Chest x-ray review: breathing

Last revised by Jeremy Jones on 14 Aug 2021

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 where B refers to breathing and the assessment of the lungs and pleural spaces.


  • introduction
    • large number of processes that cause lung abnormality
    • aeration of the lungs is often altered by pathology
      • whiter areas (increased density)
        • less gas in the lungs
      • darker areas (increased lucency)
        • more gas in the lungs
  • procedure
    • check for symmetry (allowing for mediastinum)
    • check each zone in turn and compare with the other side
      • apices, upper, middle and lower zones
      • check volume and density
      • look for any focal areas of increased density
    • check around the lungs comparing each step on both sides
      • start at the apex and trace down the edges of the lungs
      • check the costophrenic angles are sharp
      • trace the hemidiaphragms to the spine
      • check the cardiac borders are crisp and clear
      • check the hilar structures can be seen clearly
  • checklist
    • both lungs are expanded and similar in volume
    • apices, upper, middle and lower zones are symmetrical
    • normal lateral margins
    • normal CPAs
    • normal hemidiaphragms
    • normal cardiac borders
    • normal lung behind the heart

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Cases and figures

  • Breathing (lungs and pleural spaces)
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  • Figure 1: check for symmetry
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  • Figure 2: check each zone
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  • Figure 3: check the lateral margins
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  • Figure 4: check the costophrenic angles
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  • Figure 5: check the hemidiaphragms
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  • Figure 6: check the cardiac borders
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  • Figure 7: check the retrocardiac area
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