1. 1 Radiographic Technique 2 RAD 1204 A. Tahani Ahmed AL-Hozeam

2. Breathing Movements Two movement in chest during breathing : a) Inspiration b) expiration The thoracic cavity increases in diameter in three dimensions : a) Vertical diameter. b) Transverse diameter. c) Anteroposterior diameter.

3. Degree of Inspiration To determine the degree of inspiration in chest radiography,one should be able to identify and count the rib pairs. To take this number of ribs, the patient should be take deep breath and hold it to fill the lungs, and take ascend deep breath for deep inspiration. In adult patient you should count at least 10 ribs pairs above diaphragm,and start count from top to dowm.

4. 4 Radiation Protection : For chest radiography, a lead-rubber gonadal shield should be employed so to protect the abdomen below the chest (using vinyle-covered lead apron) around the waist for all patients of reproductive age, children, and pregnant women. Otherwise, an adjustable mobile lead shield screen must be used. Exposure : Low contrast ( long-scale contrast) contrast must be adopted using ‘High kV Technique ’ (100 - 130 kVp) with low mAs (3 mAs) at 72 inches (180 cm) FFD (SID) on full second inspiration, to produce more shades of gray that shows fine lung markings behind the heart and lung bases due to the higher penetration. Higher mA and short exposure times (0.01 s) must be used to reduce movement blur (due to movement unsharpness, ( U m ). Overall optimum density with sufficient mAs is necessary, which can be proved by seeing faint outlines of mid and upper vertebrae and posterior ribs. A moving or high-lattice fine- line) focused grids must be used with the high kV technique. Grids should not be used with mobile and bed-side patients (mobile radiography). For pediatrics, lower kV (60 – 70 KV) must be used with lower mAs (to reduce motion). Higher-speed films and screens are also used for pediatrics to reduce motion and exposure dose. Correct placement of patient ID and film markers are also important. Technical aspects

5. 5 For pediatrics ( small infants and newborns ), AP supine and laterals (using a horizontal beam, that is dorsal decubitus, must to be done to exclude air-fluid levels. Erect PA and lateral are advised if an immobilizing device is available. For geriatrics (old age) higher center point (CP) must be used because of less inhalation capability of old people that produces ‘shallow lung fields. X-ray chest must be taken in full arrested second inspiration to show the lungs well expanded and full with ‘contrasting air’. In case of pneumothorax, another full exposure on (expiration) must be done (on the same film) for diagnostic comparison purposes, with an increase of (+5 kVp) and half the usual mAs (that is 1.5 mAs, when using a high kVp technique). Technical aspects

6. 6 All chest radiographs must be taken in ‘standing’ erect to allow the diaphragm to move down to show greater areas of the lung fields and possible chest/subphrenic abscess or air-fluid levels. FFD for PA chest must be 72 inches (180 cm) to maintain the ‘natural’ size of the heart which is usually less in PA than in AP, and prevent geometrical unsharpness and magnification as a result of the increased OFD. Patient’s neck must be sufficiently extended (chin up) to prevent superimposition of chin or neck on lung apices. Also, large female breasts must be displaced away from lung field to avoid creating‘ breast shadows’. Technical aspects

7. 7 A left lateral chest film must be done routinely as the heart is located on the left side, unless certain pathology in the right lung necessitates the need for a right lateral. Proper CP for the chest is (T7) to avoid irradiating the eyes, thyroid gland, the sternum, and the mammary glands. Basic (routine) views are: PA and lateral. Special views include: AP or PA apical, lordatic, lateral decubitus, AP supine (or semi-erect), LAO, and LPO. Rare-earth screens and fast films combinations must be used with the short exposure times used. Technical aspects

8. Patient preparation Ask the patient to remove all objects from chest and neck regions (necklace, bra….). Ask the patient to remove all that clothing and put hospital gown. Ask female patient about the pregnancy and last period.

9. PA Chest (Normal/ ambulance patients) (Basic) PA Chest (Normal/ ambulance patients) (Basic) Erect film shows pleural effusions, infections, pneumo-thorax. Patient erect, feet apart, chin rested on film top edge, hands on lower hips, elbows partially flexed, the shoulders rotated forward (to move the clavicles below apices), top of film 5 -7 cm above the shoulders (to include the apices), exposure on 2 nd arrested (inspiration), collimation and protection should be applied. Film: HD 35x43 cm lengthwise or (crosswise for large patients), and ( 35x35 cm for females). CP: T7 (7 – 8 inches inferior to vertebra prominens, or 3 – 4 inch below the jugular notch). CR: Horizontally 90  to film center. 9

10. 10 PA Chest (Normal/ ambulance patients) (Basic)

11. Basic (additional) projection for localizing position of a lesion for the posterior heart,great vessels and sternum. A grid is used. Patient erect, turned with side of interest in close contact with the film, MSP parallel with film, arms folded over the head. Film : HD 35x43 cm longthwise. CP : at level T7. CR : 90  horizontally through the chest. Note/ in some patient CP have to be lowered a minimum of 1inch from the PA or lateral to prevent cutoff of costophrenic angle. 11 Lateral erect chest (Basic)

12. 12 Lateral erect chest (Basic)

13. For pathology situated posterior to the heart and great vessels (patients who can’t stand for an erect standing lateral) and for trauma. Film : HD 35x43 cm longthwise. CP : at level T7. CR : Horizontally 90 . 13 Lateral chest (stretcher/wheelchair patients) (Basic))

14. 14 Lateral chest (stretcher/wheelchair patients) (Basic)

15. For pathology involving lungs, diaphragm, and the mediastinum. kV for bedside is 70-80 with a grid, for large patients 80-100 kV with grid, film cross- wise to eliminate possible lateral cutoff. Patient supine on trolley, trolley head raised into a semierect position, film behind the patient, shoulders forward by rotating arms medially. Film: HD 35x43 cm crosswise. CP: at level T7 (3-4 inches below the jugular notch). CR: 5  caudal to prevent clavicles from Obscuring the apices, FFD 100 cm, at least.. NB/ With this position it is impossible to show any fluid levels. 15 AP Chest (supine/ semierect – trolley/bedside) (special)

16. 16 AP Chest (supine/semierect – trolley/bedside) (special)

17. For small pleural effusions (air-fluid levels) and for pneumothorax. A (DECUBITUS) marker or (Arrow) should be used. Patient lying on one side on radiolucent pad, chin and arms raised above head, patient back against a vertical cassette, knees flexed slightly, top of the cassette approximately 1 inch above the vertebra prominens. Film : HD 35x43 cm vertical on the couch edge. CP : at level T7. CR : Horizontally 90  to film center. 17 Lateral decubitus chest (AP horizontal beam) (special)

18. 18 Lateral decubitus chest (AP horizontal beam) (special)

19. For pathology involving the lung fields, trachea, and mediastinal structures (including the heart). Patient erect rotated 45  (left anterior shoulder against film for LAO, and right anterior shoulder against film for RAO), patient’s arm flexed, opposite arm raised to clear Lung field and rest hand on head, patient looking straight ahead, chin raised. Film : HD 35x43 cm,lengthwise. CP : at level T7. CR : horizontal 90  to film center. NB/ 1-45 LAO left anterior shoulder contact to the film, 45 RAO right anterior shoulder contact to the film. 19 LAO, RAO chest (heart) (special)

20. 20 LAO, RAO chest (heart) (special) NB/ 2- the side of interest is generally the side farthest from film,45 RAO best viisulize for left lung and 45LAObest visulize For right lung and with increase rotation 60 best visulize for the heart.

21. For rule out calcifications and mass under the clavicles, appical area. Patient stands or sits about 1 foot away from the film and leaning back with shoulders, neck,and back of head contact the film, both patient’s hands on hips, shoulders rolled forward. Film : HD 35x43 cm. CP : mid sternum (3 to 4 inches below Jugular notch) CR : Horizontally 90  to film center. NB/ if patient is weak and unstable put AP semi-axial projection the patient supine Position,shoulder are rolled forward CR: 15 to 20 Cephalad to the mid sternum. 21 AP lordatic chest (special)

22. For a right middle lobe collapse, or an interlobar pleural effusion. Patient standing in erect PA, then bends backward at the waist (30– 40 degrees). Film : HD 35x43 cm. CP : T7. CR : Horizontally 90  to film center. 22 PA lordatic chest (special)

23. For pathology ( e.g., soft-tissue swellings ) involving air-filled larynx and the trachea, thyroid, thymus glands, and the upper esophagus. A contrast medium (barium) is used to opacify these organs. Patient sitting or standing, back of the head and shoulders against film, chin raised so that acanthiomeatal line is perpendicular to fim. Film: HD 24x30 cm lengthwise. CP: at level T1-2 or 2.5 cm above the jugular notch. CR: Horizontally 90 to film center. NB/ the breathing should be slow during exposure. 23 AP larynx, pharynx, and trachea (upper airway) (Basic)

24. 24 AP larynx, pharynx, and trachea (Basic)

25. For pathology involving the air-filled larynx and the trachea, thyroid, thymus glands, and upper esophagus. A contrast medium (barium) is used to opacify these organs (usually it is a soft-tissue technique done to exclude epiglottitis in young children). Patient sitting or in erect lateral, shoulders rotated posteriorly and depressed down, hands clasped behind the back. Film: HD 24x30 cm longthwise. CP: Midway between the thyroid cartilage and the jugular notch through at level of C6-C7. CR: Horizontally 90  to film center. NB/the FFD=180cm to minimize magification. 25 Lateral larynx, pharynx, and trachea (upper airway) (Basic)

26. 26 Lateral larynx, pharynx, and trachea (Basic)

27. For pathology of the sternum (fractures /other inflammatory processes). Patient erect with arms on sides, or: Semiprone and slightly oblique (15  - 20 , to the right side ) with the left arm up and the right arm down by the side. Film: HD 24x30 cm longthwise. CP: Center of sternum (midway between jugular notch and the xiphoid process). CR: Horizontally 90  to film center, exposure on (normal) quiet breathing, or else, during a suspended expiration. 27 RAO sternum (Basic)

28. 28 RAO sternum (Basic)

29. For pathology of the sternum (#s, subluxation, and other inflammatory processes). Patient erect (arms drawn to back), or in a lateral recumbent (lying on the side, arms above the head), shoulders well back. Film: HD 24x30 cm longthwise. CP: Center of sternum (midway between jugular notch and xiphoid process). CR: 90  to film center, exposure during a suspended inspiration. 29 Lateral sternum (Basic)

30. 30 Lateral sternum (Basic)