Sunday 10 Feb

Teaching DR/CR with

Best Dose Practices
WCEC 2013
Dennis Bowman RT(R)
Clinical Instructor/Staff Radiographer
Community Hospital of the Monterey Peninsula (CHOMP)
Cabrillo – Clinical Instructor
Speaker/Consultant – Digital Radiography Solutions (DRS) & MTMI

Discussion Topics

1. What is the new Optimum kV?

2. CR and DR Universal Technique Charts
3. DI ranges for different vendors
4. Old and new EI systems
5. How EI numbers are corrupted
6. Image Critique/ Automatic rescaling

Stewart Bushong and the penguin

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Low Flier

ƒ I have 14 Low Flier’s.

Barry Burns –the CR guru

ƒ Barry Burns ‐ MS, RT(R), DABR – Retired

adjunct Professor of Radiologic Science,
University of North Carolina School of
Medicine in Chapel Hill, North Carolina,
stipulates that when using CR everyone
can increase 15‐20 kV from film/screen
techniques (except Konica which is 5‐10 kV).

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The following slides show a hand

phantom exposed from 50 to 100 kV to
demonstrate the minute differences
visualized on an image using higher kV’s
with both CR and DR.

CR 50 kV

CR 60 kV

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CR 70 kV

CR 80 kV

CR 90 kV

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CR 100 kV

DR 50 kV

DR 60 kV

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DR 70 kV

DR 80 kV

DR 90 kV

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DR 100 kV

These are the “new” digital Optimum kVs

as developed by Barry Burns

So what does kVp and mAs do?

ƒ Not what it did in the film world, that’s for sure!!

ƒ There is still an optimum kVp, but it now
controls only subject contrast.
ƒ To a huge extent, mAs does not really control
density/brightness any more.
ƒ Density and brightness are now mainly controlled by
processing algorithms.
ƒ You just need enough mAs or your image will
have quantum noise (pixel starvation, mottle).

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What does optimum kV mean?

ƒ Optimum means the best!!
ƒ Even though it’s digital, you still have to stay
in the optimum range, you can’t start using
120 kV on everything.
ƒ If you do use too much kV it will penetrate
right through your patient and hit the IR
because of incorrect attenuation.
ƒ This will cause the image to be over penetrated,
(saturated) causing a permanent loss in contrast.
ƒ Or if too little mAs is used it may cause mottle.

Film/Screen Technique Chart

Size of the Patient – The techniques

are of a small, medium and large male

ƒ Small = 120‐160 lbs.

ƒ Medium = 160‐200 lbs.
ƒ Large = 200‐240 lbs.
ƒ Females would be approximately 10 lbs. lighter.

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Film/Screen Technique Chart

How can there be a

Universal CR/DR technique chart?
ƒ As we all well know, this would have been
impossible in the film/screen processor days.
ƒ All modern generators (25 years or newer) are
high frequency, so if the tubes are in calibration
they should all be shooting the same.
ƒ Since the CR/DR manufacturers set their systems
up to have the perfect Dose Exposure Indicator #
appear when 1 mR hits the plate, then any given
technique will work with all the vendors if the
x‐ray tubes are all shooting the same.

Universal CR Technique Chart & The Konica Chart

(both) using the Most mAs

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Page 2
Universal CR Technique Chart & The Konica Chart
(both) using the Most mAs

Universal CR Technique Chart

Lowest mAs

Universal CR Technique Chart

Lowest mAs (Page 2)

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Differences between the Lowest Dose,

33% More, 66% More and Most Dose
technique charts

ƒ For example: the 33% More chart uses 33%

more mAs than the Lowest Dose chart.
ƒ This means that the Most Dose chart uses
twice the mAs (so twice the dose) of the
Lowest Dose chart.
ƒ So start with the Most Dose chart and then if
possible go down to the 66% More chart.

Speaking of How Low We Can Go…Here is the

CESIUM DR UNIVERSAL TECHNIQUE CHART.

Page 2 of the
CESIUM DR UNIVERSAL TECHNIQUE CHART.

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Here is the
GADOLINIUM DR UNIVERSAL TECHNIQUE CHART.

Page 2 of the
GADOLINIUM DR UNIVERSAL TECHNIQUE CHART.

CR versus DR

ƒ We discovered that most CR techniques used

twice the mAs of Cesium detectors.
ƒ Gadolinium detectors need 25‐50% more
radiation over Cesium detectors to make a
similar exposure.

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This is the proof of how much dose you save

your patient when you increase the kV and
decrease the mAs and/or decrease the EI #.

How Low Can You Go?

ƒ This is how I now teach ALARA.
ƒ With the new optimum kVp’s already in place,
it’s figuring out how low can you take the mAs
and get an image with no, or acceptable,
mottle.
ƒ I’m hoping that everyone will make it a
competition or goal to see what is the
minimum dose they can use for any given view.

Differences Between Digital And Film

ƒ The concept of Agfa’s 2.0‐2.3 LgM range, Fuji’s

400‐100 S range, GE’s (DR) .2‐.6 (or .8‐2.4) range
and Siemens‘ 200‐900 range.
ƒ Even with the range you should always be
shooting for the “best” number in that range
(which means the lowest dose).
ƒ Lead shields and metal in the body will
dramatically affect the EI number.
ƒ If you are not able to use at least 33% of the IR
you will probably have a corrupted EI number.

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The new standards have 3 important definitions

ƒ Exposure Index (EI) – measure of the radiation

in the region of interest (ROI) which may vary
depending on manufacturer.
ƒ Target Exposure Index (TEI) – is the exposure
index number when an image is optimally
exposed. This will be determined by each facility
depending on body part, view, procedure, image
receptor and radiologist.
ƒ Deviation Index (DI) – quantifies how much the
EI varies from the TEI.

Standardized Exposure Index and Deviation Index

International Electrotechnical Commission (IEC) 41

62494‐1 published standards in 2008.

American Association of Physicists in Medicine Task
Group (AAPM TG) 116 issued report in 2009.

Repeat Underexposed Overexposed Excessive

Deviation
Index (DI) ‐3 ‐2 ‐1 0 +1 +2 +3 Deviation
Index (DI)

‐20% ‐20% ‐20% +25% +25% +25%

Perfect Exposure
Toshiba
Leading Innovation>>>>

Here is what this system would look like with mAs

‐3 ‐2 ‐1 0 +1 +2 +3
‐20% ‐20% ‐20% Perfect +25% +25% +25%

repeat underexposed Perfect Overexposed Excessive

‐3 ‐2 ‐1 0 +1 +2 +3
15 mAs 18.5 mAs 24 mAs 30 mAs 38 mAs 48 mAs 60 mAs

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Here is the 4 color system I want to

set up and what it looks like with mAs.

“How to Fix an Incorrect mAs” – for repeats

Centering and the Dose Exposure Numbers

ƒ These EI numbers are easily corrupted

(but only up to 75% in most cases).
ƒ The following slides show the elbow, chest
and shoulder phantoms and how a change
in centering and or collimation can affect
(corrupt) the dose exposure number.

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Perfect centering – 4 sided collimation

LgM 1.81

Kitty Corner – touching at both corners

LgM 1.81 0% change

Long side touching edge

LgM 1.85 13.3% change

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Centered – top side touching

LgM 1.85 13.3% change

Seimens portable detector in bucky

Perfectly centered and collimated to 14”x14”
125 kVp @ 2.7 mAs EXI 356

Perfectly centered, no collimation

125 kVp @ 2.7 mAs EXI 351 2.8% change

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Centered 1” high ‐ 125 kVp @ 2.7 mAs

EXI 399 12.1% change

Centered 2” Low ‐ 125 kVp @ 2.7 mAs

EXI 442 24.2% change

Centered 1” low ‐ 125 kVp @ 2.7 mAs

EXI 313 ‐24.2% change

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Shoulder phantom with 3 sheets of

Polyethylene to make it the thickness of a
large adult male.
These experiments will show the difference
in EXI numbers when the collimation is left
more and more open.

GE built in detector (DEI range .42 ‐1.27)

8”x8” DEI .60 0.0% change

GE built in detector
9”x9” DEI .66 10.0% change

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GE built in detector
10”x10” DEI .71 18.3% change

GE built in detector
11”x11” DEI .80 33.3% change

GE built in detector
12”x12” DEI .89 48.3 % change

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GE built in detector
13”x13” DEI .96 60.0 % change

To summarize the previous 16

corrupted dose exposure number slides.

ƒ With all the examples, the technique always

stayed the same. It was just the centering or
collimation changes that corrupted the EI number.
ƒ Even though the dose exposure number (EXI,
S, LgM, DEI) has been corrupted up to 75%, the
image is still perfectly passable in any facility.
ƒ If your EI number is above 75% over what is
considered perfect, this means you over exposed.

Ways to Critique a Digital (DR or CR) Image

ƒ You must use the EI numbers.

ƒ You definitely need to use the magnification
mode to check for noise and burn.
ƒ You should always be able to Level and
Window and make your image look well
penetrated and contrasty.

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Problems with critiquing digital images

ƒ It is impossible to prove you used the

ideal technique if all you are using is the
finished image contrast and density as a gauge.

Witness the awesome power of

Automatic Rescaling

Fuji 85 kVp @ 4 mAs ‐ S# 357

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85 kVp @ 8 mAs ‐ S# 171

85 kVp @ 32 mAs ‐ S# 38

85 kVp @ 200 mAs ‐ S# 6

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85 kVp @ 400 mAs ‐ S# 3

85 kVp @ 500 mAs ‐ S# 4

GE built in detector (.36 – 1.07)

85 kv @ 2 mAs DEI .96

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85 kv @ 4 mAs DEI 1.97

85 kv @ 8 mAs DEI 4.0

85 kv @ 16 mAs DEI 7.72

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85 kv @ 32 mAs DEI 14.67

85 kv @ 64 mAs DEI 27.41

Grid cut‐off with grid suppression software.

Is usually very difficult to see.

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40” 99 kV @ 63 mAs
Angled up Angled up
No Angle 5 degrees 10 degrees

Horizontal and short axis grids with a 10 degree

caudad angle. The horizontal grid had a smaller LgM
number, is brighter (lighter) and has less contrast .

LgM 2.03 LgM 2.10

Siemens equipment with Canon detector.

Grid landscape, tube parallel with floor.
117 kV @2.8 mAs EXI 334

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Grid landscape, tube angled 10 degrees to floor.

117 kV @2.8 mAs EXI 205

Grid portrait, tube angled 10 degrees to floor.

117 kV @2.8 mAs EXI 331

GE portable.
Grid with handle up, tube parallel with floor.
120 kV @2 mAs DEI .65

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Grid with handle up,

tube angled 10 degrees to floor.
120 kV @2 mAs DEI .54

Grid with handle to the side,

tube angled 10 degrees to floor.
120 kV @2 mAs DEI .66

Post processing collimation (shuttering) for CR.

Courtesy of Becky Daley, TCC

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Agfa/Fuji/Carestream EI Comparisons

Konica/Shimadsu/SwissRay EI Comparisons

Radiographic Image Analysis

by Kathy McQuillen Martensen
Third Edition

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Digital
Radiography
Solutions
Specializing in Educational Conferences and Seminars

Dennis Bowman
Website: digitalradiographysolutions.com
Email: drs@redshift.com
Phone: 831‐601‐9860

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