ICU Imaging · Module 2

How to Read an ICU Chest X-Ray

A fixed, repeatable ICU chest-radiograph sequence: technical quality, airway, lungs/pleura, cardiomediastinum, diaphragm, bones/soft tissues and devices.

~35 min4 visual lessons1 practice cases

Practice an image →Jump to summary

Reference

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Pattern

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Progression

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What you will learn

See the objectives, don’t just read them

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Objective 1
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◉

Apply the same systematic sequence to every ICU chest radiograph.

Objective 2
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↔

Recognize when an AP/supine film limits assessment.

Objective 3
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△

Describe findings before assigning a diagnosis.

Objective 4
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⏱

Compare with prior imaging and identify clinically important interval change.

How to think

Use the same visual sequence every time.

See → describe → decide

1Quality

2Airway

3Lungs + pleura

4Heart + mediastinum

5Devices

6Compare

Projection changes appearance

PA reference vs portable AP example

Compare geometry, not pathology: these are different patients. Portable AP imaging can magnify the cardiac silhouette and is often obtained supine, changing how pleural fluid and pneumothorax appear.

PA erect reference
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Less cardiac magnification · erect positioning · standard reference projection

Portable AP example
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Expect magnification and positioning effects; do not call cardiomegaly from projection alone

Rotation

Compare medial clavicles with the spinous processes before interpreting asymmetry.

Inspiration

Low lung volume can crowd basal markings and exaggerate apparent opacity.

Exposure

Judge penetration before deciding whether central or basal opacity is real.

Visual example · Step 1
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Visual cue: inspect the image first, then connect what you see with the teaching points beside it.

1. Identify and assess technical quality

Portable ICU films are often imperfect; interpreting the imperfection is part of the skill.

●Projection and position

●Rotation

●Inspiratory effort

●Exposure/penetration

●Coverage and artifacts

Visual example · Step 2
Licensed clinical image · tap to enlarge

Visual cue: inspect the image first, then connect what you see with the teaching points beside it.

2. Airway and lungs

Follow the trachea first, then inspect both lungs and pleural spaces from apex to costophrenic angle.

●Tracheal position and ETT/tracheostomy

●Focal or diffuse opacity

●Volume loss

●Pleural line / pneumothorax

●Pleural fluid

●Air bronchograms and cavitation

Visual example · Step 3
Licensed clinical image · tap to enlarge

Visual cue: inspect the image first, then connect what you see with the teaching points beside it.

3. Cardiomediastinum and diaphragm

Interpret cardiac size and mediastinal contour in the context of projection and compare with prior films.

●Cardiac silhouette

●Mediastinal width/contour

●Hilar pattern

●Hemidiaphragms

●Subdiaphragmatic free gas when visible

Visual example · Step 4
Licensed clinical image · tap to enlarge

Visual cue: inspect the image first, then connect what you see with the teaching points beside it.

4. Devices, bones and the final comparison

Finish every film with devices, soft tissues, bones and the question: what changed?

●Trace every line and tube from entry point to tip

●Look for insertion complications

●Inspect ribs, clavicles and soft tissues

●Compare with the most relevant prior study

●End with one concise impression

Quick visual recall

If you remember only these

Technique first

Airway then lungs and pleura

Heart size depends on projection

Finish with every line and tube

Ask what changed

Now use your eyes

Practice with real cases

Interpret the image before revealing the reference interpretation.

CXR Case 001Open →

CXR · Foundation

LookInterpretReveal

References & related learning

Khan AN, et al. Reading chest radiographs in the critically ill (Part I): normal appearance, instrumentation and complications. ↗Khan AN, et al. Reading chest radiographs in the critically ill (Part II): lung pathologies. ↗Mathew R, et al. Chest radiographs of cardiac devices (Part 1): lines, tubes and non-cardiac devices. ↗Baldazzi F, et al. Chest X-ray in intensive care unit patients: thoracic devices. ↗

Chest cases →ICU Procedures →