Assessment of chest x-ray technical adequacy (approach)

Last revised by Craig Hacking on 18 Feb 2024

Described below are some points on an approach to the assessment of the chest x-ray technical adequacy. Rarely, a technically inadequate chest x-ray will prohibit diagnostic interpretation but knowledge of the limitations will impact on diagnostic confidence. 

  • assessed by looking at the lower thoracic vertebral bodies, whose outline should just be visible on a PA projection

  • the spine should be seen through the heart 1

  • poor penetration: pulmonary vessels and interstitial markings appear more prominent, loss of detail at the lung bases and vertebrae, results in increased density

  • anterior aspect of at least six ribs must be noted above the dome of the right diaphragm

  • alternatively, posterior aspects of at least eight to nine ribs should be visualized 1

  • poor effort: the cardiac shadow may appear spuriously enlarged, crowding of vessels at lung bases

  • thoracic spinous processes are equidistant from the medial end of each clavicle on a frontal image

  • rotation to the right may cause: pseudo-mediastinal mass, hyperlucency of the right lung

  • rotation to the left may cause: aortic arch may appear spuriously enlarged, hyperlucency of the left lung

  • films on anteroposterior views slightly magnify the heart 1

  • medial ends of the clavicles should be projected over the posterior third or fourth ribs 1

  • clavicles will have a S shape 1

Systematic chest radiograph assessment:

  1. projection

  2. assessment of the technical adequacy

  3. tubes and lines

  4. cardiomediastinal contours

  5. hila

  6. airways, lungs and pleura

  7. bones and soft tissue

  8. review areas

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