Chest x-ray review: ABCDE

Chest x-ray review is a key competency for medical students, junior doctors and other allied health professionals. Using A, B, C, D, E is a helpful and systematic method for chest x-ray review:

• A: airways
• B: breathing (the lungs and pleural spaces)
• C: circulation (cardiomediastinal contour)
• D: disability (bones - especially fractures)
• E: everything else, e.g. pneumoperitoneum

Summary

Airways

Start at the top in the midline and review the airways.

• trace down the trachea to the carina
  • is it straight and midline?
  • is there any narrowing?
• trace down both main bronchi
  • is the carina wide (more than 100 degrees)?
  • is there bronchial narrowing or cut-off?
  • is there any inhaled foreign body?

Read more: chest x-ray assessment of the airways

Breathing

Look for lung and pleural pathology.

• both lungs should be well expanded and similar in volume
  • can you count 10 posterior ribs bilaterally?
  • is one lung larger than the other?
• compare the apical, upper, middle and lower zones in turn
  • are they symmetrical?
  • are there areas of increased density?
• trace the lung vessels
  • do they branch out progressively and uniformly?
  • can you see the retrocardiac and retrodiaphragmatic lung vessels?
  • are there extra lines in the periphery that aren't vessels?
• trace the lateral margins of the lung to the costophrenic angles
  • are the costophrenic angles crisp?
• trace the hemidiaphragms in to the vertebra
  • can you see the whole of the hemidiaphragm?
• trace the cardiac borders
  • can you clearly see the left and right heart border?
  • can you see the descending aorta?

Read more: chest x-ray assessment of lungs and pleural spaces

Circulation

Look at the heart and vessels (systemic and pulmonary).

• check the cardiac position
  • is 1/3 to the right and 2/3 to the left?
• assess cardiac size
  • is the cardiothoracic ratio < 50%?
• check the position and size of the aortic arch and pulmonary trunk
• check the width of the upper mediastinum
• look at the hilar vessels
  • can you see them clearly on both sides?
  • are they at a similar height?
  • can you see a preserved hilar point bilaterally? 

Read more: chest x-ray assessment of the cardiomediastinum

Disability

Check for any bony pathology (fracture or metastasis).

• trace along each posterior (horizontal) rib on one side of the chest
  • is there a fracture or abnormal area?
• repeat with the other side of the chest
• now trace lateral and anterior ribs on the first side
• repeat on the other side
• now, check the clavicles and shoulders
  • can you trace around the cortex of the bones?
• finally the check the vertebral bodies
  • are they all rectangular and of a similar height?
  • can you see 2 pedicles per vertebral body?
  • are there disc spaces?

Read more: chest x-ray assessment of the bony thorax

Everything else

Review the upper abdomen, soft tissues and take a look at some final check areas.

• is there free gas under the diaphragms?
• is there subcutaneous emphysema?
• is the gastric bubble in the correct place?
• is there a hiatus hernia?
• is there an absent breast shadow?
• are there any surgical clips?
• check again...
  • are the lung apices clear?
  • is there any retrocardiac or retrodiaphragmatic pathology?

Read more: chest x-ray assessment of everything else