Chest X-ray Interpretation Guidelines

Systematic Review Approach

The American College of Radiology recommends examining tracheal position and patency, as well as assessing mediastinal contours and width, with a widened mediastinum potentially indicating aortic injury or dissection 1, 2
The American College of Radiology suggests evaluating cardiac size and silhouette, with a cardiothoracic ratio >0.5 indicating cardiomegaly 3
The American College of Radiology advises checking for pneumomediastinum, which can be indicated by air in the mediastinum 1
Focal opacities or consolidation in the lung fields should be examined systematically, with the American College of Radiology recommending a side-to-side comparison 1
Interstitial patterns, such as reticular, nodular, or reticulonodular patterns, should be evaluated, with the American Journal of Respiratory and Critical Care Medicine providing guidance on these patterns 4

The American College of Radiology recommends evaluating for pneumothorax, which can be indicated by a visible pleural line with absence of lung markings peripherally 1
Pleural effusion should be assessed, with the American Journal of Respiratory and Critical Care Medicine providing guidance on the meniscus sign and blunting of costophrenic angles 4, 5
Pleural thickening or plaques, which may indicate asbestos exposure, should be evaluated, with the American Journal of Respiratory and Critical Care Medicine providing guidance on these findings 4, 6

The American College of Radiology recommends examining ribs, clavicles, scapulae, and vertebrae for fractures or lesions, as well as checking for soft tissue abnormalities such as subcutaneous emphysema or masses 7
The American College of Radiology advises evaluating diaphragm contours and position, with abnormalities potentially indicating diaphragmatic injury or disease 5

In trauma patients, the American College of Radiology recommends paying special attention to widened mediastinum, rib fractures, and pneumothorax or hemothorax, which can indicate serious injury 1, 8
In suspected pulmonary embolism, the American College of Radiology suggests looking for Westermark sign and Hampton's hump, with a normal chest X-ray increasing suspicion for PE in patients with acute dyspnea and hypoxemia 5

The American Journal of Respiratory and Critical Care Medicine notes that chest X-rays have lower sensitivity compared to CT for many conditions, with up to 50% of pneumothoraces, pulmonary contusions, and rib fractures potentially being missed on standard AP radiographs 1, 4
The American College of Radiology recommends advanced imaging, such as CT or MRI, for definitive diagnosis of suspected abnormalities, with clinical correlation essential for accurate interpretation 2, 5