Dr. Prabhat AryaMD · Internal Medicine
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Your chest X-ray report, phrase by phrase.

Many chest X-ray phrases sound alarming and mean very little. Here is what each one usually means, and the few findings that need a doctor soon.

Reviewed by Dr. Prabhat Arya, MBBS, MD (Internal Medicine)

Reviewed · Next review · Sources: MedlinePlus, Radiopaedia, NHS

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A chest X-ray is one flat picture of the lungs, heart, ribs and the space around them. The radiologist describes what they see, and words like “prominent”, “opacity” or “fibrosis” describe shadows, not diseases. The same shadow can mean different things, so an X-ray is always read together with your symptoms.

The Impression line at the bottom matters most. “No active lung lesion”, “No significant abnormality” or “Normal study” means the radiologist found nothing that needs action.

The best thing you can do is compare with an old X-ray. A shadow unchanged for years is almost always a scar. Keep your old films or CDs and take them to every visit; a new report rarely says “unchanged” unless the old one is shown.

A normal chest X-ray does not rule out every problem: early TB, small growths and asthma can be missed. A cough lasting two weeks or more still needs a doctor, even with a normal X-ray.

Every value, one by one.

Poor inspiration, rotated film or AP view

Notes about how the picture was taken

What it means
If you did not breathe in fully, the film is turned slightly, or it was taken from the front (AP, often in bed or in emergency), the heart looks bigger and the lung markings look crowded. These are notes about the picture, not about you.
Usually nothing to worry about when
The rest of the report is normal. Findings like “prominent markings” or a slightly large heart on such a film are often from the technique alone.
See a doctor when
If the report says the film is not good enough to judge, a repeat X-ray (PA view, deep breath in) at your next visit settles it.

Prominent bronchovascular markings (BV markings)

The normal lines of air tubes and blood vessels look a little more visible

What it means
One of the most common phrases on Indian chest X-ray reports, and usually not a disease. It is seen with a shallow breath during the X-ray, being overweight, older age, smoking, long-standing bronchitis or asthma, a recent chest cold, and in city air pollution. Occasionally it is an early sign of fluid in the lungs from a weak heart.
Usually nothing to worry about when
You have no cough, fever or breathlessness, or you are recovering from a cold.
See a doctor when
See a doctor within a week if you have a cough for more than two weeks, breathlessness on walking, wheeze, or swollen feet; at your next check-up if you smoke, to discuss lung tests (spirometry).

Opacity, consolidation, patchy infiltrates or haziness

An area of lung that looks whiter than it should

What it means
Air looks black on X-ray, so anything filling the air spaces looks white. With fever and cough this is usually pneumonia (chest infection). In India, TB is the other common cause, especially in the upper zones. Less often it is a collapsed part of lung or, in older smokers, a growth.
Usually nothing to worry about when
It is small, you had a chest infection, and a repeat X-ray after treatment shows it has cleared.
See a doctor when
With fever, cough or breathlessness, see a doctor within a day. Without symptoms, see a doctor within one to two weeks, with any old X-rays. If symptoms have not settled, or you are over 50 or smoke, a repeat X-ray about six weeks after treatment is often advised to make sure the shadow has gone.

Nodule, small rounded opacity or “coin lesion”

A small round spot in the lung

What it means
Most small lung nodules are harmless: old healed infection (often old TB, called a granuloma), a scar or a blood vessel seen end-on. A spot that is calcified (very white) is almost always an old healed scar. A minority need a closer look, mainly in smokers and older people.
Usually nothing to worry about when
It is calcified, or it is the same size on an X-ray from two or more years ago.
See a doctor when
See a doctor within one to two weeks with your old X-rays. A CT scan of the chest is often advised if there is no older X-ray to compare, especially if you are over 40 or have smoked.

Fibrosis, fibrotic strands, fibrocalcific lesions or “old healed Koch’s”

Scars in the lung, often from an infection in the past

What it means
Very common on Indian reports. “Koch’s” is an old name for TB, and “old healed” or “fibrocalcific” means a scar left after a past TB infection or pneumonia, often one the person never knew about. A scar is not active TB and is not catching. Widespread fine fibrosis in both lungs is different: it can be a lung disease of its own.
Usually nothing to worry about when
You have no cough, fever, weight loss or night sweats, and the scar is the same as on older X-rays.
See a doctor when
See a doctor within a few days if you have a cough of two weeks or more, fever, night sweats, weight loss or blood in the phlegm: a phlegm (sputum) test for TB is needed, because TB can come back near old scars. If the report says fibrosis in both lungs or “interstitial” changes and you are breathless, see a doctor within one to two weeks.

Hyperinflated lungs, emphysematous changes or flattened domes

The lungs look larger and darker than usual, holding on to air

What it means
Seen with long-term smoking (COPD), chulha or biomass smoke exposure, and sometimes asthma. A very deep breath during the X-ray can look similar.
Usually nothing to worry about when
You are a non-smoker with no breathlessness and the rest of the film is normal.
See a doctor when
If you smoke, have cooked over wood or dung fires, or get breathless or wheezy, ask for a breathing test (spirometry) within a few weeks.

Prominent hilar shadows or bilateral hilar prominence

The area where the main air tubes and blood vessels enter each lung looks larger

What it means
Often just normal blood vessels looking prominent, or a rotated film. Sometimes enlarged lymph glands, which in India are most often from TB, and less often from sarcoidosis or other causes. Rarely, raised pressure in the lung arteries.
Usually nothing to worry about when
The radiologist calls it vascular (blood vessels) and you are well.
See a doctor when
See a doctor within one to two weeks if you have cough, fever, weight loss or breathlessness, or if the report says “lymphadenopathy” or the enlargement is on one side only and you smoke or are over 40, even if you feel well; a CT scan may be needed.

Cardiomegaly or CTR (cardiothoracic ratio)

Heart width compared with chest width

Typical adult range CTR under 0.5 on a standard PA (back-to-front) film

High usually means
A CTR over 0.5 is reported as cardiomegaly (large heart shadow). On an AP film, with a shallow breath or in overweight people, the heart often looks big when it is not. When real, it is usually from long-standing high BP, a weak heart muscle, a valve problem, or fluid around the heart.
Usually nothing to worry about when
The CTR is 0.50–0.55 on an AP or poorly-inspired film and you have no breathlessness or swelling. An X-ray is a rough guide; an echo measures the heart properly.
See a doctor when
See a doctor within a week or two for an echo if the report says cardiomegaly on a PA film, or sooner (within a day or two) if you are breathless on lying flat, wake up breathless or have swollen feet.

Unfolded aorta, prominent aortic knuckle or atherosclerotic (calcified) aorta

The main artery leaving the heart looks wider or has calcium in its wall

What it means
Common after 50, especially with high BP. The aorta gets longer and curves more with age; calcium in its wall is a sign of hardened arteries in general.
Usually nothing to worry about when
You are over 50 and nothing else is reported. Treat it as a reminder to control BP, cholesterol and sugar.
See a doctor when
At your next check-up, review BP, cholesterol and sugar. If the report says the aorta is “dilated” or “aneurysmal”, see a doctor within a week or two for a scan.

Blunted CP angle (costophrenic angle)

The sharp lower corner of the lung, where it meets the diaphragm, looks rounded

What it means
Either a small amount of fluid around the lung (a small pleural effusion) or old thickening of the lung lining left after a past infection such as TB or pleurisy. Old thickening stays the same for years.
Usually nothing to worry about when
It is unchanged on old X-rays and you are well.
See a doctor when
See a doctor within a week if it is new, especially with fever, cough, chest pain on breathing in or breathlessness; an ultrasound of the chest can tell fluid from old scarring.

Pleural effusion

Fluid collected between the lung and the chest wall

What it means
Always has a cause that needs finding. The common ones are heart failure, pneumonia, TB (a common cause in younger adults in India), kidney or liver disease, and less often a growth.
Usually nothing to worry about when
Never ignore a new effusion.
See a doctor when
See a doctor within a day or two; the fluid is often tested. Go to hospital today if you are breathless at rest or the effusion is described as large.

“No active lung lesion”, “No significant abnormality” or “Lung fields clear”

The impression line

What it means
A normal report. “No active lesion” means nothing that looks like a current infection, TB, fluid or growth. It does not mean old scars are absent; they may be listed above and are not a concern.
Usually nothing to worry about when
Always, if you feel well.
See a doctor when
Only if symptoms continue: a cough over two weeks, blood in the phlegm, weight loss or breathlessness need a doctor even with a normal X-ray.

Results that go together.

PatternsTypical, not certain
When you seeIt usually means
Prominent BV markings with a slightly large heart on an AP or poor-inspiration filmVery often the way the picture was taken. A repeat PA film with a deep breath, or an echo, usually settles it.
Upper-zone opacity with cough over two weeks, fever and weight lossTypical of TB in India. Needs a sputum test within a few days; see TB.
Fibrocalcific lesions with a blunted CP angle, unchanged for yearsOld healed TB or pleurisy with scarring. No treatment needed if you are well.
Cardiomegaly with prominent upper-lobe vessels or bilateral effusions, and breathlessnessSuggests fluid from a weak heart. See a doctor within a day; see heart failure.
Hyperinflated lungs with prominent BV markings in a smokerTypical of COPD. A breathing test confirms it; see COPD.

Get help today if

  • A report of pneumothorax (collapsed lung), or sudden sharp chest pain with breathlessness: go to hospital now, or call 112.
  • Breathless while sitting still, lips or fingertips turning blue, or an oxygen reading below 94% on a home meter, with pneumonia or a large effusion on the report: go to hospital today; call 112 if it gets worse.
  • Coughing up more than a spoonful of blood: go to hospital today.
  • Pneumonia on X-ray with new confusion, unusual drowsiness or fast breathing, at any age: go to hospital now, or call 112.

Call 112 or go to the nearest emergency department. Ambulance: 108 (102 in some states).

Read more.

Questions people ask.

  1. What does “prominent bronchovascular markings” mean?

    It means the normal lines of the air tubes and blood vessels look a little more visible than usual. It is very common and usually not a disease: a shallow breath during the X-ray, smoking, pollution, a recent cold or long-standing bronchitis can all cause it. See a doctor if you also have a cough for more than two weeks, breathlessness or swollen feet.

  2. Does fibrosis on my X-ray mean I have TB?

    No. Fibrosis or “fibrocalcific lesions” usually means a scar from an old infection, often TB that healed years ago. A scar is not active TB and does not spread to others. Only if you have a cough for two weeks or more, fever, night sweats or weight loss is a sputum test for active TB needed.

  3. Is a CTR of 0.52 a big heart?

    Not necessarily. A CTR just above 0.5 is common on AP films, when the breath was shallow, and in overweight people. An echo is the proper test. It matters more if you are breathless, wake up breathless at night or have swollen feet.

  4. Is the radiation from a chest X-ray harmful?

    The dose from one chest X-ray is very small, about the same as a few days of the natural radiation we all receive from the environment. Tell the radiographer if you might be pregnant.

Where this can be checked

These are trusted general sources. The advice on this page is Dr. Arya’s, written for patients in India. Ranges differ between labs: go by the range printed on your own report.

Your whole report, read by your doctor.

Send every page, old reports too. He reads them himself and tells you what changed and what to do.

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Dr. Prabhat Arya · MBBS, MD (Internal Medicine)