in this presentation we take an overview about the normal of chest x ray, what we need to make a good film and easily readable

1. Chest X – Ray Capsule
Lesson 2: Normal Chest X
– Ray (Part 1):
Dr: Ayub Abdulkadir Abdi
Date: 25/9/2020

2. Presenting a chest radiograph:
• This is how you should present:
o Give the type of radiograph and projection .
o Give the patient’s name.
o Give the date the X-ray was taken.
o Briefly assess the film quality to ensure it is
adequate.
o Run through the ABCDE of chest X- rays.
o Give a short summary at the end.

3. Chest X rayProjection:
• The standard view is a PA (posterior–anterior) erect chest X-
ray.
• All chest X-rays are taken PA erect unless otherwise stated.
• You should always assume that a chest radiograph is PA erect,
unless it has AP or supine printed on it.
• Reasons for performing the film erect:
1. Gas passes upwards: Pneumothorax and free air underneath
the diaphragm are more easily diagnosed.
2. Fluid passes downwards: Pleural effusion is more easily
diagnosed.
3. Physiological representation of blood vessels and lungs.

4. • Remember, as you look
at a chest X-ray:
• The left side of the
radiograph is the
patient’s right side,
and the right side of
the radiograph is
the patient’s left
side.

5. Posterio-Anterior film (PA):
• The patient stands with their anterior chest well up against
an X-ray film.
• The X-ray tube is placed optimally 6ft behind the patient so
the X-rays pass in the posterior–anterior direction.
• The patient takes a deep breath and holds it during the X-
ray to ensure there is adequate inspiration.
• Position of the patients is mostly “ERECT”.
• Reasons for performing the film PA:
1. Accurate assessment of the cardiac size due to minimal
magnification.
2. The scapulae can be rotated out of the way.

8. Anterior Posterior Film (AP):
• The patient puts their posterior chest well against an X-ray
film.
• The X-ray tube is placed in front of the patient and the X-rays
pass in the anterior–posterior direction.
• Position of the patients is mostly “SUPINE”.
• Reasons for performing the film AP:
1. Patient is too ill to stand (e.g. Intensive Care Unit, or
Resuscitation).
2. Very elderly patients.
3. Trauma.
• The major disadvantage of AP/supine films when compared
with PA films is that the mediastinum and cardiac size will
appear wider.

11. Lateral Film:
• The patient puts their chest wall {right or left} against an X-
ray film.
• Reasons for performing Lateral film:
1. Is used to give further views of the lungs “posterior
segment of lower lobe, area behind the hila, left lower
lobe”.
2. Further assessment of cardiac configuration.
3. Further anatomical location of lesions.
4. Good view of thoracic spine.
5. More sensitive for pleural effusion.
• N.B LATERAL FILMS; It is rarely performed now as CT gives
more information.

13. Others X – Ray Projection:
Expiratory PA erect view:
• Is used rarely for helping to detect a suspected pneumothorax
or suspected bronchial obstruction with air trapping.
Decubitus view:
• Performed with the patient lying on his/her side.
• Used occasionally in patient too ill to stand to exclude pleural
effusion or pneumothorax.
Lordotic view:
• Patient leaning backwards against the x-ray film and the X-ray
tube is angled up.
• To looks the apical region of the lung.
Oblique view:
• Used to show the ribs and sternum.

14. Lordotic view Decubitus view Oblique view

15. Identification & orientation
• The chest film should include:
1- Patients name
2- Date
3- Hospital name.
4- Type PA or AP or LL
5- Marks if Right (R). If Left (L).

17. Film quality:
• Before you think about the possible
abnormalities on a chest radiograph, you must
first assess the technical quality of the film to
ensure the image is adequate. There are three
things you need to look for (RIP):
o Rotation.
o Inspiration.
o penetration.

18. 1- Rotation:
• Look at the spinous processes of the upper thoracic
vertebrae they should lie midway between the medial
ends of the clavicles.
1. If the spinous process appears closer to the medial
end of the left clavicle, the patient is rotated toward
his or her own right side.
2. If the spinous process appears closer to the medial
end of the right clavicle, the patient is rotated
toward her or his own left side.
Note: This rule applies to both PA and AP films.

20. Orange dot= Rt medial clavicle
Black dot= Lt medial clavicle
Black triangle = Spinous process

21. 2- Inspiration:
• If the hemidiaphragms lie at the level of the
sixth anterior rib or below, then the
inspiration is adequate.
• Alternatively, if there are eight or nine
posterior ribs visible in the lung fields, this
also indicates adequate inspiration.
If normal: ‘There is adequate inspiration

23. • If the lungs are under- inflated then there will be five or
fewer anterior ribs (or seven or fewer posterior ribs)
visible overlying the lung fields.

25. 3- Penetration:
• X-rays must adequately penetrate body parts to
visualize the structures.
• See the thoracic spine, beyond fourth thoracic
level, through the heart shadow.
• There are two types of improper penetration:
1. Underpenetration.
2. Overpenetration.
• Both under and overpenetrated X-ray film not
good for reporting.

26. Underpenetrated (too light):
a) Diffusely bright.
b) Soft tissue structures are
not well seen especially
those behind the heart.
c) Pulmonary markings may
appear more prominent.
d) May be miss interpreted
as interstitial pulmonary
edema or pulmonary
fibrosis.

27. Overpenetrated (too dark)
a) Diffusely dark.
b) Pulmonary nodule
may miss.
c) Pulmonary marking
absent or decreased.
d) May be miss
interpreted as that the
patients has
emphysema or
pneumothorax.

28. THANK YOU