EVALUATION OF COMPLIANCE WITH STANDARD CRITERIA FOR

POSTERO–ANTERIOR (PA) CHEST RADIOGRAPHS IN PARKLANE

HOSPITAL ENUGU

Ugwuanyi, Daniel .C. Chiegwu,Hyacinth.U., Eze Ngozika C.

Department of Medical Radiography and Radiological Sciences, Nnamdi Azikiwe

University, Nnewi Campus, Anambra State, Nigeria.

CORRESPONDENT AUTHOR: Ugwuanyi Daniel Chimuanya

+2348033971062: Emails:
dc.ugwuanyi@unizik.edu.ng,
danc.1969@yahoo.com

ABSTRACT

The purpose of this research is to evaluate the level of compliance to standard criteria for
postero-anterior chest radiographs in Enugu State University of Science and Technology
Teaching Hospital, Parklane Hospital, Enugu. The research took a prospective approach.
Data was collected using assessment sheets. 300 chest radiographs were assessed and the
age range of patients whose chest radiographs participated in this study was from (1-75)
years. Findings of this study showed that, there were greater numbers of male patients
161(53.7%) than female patients 139(46.3%). Good scapular throw off were achieved in
majority of the radiographs. Density differences were witnessed in both lung fields of
some radiographs 278(92%). Some of the chest radiographs 6(2%) appeared to be
without identification and/or anatomical marker. The medial ends of the clavicles were
not equidistant from spinous process in 82(27.3%) of the studied chest radiographs.
Improper breathing technique was shown in some radiographs with poor inspirational
effort 76(25.3%) which also affected the delineation of the trachea as air was not trapped
in the trachea for it to be visible in 16(5.3%) of the chest radiographs. Some of the chest

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radiographs has the disc spaces of the thoracic vertebrae well delineated 75(25%).
54(18%) chest radiographs showed poor collimation where parts of the chest were cut off
and upper part of the abdomen was seen. The apices of the lungs were cut off in
31(10.3%) chest radiographs while the costophrenic angles were not well seen in
46(15.3%) of the chest radiographs. This study also shows that 80(26.7%) chest
radiographs were over exposed leading to burn off of vascular patterns especially close to
the periphery of the lungs.

CHAPTER ONE

INTRODUCTION

Background of study

Radiographic imaging of the chest is the commonest radiographic procedure performed

in medical imaging. The routine chest x-ray provides information about the bony frame
work of the thorax, its soft tissue, the mediastinum and the lung field. Its importance in
the diagnosis of most pulmonary and respiratory diseases and allergies cannot be over
emphasized and as such obtaining an image with good diagnostic quality is of great
importance.

A chest radiograph is a projection radiograph of the chest, its contents and nearby
structures. Chest radiographs are the most common films taken in medicine. Like all
method of radiography, chest radiography employs ionizing radiation in the form of x-
rays to generate images of the chest. The mean radiation dose to an adult from chest
radiograph is about 0.02mSv for a PA view. (Fred Et al, 2008). The role of chest
radiography has gained increasing importance in trauma cases, routine checkups, disease
conditions and metastatic problems. The rationale behind this study is that many faulty
diagnoses on chest radiographs may be associated with inappropriate radiological
techniques and application and that improvement of imaging quality of chest
radiography benefits not only the patients infected by disease but also those suffering
from various pulmonary disease. Chest radiographs with poor image quality can cause

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misdiagnoses or require repeated examinations, which in turn causes waste of economic
resources and exposing patients to unnecessary radiation.

Owing to the importance of chest radiographs in diagnosis and treatment of diseases great
care should be taken to ensure that the images produced are of good diagnostic quality
and so quality assurance tests should be carried out in other to ensure that the images
produced are of good diagnostic quality.

Quality assurance (QA) is the planned and systematic activities implemented in a quality
system so that quality requirements for a product or service will be fulfilled. (Bassy et al,
1991). It is the systematic measurement comparison with a standard, monitoring of
processes and an associated feedback loop that confers error prevention. Quality
assurance in chest radiography is a system designed to continuously improve the quality
of chest radiographs at a health facility, and it can be achieved through organized efforts
by all staff members involved in taking or reading the chest radiograph. It comprises
quality control, quality assessment, and quality improvement. Quality control includes all
quality control efforts routinely performed by staff at each health facility such as regular
maintenance or checking of x-ray equipments, accessory devices and chemicals and
consumables. Quality improvement is the process of using the information gained
through assessment to improve quality, with the key component of data collection, data
analysis, and creative problem solving. It includes continuous monitoring and
evaluation, identifying defects and retaining of staff for prevention of recurrent problems.
In other words, we can only achieve quality assurance through quality control, quality
assessment, and quality improvement.

What is important in the assessment procedure is to seek the source of the problem and to
take the steps to improve, so that in the end the quality of the chest radiograph will be
improved.

This research is geared towards ascertaining the extent to which chest radiographs
produced in Enugu State University of Science and Technology Teaching Hospital,
Parklane hospital Enugu conform to standard procedures and technique required for the
production of good diagnostic images of the chest.

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According to the European Guidelines on quality criteria for diagnostic radiographic
images the following criteria must be met for a radiographic image to be said to be of a
good diagnostic quality;

 Performed at full inspiration (as assessed by the position of the ribs above the
diaphragm — either 6 anteriorly or 10 posteriorly) and with suspended
respiration.
 Symmetrical reproduction of the thorax as shown by central position of the
spinous process between the medial ends of the clavicles.
 Medial border of the scapulae to be outside the lung fields.
 Reproduction of the whole rib cage above the diaphragm.
 Visually sharp reproduction of the vascular pattern in the whole lung, particularly
the peripheral vessels.
 Visually sharp reproduction of the trachea and proximal bronchi.
 Visually sharp reproduction of the borders of the heart and aorta.
 Visually sharp reproduction of the diaphragm and lateral costo-phrenic angles.
 Visualization of the retrocardiac lung and the mediastinum.
 Visualization of the spine through the heart shadow.

Statement of problem

 The level of compliance to the standard criteria for chest radiograph of

radiographers in Parklane Hospital is not known.
 Repeat of chest x-ray is on the high side.

 Chest x-ray being the most common radiographic projection in radiology

department of parklane hospital, its qualities has not been ascertained.
Aim of study

 To know the number of chest radiographs that meets the standard criteria for
chest radiographs

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  To know the number of chest radiographs that does not meet the standard criteria
for chest radiographs.
 To know the most occurring fault or problem in the chest radiographs.

Significance of study

 The result of this work will help radiographers to strictly adhere to the standard
technique in order to produce chest radiographs that meet the standard criteria.
 This study will help outline the main cause of the repeats encountered in chest x-
rays.
 It will also assure optimum radiographic output with less repeat of chest
radiographs and reduced radiation dose to patients.

Scope of study

This study was carried in ESUT teaching hospital, Parklane Hospital Enugu in Enugu
state from May 2017 to July 2017

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 CHAPTER TWO

LITERATURE REVIEW

2.1: THEORETICAL BACKGROUND

2.1.1Anatomy of the respiratory system

The respiratory system extends from the nose, to the lungs. Based on this study
we will discuss the structures that appear on chest radiograph.

2.1.2 The Pharynx

The pharynx is a muscular tube of irregular shape, which lies between the base of the
skull above, and the upper ends of the larynx and esophagus below. Three parts are
recognized, namely the naspharynx, oropharynx and laryngopharynx.

The nasopharynx is the highest part and it lies above the soft palate, communicating
interiorly with the nose through to the posterior nares and laterally with the middle ears
through then right and left auditory tubes. Collections of lymphatic tissues may be
present in the posterior wall of this part of the pharynx and it enlarges to constitute the
adenoid. The oropharynx is situated behind the mouth between the soft palate above and
the tip of the epiglottis below. It is common to both the alimentary and respiratory system
and it connects the nasopharynx to the laryngopharynx.

2.1.3 The larynx

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This is a hollow organ with a cartilaginous framework, which connects the pharynx
above with the branches below, it is an air passage and it is also the organ of voice
production. The larynx is situated in the midline of the neck in front of the third, fourth,
fifth and sixth cervical vertebra in the adult.

Relations of the larynx: Posteriorly lies the esophagus and on either side of the larynx
are the common carotid arteries and internal jugular vein. Anterior to the larynx are the
extensive laryngeal muscles and skin.

Blood supply: Thyroid arteries and venous drainage to the internal jugular vein by way
of the thyroid veins.

Nerve supply: This is derived from the laryngeal and recurrent laryngeal nerves. The
later nerve ascends from the superior mediastinum so that thoracic disease may manifest
its presence by laryngeal paralysis.

Lymphatic drainage of the larynx is mainly directs to the deep cervical nodes but some
lymph first traverse the pretracheal nodes. Efferent lymphatics pass from the deep
cervical nodes to the right lymph duct and to the thoracic duct.

Functions of the larynx: The larynx transmits air form the pharynx to the trachea and in
the reverse direction. During swallowing the entry of food into the air passage has to be
prevented and if any should be enter coughing expels it. The larynx is the organ
responsible for phonation and the sound produced is modified by the tongue, lips sinuses
etc in the products of coherent speech.

2.1.4 The Trachea

The trachea or windpipe is about 10-11cm (4.5in) in length and 2.5cm (1.0in) in
diameter. It extends approximately in the middle from the sixth cervical vertebra above to
the fifth thoracic vertebra below where it divides at the level of the sternal angle, into the
two main bronchi. It consist of fibrous tissue and involuntary muscle strengthened by C-
shaped rings of cartilage which surround its front and sides but are deficient

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posteriorly. It is lined by ciliated columnar epithelium. The trachea runs from the neck to
the superior mediastinum so it has a cervical and a thoracic portion.

Relations of the cervical part of the trachea: The isthmus of the thyroid gland, which
covers the 2nd to the 4th cartilaginous rings, crosses the trachea. Laterally; the tracheae is
related to the lobes of the thyroid gland that separate it from the common carotid artery.

Posteriorly; the trachea is related to the esophagus which separates it from vertebra
column. In the thoracic cavity, anteriorly the trachea is related from above downwards
the remnants of the thymus gland, the, the left common carotid artery and the arch of the
aorta. One on the right side of the trachea is related to the right lung and pleura. On the
left side, the trachea is related to the common carotid artery, the left subclavian artery and
below to the arch of the aorta. Posteriorly; the trachea is related to the esophagus.

2.1.5 The bronchi

The bronchi are formed by the division of the trachea at the level of the fifth thoracic
vertebra. They diverge from each other to reach the roots of the lungs. The right
bronchus is about 2.5cm (1.0in) in length and runs a more vertical course than the left so
that inhaled foreign bodies are more likely to pass into the right lung. This bronchus gives
a branch to the upper lobe, and after being crossed by the right pulmonary artery, it
divides into the middle lobe and lower lobe bronchi. The left bronchus is about 5cm
(2.0in) in length and passed in front of the esophagus and below the aortic arch and it
divides at the root of the lung into the upper and lower lobe branches. The lingual branch
arises from the branch to the upper lobe.

Structure of the bronchi: The bronchi are similar in structure to the trachea consisting
of fibrous tissue tube whose walls are kept from collapsing by cartilaginous rings. Within
this layer is a muscular coat of involuntary muscles and innermost is layer of mucous
membrane of ciliated columnar epithelium supplied with mucous gland.

2.1.6 The lungs

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The lungs are two light; spongy and extremely elastic structure divided into lobes by
fissures into which the visceral pleural dip. They are separated from each other by the
contents of the mediastinum. Each has an apex projecting nearly 2.5cm (1.0in) above the
sternal end of the clavicle, a base resting on the diaphragmatic pleura and a coastal
surface, which is related to the chest wall and separated from it by the coastal pleura. The
medical surface of the right lung is related to the right side of the heart and the vertebra
bodies the medial surface of the left lung is related to the left side of the heart and the
arch of the aorta and descending parts of the aorta. Each medial surface is also related to
the root of the lung through which the bronchus and pulmonary vessels pass.

The right lung is divided into three lobes, the upper, middle and lower, the horizontal
fissure separated the upper and middle lobes from lower. The left lung has two lobes, the
upper and lower separated by the oblique fissure. There is no horizontal fissure and no
middle lobe on the left.

Blood supply of the lung: The lungs are supplied with oxygenated blood by the
pulmonary artery and with freshly oxygenated blood by the bronchial arteries. The
pulmonary veins return freshly oxygenated blood to the left atrium while the
bronchial veins return deoxygenated blood to the right atrium. The pulmonary
circulation is concerned with the gaseous interchanges, which constitute respiration, the
bronchial circulation provide for the ordinary needs of the lung tissue.

Nerve supply: Vagus nerve and the sympathetic nervous system.

Lymphatic drainage of the lungs: the pulmonary lymphatic vessels consist of a

superficial network beneath the visceral pleura and a deep network that follows the
bronchi and pulmonary vessels. Both transmit lymph to the nodes of the middle
mediastinum that is the bronchopulmonary and tracheobronchial nodes. Communication
with the posterior mediastinum and paratracheal nodes also occurs. From mediastinum
nodes, the lymph passes on the right side, to the right lymph duct and on the left side to
the thoracic duct and the left bronchopulmonary trunks respectively.

Structure of the lungs: The lungs consist of air filled lobules each of which receives a
respiratory bronchiole 1-2mm in diameter. Each lobule is composed of 4-6 air sacs at the

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margins of which are the alveoli. The alveoli are lined by a thin layer of flat cells and
they are richly supplied with blood vessels, they are the site at which interchange of gases
between the blood in the pulmonary capillaries and the inhaled air occurs. The lungs are
strengthened by a fibrous tissue framework in which blood vessels and lymphatic run.

2.1.7 The pleura

The wall of the thorax and the surface of each lung are covered by a thin serous
membrane called the pleura. Lining chest wall is called parietal layer and that covering
the lung is visceral layer of pleura and they are continuous with each other at the root of
the lung. Between these layer is a closed space; the pleural cavity; this is a potential
and not an actual cavity because the lungs are distended by atmospheric pressure so
that they fill the vacuum, which would otherwise exist. Thus, the parietal and visceral
layers of pleura are in contact and the slightly moist surface glide over each other during
breathing.

The parietal pleura may be divided into costal, diaphragmatic and mediastinal according
to its position, inferiorly it tips into the angle between the diaphragm and the chest walls
forming the costodiaphragmatic (costophrenic) recess.

Surface making of the lungs and pleura: The apex of the lung and upper limit of the
pleural reach to about 4.5cm (1.75in) above the middle of the clavicle but inferiorly
the lung does not reach the lower limit of the pleura owning to the presence of the
costodiaphragmatic recess. The lower limit of the pleura is represented approximately by
a line with a slight upwards inclination drawn round each side of the body at the level of
the twelfth thoracic spinous process. This line should pass through the eighth rib in the
nipple line, the eleventh in the midclavicular line, the eleventh in the midclavicular line
and the twelfth at the lateral margin of the sacrospinalis muscle. The lower border of the
lung in approximately two intercostals spaces above that of the pleura.

2.1.8 The Anatomy of the heart

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The heart is a hollow muscular organ of conical shape situated in the middle mediastinum
in a fibrous sac, the pericardium. It lies behind the sternum and extends in a recumbent
position, form the sternal angle above to about 4cm (1.5in) beyond the xiphisternal joint
below.

The right border lies about 4cm to the right of the midline (example about 1.0m (25cm)
to the right of the sternum). The apex is situated about 9cm to the left of the midline,
behind the fifth intercostals space and the left border extends from this point to the left
of the sternal angle in the erect position, the heart moves down nearly 1.25cm in relation
to the sternum. The arch of the aorta lies behind the lower half of the manubrium of the
sternum. The heart consists of right and left halves, which are completely, separate from
each other. The right side drives the blood to the lungs and is less powerful than the left
side which is the pump for the systemic circulation and has to drive the blood to the
brain, the limbs, the alimentary canal, the kidney, etc. each half of the heart consist of
two chambers which communicate through a value, thus the right side of the heart
consist of the right atrium into which blood flows from the systemic veins to the body
(the superior and inferior venae cavae) and the right ventricle from which the pulmonary
artery pass to the lungs. Between the two chambers of the right side is the tricuspid
valve.

The side of the heart consists of the left atrium into which the pulmonary vein, carrying
blood from the lungs, flow and the very powerful left ventricle from which the aorta
conducts blood to the entire body except for that blood which is carried in the
pulmonary artery. Between the left atrium and left ventricle is the mitral value, so called
because it consists of two cups. It is also called the bicuspid valve.

The heart is so placed that the right atrium is on the right side, the right ventricle in front,
the left ventricle is on the left side and the left atrium is behind. The pulmonary vein
which discharges oxygenated blood into the left atrium therefore enters the back of the
heart. The aorta leaves the left ventricle and runs upwards and to the right but is
concealed at its commencement when viewed from the front, by the main pulmonary
artery, which comes from the most anterior chamber of the heart, the right ventricle. The
superior and inferior vena cava, by which the systemic venous blood is returned to the

11
heart, enter the right atrium from above and below respectively and form with the
atrium the right border of the mediastinum.

Relations of the heart: Behind the heart and pericardium are the oesophagus and
descending aorta. On either side are the mediastinal pleura and the mediastinal surfaces
of the lungs.

Structure of the heart: The muscular wall of the heart is known as the myocardium and
it is composed of involuntary muscle having certain microscopic characteristics which
different it from all other involuntary muscle.

The epithelial layer which lines this is the endocardium and the fibrous sac which
enclose the heart is called the pericardium. The pericardium is lined by a serum
membrane, which is contained over the surface of the heart. These serous layer the
parietal and visceral respectively) are comparable in arrangement and function with the
pleura and the peritoneum and like them, they allow the structures which they cover to
move over each other with friction.

The atria are relatively thin walled because they only have to pump blood into the
ventricle each has a small pouch called an auricle projecting from it. The atria are
separated from each other by the intertribal septum and the ventricles are separated by the
interventricular septum.

The cusps of the mitral and tricuspid values are derived from the endocardium and their
free margins are connected by tendinous cord to the papillary muscle, which project from
the ventricular walls. There are values also at the origins of the pulmonary artery and
aorta; consist of three flaps of half moon shape. The purpose of all these values is to
prevent the flow of blood in the reverse direction.

Blood supply: Right and left coronary arteries, supplies the musculature of the atrium
and ventricle of the appropriate side. Venous blood is returned from the myocardium to
the cavity of the right atrium by the coronary sinus.

Nerve supply: Vagus nerve and sympathetic has the reverse.

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2.2 EMPIRICAL LITERATURE REVIEW

The chest radiographs being the most common films taken of diagnostic condition require
appropriate planning, techniques, darkroom practices and most of all skilled readers.
Management and supervision of the operating conditions following the recommended
standards play a key role in ensuring benefits of the instrument,(Mdoe Et al, 2005), this is
because high quality x-ray images are highly beneficial in diagnosing disease, creating
standards, and also as guidance for therapeutic procedures.(Mulogara Et al, 2001). In
addition to the radiographer’s compliance to standard in the production of chest
radiographs, the x-ray machines that are being used in the different diagnostic or
radiographic centers are meant to meet certain quality control standard so as to improve
the diagnostic information and reduce the radiation dose to patient. (WHO,
2003).Langsten et al stated that quality assurance control of equipment used for the
medical exposure of patients to ionizing radiation and ancillary equipment such as film
processors, are legal requirements placed on all radiology departments and other users of
such equipment. (WHO, 2003).

National council of radiation protection and measurement (NCRP) reports no. 99

addresses factors that influence the production of an image which contains the necessary
information to enable the imaging physician to report the diagnostic findings to the
referring physician. (Sheers G Et al, 1978). It laid major emphasis on quality control as
an important element to improve the diagnostic information of a radiograph.

Thus, improper services cause unnecessary duplications of radiation and may even lead
to wrong diagnosis in most cases and as a result threatening the health and safety of the

13
patients and the radiographer. (Mulogara Et al, 2001). Again, the benefits of diagnostic x-
rays are reduced drastically, when the equipment is operated without adequate quality
control and maintenance.

Hence, there is need for frequent quality control test in the radiology department in order
to make the health care services less cost –effective. (Society of Radiographers, 1991).

In the absence of appropriate quality control measure for the x-ray machines or
equipments in place, example; in the radiology departments, the benefits of reduced dose
to the patients and early diagnosis will not be realized. (TBCTA, 2007). In a work
conducted to report the current status of diagnostic x-ray machines in Tanzania, it was
found that 55% of the units tested were defective and 34% were out of order, (TBCTA,
2007), proving that there is still need for strict implementation of quality control tests
in order to help improve the situation.

A medical surveillance program carried out in USA discovered that 40% of the facilities
participating in the first round of the examination had form 10% to 40% of their
submitted radiographs rejected as being of inadequate quality, (TBCTA, 2006), some of
the reasons for this were related to poor equipment performance and due to inadequate
implementation of quality control programs. (Ozsunar Et al, 2006).

A study carried out in Calabar, Nigeria, to confirm the areas where the current efforts at
quality control test could be improved showed that lack of quality control programs in the
areas (assessed by the use of abdominal radiographs) has negatively influenced the
quality of radiographs and also the information content of the radiographs. (Yrout Et al,
1999).

Patients’ radiographs are also a part of quality control checks and should be featured in
any departmental evaluation program because poor image quality constitutes a major
sources of unnecessary radiation dose to patients. (Yrout Et al, 1999). A cross sectional
study done by Chanda R.B et al (2003) at department of Radiology and imaging,
Tribhuvan University teaching Hospital Maharajgunj/ on evaluation of image quality in
chest radiographs. A total of 1101 chest radiographs were collected in which about 52.3%
chest radiographs met all image criteria while 47.7% did not met these criteria of which

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inadequate arrested inspiration contributed 34.8%, inadequate penetration 24%, rotation
21.8%, scapula not out of lung field 14.7% and no anatomical coverage 3.8%. The results
identified that performing good quality chest radiograph according to European
guidelines is difficult. To an extent the quality of chest radiographs depends upon skill of
radiographer, equipment condition and co-operation of patients.

The results of a survey carried out in some countries in Africa, Asia and Europe by
international Atomic Energy Agency (IAEA) using chest, pelvis, skill and abdominal
radiographs showed that 53% of all the images evaluated were of poor quality and this
affect diagnostic information. One of the consequence as revealed by the survey is repeat
examinations and consequently more radiation dose to patients because of another x-ray
exposure of the patients. The survey further recommended implementation of quality
control tests as a way of improving the quality of radiographs.

2.3 Radiographic procedure

2.3.1 Projection

We have two projections namely; basic, supplementary view. The basic view comprise
of the posterior anterior (PA) projection and lateral.

The supplementary views include; apices, anterior oblique, posterior oblique, lordotic,
lateral upper anterior regions and all these views are carried out depending on the
presenting clinical problem.

2.3.2 Posterior anterior (erect) projection care of the patients

The patient is instructed to pull off whatever he or she is wearing within the chest region.
If it is a woman, the necklace, dangling earrings, bangles or any radio-opaque materials
worn should be removed. Then he or she is told to wear a hospital gown.

2.3.3 Positioning

 The patient is made to face the vertical bucky. The chin is extended and centered
to the middle of the top of the vertical bucky.

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  The feet are slightly placed apart so that the patient is able to remain steady.
 The median sagittal plane is adjusted at right angles to the middle of the
cassette. The shoulders are rotated forward and pressed downward in contact
with the cassette.
 This is achieved by placing the dorsal aspect of the hands behind and below the
hips, with the elbows brought forward or by allowing the arms to encircle the
vertical bucky. The medial rotation helps in throwing off the scapular which can
obstruct the lung apices.
 The patients is then instructed on the breathing techniques and then asked to
rehearse it before exposure is made.

2.3.4 Centering point

 The horizontal central beam is directed at right angles to the cassette at the level
of the eighth thoracic vertebrae (spinous process of T7).
 The surface marking of T7 spinous process can be assessed by using the inferior
angle of the scapula before the shoulders are pushed forward.
 Exposure is made at full normal arrested inspiration.

2.3.5 Focus film distance

The distance is usually 150cm for lung fields and 180cm for heart shadows.

2.4 Radiographic Description of the Chest

The PA projection should be studied and described in a systematic order and the
following are suggested:

1) The trachea: The transradient shadow of the trachea can be seen in the middle
superimposed on the lower cervical and upper thoracic vertebra.
2) Superficial soft tissues: The nipples of either sex or the breastshadow in the
females may be seen superimposed on the lower part of the lung filed. The
sternormastoid and pectoralis major muscles also cast shadows.

16
3) The Diaphragm: This structure casts a dome shaped shadow slightly higher on
the right side than the left meeting the chest wall at an angle known as the
costophrenic angle or recess. Beneath the left side is the fundal gas, on the right
side is the homogenous shadows of the liver, beneath the diaphragm.
4) Bony parts: The posterior parts of the ribs, the costotransverse joints and the less
well defined anterior. Parts of the ribs which of course do not reach sternum are
seen. The costal cartilage may be calcified in which case they will be visible. The
clavicles run laterally across the upper part of each lung field. The vertebrae are
seen imperfectly and the medial borders of the scapulae may overlap the
periphery of the lung fields.
5) The mediastinal shadow: This is made up of the heart and great vessels. The
right border consists of the superior vena cava, the right atrium and sometimes the
inferior vena cava. The left border show a prominence called the aortic knuckle
caused by the arch of the aorta, below this, the left margin of the arch of the
aorta, below this, the left margin of the pulmonary trunk (artery) and the left
ventricle are the chief constituent of this parts of the mediastinal shadow. Also at
the center of the thorax, in between the lungs is the trachea.
6) The lungs: These shows the relatively dense root shadows resulting from the
superimposition of the shadows of the pulmonary and bronchial vessels, the
bronchi and lymph and bronchial vessels, the bronchi and lymph nodes. The lung
fields are relatively transradient because of air they contain and the pulmonary
vessels are seen as shadows i.e. white markings superimposed on them. When
vessels are seen end on, they appear as small round white shadow.

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 CHAPTER THREE

RESEARCH METHODOLOGY

This chapter discusses the research design, area of study, population sampling method
and sample size, method of data collection, description of the assessment sheets and
explanation of standard chest criteria that was used in this work.

3.1 RESERCH DESIGN

This research was carried out prospectively using a survey design which was
considered most suitable for getting the data that was used for this study, Since it deals
on quality of chest radiographs processed at the time of the study.

3.2 AREA OF STUDY

Radiology department of Enugu State University of Science And Technology Teaching
Hospital, Parklane Hospital, Enugu.

3.3 TARGET POPUALTION

This study is composed of the assessment of postero-anterior (PA) chest radiographs of
patients at Enugu State University of Science And Technology Teaching Hospital,
Parklane Hospital, Enugu.

3.4 SAMPLE SIZE

The sample size is 325 chest (PA) radiographs which represent the number of chest
radiographs assessed and recorded in the assessment sheets that was used for data
collection.

3.5 SAMPLING TECHNIQUE

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The sampling method that was used for this study was a convenient sampling method.
That is, the PA chest radiographs that were used are the ones that were immediately
processed at the time of study.

Criteria for inclusion: Medical Examination of PA chest radiographs without any

suspected pathology.

Criteria for Exclusion: PA chest radiographs with any pathology.

3.6 ETHICAL CONSIDERATION

Ethical clearance was collected from the committees of Faculty of Health Science and
Technology, NnamdiAzikiwe University, Nnewi Campus.

3.7 INSTRUMENT OF DATA COLLECTION

An assessment sheet was used for data collection.

3.8 METHOD OF DATA COLLECTION

An assessment sheet which was completed by the researcher was used for data collection.

3.9 DESCRIPTION OF THE ASSESSMENT SHEET

The assessment sheets that were used to assess the imaging standard of postero-anterior
chest radiographs were structured to provide the assessor with the basic standard PA
chest techniques. The techniques include:

1) Patient identification and marker

2) Patients positioning
3) Subjective Contrast

3.10 EXPLANATION OF THE STANDARD CRITERIA FOR THE

ASSESSMENT OF CHEST RADIOGRAPHS
The standard criteria are laid down guidelines by the European Guidelines on
quality criteria for Diagnostic Radiographic Images for assessment of the image quality
of radiographs. These guidelines was used to guide the assessor in filling assessment

19
sheets. It provides the platform for judging each dry processed chest radiograph thereby
removing any bias that may arise from the assessor. It will be represented as below:

1. Patient identification and marker

This comprises of six factors as;

(a) Name of patients

(b) The patient’s number
(c) Age
(d) Gender
(e) Data of examination
(f) Anatomical marker
The above identification markers of the patient in normally identified chest radiograph
should be located out of the lungs field. If all of them are found on the radiograph the
right column will be labeled ‘YES’ while if any is missing, the right column will be
labeled ‘NO’.

2) Patient positioning

Patients positing will be assessed in terms of the following six (6) Items

i. Collimation
ii. Optimal inspiration
iii. Rotation
iv. Position of scapula
v. Symmetric density of lungs

Collimation

20
Good collimation is essential to good practice and dose reduction and should be applied
in all chest radiography. A chest radiograph should not include any part of the abdomen.
Also care should be taken to ensure that the apices of the lungs and the costophrenic
angles are not conned off from the beam.

Optimalinspiration

An optimal inspiration should have the diaphragm at 10th posterior rib and 6th anterior
rib.

Rotation

The medical ends of the clavicles should be equidistant from spinous process of the
thoracic vertebrae. This will be used to overrule rotation of the patients.

Good position scapulae

Good position of scapulae should have the medial end of the scapulae off the lung fields.

Symmetric density of lung

The density of the right and left lungs should be the same since there is no suspected
pathology. So any difference in the density of the lungs will be due to change in position
of standing bucky or due to rotation or other factors.

3) Subjective Contrast

The density of the chest radiographs cannot be measured due to the absence of
densitometer, the contrast of the radiographs will be assessed through the following
parameters;

a) Lung field
b) Vascular patterns
c) Mediastinum
d) Cardiac shadow

21
Lung field

The costophrenic and cardiophrenic angles must be clearly seen. Also the apices of the
lungs should be seen.

Vascular pattern

The pulmonary vessels should be easily traced throughout the lung especially to the lung
periphery.

Mediastinum

The trachea should be clearly outlined.

Cardiac shadow

The cardiac shadow must be well outlined and the disc spaces of the thoracic vertebrae
behind the heart shadow should not be delineated because its delineation indicates over
penetration.

All these criteria were used to assess the chest radiographs that were processed and dried
at the time of study. For any of the criterion that was met, the appropriate box was filled
with ‘1’. For those that the criterion was not met, the appropriate box was filled with ‘0’.

22
 CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND RESULTS

The data collected with the assessment sheets were analyzed using simple descriptive
statistics mainly percentage and then presented using tables as shown below.

Table 1: Gender distribution of patients

Gender Number (N)Percentage (%)

Male 161 53.7%
Female 139 46.3%

From table 1 above, male chest radiographs used were 161(53.7%) while the female chest
radiographs were 139(46.3%). This shows that male chest radiographs were used more in
the study than female chest radiographs.

23
Table 2: Age distribution of patients

Age grades Number (N) Percentage (%)

1-15 117 39%
16-30120 40%
36-4545 15%
46-7018 6%
Table 2 shows the age bracket of the patient’s chest radiographs that were used for the
study and its shows that age bracket of 16-30 participated more while the age bracket of
46-70 participated less.

24
Table 3: Image criteria

N Percent (%)
Patient identification and anatomical Yes 294 98.0%
marker No 6 2.0%

Yes 224 74.7%

Performed in full inspiration
No 76 25.3%

Visually sharp reproduction of Yes 284 94.7%

trachea No 16 5.3%

Medial border of scapulae to be Yes 300 100.0%

outside lung field No 0 0.0%

Visually sharp reproduction of the Yes 220 73.3%

vascular pattern of the lungs,
No 80 26.7%
particularly the peripheral vessels

Visualization of the disc spaces Yes 75 25.0%

behind the cardiac shadow No 225 75.0%

Yes 82 27.3%
Rotation
No 218 72.7%

Visually sharp reproduction of the Yes 254 84.7%

costophrenic angles No 46 15.3%

Visually sharp reproduction of the Yes 269 89.7%

25
apices No 31 10.3%

Yes 246 82.0%

Good collimation
No 54 18.0%

Yes 278 92.7%

Symmetric lung density
No 22 7.3%
Table 2 above shows that medial border of scapulae to be outside lung field occurred
more across all the respondents (100%), while rotation occurred less (27.3%)
Table 4: Image criteria occurrence with gender

Gender
Male Female
N Percent (%) N Percent (%)
Patient identification and Yes 157 52.3% 137 45.7%
anatomical marker No 4 1.3% 2 0.7%

Yes 124 41.3% 100 33.3%

Performed in full inspiration
No 37 12.3% 39 13.0%

Visually sharp reproduction of Yes 154 51.3% 130 43.3%

trachea No 7 2.3% 9 3.0%

Medial border of scapulae to Yes 161 53.7% 139 46.3%

be outside lung field No 0 0.0% 0 0.0%

Visually sharp reproduction of Yes 111 37.0% 109 36.3%

the vascular pattern of the
lungs, particularly the No 50 16.7% 30 10.0%
peripheral vessels

Visualization of the disc spaces Yes 49 16.3% 26 8.7%

behind the cardiac shadow No 112 37.3% 113 37.7%

Yes 41 13.7% 41 13.7%

Rotation
No 120 40.0% 98 32.7%

Visually sharp reproduction of Yes 135 45.0% 119 39.7%

the costophrenic angles No 26 8.7% 20 6.7%

Visually sharp reproduction of Yes 145 48.3% 124 41.3%

the apices No 16 5.3% 15 5.0%

Good collimation Yes 132 44.0% 114 38.0%

26
 No 29 9.7% 25 8.3%

Yes 146 48.7% 132 44.0%

Symmetric lung density
No 15 5.0% 7 2.3%

Table 3 above shows that medial border of scapulae to be outside lung field occurred
more across all the gender (male=53.7%, female=46.3%), while rotation occurred less
(male=13.7, female=13.7%).

Table 5: Image criteria occurrence with age

Age
1-15 16-30 31-45 46-70
N (%) N (%) N (%) N (%)
11
Patient identification Yes 115 38.3% 38.7% 45 15.0% 18 6.0%
6
and anatomical marker
No 2 0.7% 4 1.3% 0 0.0% 0 0.0%

Performed in full Yes 86 28.7% 92 30.7% 29 9.7% 17 5.7%

inspiration No 31 10.3% 28 9.3% 16 5.3% 1 0.3%

11
Visually sharp Yes 107 35.7% 38.3% 45 15.0% 17 5.7%
5
reproduction of trachea
No 10 3.3% 5 1.7% 0 0.0% 1 0.3%

Medial border of 12
Yes 117 39.0% 40.0% 45 15.0% 18 6.0%
scapulae to be outside 0
lung field No 0 0.0% 0 0.0% 0 0.0% 0 0.0%

Visually sharp Yes 85 28.3% 89 29.7% 33 11.0% 13 4.3%

reproduction of the
vascular pattern of the
lungs, particularly the No 32 10.7% 31 10.3% 12 4.0% 5 1.7%
peripheral vessels

Visualization of the Yes 30 10.0% 27 9.0% 12 4.0% 6 2.0%

disc spaces behind the
cardiac shadow No 87 29.0% 93 31.0% 33 11.0% 12 4.0%

Yes 35 11.7% 27 9.0% 13 4.3% 7 2.3%

Rotation
No 82 27.3% 93 31.0% 32 10.7% 11 3.7%

Visually sharp Yes 108 36.0% 97 32.3% 32 10.7% 17 5.7%

reproduction of the
costophrenic angles No 9 3.0% 23 7.7% 13 4.3% 1 0.3%

27
 Visually sharp 10
Yes 105 35.0% 35.0% 41 13.7% 18 6.0%
reproduction of the 5
apices No 12 4.0% 15 5.0% 4 1.3% 0 0.0%

10
Good collimation Yes 95 31.7% 34.7% 34 11.3% 13 4.3%
4
No 22 7.3% 16 5.3% 11 3.7% 5 1.7%
10
Yes 111 37.0% 35.7% 42 14.0% 18 6.0%
Symmetric lung density 7
No 6 2.0% 13 4.3% 3 1.0% 0 0.0%

From table 4 above, in the age group of 1-15years medial border of scapulae to be outside
lung field occurred more (39%), while visualization of the disc spaces behind the cardiac
shadow occurred less (10%).
In the 16-39 years age group, medial border of scapulae to be outside lung field occurred
more (40%), while visualization of the disc spaces behind the cardiac shadow and
rotation occurred less (9% each).
In the 31-45 years age group, patient identification and anatomical markers, visual sharp
reproduction of the trachea and medial border of scapulae to be outside lung field
occurred more (15% each), while visualization of the disc spaces behind the cardiac
shadow occurred less (4%).
In the 46-70 years age group, medial border of scapulae to be outside lung field, visual
sharp reproduction of the apices and symmetric lung density occurred more (6%), while
visualization of the disc spaces behind the cardiac shadow occurred less (2%).

28
 CHAPTER FIVE

DISCUSSION, SUMMARY, CONCLUSION AND RECOMMENDATION

5.1 DISCUSSION

This study has assessed the evaluation of compliance with standard criteria for postero-
anterior chest radiographs using the immediate radiographs of patients from Enugu State
University of Science And Technology Teaching Hospital, Parklane Hospital, Enugu.

The male patients appeared to be in larger number thanfemale patients during the time of
the study. All the chest radiographs used in this work has the patients age ranging from
1year to 70years and the chest radiographs are ones without any form of pathology.

The result of table2, shows that 294 (98%) of the studied chest radiographs had a full
indication of identification of patients and anatomical markers of the patients with ‘Yes’
label which shows that the anatomical marker and the patient’s identification were seen
on the radiograph, while 98 (2%) of the studied chest radiographs were without either
patient identification or anatomical marker, thus has ‘No’ label.

Also, table2 shows that 224(74.7%) chest radiographs has optimal inspiration, while
76(25.3%) chest radiographs has poor inspirational effort.

29
In the third column in table 2, 284(94%) of the chest radiographs has a welldelineated
trachea while in 16(5.3%) of the chest radiographs the trachea was not well delineated.

The scapula was not found in the lung field in any of the chest radiographs used for the
study.

220(73.3%) of the chest radiographs showed visually sharp reproduction of the vascular
patterns especially towards the periphery while 80(26.7%) showed otherwise.

The disc spaces of the thoracic vertebrae behind the heart shadow were visible in
75(25%) of the chest radiographs which shows that high exposure factors were used for
those examinations while the disc spaces were not well delineated in 225(75%) of the
chest radiographs used for the study.

In the seventh row of table2, 82(27.3%) showed rotation which was identified by the
median ends of the clavicle not being equidistant from the spinous process of the thoracic
vertebrae. 218(72.7%) chest radiographs didn’t show any rotation.

The costophrenic angles were visually sharp in 254(84.7%)of the chest radiographs while
they were cut off in 46(15.3%)chest radiographs used for the study.

The apices of the lung were cut off in 31(10.3%) of the chest radiographs used for the
study while 269(89.7%) chest radiographs has the apices included in the radiographs.

The twelfth row shows that 246(82%) chest radiographs were well collimated including
both the apices of the lungs and the costophrenic angles, conning of the abdomen and
upper cervical vertebrae.

Also table 2 shows that 278(92.7%) chest radiographs studied has both lung fields with a
symmetric density which showed a good alignment of the beam and grid while
22(7.3%) of chest radiographs has asymmetric density of the lung fields.

5.2 SUMMARY OF FINDINGS

The following findings were obtained after the collection of data and analysis.

30
 1) There are greater number of male patients than female patients at the time of
study
2) Loss of image contrast towards the lung periphery (vignetting).
3) Density differences were witnessed in both lung fields of some radiographs
which can either be caused by rotation, unilateral mastectomy or
misalignment of the x-ray beam.
4) Some of the chest radiographs appeared to be without identification and/or
anatomical marker.
5) The medical ends of the clavicles were not equidistant from spinous process in
82(27.3%) of studied chest radiographs. And owing to the rotation, one of the
costophrenic angles can becut off in cases of asthenic patients.
6) Some of the chest radiographs were not well collimated leading to cut off of
either the apices of the lungs or the costophrenic angles.
7) The study shows that good scapular throw off were achieved in majority of
the radiographs.
8) Improper breathing technique was shown in some radiographs with poor
inspirational effort which also affected the delineation of the trachea as air
was not trapped in the trachea for it to be visible.
9) Some of the chest radiographs has the disc spaces of the thoracic vertebrae
well delineated which should not be so as it shows that high exposure factors
were used on the patients involved.

5.3 CONCLUSION

The project reports that some of the posterior anterior (PA) chest radiographs studies
have rotations, as indicated by unequal in length of medial ends of clavicles to spinous
process. This denotes that immobilization devices and instructions have not been properly
utilized. Also, number of radiographs shown that proper breathing mechanism were not
fully exercised with the patients before taking exposure, which left the radiographs
without normal 6 anterior ribs and 10 posterior ribs rules.

31
It has been shown that good scapular throw off were fully instructed in the research work.
Again, identification markings of the radiographs were good but need to be optimum
leading to the consequences of repeating the films. This is due to manually marking with
pencil or actinic marker. This gives marking with low archival permanence and
misdiagnosis.

Also, due to misalignment of the vertical bucky to the x-ray tube most chest radiographs
are rotated.

Also, the quality assurance control of x-ray machine and vertical bucky is at average.
More also, the dark room equipment and procedures were of low standard and thus needs
standardization.

Finally, the compliance to the standard posterior anterior (PA) chest techniques has not
been fully utilized in Enugu State University of Science and Technology Teaching
Hospital, Parklane Hospital Enugu.

5.4 RECOMMENDATION
The following recommendations are made based on the results of the study.

1. Routine quality assurance control should be always carried out to maintain a close
range in energy difference of central and peripheral rays of x- ray beams and also
ensure the vertical bucky is well aligned to the x-ray tube. This is to annul
vignetting effects that do arise in some radiographs and also prevent cut off of the
costophrenic angles.
2. Quality assurance programs should be carried out on the equipments to ensure
they are working at optimal efficiency so as to rule out equipment faults when
images of poor quality are produced.
3. Radiographers should be always cautioned on need of proper identification
markers one films to avoid waste, biased minds, misdiagnosis and unnecessary
patient irradiation.
4. The radiation medicine department should discard any cassette with light leakages
and darkroom equipment and procedures should always be up to standard to
exclude artifacts.

32
5. Grid in vertical bucky should always be checked by engineers to ensure it is well
aligned to the image receptor and nice to avoid elongation or foreshortening that
creates difference in density of lung fields of some radiograph.
6. All immobilization devices and techniques should be provided and applied to
exclude rotation of the patients while undergoing chest radiography especially for
pediatric and geriatric patients.
7. Government and hospital managements should help the radiation medicine
department in provision of new equipments and accessories to maintain a good
quality of image outputs.

5.5 AREA OF FURTHER STUDIES

1. Assessment of quality assurance control of x-ray equipment and accessories
use in radiography department Parklane hospital Enugu.
2. Evaluation of common faults in chest radiography in tertiary hospitals in
Enugu Metropolis.
3. Assessment of intern radiographer’s efficiency of chest radiography in Enugu
State University of Science and Technology Teaching Hospital, Parklane
Hospital Enugu.

5.6 LIMITATIONS OF STUDY

1. The study was limited to only patients in Enugu State University of Science
and Technology Teaching Hospital, Parklane Hospital Enugu.
2. The density of each radiograph was not checked due to lack of densitometer in
the radiation medicine department.

33
 3. The radiographs of patients used in this study are those without any indicated
or suspected pathology.

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