Ahpra registration PHY0002298174
How these guides are written and reviewed →
Chest radiograph interpretation for physiotherapists: a systematic read, the findings that change airway clearance, positioning and mobilisation, and what a single film cannot tell you. The client guide to having an X-ray follows below.
A systematic read
- Details: patient, date and time, and projection (PA or AP; erect or supine). Always compare with the previous film.
- Quality: rotation (clavicle heads equidistant from the spinous processes), inspiration (about 6 anterior ribs above the diaphragm) and penetration.
- Airway and mediastinum: tracheal position, mediastinal width and contour, and the hila.
- Lungs: compare zones side to side for volume, opacity and lucency.
- Pleura: costophrenic angles, a visible pleural edge, or a fluid meniscus.
- Heart and diaphragms: cardiothoracic ratio (PA films only), diaphragm level and contour.
- Lines, tubes and devices: endotracheal tube tip, drains, central lines, pacing wires and sternal wires.
Findings that change physiotherapy
| Finding | Usually means | What it changes |
|---|---|---|
| Collapse with volume loss (shift towards the opacity, raised hemidiaphragm) | Retained secretions, mucus plugging or obstruction | Airway clearance, positioning with the affected lobe uppermost, early mobilisation; escalate if it does not respond |
| Consolidation without volume loss, air bronchograms | Pneumonia | Clearance only if secretions are retained; mobilise and titrate oxygen to target |
| Pleural effusion (blunted angle, meniscus) | Fluid in the pleural space | Clearance will not shift it; positioning and mobilisation, and liaise about drainage |
| Pneumothorax (pleural edge, absent lung markings) | Air in the pleural space | No positive-pressure techniques (PEP, IPPB, CPAP, manual hyperinflation) until it is drained or reviewed; escalate a new one |
| Hyperinflation (flattened diaphragms, more than 6–7 anterior ribs) | Air trapping in COPD or asthma | Breathing control and positioning; consider when setting PEP or NIV |
| Pulmonary oedema (upper-lobe diversion, septal lines, perihilar haze) | Fluid overload | Clearance will not help; sit upright, liaise medically; CPAP or NIV may be indicated |
| Tube or line out of position | For example an endotracheal tube in the right main bronchus | Report before treatment; it changes suction and hyperinflation |
A film lags the clinical picture by a day or more, and a supine AP film overstates heart size and can hide effusions and pneumothoraces. Read it alongside auscultation, lung ultrasound and the patient in front of you.
What this changes in practice
- Read the film yourself before treating, then check your read against the radiologist's report.
- Treat the patient, not the picture: an unchanged film with improving breathing and oxygen is a good response.
- A pneumothorax, a malpositioned tube or new pulmonary oedema changes the plan before the session starts.
A chest X-ray is a quick, painless picture of the inside of your chest — the lungs, heart, ribs and diaphragm. It uses a very small dose of radiation and takes only moments. It's often the first test when there's a cough, breathlessness, chest infection or chest pain, because it gives a fast overview of what's going on. It doesn't show everything — finer detail needs a CT scan — but it's a valuable snapshot that helps your team, including your physiotherapist, target treatment.
Why it's done
A chest X-ray (CXR) is used to look for a cause of breathlessness, cough, fever or chest pain; to check for chest infection or fluid; to review the heart size; and to check the position of tubes and lines in hospital. It is quick, widely available and low-dose, which is why it is usually the first-line chest image.
What it can show
| Finding | What it may indicate |
|---|---|
| Areas of white "shadowing" (consolidation) | Infection / pneumonia, or fluid in the lung tissue |
| Fluid at the lung bases (effusion) | Pleural effusion, heart failure |
| A dark area with a collapsed lung edge | Pneumothorax (collapsed lung) |
| Loss of volume / raised diaphragm | Collapse (atelectasis) |
| Over-large, dark lungs with a flat diaphragm | Hyperinflation, as in chronic obstructive pulmonary disease (COPD)/emphysema |
| Enlarged heart outline | Cardiomegaly / heart strain |
What to expect
You'll usually stand against a flat plate with the machine in front, take a deep breath in and hold it for a second while the image is taken. It's over in moments and you feel nothing. You may be asked to remove clothing and jewellery from the upper body. Tell staff if you are, or could be, pregnant.
Radiation & safety
The dose from a single chest X-ray is very small — roughly equivalent to a few days of natural background radiation — so the benefit of the information almost always outweighs the tiny risk.1
How physiotherapists use it
Cardiorespiratory physiotherapists read the report and, where appropriate, the image alongside their own assessment. It helps to localise a problem (which part of which lung), choose and target treatment (for example, positioning and airway clearance for a collapsed or consolidated area), and check safety before certain techniques — for instance, being cautious with positive-pressure or vigorous techniques if there is an untreated pneumothorax. The X-ray complements, but never replaces, hands-on assessment. See Auscultation and Principles of Airway Clearance.2
Limitations
A chest X-ray is a flat, two-dimensional summary, so overlapping structures can hide or mimic problems, and subtle changes may not show. When more detail is needed — small nodules, bronchiectasis, lung fibrosis or a suspected clot — a CT scan is used.
References & evidence base
- Royal Australian and New Zealand College of Radiologists. Inside Radiology: chest X-ray. Sydney: RANZCR, 2024. Available at: insideradiology.com.au
- Corne J, Pointon K. Chest X-ray made easy. 4th ed. Edinburgh: Churchill Livingstone, 2015.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.