Pharos university faculty of Allied medical sciences Clinical Practice I (RSCP-201) Department of Radiological Sciences and Medical Imaging Technology Prof. Dr. Hesham Badawy Dr.Mohamed El Safwany 

Intended Learning Outcomes The student should be able to learn how to perform adequate chest radiograph at the end of this lecture.

Chest Radiography All chest views are taken at 72” SID to minimize magnification. All chest view are taken using high kVp to obtain a broad scale of contrast. Routine: P-A & Lateral Supplemental: Apical Lordotic, Anterior Oblique Views

P-A Chest Measure: P-A at mid chest Protection: Half Apron SID: 72” Bucky No Tube Angle Film: 14” x 17” regular I.D. up Portrait unless wider than 35 cm. Marker: Pronated

P-A Chest Patient stand P-A, facing Bucky with hands on hips. Shoulders rolled forward to get scapulae clear of lungs. Film placed two inches above the shoulders.

P-A Chest Horizontal central ray: centered to film Vertical central ray: mid-sagittal Collimation: slightly less than film size. Breathing Instructions: “Take a deep breath in and hold it .” Inspiration Make exposure and let patient relax.

P-A Chest Film The scapulae should be clear of the lung fields. The thoracic spine can be made out through the heart. Respiratory effort should be to the 10 ribs. No rotation: S.C. joints equal distance from spine.

P-A Chest Film Note that this is a large patient. For large patients, the film may be turned 17” x 14” with the I.D. up. If the lateral measurement is greater than 35 cm turn film 17” x 14” Landscape.

Lateral Chest Routine lateral is the left lateral. If pathology is suspected in the right lung, take a right lateral. Important to have arms over head for view of apices.

Lateral Chest Measure: Lateral mid-chest Protection: Half apron SID: 72” Bucky Film: 14” x 17” regular I.D. up Portrait Top of film two inches above shoulder. Center horizontal central ray to film

Lateral Chest Instruct patient to interlock fingers with arm over head. May place arm behind head. Make sure patient is as close as possible to the Bucky. Vertical central ray: mid coronal plane. Push film into Bucky.

Lateral Chest Collimation top to bottom: slightly less than film size. Collimation side to side: skin of chest Breathing instructions: “Take a deep breathe and hold it.” Inspiration Make exposure and have patient breathe and relax.

Lateral Chest Film Should see apical area of chest. Respiratory effort down to tenth ribs. No rotation: ribs superimposed. Evidence of collimation

Chest Supplemental Views Chest oblique views should be taken as anterior obliques. The RAO will show the left lung field. The LAO will show the right lung field. The heart should be clear of the t-spine. The Apical Lordotic View will demonstrate the apices clear of the clavicles and ribs.

Apical Lordotic Chest Measure: A-P at mid chest Protection: Half Apron SID: 72” Bucky Tube Angle: 10 to 20 degrees cephalad Film: 14” x 17” Portrait or 12” x 10” regular I.D. up Landscape Preferred Marker: Anatomical

Apical Lordotic Chest Patient stands facing tube about 12 inches from Bucky. Patient asked to extend backwards until their back touches Bucky. Assist patient if necessary. Tube angle is dependent upon how well the patient can extend.

Apical Lordotic Chest Horizontal Central Ray: mid way between xiphoid and manubrium Vertical Central Ray: mid sagittal Center film to horizontal central ray. Instruct patient to put hand on hips and roll shoulders forward.

Apical Lordotic Chest Collimation: slightly less than film size. Breathing Instructions: “Take a deep breathe and hold it” Inspiration. Make exposure Assist patient out of position.

Apical Lordotic Chest Film View taken to achieve a clear view of the lung apices. Clavicles should be clear of the lung apices. Views used to rule out pathologies in the lung apices such as tuberculosis.

Right Anterior Oblique Chest Measure: P-A at mid chest Protection: Half Apron SID: 72” Bucky No Tube Angle Film: 14” x 17” regular I.D. up Portrait unless wider than 35 cm Marker: Pronated

Right Anterior Oblique Chest Patient stands facing Bucky.Body is rotated to a 45 degree anterior oblique with the right shoulder touching the Bucky. Top of film placed two inches above the shoulder. Horizontal Central ray centered to film.

Right Anterior Oblique Chest Center sternum to center line of Bucky or set collimation. Collimation is set slightly less than film size. Using the collimator light field, make sure that all of left lung field is within the lighted field.

Right Anterior Oblique Chest If possible make sure that all of the chest is within the light field. Have patient put right hand on hip. The left arm is raised and rests on the Bucky. Breathing Instructions: “Take a deep breathe and hold it.

Right Anterior Oblique Chest Make exposure. Have patient breathe and relax.

Right Anterior Oblique Chest Film The heart borders should be clear of the thoracic spine. You will be able to evaluate the left bronchial tree and hilar area and the lung fields. Oblique views can help locate a pulmonary lesion seen on the P-A or Lateral chest but not seen on both.

Left Anterior Oblique Chest Measure: P-A at mid chest Protection: Half Apron SID: 72” Bucky No Tube Angle Film: 14” x 17” regular I.D. up Portrait unless wider than 35 cm Marker: Pronated

Left Anterior Oblique Chest Patient stands facing Bucky.Body is rotated to a 60 degree anterior oblique with the left shoulder touching the Bucky. Top of film placed two inches above the shoulder. Horizontal Central ray centered to film.

Left Anterior Oblique Chest Center sternum to center line of Bucky or set collimation. Collimation is set slightly less than film size. Using the collimator light field, make sure that all of right lung field is within the lighted field.

Left Anterior Oblique Chest If possible make sure that all of the chest is within the light field. Have patient put left hand on hip. The right arm is raised and rests on the Bucky. Breathing Instructions: “Take a deep breathe and hold it.

Left Anterior Oblique Chest Make exposure. Have patient breathe and relax.

Left Anterior Oblique Chest Film The heart borders should be clear of the thoracic spine. You will be able to evaluate the right bronchial tree and hilar area and the lung fields. Oblique views can help locate a pulmonary lesion seen on the P-A or Lateral chest but not seen on both.

Locating an Abnormality An abnormality was seen on the A-P thoracic spine. The P-A and Lateral Chest were requested.

Locating an Abnormality If was felt that the abnormality was cardiac so oblique views were ordered to confirm location of nodule.

Chest & Thoracic Spine Review Film is centered to anatomy and central ray set to the film. Two inches above C-7 for thoracic spine Two inches above shoulders for the chest Thoracic Spine taken with 40” SID kVp 70 to 80 kVp for thoracic spine Short scale of contrast for spine.

Chest & Thoracic Spine Review Chest views taken with 72” SID kVp is from 100 to 115 kVp for chest. Broad Scale of contrast for soft tissue visualization.. All views except swimmers projection taken on full inspiration. I.D. is up whenever 14” x 17” is used.

Why Do I Need This Class? Radiography is a key diagnostic tool. Proper interpretation is easier when the films are of good quality. When taking films , you are exposing the patient to radiation. Do it right the first time.

Clinical History Age and sex of the patient Over 50 years old -determine extent of degeneration. No recent films. Menopause and hormone therapy; bone loss or osteoporosis

Clinical History Trauma that may have resulted in a fracture, dislocation or significant soft tissue injury. Mode of injury may help determine views needed. Chest pain with cardiopulmonary disease history.

Clinical History Malignancy that may metastasize to osseous structures. i.e. prostate cancer Unexplained weight loss, prolonged hormonal therapy or corticosteriod therapy or abuse.

Physical Examination Clinical indications of active or aggressive bone or joint pathology: chronic nocturnal pain fever ,warm and swollen joints bony or soft tissue masses Severe restriction of active range of motion

Physical Examination Active or progressive neurologic or neuromotor deficits Suspicion of possible peripheral joint or spinal instability A significant or progressing scoliosis

Risk Vs Benefits of the Examination Will x-rays affect the certainty of my differential diagnosis? How much? Will the information expected from the x-ray change my treatment plan? What test would be most sensitive in detecting or excluding the disease process?

Other factors to be considered Your ability to interpret your films should also be considered. Are you sending them to a radiologist? You must be able to detect gross pathologies or fracture on the films that may require immediate attention and referral.

What is a complete study? We must have right angle views to have a complete exam in most cases. There are exceptions: A P-A chest could be considered a complete exam. A single Waters view of the sinuses cane be a complete exam.

What is a complete study? Generally we will need a A-P or P-A view and lateral view. Oblique view are done when indicated. Most extremity studies will include a oblique view. Stress views or flexion and extension views are done when indicated.

Assignment One student will be selected for assignment.

Suggested Readings Clark’s radiographic positioning and techniques.

Question What are the technical aspects for optimal chest PA radiograph?.

Thank You