An enlarged heart is indicative of cardiac disease, but a "normal"-size heart does not imply normality; for example, significant

hypertrophy does not cause dilatation and relative enlargement may not be appreciated without comparison films. A "normal" 12 cm heart is not normal if it measured 10 cm 6 months ago. Among many available measurements, the cardiothoracic ratio (or CT ratio) benefits from simplicity and utility. It is measured by dividing the maximal transverse cardiac silhouette by the maximal internal thoracic diameter using 0.5 as the upper limit of normal. This will give some false positives, particularly if a film is taken on a poor inspiration. The degree of inspiration has the greatest effect on apparent heart size. An optimal film would have the diaphragm at the posterior tenth rib at maximal inspiration to eliminate "pseudocardiomegaly" and pulmonary plethora. Other causes of a false impression of cardiomegaly are the greater magnification of the heart on an AP film. A good estimate of cardiomegaly is a heart greater than 15 cm in transverse diameter or greater than 1 to 2 cm increase in size over one year. The identification of individual chamber enlargement is fraught with many difficulties, and it is often impossible to specify which chamber is enlarged. Certain things can be ascertained with relative ease. On a PA view, the right heart border is formed by the right atrium, and the left heart border is formed by the appendage of the left atrium superiorly and the left ventricle inferiorly. On the lateral view, the anterior cardiac border is formed by the right ventricle and the posterior heart border by the left atrium superiorly (just below the carina) and left ventricle inferiorly. Enlargement of individual chambers is usually reflected in a globular bulge in the expected position of that chamber; for example, the right ventricle will expand and fill the retrosternal space on the lateral view. With massive right ventricular enlargement there will be additional rotation of the heart. This causes a portion of the right ventricle to show as the right heart border and the left ventricular silhouette to disappear (i.e., it is rotated posteriorly) on the PA view. In the adult, the cause of isolated right ventricular enlargement is usually cor pulmonale, and therefore the pulmonary outflow tract and often the central hilar vessels are also enlarged. Left ventricular enlargement expands the left heart border on the PA view (Figure 34.2) and the inferior posterior border on the lateral. This is probably the most common isolated chamber enlargement in adults. It occurs frequently with ischemic heart disease and systemic hypertension. It tends to give the heart a "boot-shaped" appearance on the PA view. However, there can be significant hypertrophy or restrictive cardiomyopathy without any chamber enlargement. Left ventricular enlargement tends to round the left heart border as it enlarges laterally and downward. Left atrial enlargement is reflected earliest by enlargement of the appendage on the PA view. More difficult to see is the posterior bulge on the lateral view just below the carina. This is often obscured by slight patient rotation and the hilar vessels. Other classic but not as often seen signs of left atrial enlargement are the double density and widening of the angle of the carina on the PA view. The double density is the shadow of the left atrium seen through the right atrial shadow just below and to the right of the carina on the PA view. The normal carinal angle is said to be 50 to 100 degrees, a more obtuse angle reflecting left atrial enlargement. However, a poor inspiratory excursion is also a cause of an increased angle, making this sign of limited usefulness. A prominent left atrial appendage on the PA view is probably the most consistent sign of enlargement. A common cause of isolated left atrial enlargement is mitral valve disease. Often, if there is significant left atrial enlargement, there will be associated changes in the lung fields. Left ventricular enlargement (generally from ischemic or hypertensive heart disease), when it progresses to early cardiac decompensation, is often accompanied by left atrial enlargement. Generalized cardiac enlargement with a globular or water-bottle shape (Figure 34.3) indicates either pericardial effusion or cardiomyopathy. The two cannot be differentiated on chest x-ray except by the infrequently seen pericardial fat sign on the lateral view. Occasionally, the pericardial fat is seen as a thin, lucent crescent between the soft tissue density of the myocardium and the effusion. It is seen on the

lateral view behind the sternum in the region of the right ventricle. Echocardiography is a more reliable way to detect a pericardial effusion. Even small effusions can interfere with right heart filling and the chest x-ray will not be abnormal until at least 200 ml of fluid have accumulated. The classic "water bottle" heart is nonspecific for pericardial effusion and can be seen in cardiomyopathy. Sonography is the most sensitive diagnostic technique in diagnosing an effusion. Constrictive pericarditis is difficult to diagnose on chest x-ray as it is not routinely associated with either a large or small heart. Additionally, pericardial calcification is not diagnostic of constriction. It can be seen as the sequelae of infection or surgery (e.g., pericardial window). In general, cardiac calcifications, whether valvular, pericardial, myocardial, or coronary arterial, are best seen by fluoroscopy. The intrinsic motion of the heart improves visualization on fluoroscopy and obscures visualization on plain films. When pericardial calcification is seen on plain films, it is best visualized on the lateral view as a circular or crescentic calcification surrounding the heart. It may involve the entire heart shadow or only a small portion. Valvular calcium is also best seen on the lateral view. If the heart is bisected along its long axis on the lateral view, aortic valve calcification will lie anterior to this line and mitral calcification posterior (Figure 34.4). Coronary artery calcification is seen anywhere along the expected course of the arteries. The left anterior descending and circumflex arteries are the easiest to see and, again, are best seen on the lateral view. Coronary artery calcification is infinitely easier to see on fluoroscopy and indicates significant coronary artery disease.

Now that you have mastered some basic radiologic principles of interpretation, let us put them to clinical use. With the exception of pulmonary edema, alveolar infiltrates tend to be localized, whereas interstitial infiltrates tend to be diffuse. Certain other characteristics of an infiltrate may be helpful in the differential diagnosis. Location of an infiltrate is of prime importance. Tuberculosis is far more common in the upper lobes than in any other lobes. In addition, the tubercle bacillus favors the superior or posterior segments and will rarely be seen in the anterior segment alone. The superior segment of the lower lobes and the posterior segment of the upper lobes are the most frequently involved segments with aspiration pneumonia. Pneumocystis carinii pneumonia is the most frequently seen as a diffuse interstitial infiltrate. The character of the infiltrate is also important. A consolidative infiltrate is most commonly seen with a bacterial pneumonia. The presence of multiple lucent areas within a pneumonic infiltrate suggest a necrotizing process. One would think of tuberculosis, proteus, and pseudomonas, as well as anaerobic pulmonary infections. An alveolar infiltrate in an area of severe emphysema can simulate a necrotizing process because the dilated alveolar spaces of the emphysematous process can simulate cavities. When evaluating a pulmonary mass, the most important thing to try to exclude is a neoplastic process. The presence of dense central calcification is one of the most reliable signs that a mass is not malignant. A calcified mass most frequently represents an old healed and clinically inactive inflammatory process. If there is no calcium present, one must rely on previous chest x-rays to see how long the mass has been there and if it is growing in size. As a general rule, if a mass is seen on an older film and is unchanged in size for 4 to 5 years, it is most likely a benign process, and invasive investigation of the mass is not mandatory. If old films show that the mass was smaller previously and is now growing, or that it was not present previously, then invasive investigation is mandatory. A mass on a chest x-ray of a cigarette

smoker should be considered cancer until proven otherwise. The same is true for a pulmonary mass with a pleural effusion or mediastinal node in a smoker. Cavitation within a mass most frequently represents either a necrotizing infectious process or a cavitating neoplastic lesion. When a carcinoma cavitates, the walls of the mass are thick and irregular; when an inflammatory process cavitates, the walls are thinner and more regular. One of the more difficult things to determine is whether a hilar mass represents a large pulmonary artery or an enlarged mediastinal node. On the PA or AP projection, if you can clearly see vessels going into and joining the mass, it is more likely to be a vascular structure. One can also perform fluoroscopy on the patient and have him or her perform a Valsalva maneuver. If the structure compresses with a Valsalva maneuver, it is more likely to be venous. Similarly, if one appreciates pulsations of the structure, it is more likely to be arterial. Nevertheless, one must be careful that these are not transmitted pulsations from a vascular structure underneath the mass. The lateral view is by far the more helpful view in evaluating the hilar area. The large pulmonary arteries can be appreciated on the lateral view as a large vascular shadow, as described previously. Tumorous enlargement of the hila area can be appreciated much earlier and with greater ease on the lateral. Volume loss of the pulmonary parenchyma is caused by one of three pathophysiologic processes: obstruction, compression, or contraction. Obstruction of a lobar or segmental bronchus will result in a resorption of the air distal to the obstruction with loss of volume of the involved segments. This is seen most commonly with an endobronchial carcinoma; however, extrabronchial masses can cause bronchial obstruction by extrinsic compression. Compression of the parenchyma occurs with a pleural effusion or pneumothorax. Contraction or scarring of the lung occurs as a sequela of a previous inflammatory process such as tuberculosis. With compression there may be obvious signs of pleural effusion or pneumothorax. With contraction there will be the interstitial infiltrate from the fibrous scarring. Volume loss from endobronchial obstruction has several direct and indirect radiologic signs. Dr. Felson has thoroughly described the radiologic signs of obstructive volume loss (see Table 48.1). Displacement of the fissures is the most reliable sign of volume loss. The fissure is displaced toward the affected segment. For example, with upper lobe collapse the major fissure is pulled superiorly and anteriorly toward the collapsed upper lobe; in lower lobe collapse the major fissure is pulled inferiorly and posteriorly toward the collapsed lower lobe. An increase in radiodensity in the affected segment occurs because, as the segment loses volume, the tissues in that segment come closer together and hence are more dense. The final direct sign of volume loss is vascular or bronchial crowding in the effected segment. This occurs for the same reason as the increase in radiodensity.

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful. Reading a chest X-ray (CXR) requires a systematic approach. It is tempting to leap to the obvious but failure to be systematic can lead to missing "barn door" pathology, overlooking more subtle lesions, drawing false conclusions based on a film that is technically poor and, hence, misleading or even basing management on an inaccurate interpretation. There is not just one way to examine a chest X-ray but every doctor should develop his own technique. This article is not a tablet of stone but should be a good starting point to develop one's own routine. Traditionally, GPs rarely see X-rays. Connecting for Health has changed this and GPs should be able to peruse images as well as having access to radiologists' reports via the Picture Archiving and Communications System (PACS).[1] Hence, learning to interpret X-rays is a skill learned as a junior hospital doctor that should not be lost. There may be occasions when a GP has to make decisions based on an unreported film.

The "right film for the right patient"

This may sound pedantic, but it is very important. Check that the film bears the patient's name. However, as names can be shared, check other features such as date of birth or hospital number too. The label may also tell of unusual but important features such as anteroposterior (AP) projection or supine position. Having checked that it is the correct patient, check the date of the film to ascertain which one you are viewing. Save time & improve your PDP on Patient.co.uk

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Technical details
Technical aspects should be considered briefly:

Check the position of the side marker (left or right) against features such as the apex of the heart and air bubble in the stomach. A misplaced marker is more common than dextrocardia or situs inversus. Most films are a posteroanterior (PA) projection. The usual indication for AP is a patient who is confined to bed. It may be noted on the radiograph. If there is doubt, look at the relationship of the

scapulae to the lung margins. A PA view shows the scapulae clear of the lungs whilst in AP projection they always overlap. Vertebral endplates are more clearly visible in AP and laminae in PA. This is important because the heart looks bigger on an AP view. The distance from the tube to the patient is also usually reduced in portable films and this also enlarges the shadow of the heart. X-rays are not so much like pictures as like shadows. The normal posture for films is erect. Supine is usually for patients confined to bed. It should be clear from the label. In an erect film, the gastric air bubble is clearly in the fundus with a clear fluid level but, if supine, in the antrum. In a supine film, blood will flow more to the apices of the lungs than when erect. Failure to appreciate this will lead to a misdiagnosis of pulmonary congestion. Rotation should be minimal. It can be assessed by comparing the medial ends of the clavicles to the margins of the vertebral body at the same level. Oblique chest films are requested to look for achalasia of the cardia or fractured ribs. CXR should be taken with the patient in full inspiration but some people have difficulty holding full inspiration. The major exception is when seeking a smallpneumothorax as this will show best on full expiration. A CXR in full inspiration should have the diaphragm at the level of the 6th rib anteriorly and the liver pushes it up a little higher in the right than on the left. Do not be unduly concerned about the exact degree of inflation. Penetration is affected by both the duration of exposure and the power of the beam. More kV gives a more penetrating beam. A poorly penetrated film looks diffusely light (an x-ray is a negative) and soft tissue structures are readily obscured, especially those behind the heart. An over-penetrated film looks diffusely dark and features such as lung markings are poorly seen. Note breast shadows in adult women.

So far you have checked that it is the right film for the right patient and that it is technically adequate.

Systematic search for pathology

Just as palpation of the abdomen and auscultation of the heart is the last part of that examination, so must the search for pathology be deferred until the preliminaries have been completed.

Have a brief look for obvious unusual opacities such a chest drain, a pacemaker or a foreign body. This is a two-dimensional picture and so a central opacity may not be something that was swallowed and is now impacted in the oesophagus. It might be a metal clip from a bra strap or a hair band on a plait. Look at the mediastinal contours, first to the left and then to the right. The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery. The branches of the pulmonary artery fan out through the lung. Check the cardio-thoracic ratio (CTR). The width of the heart should be no more than half the width of the chest. About a third of the heart should be to the right and two thirds to the left of centre. Note: the heart looks larger on an AP film and thus you cannot comment on the presence or absence of cardiomegaly on an AP film. The left border of the heart consists of the left atrium above the left ventricle. The right border is only the right atrium alone and above it is the border of the superior vena cava. The right ventricle is anterior and so does not have a border on the PA chest X ray film. It may be visible on a lateral view.

The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes or primary tumours make the hilum seem bulky. Know what is normal. Abnormality may be caused by lung cancer or enlarged nodes from causes includingsarcoidosis (bilateral hilar lymphadenopathy) and lymphoma. Now look at the lungs. The pulmonary arteries and veins are lighter and air is black, as it is radiolucent. Check both lungs, starting at the apices and working down, comparing left with right at the same level. The lungs extend behind the heart, so try to look there too. Note the periphery of the lungs - there should be few lung markings here. Disease of the air spaces or interstitium increases opacity. Look for a pneumothorax which shows as a sharp line of the edge of the lung. Ascertain that the surface of the hemidiaphragms curves downwards, and that the costophrenic and cardiophrenic angles are not blunted. Blunting suggests an effusion. Extensive effusion or collapse causes an upward curve. Check for free air under the hemidiaphragm - this occurs with perforation of the bowel but also after laparotomy or laparoscopy. Finally look at the soft tissues and bones. Are both breast shadows present? Is there a fractured rib? If so, check again for a pneumothorax. Are the bones destroyed or sclerotic?

There are some areas where it is very easy to miss pathology and so it is worth repeating examination. Attention may be merited to apices, periphery of the lungs, under and behind the hemidiaphragms and behind the heart. The diaphragm slopes backwards and so some lung tissue is below the level of the highest part of the diaphragm on the film.

Lateral films
A lateral view may have been requested or performed on the initiative of the radiographer or radiologist. As an X-ray is a two-dimensional shadow, a lateral film helps to identify a lesion in 3 dimensions. The usual indication is to confirm a lesion seen on a PA film. The heart lies in the anteroinferior field. Look at the area anterior and superior to the heart; this should be black because it contains aerated lung. Similarly, the area posterior to the heart should be black right down to the hemidiaphragms. The degree of blackness in these two areas should be similar, so compare one with the other. If the area anterior and superior to the heart is opacified, it suggests disease in the anterior mediastinum or upper lobes. If the area posterior to the heart is opacified there is probably collapse or consolidation in the lower lobes.

Diagrams
The following diagrams help to understand the interpretation of the chest X-ray.

Mentor media contain a number of pictures of X-rays that may be compared with these diagrams to facilitate interpretation.

Abnormal opacities
When observing an abnormal opacity, note:

Size and shape Number and location Clarity of structures and their margins Homogeneity

If available, compare with an earlier film. The common patterns of opacity are:

Collapse and consolidation

Collapse, also called atelectasis, and consolidation are caused by the presence of fluid instead of air in areas of the lung. An air bronchogram is where the airway is highlighted against denser consolidation and vascular patterns become obscured.

Confluent opacification of the hemithorax may be caused by consolidation, pleural effusion, complete lobar collapse, and after a pneumonectomy. Consolidation is usually interpreted as meaning infection but it is impossible to differentiate between infection and infarction on X-ray. The diagnosis of pulmonary embolism requires a high index of suspicion. To find consolidation, look for absence or blurring of the border of the heart or hemidiaphragm. The lung volume of the affected segment is usually unaffected. Collapse of a lobe (atelectasis) may be difficult to see. Look for a shift of the fissures, crowding of vessels and airways, and possible shadowing caused by a proximal obstruction like a foreign body or carcinoma. A small pleural effusion will cause blunting of the costophrenic or cardiophrenic angles. A larger one will produce an angle that is concave upwards. A very large one will displace the heart and mediastinum away from it, whilst collapse draws those structures towards it. Collapse may also raise the hemidiaphragm. The heart and mediastinum are deviated away from a pleural effusion or a pneumothorax, especially if it is a tension pneumothorax and towards collapse. If the heart is enlarged, look for signs of heart failure with an unusually marked vascular pattern in the upper lobes, wide pulmonary veins and possible Kerley B lines. These are tiny horizontal lines from the pleural edge and are typical of fluid overload with fluid collecting in the interstitial space. If the hilum is enlarged, look for structures at the hilum such as pulmonary artery, main bronchus and enlarged lymph nodes.

Heart and mediastinum

Chest X-ray in children

Children are not just small adults and this is important when interpreting a child's X-ray. Such matters as identification of the patient are still important. A child, especially if small, is more likely to be unable to comply with instructions such as keeping still, not rotating and holding deep inspiration. Technical considerations such as rotation and under or over penetration of the film still merit attention and they are more likely to be unsatisfactory. A child is more likely to be laid down and have an AP film with the radiographer trying to catch the picture at full inspiration. This is even more difficult with tachypnoea.

Assess lung volume

Count down the anterior rib ends to the one that meets the middle of the hemidiaphragm. A good inspiratory film should have the anterior end of the 5th or 6th rib meeting the middle of the diaphragm. More than six anterior ribs shows hyperinflation. Fewer than five indicates an expiratory film or underinflation. Tachypnoea in infants causes trapping of air. Expiration compresses the airways, increasing resistance and, especially under 18 months, air enters more easily than it leaves and is trapped, causing hyperinflation. Bronchiolitis, heart failure and fluid overload are all causes. With underinflation, the 3rd or 4th anterior rib crosses the diaphragm. This makes normal lungs appear opaque and a normal heart appears enlarged.

Positioning
Sick children, especially if small, may not be cooperative with being positioned. Check if the anterior ends of the ribs are equal distances from the spine. Rotation to the right makes the heart appear central, and rotation to the left makes the heart look large and can make the right heart border disappear.

Lung density
Divide the lungs into upper, middle, and lower zones and compare the two sides. Infection can cause consolidation, as in an adult. Collapse implies loss of volume and has various causes. The lung is dense because the air has been lost. In children, the cause is usually in the airway, such as an intraluminal foreign body or a mucous plug. Complete obstruction of the airway results in reabsorption of air in the affected lobe or segment. Collapse can also be due to extrinsic compression such as a mediastinal mass or a pneumothorax. Differentiating between collapse and consolidation can be difficult or impossible, as both are denser. Collapse may pull across the mediastinum and deviate the trachea. This is important, as pneumonia is treated with antibiotics but collapse may require bronchoscopy to find and remove an obstruction.

Pleural effusion
The features of effusion have already been noted for adults. In children, unilateral effusion usually indicates infection whilst bilateral effusion occurs with hypoalbuminaemia as in nephrotic syndrome.

Bronchial wall thickening is a common finding on children's X-rays. Look for "tram track" parallel lines around the hila. The usual causes are viral infection or asthma but this is a common finding with cystic fibrosis.

Heart and mediastinum

The anterior mediastinum, in front of the heart, contains the thymus gland. It appears largest at about 2 years old but it continues to grow into adolescence. It grows less fast than the rest of the body and so becomes relatively smaller. The right lobe of the lung can rest on the horizontal fissure, which is often called the sail sign. Assessment of the heart includes assessment of size, shape, position and pulmonary circulation. The cardiothoracic ratio is usually about 50% but can be more in the first year of life and a large thymus can make assessment difficult, as will a film in poor inspiration. As with adults, one third should be to the left of centre and two thirds to the right. Assessment of pulmonary circulation can be important in congenital heart disease but can be very difficult in practice