2. Most common radiological investigation
Standard component of a pulmonary
examination
Systematic review is vital in interpretation of
chest x-rays
Chest radiographs are one of the most difficult
X Rays to interpret because of subject to subject
variation.
3. 2 dimensional image of a 3 dimensional
structure
X-ray findings may lag behind other clinical
features
Normal x-ray does not rule out pathology
Dependent on good quality image
4. 1: Name
2: Date
3: Old films
4: What type of view(s)
5: Penetration
6: Inspiration
7: Rotation
8: Angulation
9: Soft tissues / bony structures
10: Mediastinum
11: Diaphragms
12: Lung Fields
Quality Control
Findings
}
}
Pre-read
}
5. 1. Check the name
2. Check the date/Side
3. Obtain old films if available
4. Which view(s) do you have?
PA / AP, lateral, decubitus, AP lordotic
6. 5. Penetration
Should see ribs
through the heart
Barely see the spine
through the heart
Should see
pulmonary vessels
nearly to the edges of
the lungs
7. Overpenetrated Film
• Lung fields darker than
normal—may obscure
subtle pathologies
• See spine well beyond the
diaphragms
• Inadequate lung detail
12. Should be kept minimum to
decrease/minimize motion unsharpness
For faster cassette we have to compromise on
the kV and penetration but exposure time is
minimized
13. 6. Inspiration
Should be able to
count 9-10 posterior
ribs
Heart shadow should
not be hidden by the
diaphragm
1
2
3
4
5
6
7
8
9
10
14. 9-10 posterior ribs are
9
About 8 posterior ribs are
showing
8
With better inspiration,
the “disease process” at
the lung bases has
cleared
15. 7. Rotation
Medial ends of
bilateral clavicles are
equidistant from the
midline or vertebral
bodies
16.
17. If spinous process appears closer to the right clavicle (red arrow),
the patient is rotated toward their own left side
If spinous process appears closer to the left clavicle (red arrow),
the patient is rotated toward their own right side
19. Pitfall Due to AngulationPitfall Due to Angulation
A film which is apical lordotic (beam is angled upA film which is apical lordotic (beam is angled up
toward head) will have an unusually shaped heart andtoward head) will have an unusually shaped heart and
the usually sharp border of the left hemidiaphragm willthe usually sharp border of the left hemidiaphragm will
be absentbe absent
Apical lordotic Same patient, not lordotic
24. Standard, radiology dept
X-rays posterior to anterior
Standing position
Cassette in the front
FFD of 180 cms
Centring inferior angle of scapula(T7)
kV,mAs and cassette selection depends on the
patient
29. Chest PA Expiration study
Expiratory view demonstrates
air trapping and diaphragm
movement
Exp : pneumothorax,
interstitial shadowing,
obstructive emphysema
(foreign body)
30. Cassette placed behind patient
X-rays anterior to posterior
Sitting in chair, semi-erect in bed, supine
AP marked on film
Heart enlarged, poor inspiration
Collimation
31. Cassette above lung
apices.
MSP perpendicular to
cassette
Shoulder brought
downwards, hand
behind the back and
elbows way forward
The central ray is then
angled until it is
coincident with the
middle of the film
36. Cassette should be
parallel to the coronal
plane
Central ray is angled
till it is coincidental
with middle of the
cassette
Centring is at sternal
notch
37. Used to visualize ribs
Used for non ambulatory patients
Used for pediatric age group
38. The patient is turned to bring the
side under investigation in
contact with the cassette.
The median sagittal plane is
adjusted parallel to the cassette.
The arms are folded over the head
or raised above the head
to rest on a horizontal bar.
The mid-axillary line is coincident
with the middle of the film, and
the cassette is adjusted to include
the apices and the lower lobes to
the level of the first lumbar
vertebra.
Direct the horizontal central ray at
right-angles to the middle of the
cassette at the mid-axillary line.
39.
40.
41. With the patient in the
position for the postero-
anterior projection, the
central ray is angled 30
degrees caudally towards the
seventh cervical spinous
process coincident with the
sternal angle.
With the patient in the
position for the antero-
posterior projection,
the central ray is angled 30
cephalad head towards the
sternal angle
42.
43.
44.
45. The patient is placed for the
postero-anterior projection.
he clasps the sides of the
vertical Bucky, the patient
bends backwards at the
waist.
The degree of dorsiflexion
varies for each subject, but in
general it is about 30–40
degrees.
The horizontal ray is
directed at right-angles to
the cassette and towards the
middle of the film.
46.
47.
48. The patient lies supine, with the
median sagittal plane adjusted
to coincide with the central long
axis of the imaging couch.
The chin is raised to bring the
radiographic baseline to an
angle of 20 degrees from the
vertical.
The cassette is centred at the
level of the sternal notch.
Central beam is directed at the
midline at the level of the
sternal notch.
Exposure is made on forced
expiration.
51. The patient stands or sits with
either shoulder against a
vertical Bucky.
The median sagittal plane of
the trunk and head are parallel
to the cassette.
The cassette should be large
enough to include from the
lower pharynx to the lower end
of the trachea at the level
of the sternal angle.
The shoulders are pulled well
backwards to enable the
visualization of the trachea.
This position is aided by the
patient clasping their hands
behind the back and pulling
their arms backwards.
The cassette is centred at the
level of the sternal notch.
52.
53. Patient lie semi prone on the affected side.
Arms over the head
Upper edge of the cassette is placed just above the lung apices
Centering is at the middle of the cassette or at the level of T7.
AP setup should be made.
Knee flexed and should be on top of one another
The affected side should be supported by some radiolucent
material so that the affected side completely comes in the xray.
Marker
Decubitus - useful for differentiating pleural effusions from
consolidation (e.g. pneumonia) ; Loculated effusions from free
fluid in the pleura. Abscess
54.
55.
56.
57. Radiographic positioning by clarks
Wikipedia
Radiographic positioning and procedures by
Greathouse
Valuble inputs by Dr Kirti and Dr Gandhi
58. Thank You for The long and ?? BoringThank You for The long and ?? Boring
presenTaTionpresenTaTion
59. CT
Hrct
MRI
Angiography
But due to limitation of time and topic these
modalities will be covered in subsequent
presentations
Editor's Notes
PA Standard investigation carried out in the x-ray dept Cassette anterior to chest, x-rays shot post-ant from 2 metres away, shoulders abducted to remove scapula Carried out in standing therefore better inspiration
AP Cassette placed behind the patient, portable machine Patient could be sitting in a chair, semi erect in bed, supine in bed. NOTE the patient position will affect the CXR Marked AP on film Heart enlarged often poorer expansion