CHEST RADIOGRAPHY

Speaker: Mr. Aditya Thakur 2nd Year B.Sc RADIODIAGNOSIS AND Moderator: IMAGING Mr. S.R CHOUDHRY Department of Radiodiagnosis & Imaging P.G.I.M.E.R., Chandigarh.

INTRODUCTION
Chest x-ray is the most commonly performed diagnostic xray examination. Approximately half of all x-rays obtained in examination. medical institutions are chest x-rays. A chest x-ray is usually rays. done for the evaluation of lungs, heart and chest wall. wall. Pneumonia, heart failure, emphysema, lung cancer and other medical conditions can be diagnosed or suspected on a chest x-ray. Traditionally, chest x-ray have been taken prior to ray. employment, prior to surgery or during immigration. The use immigration. of routine chest x-ray is being re-evaluated because there is rea lack of evidence for their usefulness. Routine x-rays are usefulness. obtained in absence of specific signs symptoms or Medical conditions. conditions.

ANATOMY  

The trunk of body is divided by the diaphragm into an upper and lower part. Upper part is called thorax and lower part is called abdomen. Thorax is formed by following bones : Anteriorly by sternum : Posteriorly by the 12 thoracic vertebra and inter vertebral disc : On each side by 12 ribs

THORACIC CAVITY: The cavity of the thorax contains the right and left pleural cavities which are completely invaginated and occupied by the lung. The right and the left pleural cavities are separated by a thick median portion called the mediastinum. The heart mediastinum. lies in the middle mediastinum.

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Structure lies inside the mediastinum 1 Trachea and its bronchus 2 Oesophagus 3 Muscles 4 Heart enclosed in pericardium 5 Aorta Trachea: It is fibro elastic tube about 11cm long extending from the larynx at the level of 6th cervical vertebra to lower border of 4th thoracic vertebra where it is divided in the right & left bronchi one for each lung.

Lung: The lungs are pair of respiratory organs and spongy in texture. Each lung is conical in shape. The right lung is divided into 3 lobes a) Superior b) Middle c) Inferior by the two fissure a) Oblique b) Horizontal

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Structure lies inside the mediastinum Contd«
Left lung is divided into two lobes by the oblique fissure. A. Superior B. Inferior Heart: The heart is a conical, hollow muscular organ situated into the middle mediastinum. It is enclosed with in pericardium. The heart is placed obliquely behind the body of the sternum so that 1/3 of its lies the right and 2/3 to the left of the median plane.

Indications of the Chest Radiography
1. Pulmonary diseases such as 

Koch s disease.

2. Pleural disease 


Pleuritis.

Pleurisy - inflammation of plural. Pleural effusion - fluid in pleural cavity..

3. 4. 5. 6. 7. 8.

Pericarditis Chest x-ray are done for follow up pts. xPre-operative and post-operative cases PrepostTo see the heart disease like cardiomegally To see diaphragm movement. Blunt Trauma Chest

9. Bronchial asthma 10. Bronchial pneumonia

Equipment and Accessories 
  

X-ray Unit High Power Generator Chest stand or vertical bucky, Air Gap Stand Cassettes

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X-Ray Unit: The heart cycle is completed in Unit: about 0.08 second. So the exposure time should second. be lesser than 0.08 sec to prevent the blurring of heart shadow due to involuntary movement of heart. heart. This type of exposure can be achieved by high mA and high KV X-ray units with output in the range. range. 800mA 1000mA 40KV - 150 KV  Exposure time can be reduced further by the use of high speed screen faster film combination.  It can also be achieved with the added advantage of selecting a smaller focal spot within the tube rating.

- High Power Generators: The essential function of H.T generator in xray tube is to provide such power which is needed by X-ray tube so an important specification in the description of any generator is a statement on its power out put. put. Unit 70KW 100KW generator is used which 70KW 100KW can give 1000- 1250mA and upper voltage 1000- 1250mA limit 150KV. 150KV.

- CHEST STAND OR VERTICAL BUCKY The chest stand is a holder for cassettes that is used to examine patients in erect position, for chest or other radiography. It radiography. must hold the size of cassette used for chest examination and rigidly. rigidly.

Preparation For The Chest Radiography
This procedure requires no special preparation. But a brief preparation. explaination to patients with a rehearsal of the procedure should ensure a satisfactory result. Respiratory movement result. should be repeated several times before the performance Is considered to be satisfactory. satisfactory. Patients will also be asked to remove all metallic jewellery or undergarments that may contain metal that may interfere with x-rays. rays.

Basic Projections 
 

PA (Postero -anterior) Erect AP ( Antero posterior ) Erect or supine Lateral (Erect or sitting)

Additional Projections
OBLIQUE a. PA Oblique Left PA Oblique Right PA Oblique b. AP Oblique Left AP Oblique Right AP Oblique 2. Apicogram 3. Lordotic 4. Decubitus

PA View
Position of patient :  Patient is made to stand in PA position, facing the cassette, in front of vertical chest stand.  Chin of the patient is placed over the cassette  The cassette is adjusted 1 ½ above the upper border of the shoulder. Position of part :  Hands of the patient should be placed on waist level below the hips , so that they will not be superimposed on CP angles.  Palms should face upwards and arms are rotated internally to throw out the scapula out of lungs.  Shoulders sould lie in the same transverse plane and depressed to carry the clavicles below the apices.

Cassette Size: The cassette size is chosen so Size: that it must include the apices and lower region of the diaphragm and chest wall. It wall. must includes the costophrenic angle (CP) Central Ray: C.R. is directed at right angle to Ray: the film at the Junction of 4th & 5th thoracic vertebra, FFD: FFD: generally 5 feet (6 feet for Heart size). size). Breathing Instructions: The exposure is given Instructions: in arrested inspiration phase, to show the greatest possible area of lung structure. structure.

P.A Position

L

P.A. Resultant Image

Structures shown 
   

Air filled trachea Lungs Diaphragmatic domes Heart Aortic knob

Evaluation Criteria
Position wise: It must include whole of the lung field.  Apices  C.P. Angle  Any rotation is easily detected by the position of medial end of the clavicle.  Scapula should not over shadow the lung field Exposure Wise a. Trachea & bifurcation of trachea must be seen in the midline. b. Vertebral bodies should be faintly visible but not inter vertebral space. c. Heart & diaphragm show a sharp outline. d. Peripheral lung vessels must be seen.

Processing wise: Put a finger under the darkest area of the film. If finger is not seen properly, then it is properly developed.

PA in expiration
This view is done in two conditions.  For pneumothorax, PA is done in expiration to confirm the disease. This has effect of intra pleural pressure which result in compression of lung making a pneumothorax bigger.  This technique also demonstrates the effect of inhaled foreign body obstructing the passage of air in lung segment and extent of diaphragmatic movement.

AP Projection (Erect or sitting)
This view is done as an alternative to PA erect projection. When the patient s shape or medical condition makes it difficult or unsafe for the patient to stand or sit for basic projection. For the latter, the patient is usually supported sitting erect on a trolley or bed side.

Positioning of patient & film for AP erect projection
The patient may be standing or sitting with their back against the cassette which is supported vertically with the upper edge of the cassette above the lungs apices.  The median sagittal plane is adjusted at right angle to the center of the film.  The shoulders are brought downward & forward with the back of the hands below the hip & elbow forward Central ray: Is directed at right angle to the film and ray: towards the sternal notch. The central ray is then angled until it is coinciding with the middle of the film. The exposure is taken on normal full inspiration 

AP Supine projection (on bedside)
Positioning of patient & film: With assistance, a cassette is carefully positioned under the pt s back with the upper edge of cassette above the lung apices. The median sagittal plane is adjusted at right angle to the middle of the film & pt s pelvis is checked to ensure that it is not rotated. The arms are laterally rotated. Chin slightly raised. Central Ray : Is same as erect AP projection Exposure: is taken on normal full inspiration

Lateral projection
Positioning of patient and film: Patient is made to stand in lat position in front of the vertical cassette holder with side to be examined touching the film. Both arms are raised over the head. Distance between film & xiphisternum equal to the distance between line joining spinous process.  Mid axillary line should be 2 posterior to midline of grid. Central Ray: Is directed through axilla at the level of D5. Ray: FFD is generally 40. Grid is used because KVP is more than 70. To prevent the scatter Rad . Note: Note: For diaphragmatic abscess (to see the movement of diaphragm)  Two exposures are given on single film.  1st in inspiration 2/3mAs.  2nd in expiration 1/3 mAs.  Alternate procedure - Fluoroscopy

Lateral projection Cont«
Lateral view is done to see the: 
  

Depth of tumors. Part of the lungs overlapped by heart. To demonstrate the inter lobar fissures To localize the pulmonary lesion. Posterior rib superimposed Sternum should not be rotated C.P. Angle and apices should be included. Hilum should approx in centre. Exp. Should penetrate the lung field of heart.

Evaluation Criteria: 
   

Lat. Position

Resultant Image

Penetrating View Of Chest
It is done to see rib & heart.  It is done when one side appears opaque on normal chest radiograph. Opacity due to hydrothorax or pyothorax. Thus to penetrate through these densities more exposure is required. Grid is used one side which is normal will be over exposed so wedge filters can be used to see both sides with same opacity. 

Oblique projection
Mediastinum & lung fields, incase of asbestosis pleural plaques not seen in PA projection.  Rt. Middle lobe Ant. oblique  Both lower lobe - Post oblique

a. Right anterior oblique: The patient in PA position & oblique: the Rt. Side of the trunk is kept in contact with the cassette & patient is rotated to bring the left side away from the films so that the coronal plane is at an angle at 450 to the film. Central rays: Directing at right angle to the middle of film. or at the level of 6th thoracic vertebra. oblique: b. Left anterior oblique: The patient in PA position & the left side of the trunk is kept in contact with cassette & the patient is rotated to bring the right side away from the film so that the coronal plane is at an angle of 450 to the film. Central Ray: Is directing at right angle to the middle of film or at the level of 6th thoracic vertebra.

Structure shown: Lung field usually appear shorter due to magnification of diaphragm.

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Left posterior oblique: The patient in AP position & oblique: the left side of the trunk is kept in contact with the cassette. Patient is rotated to bring the right side away from the film. So the coronal plane is an angle of 450 to the film. Central Ray: at right Angle to the middle of the film or at the level of 6th thoracic vertebra. Structure shown:  The maximum area of lung.  Trachea & its bifurcation.  Heart descending aorta and arch of Aorta.

Right posterior oblique: The patient in AP position and right side of the trunk is kept in contact with the cassette and patient is rotated to bring the left side away from the film so the coronal plane is an angle of 450 to the film Central ray at right angle to the middle of the film or at the level of 6th thoracic vertebra.

Structure shown:  Maximum area of right lung & mediastinal content.  Also shown trachea & entire left branch of bronchial tree.  Left atrium, left main branch of the pulmonary artery.

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APICOGRAM
Apicogram is done when there is doubt of T.B. T.B mostly begins in apex region where the lesion is superimposed by clavicle. Apicogram can be done in two ways:  Tube angle, patient straight  Patient angle, tube straight Tube angle, patient straight (Axial projection) patient in AP angle, position. Patient is made to stand in front of tube & back touching to the film. Film is placed 4 -5 above the upper border of shoulder Central ray is directed just below sternal notch with 150 to 200 angulation towards head.

Patient in PA Position : Patient is made to stand in PA position in front of vertical cassette holder. A cassette is placed 4 to 5 above the border of shoulder. Central ray is directed at level of C7 with 15-20 angulation 15toward the feet. Patient angle & tube straight method : The patient is made to stand facing the tube 6 to 8 away from the film. Patient is asked to lean backward touching the head and neck on the cassette. So the clavicle is thrown away from the apex of the lung. Central ray: is directed at the sternal notch. Structure shown : The apices lying below the shadow of clavicles.

Evaluation criteria:  The clavicles should lie superior to the apices.  Sternal ends of clavicle should equidistance from the vertebral column.  The apices should be included.

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Apicogram Axial Projection

LL
Clavicle
Apex

Resultant Image

Lordotic View
This projection is done to see  Middle lobe collapse of R Lung  Demonstrate the magnified interlobular effusions Positioning of patient & Cassette: Patient is made to stand in PA position in front of a vertical cassette holder, patient is asked to hold stand with hand and he is made to lean back Ward i.e. approx 300 inclination. Central ray: is directed at level of D5

Lordotic Position

L

Resultant Image

Decubitus Projection
Lat Decubitus: Patient is made to lie in lateral Decubitus: position on affected side, Film is placed either touching to anterior or posterior aspect. Tube is aspect. brought horizontal. Both Decubitus should be done. horizontal. done. Fluid will come to the side which is lowered. lowered. Cassette Position: The cassette is placed Position: posteriorly or anteriorly in contact with the chest and adjusted approximately 2 above the shoulder. shoulder. Central ray is directed at right angle to D5 Make the exposure at the end of full inspiration. inspiration.

Structures shown : This projection demonstrates the change in fluid position and reveals any previously obscured pulmonary areas or in case of suspected pneumothorax, presence of any free air. Evaluation criteria  The patient should not be rotated from a true frontal position.  The affected side should be included.  The apices should be included.  Proper identification should be visible.

Decubitus Position

Resultant Image

Ventral or dorsal Decubitus position
Patient is made to lie down in prone or supine position. Elevate the thorax 2-3 on foam pad. 2Arms are kept over the head, cassette is placed against the affected side. The cassette is adjusted so that it extends to the level of laryngeal prominence. Make the exposure at the end of full inspiration Central ray: is directed center to the mid axillary line at the level of the 6th thoracic vertebra.

PEDIATRIC CHEST RADIOGRAPHY
Although there are many similarities in pediatric and Adult chest radiography in basic positioning and image quality. To maintain the proper positioning and image quality, it is essential to immobilize the child by using immobilization devices.  Some time we have to take help by parents for immobilization of patient during radiography.  We have to provide radiation protection by using lead apron, thyroid shielding to the child s parent as well as child.  If patient is cooperative then immobilization device is not used.  Basic positioning of child is as adult PA. AP. LAT.  Exposure time should be lesser about 0.08 sec.

AP Projection

L

Resultant Image

Selection Of Kilovoltage
In general 60-70kvp is adequate for the Posterio60Posterioanterior projection. In which case there will be minor penetration of the mediastinum and heart. An increase in kilovoltage however is necessary for penetration of the denser mediastinum and heart to show the lung behind those structures and behind the diaphragm as well as the lung bases in a very larger or heavy breasted patient

High KV Technique
We used KV in the range of 90-140. Which reduce contrast 90between the lung field and mediastinum. However, using this technique there is loss of inherent contrast and visualization small lesion of soft tissue density because possibility of photoelectric effect is decreased at the same time possibility of Compton effect is increase. The purpose of high KV technique, we make use of Compton effect which is independent of atomic number. Purpose: The application of high kilovolgate technique is primarily with a view to obtaining exposure time in the region of milliseconds. The effect control to blur the image by involuntary movement.

Airgap Technique
The technique of leaving a gap between the patient and film during radiography is called air gap technique. AIM : The aim of this technique like grid, is also reduce the effect of scattered radiation produced on the film. Principle : The scatter radiation arising in the patient, from compton scattering travels in all directions. When an air gap is left between the patient. Some of scatter radiation will not be able to reach the film. Some will be reduced in intensity due to inverse square law, some will be deflected in other direction before reaching the film e.g. in chest x- ray, cervical spine lateral projection.

Newer Developments
Due to higher radiation dose and cost involved as bigger size of films are being used. There is growing need to look into this aspect. Thus newer developments have taken place as following Mass miniature radiography (Odelca camera) To reduce the cost of film because a small film is used (100to 70mm) for follow up cases at T.B. in specialized T.B. Hospitals.

Advantage a. It is less costly b. Storage problem solved c. It is done for TB screening

Disadvantage a. High radiation dose b. Information is less

2. High KV Technique 3. Image intensifier system (D.F. System) 4. Digital chest radiography
This is done by two methods.  Flat panel detector system  Using imaging plate system

F.P.D. System: There is detection at the outer end which picks up signal and passes to analog convertor. In this analogue data is converted as:

Imaging plate Method: Advantage :  Post processing.  Radiation dose less.  Tele radiography.  Image can be store.  Cost reduce.  Better edge enhancement. enhancement. Disadvantage : Initial investment cost high.

Computed tomography After development of CT technology CT is done for chest to visualize the mass lesion in the lung field as well as mediastinal mass, so we can distinguish, The tumour or pleural effusion, cavitation by giving intravenous contrast media to enhance the lesion for better visualization for diagnosis whether it is malignant or benign tumor. tumor. Bronchography is replaced by the development of HRCT chest it is done to visualize the bronchiactasis, as well as the interstitial parenchymal lung lesion. lesion.

Radiation protection
The radiation protection can be achieved by applying ALARA Principle As low as reasonably achievable)  Distance  Time  Shielding 1. Limitation of filed size by using collimators. 2. Directing the beam. 3. Use of gonad shields. 4. Careful preparation of the patient. 5. Use of the high speed film, screen, high mA and short exposure time. 6. Presence of essential staff only. 7. Use of protective apron or protective screen

Conclusion
Chest x-ray is the basic investigation which may reveal more information about the patients disease. disease. Approximately ½ of the all x-ray examination is obtained in medical institution are chest x-ray. The quality of ray. Chest x-ray is of utmost importance but it is difficult to maintain it as slight variation in exposure factors, processing time and slight rotation due to malpositioning may result into loss of the information. So the information. chest radiography is to be done very carefully. carefully.

we can say in other words that proper chest radiography is a challenge for Radiological technologist. technologist. This challenge is met more effectively with the help of digital radiography and more information is being gathered by other new modalities like CT scan, MRI etc

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