Airway: The trachea is located in the midline. Inspect the trachea and right and left main bronchi. If the trachea is pushed to the left or right look for a cause. Either mass effect pushing the trachea or volume loss (atelectasis) pulling on it.

Breathing: The lobes of the lungs. 3 on the right (upper, middle, lower) and two on the left (upper and lower). Look for consolidation, nodules, masses. Things replacing normal aerated lung (black) will show up as white.

Cardiac: look at the heart size (should be less than 50% of the diameter of the chest). Make sure the borders are clear and sharp. The right atrium makes up the right heart border and the left ventricle makes up the left heart border on the chest X-ray. If the border is obscured, think pneumonia or mass.

Diaphragm: should be well defined to the costophrenic angle. Becomes obscured by lower lobe pneumonia and pleural effusions. Always look for free air under the diaphragm.

Everything else:

  • Bones – look for fractures and destructive lesions
  • Hilar contours – look for enlargement caused by lymphadenopathy or masses
  • Vascular structures – enlarged pulmonary arteries and aortic aneurysms.

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⬇️ Vertical Dimension

1) Mediastinal shift to opposite side

2) Blunting of costophrenic angle

3) Homogenous opacity (Presence of fluid)

4) Ellis S-shaped curve (Concave border)



➡️ Both treatment and prognosis are completely dependent on the underlying cause:

  • an infected effusion should be drained with an intercostal drain
  • a large effusion secondary to heart failure or in a patient with cirrhosis may respond to diuretics
  • an effusion secondary to malignancy may require pleurodesis following drainage

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