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The Chest

The Chest. Dr Mohamed El Safwany, MD. The student should be able to recognize technological principles of radiographic chest imaging. Intended Learning Outcome. Technical aspects. Radiation Protection : For chest radiography, a lead-rubber gonadal shield should be

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The Chest

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  1. The Chest Dr Mohamed El Safwany, MD.

  2. The student should be able to recognize technological principles of radiographic chest imaging. Intended Learning Outcome

  3. Technical aspects • Radiation Protection: For chest radiography, a lead-rubber gonadal shield should be • employed so to protect the abdomen below the chest (using vinyle-covered lead apron) • around the waist for all patients of reproductive age, children, and pregnant women. • Otherwise, an adjustable mobile lead shield screen must be used. • Exposure:Low contrast ( long-scale contrast) contrast must be adopted using ‘High kV • Technique ’ (100 - 130 kVp) with low mAs (3 mAs) at 72 inches (180 cm) FFD (SID) on full • second inspiration, to produce more shades of gray that shows fine lung markings behind • the heart and lung bases due to the higher penetration. Higher mA and short exposure • times (0.01 s) must be used to reduce movement blur . • Overall optimum density with sufficient mAs is necessary, which can be proved by seeing • faint outlines of mid and upper vertebrae and posterior ribs. A moving or high-lattice fine- • line) focused grids must be used with the high kV technique. Grids should not be used • with mobile and bed-side patients (mobile radiography). • For pediatrics, lower kV (60 – 70 KV) must be used with lower mAs (to reduce motion). • Higher-speed films and screens are also used for pediatrics to reduce motion and exposure • dose. Correct placement of patient ID and film markers are also important.

  4. Technical aspects • X-ray chest must be taken in full arrested second inspiration to show the lungs well expanded • and full with ‘contrasting air’. In case of pneumothorax, another full exposure on (expiration) • must be done (on the same film) for diagnostic comparison purposes, with an increase of (+5 • kVp) and half the usual mAs (that is 1.5 mAs, when using a high kVp technique).

  5. Technical aspects • All chest radiographs must be taken in ‘standing’ erect to allow the diaphragm to move • down to show greater areas of the lung fields and possible chest/subphrenic abscess or • air-fluid levels. • FFD for PA chest must be 72 inches (180 cm) to maintain the ‘natural’ size of the heart • which is usually less in PA than in AP, and prevent geometrical unsharpness and • magnification as a result of the increased OFD. • Patient’s neck must be sufficiently extended (chin up) to prevent superimposition of chin or • neck on lung apices. Also, large female breasts must be displaced away from lung fields • to avoid creating‘ breast shadows’.

  6. Technical aspects • A left lateral chest film must be done routinely as the heart is located on the left side, • unless certain pathology in the right lung necessitates the need for a right lateral. • Proper CP for the chest is (T7) • Basic (routine) views are: PA and lateral. Special views include: AP or PA apical, • lordatic, lateral decubitus, AP supine (or semi-erect), LAO, and LPO. • fast film screen combinations must be used with the short exposure • times used.

  7. PA Chest (Normal/ ambulance patients) (Basic) • Erect film shows pleural effusions, infections, atelectasis, pneumo-thorax. • Patient erect, feet apart, chin rested on film top edge, hands on lower hips, elbows partially flexed, the shoulders rotated forward (to move the clavicles below apices), top of film 5 -7 cm above the shoulders (to include the apices), exposure on 2nd arrested (inspiration), collimation and protection should be applied. • Film: HD 35x43 cm lengthwise (crosswise for large patients), and 35x35 cm for females) . • CP: T7 (7 – 8 inches inferior to vertebra prominens, or 3 – 4 inch below the jugular notch). • CR: Horizontally 90 to film center.

  8. PA Chest (Normal/ ambulance patients) (Basic)

  9. AP Chest (supine/ semierect – trolley/bedside)(special) • For pathology involving lungs, diaphragm, and the mediastinum. kV for bedside is 70-80 with a grid, for large patients 80-100 kV with grid , film cross-wise to eliminate possible lateral cutoff. • Patient supine on trolley, trolley head raised into a semierect position, film behind the patient. • Film: HD 35x43 cm crosswise. • CP: T7 (3-4 inches below the jugular notch). • CR: 5 caudal to prevent clavicles from obscuring the apices, FFD 120 cm, at least. NB/ With this position it is impossible to show any fluid levels.

  10. AP Chest (supine/semierect – trolley/bedside) (special)

  11. Lateral erect chest (Basic) • Basic (additional) projection for localizing position of a lesion, or for the heart. A grid is used. • Patient erect, turned with side of interest in close contact with the film, MSP parallel with film, arms folded over the head. • Film: HD 35x43 cm. • CP: T7. • CR: 90 horizontally through the chest. • NB/ kV 125, at 6 mAs (with grid).

  12. Lateral erect chest (Basic)

  13. Lateral chest (stretcher/wheelchair patients) (Basic) • For pathology situated posterior to the heart and great vessels (patients who can’t stand for an erect standing lateral) and for trauma. • Film: HD 35x43 cm. • CP: T7. • CR: Horizontally 90.

  14. Lateral chest (stretcher/wheelchair patients) (Basic)

  15. Lateral decubitus chest (AP horizontal beam) (special) • For small pleural effusions (air-fluid levels) and for pneumothorax. A (DECUBITUS) marker or (Arrow) should be used. • Patient lying on one side on radiolucent pad, chin and arms raised above head, patient back against a vertical cassette, knees flexed slightly, top of the cassette • Film: HD 35x43 cm vertical on the couch edge. • CP: T7. • CR: Horizontally 90 to film center.

  16. Lateral decubitus chest (AP horizontal beam) (special)

  17. LAO, RAO chest (heart) (special) • For pathology involving the lung fields, trachea, and mediastinal structures (including the heart). • Patient erect rotated 45 (left anterior shoulder against film for LAO, and right anterior shoulder against film for RAO). • Film: HD 35x43 cm. • CP: T7. • CR: 90 to film center. .

  18. LAO, RAO chest (heart) (special)

  19. AP lordatic chest (special) • For a right middle lobe collapse, or an interlobar pleural effusion. Patient standing in erect PA , then bends backward at the waist (30– 40 degrees). • Film: HD 35x43 cm. • CP: T7. • CR: Horizontally 90 to film center.

  20. AP lordatic chest (special) • For opacities obscured in the apical region by the ribs or by the clavicular shadows (masses, TB, etc..). • Patient stands or sits in AP projection with the coronal plane 30 degrees to the film with the inion resting against upper border of the film. • Film: HD 35x43 cm. • CP: Sternal angle. • CR: Horizontally 90 to film center.

  21. AP lordatic chest (alternative positions) (special)

  22. PA (penetrated) chest (heart and aorta) (Basic) • Patient positioned as for PA chest. • kV is adjusted to give enough penetration of the thoracic vertebrae (just visible through the heart). The lung fields must appear over-penetrated. Exposure time 0.01 – 0.04 seconds with high mA, FFD must be 180 cm to maintain normal size of the heart.A grid is also used. • Film: HD 35x43 cm. • CP: T7 (as for the chest). • CR: 90 to film center. NB/ Exposure during suspended inspiration (120+ kV).

  23. PA (penetrated) chest (heart and aorta) (Basic)

  24. Lateral chest (heart and aorta) (Basic) • Patient positioned as for true (left) lateral chest. • kV is adjusted to give enough penetration of the thoracic vertebrae (just visible through the heart). The Lung fields must appear over-penetrated. • Film: HD 35x43 cm. • CP: T7 (as for the chest). • CR: 90 to film center. NB/ Exposure during suspended inspiration, (125+ kV).

  25. Lateral chest (heart and aorta) (Basic)

  26. LAO/RAO (heart and aorta) (special) • Obliques are done to separate the heart and the vertebral column. In the RAO, the right side must be in contact with the film, coronal plane makes 60 with the film. In LAO, the left side is in contact with the film, coronal plane makes 70 with the film. • kV is adjusted to give enough penetration of the thoracic vertebrae (just visible through the heart). Lung fields must appear over-penetrated. • Exposure: 125 kVp, 4 mAs, with grid. • CR: T7.

  27. Barium swallow (heart and aorta) (special) • For cardiomegaly. The esophagus is outlined with (thick) barium and patient is positioned for a RAO. • Patient holds a mouthful of (barium sulphate) drink in the mouth, then swallow it. Exposure is made three seconds after movement of the thyroid cartilage. A LAO is also done together with PA and lateral. • Exposure: 125 kVp, 4 mAs, with grid. • CR: T7. RAO RAO

  28. AP larynx, pharynx, and trachea (Basic) • For pathology ( e.g., soft-tissue swellings ) involving air-filled larynx and the trachea, thyroid, thymus glands, and the upper esophagus. A contrast medium (barium) is used to opacify these organs. • Patient sitting or standing supine, back of the head and shoulders against film, chin raised so that RBL is 20 to the horizontal axis. • Film: HD 24x30 cm. • CP: Level of C4, with exposure during the valsalva maneuver. • CR: Horizontally 10 cephalic to film center.

  29. AP larynx, pharynx, and trachea (Basic)

  30. Lateral larynx, pharynx, and trachea (Basic) • For pathology involving the air-filled larynx and the trachea, thyroid, thymus glands, and upper esophagus. A contrast medium (barium) is used to opacify these organs (usually it is a soft-tissue technique done to exclude epiglottitis in young children). • Patient sitting or in erect lateral, shoulders rotated posteriorly and depressed down, hands clasped behind the back. • CP: Midway between the thyroid cartilage and the jugular notch through C4. • Film: HD 24x30 cm. • CR: Horizontally 90 to film center.

  31. Lateral larynx, pharynx, and trachea (Basic)

  32. RAO sternum (Basic) • For pathology of the sternum (fractures /other inflammatory processes). • Patient erect with arms on sides, or: Semiprone and slightly oblique (15 - 20, to the right side ) with the left arm up and the right arm down by the side. • Film: HD 24x30 cm. • CP: Center of sternum (midway between jugular notch and the xiphoid process). • CR: Horizontally 90 to film center, exposure on (normal) quiet breathing, or else, during a suspended expiration.

  33. RAO sternum (Basic)

  34. Lateral sternum (Basic) • For pathology of the sternum (#s, subluxation, and other inflammatory processes). • Patient erect (arms drawn to back), or in a lateral recumbent (lying on the side, arms above the head), shoulders well back. • Film: HD 24x30 cm. • CP: Center of sternum (midway between jugular notch and xiphoid process). • CR: 90 to film center, exposure during a suspended inspiration.

  35. Lateral sternum (Basic)

  36. PA bilateral sternoclavicular joints (SCJs) (Basic) • For joint separation and pathology. • Patient prone, pillow for head which must be turned to one side, arms up beside the head. • Film: HD 18x24 cm. • CP: At level of T2-T3. • CR: 90 to the film center, exposure done during suspended expiration.

  37. PA bilateral sternoclavicular joints (Basic)

  38. PAO SCJs (Basic) • For joint separation and pathology. • Patient prone, rotated 15, upside arm in front of the patient, opposite arm behind, the spinous process 1 to 2 inches lateral to midline of couch. • Film: HD 18x24 cm. • CP: At level of T2-T3. • CR: 90 to the film center, exposure during suspended expiration.

  39. Assignment • One student will be selected for assignment

  40. Suggested Readings • Clark’s Radiographic technology

  41. Question • Describe radiographic principles of chest radiogram?

  42. Thank You

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