Chest radiograph assessment using ABCDEFGHI
Updates to Article Attributes
ABCDEFGHI can be used to guide a systematic interpretation of chest x-rays.
Assessment of quality
The quality of the image can be assessed using the mnemonic PIER:
- position: is this a supine AP file? PA? Lateral?
- inspiration: count the posterior ribs. You should see 10 to 11 ribs with a good inspiratory effect
- exposure: well-exposed films have good lung detail and an outline of the spinal column
- rotation: the space between the medial clavicle and the margin of the adjacent vertebrae should be roughly equal
onto each other; look for indwelling lines or objects
Bones and soft tissues
Scan the bones for symmetry, fractures, osteoporosis, or metastaticand lesions. Evaluate the soft tissues for foreign bodies, oedemaswelling, orand subcutaneous air.
Cardiac
Evaluate the heart size: the heart should be <50% of the chest diameter on PA films and <60% on AP films. Check for the heart shape, calcifications, and prosthetic valves.
DiaphragmsDiaphragm
Check diaphragmsthe hemidiaphragms for the position (the right is commonly slightly higher than the left due to the liver) and shape (may be flatflattened bilaterally in asthma or COPD, or unilaterally in case of tension pneumothorax or foreign body aspiration). Look below the diaphragmsdiaphragm for free air.
Effusions
Pleural effusions may be large and obvious or small and subtle. Always check the costophrenic angles for sharpness (blunted angles may indicate small effusions). Check athe lateral film for small posterior effusions (more sensitive for small effusions).
Fields and fissures
Check lung fields for infiltrates (interstitial vs. alveolar), masses, consolidation, air bronchograms, pneumothoraces, and vascular markings. Vessels should taper and should be almost invisible at the lung periphery.
Evaluate the major and minor fissures for thickening or fluid.
Great vessels
Check aortic size and shape and the outlines of pulmonary vessels. The aortic knob should be clearly seen.
Hila and mediastinum
Evaluate the hila for lymphadenopathy, calcifications, and masses. The left hilum is normally higher than the right. Check for widening of the mediastinum (which may indicate aortic dissection in the appropriate clinical setting) and tracheal deviation (which may indicate a mass effect, e.g. from large goitre, or tension pneumothorax). In children, be careful not to mistake the thymus for a mass!
Impression
In most cases, an impression is worth whileworthwhile as it not only forces you to synthesise all the findings together but acts as a double check.
-<li>rotation: the space between the medial clavicle and the margin of the adjacent vertebrae should be roughly equal on each other; look for indwelling lines or objects</li>-</ul><h4>Bones and soft tissues</h4><p>Scan the bones for symmetry, fractures, osteoporosis, or metastatic lesions. Evaluate the soft tissues for foreign bodies, oedema, or subcutaneous air.</p><h4>Cardiac</h4><p>Evaluate the heart size: the heart should be <a href="/articles/cardiothoracic-ratio"><50% of the chest diameter on PA films</a> and <60% on AP films. Check for the heart shape, calcifications, and prosthetic valves.</p><h4>Diaphragms</h4><p>Check diaphragms for the position (the right is slightly higher than the left due to the liver) and shape (may be flat in <a title="Asthma" href="/articles/asthma-1">asthma</a> or <a href="/articles/chronic-obstructive-pulmonary-disease-1">COPD</a>). Look below the diaphragms for free air.</p><h4>Effusions</h4><p><a title="Pleural effusions" href="/articles/pleural-effusion">Pleural effusions</a> may be large and obvious or small and subtle. Always check the costophrenic angles for sharpness (blunted angles may indicate small effusions). Check a lateral film for small posterior effusions.</p><h4>Fields and fissures</h4><p>Check lung fields for infiltrates (interstitial vs. alveolar), masses, consolidation, <a title="Air bronchograms" href="/articles/air-bronchogram">air bronchograms</a>, <a title="Pneumothoraces" href="/articles/pneumothorax">pneumothoraces</a>, and vascular markings. Vessels should taper and should be almost invisible at the lung periphery.</p><p>Evaluate the major and minor fissures for thickening or fluid.</p><h4>Great vessels</h4><p>Check aortic size and shape and the outlines of pulmonary vessels. The <a href="/articles/aortic-arch">aortic knob</a> should be clearly seen.</p><h4>Hila and mediastinum</h4><p>Evaluate the hila for lymphadenopathy, calcifications, and masses. The left hilum is normally higher than the right. Check for widening of the mediastinum (which may indicate <a href="/articles/aortic-dissection">aortic dissection</a>) and tracheal deviation (which may indicate a mass effect or tension <a href="/articles/pneumothorax">pneumothorax</a>). In children, be careful not to mistake the <a title="Thymus" href="/articles/thymus">thymus</a> for a mass!</p><h4>Impression</h4><p>In most cases an impression is worth while as it not only forces you to synthesise all the findings together but acts as double check.</p>- +<li>rotation: the space between the medial clavicle and the margin of the adjacent vertebrae should be roughly equal to each other; look for indwelling lines or objects</li>
- +</ul><h4>Bones and soft tissues</h4><p>Scan the bones for symmetry, fractures, osteoporosis, and lesions. Evaluate the soft tissues for foreign bodies, swelling, and subcutaneous air.</p><h4>Cardiac</h4><p>Evaluate the heart size: the heart should be <a href="/articles/cardiothoracic-ratio"><50% of the chest diameter on PA films</a> and <60% on AP films. Check for the heart shape, calcifications, and prosthetic valves.</p><h4>Diaphragm</h4><p>Check the hemidiaphragms for position (the right is commonly slightly higher than the left due to the liver) and shape (may be flattened bilaterally in <a href="/articles/asthma-1">asthma</a> or <a href="/articles/chronic-obstructive-pulmonary-disease-1">COPD</a>, or unilaterally in case of <a title="Tension pneumothorax" href="/articles/tension-pneumothorax">tension pneumothorax</a> or <a title="Foreign body aspiration in children" href="/articles/airway-foreign-bodies-in-children">foreign body aspiration</a>). Look below the diaphragm for <a title="Free peritoneal air" href="/articles/pneumoperitoneum">free air</a>.</p><h4>Effusions</h4><p><a href="/articles/pleural-effusion">Pleural effusions</a> may be large and obvious or small and subtle. Always check the costophrenic angles for sharpness (blunted angles may indicate small effusions). Check the lateral film for small posterior effusions (more sensitive for small effusions).</p><h4>Fields and fissures</h4><p>Check lung fields for infiltrates (interstitial vs. alveolar), masses, consolidation, <a href="/articles/air-bronchogram">air bronchograms</a>, <a href="/articles/pneumothorax">pneumothoraces</a>, and vascular markings. Vessels should taper and should be almost invisible at the lung periphery.</p><p>Evaluate the <a title="Major fissure" href="/articles/oblique-fissure">major</a> and <a title="Minor fissure" href="/articles/minor-fissure">minor fissures</a> for thickening or fluid.</p><h4>Great vessels</h4><p>Check aortic size and shape and the outlines of pulmonary vessels. The <a href="/articles/aortic-arch">aortic knob</a> should be clearly seen.</p><h4>Hila and mediastinum</h4><p>Evaluate the hila for <a title="Causes of bilateral hilar lymphadenopathy" href="/articles/bilateral-hilar-lymph-node-enlargement">lymphadenopathy</a>, calcifications, and masses. The left hilum is normally higher than the right. Check for widening of the mediastinum (which may indicate <a href="/articles/aortic-dissection">aortic dissection</a> in the appropriate clinical setting) and tracheal deviation (which may indicate a mass effect, e.g. from large <a title="Goitre" href="/articles/goitre-2">goitre</a>, or tension <a href="/articles/pneumothorax">pneumothorax</a>). In children, be careful not to mistake the <a href="/articles/thymus">thymus</a> for a mass!</p><h4>Impression</h4><p>In most cases, an impression is worthwhile as it not only forces you to synthesise all the findings together but acts as a double check.</p>