Journal of Radiation Research and Applied Sciences 16 (2023) 100518

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Journal of Radiation Research and Applied Sciences

journal homepage: www.journals.elsevier.com/journal-of-radiation-research-and-applied-sciences

Optimization of chest X-ray exposure factors using machine

learning algorithm
Zuhal Y. Hamd a, H.I. Alrebdi b, Eyas G. Osman c, Areej Awwad b, Layan Alnawwaf b,
Nawal Nashri b, Rema Alfnekh b, Mayeen Uddin Khandaker d, e, *
a
Department of Radiological Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671,
Saudi Arabia
b
Department of Physics, College of Sciences, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
c
Applied College, Shaqra University, Shaqra, 15551, Saudi Arabia
d
Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, Bandar Sunway, 47500, Malaysia
e
Department of General Educational Development, Faculty of Science and Information Technology, Daffodil International University, DIU Rd, Dhaka, 1341, Bangladesh

A R T I C L E I N F O A B S T R A C T

Keywords: A better quality radiographic image helps the radiologist to make a proper diagnosis of the disease. In general,
Exposure factors the use of more radiation provides a better quality image, but it gives the patient a higher radiation dose, which
Body mass index shows the need for optimization of imaging conditions to minimize the risk to patients from excessive radiation
Chest X-ray
exposure. In this study, the chest X-ray exposure factors for 178 patients with different body mass index (BMI)
Machine learning
values have been analyzed using the Python Machine Learning algorithm. Patient data were collected from the
King Abdullah bin Abdulaziz University Hospital, Saudi Arabia. The role of BMI in the selection of radiation
exposure factors (kVp, mAs) was evaluated. It has been found that the BMI of each patient has specific exposure
factors, and that if it gets higher than the specific value it could harm the patient’s health. The obtained results
provide detailed information about the relation between BMI and optimal chest X-ray exposure factors without
affecting the quality of the X-ray image.

1. Introduction
Following the discovery of the X-ray by Wilhelm Conrad Röntgen on
8th November 1895, an amazing step in the history of health sciences has
been introduced, which made visible the inner structures of the body
without the need for any physical operation (Panchbhai, 2015). Plain
X-rays are the most commonly used in medical imaging method, it is
used to form images of different inner body parts with different dose
rates according to their densities (Thomas & Banerjee, 2013). There are
various types of plain radiography. In this research, we have focused on
the Chest X-ray that shows the images of chest bone, spine, lungs, blood,
vessels, and airways. Body Mass Index (BMI) affects the dose received by
the patient. The body mass was classified into four sections (under­
weight, normal, overweight, and obese) (Centers for Disease Control and
Prevention, 2011, pp. 1–4). Overweight patients usually need higher
doses due to larger surface area and body density. Hence, the radiology
departments face challenges to take quality imaging for obese adult
patients (Uppot, 2005; Uppot et al., 2007). In a previous study con­
ducted by Le et al. reported that obese patients who need medical im­
aging for both acute and chronic diseases are more frequently showing
up at emergency rooms. Obesity has wide-ranging indirect consequences
on the patients with medical diseases like type 2 diabetes, coronary
artery disease, hypertension, asthma, and sleep apnea (Le et al., 2015).
Considering these facts, the present study focuses on the relationship
between BMI and exposure factors since they vary with one another. A
radiologist aims to obtain a good quality image that generates full
diagnostic information. This can be achieved by a suitable selection of
X-ray exposure factors. The exposure factors are used to determine

Peer review under responsibility of The Egyptian Society of Radiation Sciences and Applications.
* Corresponding author. Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, Bandar Sunway
47500, Malaysia.
E-mail addresses: Zyhamd@pnu.edu.sa (Z.Y. Hamd), Hialrebdi@pnu.edu.sa (H.I. Alrebdi), eyas-gaffar@su.edu.sa (E.G. Osman), aamma1995@gmail.com
(A. Awwad), layanalnawaf@outlook.com (L. Alnawwaf), nf.nashri@gmail.com (N. Nashri), remaalfnekh@gmail.com (R. Alfnekh), mayeenk@sunway.edu.my
(M.U. Khandaker).

https://doi.org/10.1016/j.jrras.2022.100518
Received 10 September 2022; Received in revised form 10 November 2022; Accepted 14 December 2022
Available online 28 December 2022
1687-8507/© 2022 The Authors. Published by Elsevier B.V. on behalf of The Egyptian Society of Radiation Sciences and Applications. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Z.Y. Hamd et al. Journal of Radiation Research and Applied Sciences 16 (2023) 100518

Table 1
The minimum, maximum and mean values of exposure factors and BMI.
Parameters Weight (kg) Height (cm) BMI kVp mAs Time (ms) SID (cm) Age (years)

Sample number, n 178 178 178 178 178 178 178 178
mean 82.21 161.62 31.30 113.71 1.88 11.58 180 41.83
std 26.33 9.24 9 5.77 0.74 7.62 0.00 18.04
min 37.7 142 16.19 85 0.60 1.10 180 18
25% 64.03 155 24.59 110 1.30 3.50 180 24
50% 78 161 29.59 110 1.80 11 180 39
75% 95.48 167 37.76 120 2.40 17.75 180 55
max 166 188 59.52 120 6.40 43.70 180 91

appropriate doses to produce a high-quality X-ray image. Exposure
factors include several parameters, peak kilovoltage (kVp), milliampere
(mA), exposure time (s), and distance from the X-ray source to the pa­
tient (SID). The kVp controls the penetrating power of the X-ray, the
greater the kVp the more energetic X-rays are produced, and the higher
the energy, the lower the picture contrast (Sipa & Aminuddin, 2019).
Image quality is influenced by the current (mA) which denotes the
amount of filament flow. The greater the mA flowed through the fila­
ment; the more electrons are available in the (space charge) to accel­
erate through the target. Odds the kVp current doesn’t affect the picture
contrast, it only affects the blackness of the radiograph. The exposure
time is found to be linked to tube current regulation. Exposure time and
mA are inversely linked. With an increase in mA, the exposure time is
required to maintain the required number of X-rays to be generated.
Furthermore, there are some external effects that affect the quality of
X-ray images which leads to the modification of its exposure factors, for
instance, the impact of obesity on medical imaging, where a human’s
weight and body diameter are significant factors. The random increase
of exposure factors like (mAs and kVp) is not desirable, this is because it
may provide unnecessarily extra exposure to the obese patient which
might be harmful to the patient. The X-rays exposure during diagnostic
radiology is often related to the risk of cancer induction and other side
effects (Alqahtani et al., 2018; Hendee & O’Connor, 2012). Whereas a
previous study concluded that obese patient is more likely to have
cancer compared to people with normal weight, due to the need of in­
crease radiation exposure rates (Alqahtani et al., 2019), therefore raising
this awareness of this danger is also a purpose of the study.
On the other hand, the study of BMI role in Lumbar Sacrum Spine
Anteroposterior and Lateral Radiography found that the amount of x-
rays dose can be decreased by up to 30% without affecting the image
quality for normal and overweight BMI patients (Yadav et al., 2020).
Several statistical studies reported that the dose monitoring concerning
the patients’ BMI values is very significant where the findings of the
statistical analysis observed an increase in the radiation dose from
diagnostic x-rays for overweight and obese adult patients compared to
the normal BMI patients. As a consequence, it has been called for the
need to properly modify imaging protocols to reduce the dose received
by patients who are overweight or obese without compromising the
image quality (Metaxas et al., 2019a). Besides this, some researchers
studied the impact of diagnostic x-rays for low BMI adult patients, and
they concluded that the radiographic techniques should be modified
accurately to reduce the dose received by low BMI patients while
maintaining image quality where they found a statistically clear vari­
ance in dose amounts compared to normal patients (Efthymiou et al.,
2020). Now it is well known that radiation doses should be kept as low
as reasonably achievable (ALARA) to reduce radiation exposure and
avoid harm as the International Commission on Radiological Protection
(ICRP) said “the radiation exposure of the patient should be reduced as
much as is compatible with successful diagnostic investigation or ther­
apeutic treatment” (Miller & Schauer, 1983). The radiographer is
responsible for the selection of suitable x-ray exposure factors for each
patient. It is important to establish a convenient means for the selection
of a proper set of exposure parameters by the radiographers and they
must make every effort to limit radiation exposure, keeping the ALARA
principle in mind to maintain a healthy life for the patient. Therefore,
this study investigates the effect of BMI on the X-ray exposure factors
without compromising the image quality in the chest radiography.
2. Methodology
2.1. Exposure factors
Our purpose is to estimate radiation exposure factors that must be set
to different BMIs, and varying the radiation doses to get a better image
quality based on different BMI (Alqahtani et al., 2018). High BMI,
especially females with oversized breasts are at risk of being more
exposed to radiation due to the fact of having more soft tissues (Ghanem
et al., 2011). In order to get a decent image, an obese patient should get a
higher kVp peak than a normal-weight patient (Alqahtani et al., 2018),
because image features are frequently restricted by soft tissue attenua­
tion, and a higher amount of tissues may sabotage image quality
(Efthymiou et al., 2020). Unfortunately, rising the kilo voltage peak
increase the risk to the patient’s health which requires the right diag­
nosis. The image quality depends on three main factors, called exposure
factors: (i) kilo voltage (kVp) peak accelerates the electrons and forces
them to go to the x-ray tube and controls the penetrating power of
x-rays, (ii) milliamperes (mA) controls the number of electrons, by
increasing the current, the number of electrons can be increased but it
has a limit of 1000 mA (which is called the space charge effect if the
space charge becomes so high then no more electrons are created), (iii)
and finally, the exposure time (s) which controls the duration of the
exposure, it stops automatically when it reaches the suitable exposure
quantity (Kumar et al., 2011; Saia, 2015; Sipa & Aminuddin, 2019).
Exposure factors are controlled according to the area of examination, the
patient’s body mass index, and the distance from the X-ray source to the
patient which is known as the source to image receptor distance (SID).
However, in this study the SID was kept constant at 180 cm, hence it
contributes equally (i.e., same amount) to every patient. Therefore, this
factor was not investigated. It is also known as the distance of the tube
from the image receptor, affecting magnification the greater the SID,
however, the less magnification the image quality suffers, also the pa­
tient’s physical condition affects the image quality (Sipa & Aminuddin,
2019). If the exposure factor value is too high or too low, it results in the
image on the X-ray film being too bright or too dark, which makes it
difficult to be read by the doctor and gives radiation effects. Therefore,
checking the dose is important to improve the radiation protection of
patients in diagnostic radiography. As shown in equation (Panchbhai,
2015), the Body Mass Index (BMI) is a measure of weight adjusted for
height, calculated as weight in kilograms divided by the square of height
in meters (kg/m2) (Centers for Disease Control and Prevention, 2011,
pp. 1–4),
weight(kg)
BMI = (1)
heigh(m)2
Although BMI is often considered an indicator of body fatness, it is a
surrogate measure of body fat because it measures excess weight rather
than excess fat. Despite this fact, studies have shown that BMI is
correlated to more direct measures of body fat, such as underwater

2
Z.Y. Hamd et al.
Fig. 1. The density distribution with respect to BMI and kVp and mAs.
weighing and dual-energy x-ray absorptiometry. In chest examinations,
depending on how the patient is positioned, the fat distribution may
change (Metaxas et al., 2019b). Therefore, the position of the patient in
this study is a standing position to avoid the effect of fatty tissues.
2.2. Patients’ sample
The data of 178 patients with different BMI values and radiation
exposure factors values (e.g., kVp, mAs, time and SID) were collected.
The patients were in standing position, the posteroanterior (PA) pro­
jection was done using Computed Radiography (CR) technique (Philips
digital radiography systems). Before the data collection, an Institutional
Review Board (IRB) approval from Princess Nourah bint Abdulrahman
University and KAAUH (No.22-0089) was obtained. The list contains the
patient’s height (cm), weight (kg), age ranges from 18 to 91 years old,
and related exposure factors (shown in Table 1).
2.3. Statistical analysis
The collected data were analyzed statistically using Python Machine
Learning to evaluate and explore the role of BMI values on radiation
dose for the patients and investigate the correlation between BMI and X-
ray exposure factors. These models were built using linear regression
machine learning in algorithms (see algorithms 1 and 2), considering the
given BMI as an explanatory variable. The two algorithms aim to mea­
sure the prediction of the target variable using mean square error MSE
and adj R-Square function.
Fig. 2. The data distribution of the relation between (a) BMI with kVp and (b) BMI with mAs.
3
Journal of Radiation Research and Applied Sciences 16 (2023) 100518
3. Results and discussion
The analyzed data is shown in Table 1, which presents the minimum,
main, maximum, medium and quartile values of the variables under
study BMI, kVp and mAs.
Figure (1a) shows the Body Mass Index density distribution, which is
a normal distribution (bell curve). The density kept rising with the in­
crease of the BMI until it reached its highest point on the curve at BMI’s
sample mean value (30 ≈ Overweight), when the BMI exceeded 31, the
density distribution shows decreasing in the overweight and obese pa­
tients’ body mass index until it reaches the density’s medium point, as
for extremely obese patients, starting from 54, it shows a little defect
while the density decreasing until it reaches zero.
Otherwise, figure (1b) illustrates the kVp density distribution among
a list of 178 people. As is clear from the figure, it is not a normal dis­
tribution, where the curve skews to the left. The probability density
remains relatively steady between 80 and 100 in the kVp. As the kVp
reaches 100 the density rises rapidly reaching its peak around 110 kVp
which represents the patients with a normal BMI, decreasing gradually
where there were no kVp values between 110 and 120 then increasing
rapidly reaching its peak around 120 of kVp for patients with higher
BMIs, thus it is with double peak.
Figure (1c) of the density curve shows the overall shape of mAs
distribution for 178 patients, and as we mention before mAs are the
main control of X-ray exposure. From the third probability density
curve, it’s clear that the vast majority of patients are underweight pa­
tients because they have small values of mAs in the range between 0 and
Z.Y. Hamd et al.
Fig. 3. The observed measures in blue and estimated measures in red, for each kVp and mAs with case numbers based on BMI. (For interpretation of the references to
colour in this figure legend, the reader is referred to the Web version of this article.)
1 approximately which indicates low exposure time, then with
increasing in mAs there are normal patients where the curve is suddenly
bottomed out staying stable with slightly soar between 4 and 7 mAs for
obesity patient therefore, the higher the BMI, the higher the amount of
mAs.
On the other hand, the data distribution of the relation between BMI
and kVp, in addition between BMI and mAs is demonstrated in Fig. 2.
Figure (2a) shows a scatter points plot between kVp and BMI, the
BMI ranges from underweight adults to overweight patients, and the
majority of all patients lie under the value of 110–120 kVp. Meanwhile,
figure (2b) shows a positive relationship between the BMI and mAs, the
pointsscattered in various values depending on the BMI of the patient.
The aim of this study is based on the observation analysis of BMI
patient values as well as X-ray exposure factors. Thus, the comparison
between the estimated values of kVp which was obtained by Ordinary
Least Squares (OLS) regression with the actual current values was made
and shown in figure (3a). The estimated kVp output is represented in a
blue line and the actual kVp is represented in a red line. The estimated
values of kVp fluctuated between 105 and around 120. The actual values
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Journal of Radiation Research and Applied Sciences 16 (2023) 100518
showed a similar fluctuation as expected. Case numbers 131 and 165
indicate outlier cases. This was due to the underweight patients who
needed less kVp exposure factor to get a decent image.
Figure (3b) indicates the relation between the estimated and actual
values of mAs over time for 178 patients. The estimated mAs output is
represented in the blue line and the actual mAs are represented in the
red line. The blue line shows good agreement with the actual mAs, but
case number 141 has a high deviation from the estimated output.
Noticing later the fluctuation of the estimated and actual values are
approximately in the same range as a result of the variation of the pa­
tient’s BMIs.
The Confusion Matrix in Fig. 4 shows the correlation between the
variables under study. Cells in beige show the highest correlation that
can be achieved between the x and y variables. The correlation gets
weaker as we go to darker cells. For example, the correlation between
BMI and kVp is 0.2 which is weaker than the correlation between BMI
and mAs which equals 0.62, where the highest correlation we can ach­
ieve is 1.0. These correlations confirm the effective role of BMI in
determining X-ray exposure factors (Uppot, 2005).
Z.Y. Hamd et al.
Fig. 4. This heat map matrix shows the correlation coefficients between
study variables.
4. Conclusion
The study concludes that, the medical imaging protocols need to be
modified to reduce the dose received by obese patients, without
Appendices.
Algorithm 1. Algorithms for the kVp and BMI dataset used in the study.
Algorithm 2. Algorithms for the mas and BMI dataset used in the study.
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Journal of Radiation Research and Applied Sciences 16 (2023) 100518
compromising on having a high-quality image. Inaccuracy in deter­
mining the X-ray exposure factors for each X-ray procedure is an un­
professional behavior of the radiographer as well as the radiography
department. The X-ray dose observation concerning the patient’s BMI is
an important topic for the improvement of diagnostic radiography.
5. Limitations and recommendations
This study has a few limitations. The first one is the sample size
which cannot be controlled due to the fact of having discrete and limited
time for collecting and analyzing data. The second one was the lack of
proper information of the field size, because it could affect the exposure
to x-ray. However, since the SID was fixed in this study, therefore the
field size was not varying, hence effect of field size was avoided. How­
ever, we recommend further study of this important parameter.
Funding
The present research work was funded by Princess Nourah bint
Abdulrahman University Researchers Supporting Project number
(PNURSP2023R106), Princess Nourah bint Abdulrahman University,
Riyadh, Saudi Arabia.
Acknowledgements
The present research work was funded by Princess Nourah bint
Abdulrahman University Researchers Supporting Project number
(PNURSP2023R106), Princess Nourah bint Abdulrahman University,
Riyadh, Saudi Arabia.
Z.Y. Hamd et al. Journal of Radiation Research and Applied Sciences 16 (2023) 100518

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