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🫁 Chest X-Ray Patterns in Respiratory Disease - The Complete Guide

Sources: Murray & Nadel's Respiratory Medicine, Goldman-Cecil Medicine, Harrison's Principles (22nd Ed.), Rosen's Emergency Medicine, Grainger & Allison's Diagnostic Radiology

Quick Memory Framework: The 5 Core CXR Patterns

Pattern	Appearance	Think of
Consolidation	White/opaque area - airspace filled	Pneumonia, pulmonary oedema
Hyperinflation	Black/over-dark lungs, flat diaphragm	COPD/Emphysema
Pleural effusion	White lower zone, blunted angle	Heart failure, infection, cancer
Pneumothorax	Black rim + no lung markings	Trauma, spontaneous
Reticulation/Nodules	Fine mesh/lace or dots	TB, ILD, sarcoidosis

1. LOBAR PNEUMONIA (Consolidation)

CXR Appearance:

Homogeneous white opacity conforming to a lobe
Air bronchograms (dark branching airways inside the white area - pathognomonic of airspace filling)
Lobar or segmental distribution
No volume loss (the lobe is FULL, not collapsed)

Causes:

Streptococcus pneumoniae (most common, right upper lobe classic)
Klebsiella pneumoniae (right upper lobe, "bulging fissure" sign)
Community-acquired pneumonia (CAP)

Lobar pneumonia - homogeneous right upper lobe opacity with air bronchograms (arrows). This is the "textbook" lobar pattern of pneumococcal infection.

Key points: The arrow shows air bronchograms - dark air-filled airways visible through the white consolidated lobe. No volume loss = consolidation (not collapse).

2. BRONCHOPNEUMONIA (Patchy Consolidation)

CXR Appearance:

Patchy, multifocal, ill-defined opacities - scattered like "cotton balls"
Bilateral or unilateral
No single lobe boundary
May have small centrilobular nodules

Causes:

Staphylococcus aureus (MRSA - can cavitate)
Mycoplasma pneumoniae (bilateral, basal)
Haemophilus influenzae
Aspiration pneumonia (RLL predominant, dependent regions)
Measles, adenovirus (viral - peribronchial pattern)

Measles/viral pneumonia - bilateral patchy peribronchial infiltrates with mottled, bronchovascular thickening throughout both lung fields.

Aspiration pneumonia - right lower lobe consolidation with volume loss and tracheal shift toward right. Note: dependent position favors right lower lobe.

3. PULMONARY OEDEMA (Perihilar Bat-Wing / Alveolar Flooding)

CXR Appearance:

Bilateral perihilar ("bat-wing") infiltrates
Kerley B lines - 1-2 cm horizontal lines at lateral lung bases (dilated lymphatics/fluid in interlobular septa)
Upper lobe vascular diversion (cephalization of flow)
Cardiomegaly (heart > 50% of thoracic diameter)
Blunted costophrenic angles (effusions)
Hazy/ground-glass shadowing bilateral, perihilar > peripheral

Causes:

Left ventricular failure / heart failure (cardiogenic)
ARDS / sepsis (non-cardiogenic - no cardiomegaly, no effusions)
Renal failure, volume overload
Mitral stenosis

Pulmonary oedema (COVID-19 organizing pneumonia pattern shown) - bilateral confluent ground-glass opacities and consolidation with perihilar distribution. Also shows small left pleural effusion blunting the left costophrenic angle.

4. PLEURAL EFFUSION

CXR Appearance:

Blunting of the costophrenic angle (>200 mL visible on PA)
Homogeneous basal opacity with a concave upper margin (meniscus sign)
Fluid layers laterally higher than medially
Massive effusion: complete opacification of a hemithorax
On supine films: diffuse haziness of the hemithorax

Causes:

Transudate: Heart failure (bilateral, R > L), hypoalbuminaemia, renal failure
Exudate: Pneumonia (parapneumonic), TB, malignancy, pulmonary embolism

Right-sided pleural effusion - portable film showing right hemithorax opacification with meniscus. The left side shows a relatively normal lung field for comparison.

How to spot: Start at the costophrenic angles - they should be sharp and acute. Any blunting = suspect effusion.

5. PNEUMOTHORAX

CXR Appearance:

Visible pleural line - a thin white line parallel to the chest wall
Complete absence of lung markings peripheral to that line (black space)
Lung "falls away" from the chest wall
Tension PTX: mediastinal shift AWAY from affected side + depressed hemidiaphragm - medical emergency!

Causes:

Primary spontaneous: Tall, thin young males (ruptured apical bleb)
Secondary spontaneous: COPD (emphysematous bullae), asthma, TB, cystic fibrosis
Traumatic: Rib fractures, iatrogenic (central line, thoracentesis)

Pneumothorax comparison - Left (A): upright film showing pleural line (arrows) at apex of right lung with loss of vascular markings beyond it. Right (B): lateral decubitus view showing the free air tracks to the nondependent space.

6. TUBERCULOSIS (TB)

CXR Appearance:

Type	Location	Pattern
Primary TB	Middle/lower zone + ipsilateral hilar adenopathy	Consolidation + enlarged hilum
Reactivation TB	Apical/posterior segment upper lobes (R > L)	Cavitation, fibrosis, calcification
Miliary TB	Diffuse both lungs	1-3mm nodules "millet seeds" throughout
HIV-associated TB	Lower zones, diffuse	Atypical - no cavity, adenopathy

Causes: Mycobacterium tuberculosis - reactivation of latent infection

Reactivation/Cavitary TB - extensive right upper lobe cavitation with surrounding consolidation and fibrosis. Upper lobe predominance with cavities = TB until proven otherwise.

7. COPD / EMPHYSEMA

CXR Appearance:

Hyperinflation - lungs look too dark, >6 anterior ribs visible above diaphragm on PA
Flattened hemidiaphragms (most reliable sign)
Increased AP diameter ("barrel chest")
Increased retrosternal airspace on lateral view
Prominent pulmonary arteries (cor pulmonale if right heart fails)
Bullae (black avascular areas with thin walls) in emphysema

Causes: Smoking (>90%), alpha-1 antitrypsin deficiency, occupational dust

Memory trick: Flattened diaphragm + dark lungs + SMALL heart = COPD

8. COVID-19 PNEUMONIA (Organizing Pneumonia Pattern)

CXR Appearance:

Bilateral, peripheral, lower-zone predominant consolidation
"Ground glass" opacities
Rounded/confluent consolidations
Spares central/perihilar regions (unlike pulmonary oedema)
Often accompanied by small pleural effusions

COVID-19 organizing pneumonia - bilateral extensive confluent ground-glass opacities with heterogeneous consolidation and linear opacities, sparing upper zones.

MASTER DIFFERENTIATION TABLE

Feature	Pneumonia (Lobar)	Pulm. Oedema	Pleural Effusion	Pneumothorax	TB (Reactivation)	COPD
Location	Lobar/segmental	Bilateral perihilar	Basal	Apex (rim)	Upper lobe	Diffuse
Opacity	Dense white, lobar	Perihilar haze	Lower zone white	Black (avascular)	Patchy + cavities	Hyper-dark
Air bronchograms	YES (hallmark)	May be present	No	No	Variable	No
Meniscus sign	No	No	YES	No	No	No
Kerley B lines	No	YES	Sometimes	No	No	No
Cardiomegaly	No	YES (cardiac cause)	No	No	No	Late (cor pulm)
Cavitation	Possible (MRSA)	No	No	No	YES (classic)	Bullae
Trachea/mediastinum	Midline	Midline	Shifted AWAY	Shifted AWAY (tension)	Shifted TOWARD (fibrosis)	Midline
Diaphragm	Normal	Normal-elevated	Obscured	Depressed (tension)	Elevated (fibrosis)	Flat
Volume	Preserved	Increased	Decreased (compressed)	Increased	Decreased	Increased
Key memory hook	Air bronchograms	Bat wings + Kerley B	Costophrenic blunting	Pleural line + black	Upper lobe cavity	Flat diaphragm

QUICK MNEMONICS

For PLEURAL EFFUSION vs CONSOLIDATION:

Effusion: Concave upper border (meniscus), no air bronchograms, shift AWAY
Consolidation: Air bronchograms, no shift (unless collapse), lobar shape

For PULMONARY OEDEMA (ABCDE):

Alveolar oedema (bat-wing), B-lines (Kerley), Cardiomegaly, Diversion of vessels (upper lobe), Effusions (bilateral)

For TB upper zone lesions:

"FACTS" = Fibrocavitary, Apical, Calcification, Top (upper) lobe, Scarring

Pneumothorax vs Bullae:

Pneumothorax: rim of air wraps the ENTIRE edge of lung
Bullae: confined, localized, thin-walled bubble, lung markings present beyond it

CXR INTERPRETATION APPROACH (ABCDE System)

A - Airways: trachea midline? carina angle (<70°)?
B - Bones/soft tissue: rib fractures, mastectomy?
C - Cardiac: size, shape (>50% of thorax = cardiomegaly)
D - Diaphragm: flat (COPD), high (effusion, phrenic paralysis), costophrenic angles sharp?
E - Everything else: lung fields zone by zone, hilum, mediastinum

Sources: Murray & Nadel's Respiratory Medicine | Goldman-Cecil Medicine | Harrison's Principles of Internal Medicine 22nd Ed. | Rosen's Emergency Medicine | Grainger & Allison's Diagnostic Radiology

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