Assessment of lungs, pleura and airways on chest x-ray (approach)

Described below is one approach to the assessment of airways, lungs and pleura on chest x-ray. Start by assessing the tracheal air column, followed by the lungs and finally the pleural spaces. 

Tracheobronchial tree

• assess position, should be central and deviation can be due to

  • positive mass effect, e.g. mediastinal mass, pleural effusion, tenion pneumothorax

  • negative mass effect, e.g. atelectasis, volume loss

Lungs

• assess lung volume

  • increased: emphysema

  • decreased: atelectasis, pulmonary fibrosis

• assess each lung zone individually as well as comparing to the contralateral side

• assess for pulmonary nodule/mass, airspace opacity and/or reticular opacity

  • pulmonary nodules can be mimicked by nipple shadows

• assess pulmonary vasculature

  • enlarged: congestive heart failure, pulmonary hypertension

  • decreased: Westermark sign

Pleura

• lung edge sign of pneumothorax

  • if hydropneumothorax an air-fluid level will be present

• abnormal pleural opacification, e.g.

  • pleural effusion: meniscus sign

  • pleural plaque (can be calcified)

  • pleural mass

See also

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