How to Interpret a Chest X-Ray (Lesson 4 - Airways, Bones, and Soft Tissues)

An overview of how to assess the airways, bones, and soft tissues on chest X-ray, including the important etiologies of common radiographic abnormalities.
Video includes following images (among others):
Left atrial enlargement, downloaded from Radiopaedia.org, originally provided by Alexendra Stanislavsky.
Cervical ribs, downloaded from Radiopaedia.org, originally provided by Jeremy Jones.
Rib notching, downloaded from Radiopaedia.org, original uploader undetermined (image can no longer be located on site).
Sources for other images may include Wikimedia Commons, radiologypics.com, and Jose Caceres' wonderful radiology blog: Caceres Corner (blog.myesr.org/category/caceres-corner/)

[@curvedcut]

Thank you for your selfless contribution to medical education. An inspiration!

[@keilistradling9945]

I am a PA student and whenever I need extra clarification or have extra time I watch your videos they are truly amazing! Thank you so much!

[@modernsamurai86]

I'm studying med and this is a great and informative series for understanding X rays which looked pretty intimidating at first. Love how you hinted at the brand of the furniture with the colours you displayed.

[@cheechee12345]

Dr. Eric, I recently discovered these videos - they are 'awesome'. I am an intern and love having this as a quick review on key concepts. I'm anxiously waiting for lesson 5! Take care and thanks for everything you seem to be doing for us in training.

[@nicholascain594]

Thank you for this series. I have been struggling understanding x-rays and these videos really break it down.

[@borisyadershik]

Thank you for this great lecture series!

[@markolucijanic1179]

thank You Dr. Eric

[@christianijeoma2609]

Excellently presented and even easy for a beginner to recall

[@bryan1598]

Keep making videos doctor, they are great! :)

[@manu27190]

thank dr.Eric this is very good video

[@btuesday]

Excellent lesson.

[@nobzstudio1372]

very interesting presentation, very easy to understand.

[@samratspeaks]

Outstanding lecture :)

[@niamatullah4442]

Thank you sir. Great job ,,,appreciated

[@kadderley8676]

Life saver. Thank you

[@faxm9061]

I love u, Dr.Eric!

[@cristianbindar5393]

Brilliant! Thank you!

[@ayoubbasham4984]

Insanely useful. I'm grateful living in internet era

[@vishubaba11]

Thanks !

[@ayyuce7120]

Thanks this is great for radio lessons

[@bakrimalek4696]

Absolutely the best 👌

[@miriami7]

thank you

[@mustafamukaram7412]

Thank you so much.

[@HafizahHoshni]

Thank youuu so much! 11/11/2017 ✨

[@mohamadigbarea5764]

it's great thank you very much

[@DoctorAmritPandey]

Masterclass ❤❤

[@duongcaovan3643]

thank you Dr Eric !

[@quiksilver545]

Awesome job! Love this!

[@srinivasaraosirasapalli5104]

excellent

[@vannithlong3585]

thanks sir! Thanks

[@ha-med8677]

Great ☄️

[@akshitajain5724]

Thanks 😊

[@kamalpreethara3233]

very informative lectures dr.eric. can you please upload some more xrays of sclerosis and lytic lesions.

[@StrongMed]

I'm glad you found them helpful. The next couple of videos on X-rays will be covering abnormalities of the heart, mediastinum, and pleura. However, I plan to conclude the X-ray series with a review of some "unknown" films, and will include some more sclerotic and lytic lesions then.

[@balqees9214]

great ,,, thank you doctor :)

[@kimhappy1249]

this is very interesting, I have pain on my left side of ribs and I have a feeling that the pain is coming from my ribs not my organs, iv had this pain for a few months it first started as one Mitty sharp in it was very intense and over time the pain is still there and it as spread it goes around the left side of my rids, what could it be

[@rashadovchuyev4326]

very helpfull

[@fredastaire6156]

On to lesson 5!

[@lovelyroroa]

Again I send youmy thanks

[@venkybly]

Tq sir

[@benjaminazumah9833]

Notched superior surfaces of ribs; caused by intrinsic bone abnormalities Notched inferior surfaces of ribs; caused by vascular abnormalities especially those involving the great vessels.

[@shivani4862]

Thank u so much.. really amazing and can you include vedios about CT , ECG, EMG interpretation

[@StrongMed]

I have roughly 20 videos on ECG interpretation. No videos on CT yet, but hopefully at some point in the next 1-2 years (abdominal). Regarding the interpretation of EMGs, they are outside the scope of my clinical practice and expertise.

[@shivani4862]

@@StrongMed thank u sir

[@kartace1]

Amazing lecture, thank you so much- technically it's a porcelain fused to metal crown on that tooth though, you can tell by the contour of the radiopaque metal core and the overlying, relatively radiolucent porcelain superstructure ;) (just because i know radiologists love to be pedantic!) haha

[@kartace1]

It may actually even just be an amalgam filling and not a crown at all, hard to tell for sure

[@shammosunni5755]

Thanx for replying. You said the risk is very very very small of getting cancer from chest xray and people get the same radiation by a incontinent flight. If so why is chest X-rays radiation on the breast cancer risk list and not flight traveling? Is there not a difference in X-ray radiation and space radiation. Like X-ray radiation does space radiation go through your body too?and does it affect your breasts or cells in the same way a chest x-ray would affect your breasts or cells? How much have I increased my risk by having chest X-ray? less than 1%? is it something to worry about?Or am I the same risk as my sister who hasn't had a xray but has travelled on a flight for 7 hrs?

[@alexphongbui8734]

Hi Dr. Eric! As a hospitalist, how often do you find yourself consulting with a radiologist? Or do you prefer to read most thing on your own if you feel comfortable with it?

[@StrongMed]

Alex, this will be a mildly lengthy answer, but you've posed a question that may be more interesting than you might realize... It depends greatly on the specific type of study, and what you mean by "consulting with a radiologist" (e.g. delaying a clinical decision until the official report becomes available in the electronic medical record, or physically walking to the radiology department to review the images face to face with a radiologist). On one extreme, for chest and abdominal x-rays, I make decisions immediately based on my own read, but will double-check with the report once it's available. I'll only discuss the study with the radiologist if I disagree with the final report in a way that is highly clinically relevant. For example, last week a CXR showed a reticulonodular interstitial pattern, but was officially read as "airspace opacities likely due to pulmonary edema", prompting a visit to the radiology reading room. On the other extreme, for MSK films, they come up infrequently enough on the medicine wards that testing myself and practicing reading them is of low enough yield that I usually don't bother looking at the films themselves unless the report describes something unusual or dramatic. In the middle of the road are CTs of head, chest, and abdomen/pelvis, brain MRIs, and most nuclear medicine studies. For these, I always look at the scan first (largely for practice, but also on the off-chance that I catch something critically time-sensitive), but usually defer making an actual decision until either the report is available (if low suspicion of an abnormality) or after I track down the radiologist right away in person (if high suspicion of an abnormality). There's also an interesting dilemma when it comes to reading studies on your own patients. While it would seem like the bedside clinician is the best person to interpret the study (assuming they are qualified to do so), in a formal scientific sense, they are the least appropriate. Using any test to rule in or rule out a diagnosis requires both a pretest probability of disease, as well as knowledge of the test's sensitivity and specificity (or positive and negative likelihood ratios, if you prefer). However, studies in the literature which establish the sensitivity and specificity of certain radiographic modalities for diagnosing specific diseases almost always use interpreters who are blinded to the clinical history. Therefore, if I as the bedside clinician who interviewed and examined the patient am the one who interprets the x-ray or CT, the interpretation is no longer blinded, and the published sensitivity and specificity of the radiographic test is no longer valid. Without a valid estimate of the test's sensitivity and specificity, there is no way to determine the post-test probability, and from a statistical and scientific standpoint, the test therefore cannot be used in the diagnostic process. Of course, this is an academic point only; in practice, no one ever uses this as an argument against looking at studies on their own patients. This is seemingly paradoxically due to a combination of a lack of appreciation for simple biostats, and an appropriate appreciation for how limited formal biostats are in most real-life situations. However, I have seen it argued (and occasionally argued by myself) that there is value in requesting the radiologist make an initial interpretation of a study without knowing anything about the clinical history which might compromise the objectivity of the interpretation. Radiologists usually don't like to do this because it can make them feel like their clinical knowledge is unappreciated, but from a formal statistical point of view, they really should be interpreting studies blinded, and perhaps only as a second step, give an updated unblinded impression once the clinical history is revealed. This is probably most relevant with interpretation of V/Q scans, in which I have seen more than one scan miscategorized (i.e. read as "mod probability for PE" instead of "low probability for PE") due to the fact that the interpreter was swayed by information provided in the chart.

[@alexphongbui8734]

Eric's Medical Lectures Thank you for the great and in-depth reply! I surely did not expect such a detailed explanation but I really appreciate it as a medical student. I meant consulting as in how much do you depend on the radiology report. Do all medical studies go to the radiologist or do you review them first and if you have a good grasp on it, you'll call that case closed and move on without the radiologist reading. With all that being said, what do you believe is the main value of a radiologist? Are radiologists supposed to be an unbiased opinion as you mentioned about them reading initial reports as "blind"? You mentioned about CTs, MRs, etc. is that the main modality that you will defer to a final read? How about other subspecialties in orthopedic or neurology that can read MSK and neruoimages? Sorry for all the questions.. I just find this partnership of clinician to diagnostic specialties (radiology and pathology) very interesting. Thank you again Dr. Eric!

[@shammosunni5755]

Hi Eric are chest X-ray's radiation safe. I had a chest xray 4 days ago( just to check everything is fine, and it was). I just recently was looking at a breast cancer risk list and one of the risks of breast cancer is radiation on chest and it also said 60 people who had chest X-rays ended up with radiation caused breast cancer! I'm now worried! Have I increased my risk of breast cancer by having a chest x ray? Or have I missunderstood the text? I noticed you have xray images of a 3 year old child, are the radiation doses the same for adults and children ? Is it common for people especially women to get chest X-rays and am I right to be worrying of wrong?

[@shammosunni5755]

Oh I forgot to mention I'm 29 now and have had an xray on my head to check for broken nose at age 10 and also had tooth xray last year. Should I be worried about the radiation I've received? I'm very worried about the chest xray coz of the reason explained above.. If you could reply quickly please. 😰

[@StrongMed]

Shammo, while I cannot give you specific advice about your own medical situation, here is what I can say. The amount of radiation given to you by a chest X-ray is very very small, and has a very very very small risk associated with it. Specifically, a standard adult X-ray gives a person about 0.1 milisieverts (the standard measure of the biological effect of ionizing radiation), which is approximately the same amount of extra radiation people receive from space when taking an intercontinental flight (e.g. San Francisco to London) - and almost no one ever gets concerned about radiation while flying (except for the body scanners at the airport). While there is no "safe" level of radiation in the sense that any amount of radiation will theoretically increase your risk of cancer, for a chest X-ray, the increase is trivially small (1 in a million). For example, in the US, the lifetime risk of dying from cancer is approximately 23%. The lifetime risk from dying from cancer after receiving a chest X-ray is therefore something on the order of 23.000001%. This is a negligible increase that you shouldn't worry about. (X-rays of the skull are of similar degree of negligible risk) Other radiology tests can vary quite a bit in terms of how much radiation they give a person. For example, the worst conventional radiographic study is probably a CT of the abdomen and pelvis with contrast, which increases the risk by about 1 in 1000. But even this would only increase lifetime cancer risk from 23% to 23.001% - still a very small difference. It's an interesting academic question as to whether the presence of breast tissue in the chest should necessarily result in different thresholds for getting chest X-rays in men and women, since the added risk to women would theoretically be greater than the added risk to men, but once again, the difference are so extremely small that from a practical standpoint, it doesn't (and shouldn't) change how doctors order X-rays. The major exception to this principle is performing CT scans in pregnant women, which should be avoided if at all possible, due to the substantially higher amount of radiation, and the substantially higher susceptibility of fetuses to chromosomal/genetic damage from radiation. Hope that helps to ease your mind.

[@drhashim1985]

chest x-rays causes 1 cancer per 1 million chest x-rays, if 60% of women who had chest x-rays ended up with cancer, it would be illogical to continue using this technology, one info I read that might ease your worries: women who had CT angiography of the lungs (has a radiation dose of more than 2000 times that of chest x-ray) during pregnancy (where the breast tissue is sensitized to radiation injury) had a life time risk of breast cancer of around 14% (as I remember)

[@shreyashjhunjhunwala3021]

I laughed so hard when at the end he told that it was a hair braid in the xray

[@erincasey514]

Do you have these presentations available as a PDF or powerpoint? They are great!! Thank you!

[@StrongMed]

Erin Casey I have some available as a PDF (e.g. antibiotics, electrolyte disorders, hypertension, thyroid disease, PFTs, and cardiac auscultation). Unfortunately the chest X-ray videos were created directly in Premiere, and can't be easily exported in a printable format.

[@abdihakimaden934]

Erin Casey 9wi

[@dicksonjohn3755]

6:40 Thank you for this video. But at 6:40 you are saying numerous fractures on left posterior ribs. As this is an AP view, the fractures are on anterior ribs, correct?

[@vuxteam90]

do x-ray can see if i inhaled a lil bbq peanut ? if not how i can be healed and spotted? i know it sound weird but i need more knowedge on that ! is it critical or as a adult its okay

[@StrongMed]

This isn't something I've personally encountered before (aspiration of a peanut), but one study I found reported that about 1/2 of children who inhaled a peanut had it visible on X-ray, though it is likely lower in adults. If you are concerned that you personally inhaled a peanut, I would speak with your physician ASAP. I'm sorry, but I cannot give more specific individualized medical advice on here.

[@billyrubin1342]

4:20 The spinous process here does not bisect the clavicles suggesting rotation around the Z axis. How can we make a judgement about tracheal deviation?

[@StrongMed]

Thank you for this excellent point. I don't know of a strictly applied rule about this, but since the trachea is more-or-less halfway between the clavicular heads and the spinous processes, I would say that *very roughly* the trachea should run along an imaginary vertical line that is halfway between the bisection of the clavicular heads and the spinous processes. Although this is just an approximate rule-of-thumb, in the two examples @4:20, the trachea is deviated significantly enough to still make the associated conclusions about possible underlying pathology.

[@billyrubin1342]

@@StrongMed That makes sense. Thank you for your explanation Doctor.

[@user-yc2cm5co3h]

cxr which was clear but quite tall, meaning please

[@doodzy2]

as a 1st year medical student, you've interested me in radiology

[@stephaniecummings9494]

3rd year now?

[@mohammadkuolhasn8705]

👍

[@TCBRCB]

Very didatic and in a good academicism.

[@sushmamahat9995]

What is means of soft tissue

[@Tutanero97]

Why is it that in the foreign body aspiration x-rays the patient's arms are up?

[@StrongMed]

I'm not a pediatrician, but I think this is sometimes done for young children to keep them still while the film is being taken. (A person holds their arms up against their head).

[@Tutanero97]

@@StrongMed It make sense. Thank you for answering!

[@abdallahrallam6167]

is there a hand out for this course

[@StrongMed]

I'm very sorry, but there currently isn't one. Something I hope to work on in the future.

[@abdallahrallam6167]

@@StrongMed it's ok you doing great thank you

[@elsasana224]

superp

[@HasanAlKharfan]

At 9:44 am I just dum or are the airways really not visible?

[@StrongMed]

The trachea and right mainstem bronchus are visible. The left mainstem bronchus not so much.

[@tilak231]

That’s not easy to find the Lighter and Darker areas as you say!! You are changing the contrasts to highlight the pathology, in general we don’t have the power!

[@1rrrrrrrrrrr544f]

Even after zooming in the rib fx,i still didn't see it😢

[@shirinaminoroaya3171]

wooooowwwwwww

[@Sku11Hax]

5:40 must be some Ukrainian furniture shop.. :D //Swedish guy

[@Macsooder]

This is by far one of my favourite channels to watch and I just wish I had found it earlier in my studies. Thank you so much for your excellent resources. I now recommend your channel to everyone I know.

[@StrongMed]

You're very welcome!

[@tilak231]

That’s not easy to find the Lighter and Darker areas as you say!! You are changing the contrasts to highlight the pathology, in general we don’t have the power!