila
- Heart size and shape; mediastinal width and contour.
- Hilar enlargement or abnormal contours suggesting lymphadenopathy or mass.
Review pleura and diaphragms
- Pleural effusions, thickening, calcifications, pneumothorax.
- Diaphragmatic elevation, flattening, eventration, or hernia.

Click on Images to Enlarge

Radiological anatomy of a normal chest X-ray — Radiological anatomy of a chest X-ray

Checklist of areas to review on a chest X-ray — Key areas that should be reviewed on every CXR

Pneumonia

Feature	Description
Consolidation	Lobar or segmental increased opacity obscuring lung detail.
Air bronchogram	Visible air-filled bronchi within opacified lung parenchyma.
Silhouette sign	Loss of normal borders (e.g. heart border, diaphragm) due to adjacent consolidation.

Pleural Effusion

Feature	Description
Blunted costophrenic angle	Loss of sharp angle between diaphragm and chest wall.
Fluid layering	Horizontal fluid level, more evident on erect or decubitus views.
Meniscus sign	Crescent-shaped opacity rising higher laterally than medially at the lung base.

Pneumothorax

Feature	Description
Visceral pleural line	Thin sharp white line marking the lung edge, separated from chest wall.
Absence of lung markings	No pulmonary vascular markings peripheral to the visceral pleural line.
Deep sulcus sign	In supine films, abnormally deep and lucent costophrenic angle suggesting an anterior pneumothorax.

Heart Failure

Feature	Description
Cardiomegaly	Enlarged cardiac silhouette (CTR > 0.5 on PA film).
Kerley B lines	Short, horizontal lines at lung bases representing interstitial oedema.
Upper lobe diversion	Prominent upper lobe vessels indicating pulmonary venous hypertension.
Peribronchial cuffing	Thickened bronchial walls due to interstitial fluid.

Typical features of CCF on chest X-ray — Typical congestive cardiac failure CXR

Chronic Obstructive Pulmonary Disease (COPD)

Feature	Description
Hyperinflated lungs	Increased lung volume, flattened diaphragms, more than 6 anterior ribs above diaphragm.
Bullae	Round, thin-walled, air-filled spaces within lung parenchyma.
Narrowed mediastinum	Compressed mediastinal structures due to hyperinflation.

Four stages of COPD — The four stages of COPD

Typical COPD findings on chest X-ray — Typical COPD findings on CXR

Pulmonary Tuberculosis (TB)

Pulmonary tuberculosis is caused by Mycobacterium tuberculosis. It primarily affects the lungs but can disseminate to other organs.

Stage	Description	Chest X-ray Findings
Latent TB infection	Infection without symptoms	Chest X-ray often normal.
Pulmonary TB (active disease)	Symptomatic pulmonary infection	Primary TB: hilar lymphadenopathy, Ghon focus / Ghon complex. Post-primary (reactivation) TB: upper lobe/apical consolidations, cavitation, fibrosis, sometimes pleural effusions.
Miliary TB	Haematogenous dissemination	Diffuse tiny nodules throughout both lungs (miliary pattern). May have associated involvement of liver, spleen, brain, etc.

Diagnostic Clues

Positive TST or IGRA.
Sputum AFB smear/culture or molecular tests.
CXR pattern consistent with TB, interpreted with clinical context.

Treatment requires combination anti-TB therapy over several months according to national guidelines.

Ghon complex on X-ray — Ghon complex on CXR

Lung Cancer

Lung Cancer Type	Radiological Features
Non–small cell lung cancer (NSCLC)	Solitary nodule or mass, irregular/spiculated margins, possible cavitation.
Small cell lung cancer (SCLC)	Central or hilar mass, rapid growth, prominent lymphadenopathy.
Adenocarcinoma	Peripheral nodule, sometimes ground-glass opacity or lepidic growth pattern.
Squamous cell carcinoma	Central mass or nodule, frequent cavitation, hilar lymphadenopathy.
Large cell carcinoma	Peripheral or central mass, rapid growth, may cavitate.
Bronchial carcinoid tumour	Well-defined, round/oval nodule; central or peripheral; usually slow-growing.
Metastases to the lung	Multiple nodules of varying size, well-defined margins, random distribution; may cavitate depending on primary.

Pulmonary metastases — Metastatic deposits in the lung

Final Note

This page provides a rapid overview of common CXR patterns for ED practice. Always integrate radiographic findings with clinical assessment, lab results, and further imaging where indicated, and discuss uncertainties with radiology or a senior colleague.