Ministry of Higher Education and Scientific Research

Middle Technical University

Institute of Medical Technology Baghdad

__________(THE CHEST X-RAY)__________

BY: DUHA Mohammed Mohammedali
1ST STAGE /GROUP-B-/MORNING STUDY
SUPERVISOR: DR. Sami Hasan
2019-2020
Introduction
X-ray examination on the chest is one of the most important and routine medical
exams in the medical field. It is a quick and easy scan that takes a few minutes. It is
considered one of the most requested tests from doctors, especially in emergency
situations. This examination uses X-rays to produce radiation pictures

BASIC RADIOGRAPHY
X-rays have very short wavelengths of electromagnetic radiation that penetrate
matter.
A traditional radiograph is created when X-rays penetrate body structure and
produce images on a piece of photographic film usually contained in a cassette.
However, in most hospitals and medical centers, the traditional X-ray film has been
replaced with digital images. The basics of chest X-ray interpretation is the same
irrespective of whether it is a digital image or conventional X-ray film .
Black and White Principles ,
• White color indicates lack of exposure and black color indicates intense exposure.

• Dense substances absorb all the rays and appear white on the film – radiopaque.
• Soft tissues and air absorb part of the beam and appear gray (tissues) or black (air)
– Radiolucent.

Indications for chest X-ray

• Infection: exclude pneumonia, positive Mantoux test
• Major trauma: exclude widened mediastinum, pneumothorax and
haemothorax
• Acute chest pain: exclude pneumothorax, perforated viscus, aortic dissection
• Asthma/bronchiolitis: when diagnosis unclear and/or not responding to usual
therapy
• Acute dyspnoea: exclude heart failure, pleural effusion
• Chronic dyspnoea: exclude heart failure, effusion and interstitial lung disease
• Haemoptysis
• Suspected mass, metastasis or lymphadenopathy
Chest X-ray (CXR) Positions

-Basic Chest X-ray Views

A chest X-ray is a 2D projection of a 3D thoracic viscera. Therefore, what we see in a

chest X-ray is a summated and compressed image. Two of the most common chest
radiographs are postero anterior (PA) and antero posterior (AP), both taken in frontal
projections.
For PA views (Fig. 1.1), the X-ray beam passes through the chest from the back to the
front.
For AP views (Fig. 1.2), the beam passes through the chest from the front to the back.

By convention most of the PA views are taken with patient in erect posture and most
of the AP views are taken with patient in supine posture. For acutely ill patients who
are bedridden and who cannot stand up for a PA view, AP views are obtained with a
portable X-ray machine.

1.Chest postero anterior (PA) erect:

• The patient is in erect position.

• Lift and place chin on vertical image receptor device. Put shoulders close to
image receptor (IR) by having the hands on the bilateral hip regions or having
both arms around vertical IR device.
• Place midsagittal plane of the body in the middle of IR and make sure the chest
is not rotated.

Region
-lung, trachea, bronchus, heart, diaphragm, mediastinum, costophrenic angle

Pathology
- lung disease, mediastinal disease and heart disease

-Central Ray Project perpendicularly toward the center of chest with the height of 7th
thoracic (T 7)

Respiration
-suspended with deep inspiration
2.Chest antero posterior (AP) supine:

• The patient is placed in supine position.

• Place upper edges of image receptor (IR) to be 5cm above bilateral shoulders
and match its Centerline with midsagittal plane of chest.
• By flexing bilateral arms, if possible, place bilateral shoulders in front.

Region
-lung, trachea, bronchus, heart, diaphragm, mediastinum, costophrenic angle

Pathology
-lung disease, mediastinal disease and heart disease

Central Ray
-Project perpendicularly toward the center of chest with the height of 7th thoracic (T7).

Respiration
-suspended with deep inspiration
 Postero anterior (PA) View vs Antero posterior (AP) View

There are certain findings that can distinguish a supine AP from erect PA view; For
e.g. PA view shows the scapulae clear of the lungs whilst in AP view they always
overlap. The clavicles are overlie the lung fields in PA view, while in AP they are usually
projected above the lung apices. The level of the diaphragm is lowest in PA view, while
in AP view they are placed higher up. Further the heart looks bigger on an AP view
because of the technical magnification In an erect film, the gastric air bubble is clearly
seen in the fundus with a clear fluid level just

Below the left dome of diaphragm. In a supine film, blood will flow more to the apices
of the lungs than when erect. Failure to appreciate this will lead to a misdiagnosis of
pulmonary Congestion. The recognising a chest X-ray film as AP or PA view is of very
important as the Normal anatomy significantly changes (Fig. 1.3). Therefore, doctors
have to be careful about This aspect before interpreting any abnormality .
 Parameter PA view AP view
1. Patient posture Erect (standing) Supine (lying on back)

2. Scapulae Away from lung Ovelie lung fields

fields
3. Clavicle Project over Project above lung
lung zones apices
4. Distinct ribs end Posterior end Anterior end
5. Patients hands Placed on hips On the sides of thorax

6. Heart magnification Minimal, Moderate, significant

negligible
7. Cardiothoracic ratio Normal 1:2 Spuriously increased

8. Diaphragm Lowest level Highest level

9. Gastric air/fluid Seen Not seen, only gas seen

10. Respiratory phase Deep Mid inspiration or

inspiration expiration
11. Lung expansion Maximal Restricted
12. Lung markings Normal, only Crowded, upper zone
lower zone vessels unduly
vessels prominent
prominent due
to gravity
13. Lung volume Normal Apparently reduced
PA view and AP view in chest X-ray—a comparison :

3.chest lateral Position :

• The patient is in erect position.

• Adhere the filming side to image receptor (IR), raise and put hands around the
hand and lift chin.
• Place midsagittal plane of chest on the center of IR.
• Place upper edges of IR to be 2.5cm above bilateral shoulders.

Region
-lung, trachea, bronchus, heart, diaphragm, mediastinum, costophrenic angle.

Pathology
-lung disease, mediastinal disease and heart disease.

Central Ray
-Project perpendicularly toward the center of chest with the height of 7th thoracic (T7).

Respiration
Suspended with deep inspiration.
4.Chest LAO, RAO
• patient is in erect position.
• Rotate the patient 45° to the filming side.
• Adhere one arm to image receptor (IR) and place it on hip region facing the
palm external side.
• Lift the chin and raise the opposite arm high to exclude them in inspecting
area.
Region
-aortic arch, heart, thorax, right lung, trachea

Pathology
-lung disease, mediastinal disease and heart disease

Central Ray
-Project perpendicularly toward the center of chest with the height of 7th thoracic (T7).

Respiration
-suspended with deep inspiration
5.Chest LPO, RPO

• The patient is in erect position.

• Rotate back of patient's shoulder 45° to the filming part and adhere to the
table.
• Raise the arm of filming side and put it above the head. Place the opposite arm
on hip region with palm facing external side.
• Lean right or left back area to image receptor (IR).

Region
-aortic arch, heart, thorax, left lung, trachea

Pathology
-lung disease, mediastinal disease and heart disease

Central Ray
-Project perpendicularly toward the center of chest with the height of 7th thoracic (T7)

Respiration
-suspended with deep inspiration.

6.Chest apical lordotic (Erect)

• The patient is placed a step ahead from vertical image receptor device in erect
position.
• Lean the patient to the back to lean shoulders and neck on vertical image
receptor device.
• Place patient's midsagittal plane on the center of Image receptor (IR).
• Place the palm on hip region facing external side.
Region
-pulmonary apex

Pathology
-inflammation and tumor of lung apex

Central Ray
-Project perpendicularly toward the center of manubrium

Respiration
-suspended with deep inspiration

7.Chest apical axial (supine) :

• The patient is placed in supine position.

• Hold bilateral shoulders out in front by placing bilateral hands on hip region.
• Lean patient's back on image receptor (IR) and match patient's midsagittal
plane with vertical axis Of IR.

Region
-pulmonary apex

Pathology
-inflammation and tumor of lung apex.

Central Ray
-Project perpendicularly toward the center of manubrium

Respiration
-suspended with deep inspiration
8.Chest lateral decubitus :

• Place a support with thickness of 5 ~10cm on the filming table and place the
patient on the support in Lateral decubitus position.
• Place image receptor (IR) in front of patient's Chest and put arms around IR.

Region
-pleural effusion, mediastinitis, empyema, pneumothorax.

Pathology
-pleural effusion, pneumothorax, mediastinitis and empyema

Central Ray
-Project perpendicularly toward the center of chest with the height of 7th thoracic (T7).

Respiration
-suspended with deep inspiration
THE IMPORTANCE OF CXR IN DIAGNOSING CORONA VIRUS

As the global pandemic of coronavirus disease-19 (COVID-19) progresses, many

physicians in a wide variety of specialties continue to play pivotal roles in diagnosis
and management. In radiology, much of the literature to date has focused on chest CT
manifestations of COVID-19 . However, due to infection control issues related to
patient transport to CT suites, the inefficiencies introduced in CT room
decontamination, and lack of CT availability in parts of the world, portable chest
radiography (CXR) will likely be the most commonly utilized modality for
identification and follow up of lung abnormalities. In fact, the American College of
Radiology (ACR) notes that CT decontamination required after scanning COVID-19
patients may disrupt radiological service availability and suggests that portable chest
radiography may be considered to minimize the risk of cross-infection. Furthermore,
in cases of high clinical suspicion for COVID-19, a positive CXR may obviate the need
for CT. Additionally, CXR utilization for early disease detection may also play a vital
role in areas around the world with limited access to reliable real-time reverse
transcription polymerase chain reaction (RT-PCR) COVID testing.

Normal Chest X-ray Chest X-ray Corona Virus

^ Kern Radiology Medical Group
^ General X‐Ray Positioning Mohammed Zaid Al‐Keilani Jordan hospital
^ Interpretation of Chest X-ray/G Balachandran MD DNB DMRD/Associate
Professor/Department of Radiology/Sri Manakula Vinayakar Medical College and
Hospital /India

^ AP CHEST X – RAY | SUPINE OR SEMIERECT | BESIDE PORTABLE/

radtechduty/http://www.radtechonduty.com/2011/12/ap-chest.html?m=1

^ X-RAY PATIENT POSITIONING MANUAL/ Dr. Naveed Ahmad. 2003

^ The role of imaging in 2019 novel coronavirus pneumonia (COVID-19) / European

Society Of Radiology 2020
^ Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review
/Adam Jacobi, Michael Chung, and Corey Eber /Published online 2020 Apr
8.