In addition, if ventricle enlargement is sus-pected on the frontal chest image, a lateral viewmay help confirm the finding. Portable lateralview chest images are also used to evaluatepresence of pleural effusions that cannot beseen on frontal views because they are small insize.
It takes 250 mL of fluid to blunt a lateralcostophrenic sulcus on a frontal radiograph,but only 75 mL to blunt the posteriorcostophrenic sulcus on a lateral radiograph.
Sometimes, a lateral decubitus view radiograph(patient lying either on one side or on theother) is obtained to evaluate possible pleuraleffusions and their fluid levels.
Figure 4 showslateral view chest structures and tissues.
Technical Factors of Viewing Chest Radiographs
It is necessary to consider whether each of thefollowing factors are adequate or appropriateto accurately assess and evaluate normal andabnormal chest radiograph findings.
X-rays must adequately penetrate body struc-tures to visualize the structures. For example,one should be able to faintly see the thoracicspine through the heart shadow.
If you cannot,the chest radiograph is underpenetrated ortoolight. In this situation, the left hemidiaphragmmay not be visible because the left lung base canappear opaque, which may hide or mimic truedisease in the left lower lung field.
A lateral viewwill be necessary to confirmany abnormalitiesin the left lower lung field. In addition, the pul-monary markings may appear more prominentthen they really are and may be interpreted asinterstitial pulmonary edema or pulmonaryfibrosis.
Again, a lateral view will be neces-sary to confirm the interstitial findings.If the chest radiograph is overpenetrated ortoo dark, the lung markings may appear to beabsent or decreased.
It is then possible tomake the judgment that the patient hasemphysema or pneumothorax when in realitythis pathophysiology does not exist.
Onecould also miss a pulmonary nodule when thechest radiograph is overpenetrated.
A full-inspiration chest radiograph can bereproduced from one time to the next to elimi-nate the possibility of artifacts that may con-fuse the viewer to think that disease ispresent.
If one can count 10 posterior ribsabove the diaphragm, it is an excellent inspira-tory film.
When less than 10 ribs can becounted above the diaphragm, it is either poorinspiratory effort or a sign of low lung volume.Low lung volume from a poor inspirationeffort can crowd and compress the lung mark-ings, producing the impression that a lowerlobe pneumonia is present.
In AP radiographs, patient malposition orrotation may appear to indicate abnormalitiesin cardiac, vascular, or mediastinal contourswhen, in fact, they may not exist.
The posi-tion of the clavicles help identify a patient’srotation.
If one clavicle appears to beshorter in length than the other, then one sideof the chest may be rotated close to or awayfrom the detector cassette, producing whatappear to be abnormalities.
Figure 9 showsa difference in clavicle length. Comparing thelength of the clavicles in addition to compar-ing the symmetry of the distance between thespinal pedicles and clavicle heads as a methodof identifying chest rotation is an importantpart of the radiograph examination. If oneidentifies asymmetry in the distance betweenthe pedicles (outer edge of spinal vertebra) andthe clavicle heads, the chest is likelyrotated.
Figure 9 shows an example of asymmetry between the spinal pedicles and theclavicle heads due to chest rotation.
Anteroposterior views obtained with aportable machine have some disadvantages.Structures in the anterior part of the chest aremagnified on AP views, so structures such asthe heart are not as distinct as on PA views andmay even be distorted.
The heart and themediastinum appear about 15% wider thanon the PA view.
This phenomenon occurs onan AP view mainly because of the shorter dis-tance between the x-ray tube and the patientthan occurs in a PA view.
Posteroanterior views are sharper and more dis-tinct with less chest rotation and have consis-tent clavicle placement because they are alwaysobtained with the patient upright and 2 m(6 ft)away from the source of the x-rays and at a90
angle to the beam, whereas angles lessthan 90
are often used for AP radiographsbecause of inability of critically ill patients to
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