1 Pharos university faculty of Allied medical sciences Clinical Practice I (RSCP-201) Department of...

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Pharos universityfaculty of Allied medical sciences

Clinical Practice I (RSCP-201) Department of Radiological Sciences and Medical

Imaging Technology

Prof. Dr. Hesham BadawyDr.Mohamed El Safwany 

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Intended Learning Outcomes

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

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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

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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

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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Lateral Chest Film

• Should see apical area of chest.

• Respiratory effort down to tenth ribs.

• No rotation: ribs superimposed.

• Evidence of collimation

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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Right Anterior Oblique Chest

• Make exposure.• Have patient breathe

and relax.

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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.

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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

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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.

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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.

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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.

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Left Anterior Oblique Chest

• Make exposure.• Have patient breathe

and relax.

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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.

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Locating an Abnormality

• An abnormality was seen on the A-P thoracic spine.

• The P-A and Lateral Chest were requested.

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Locating an Abnormality

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

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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.

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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.

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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.

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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

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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.

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Clinical History

• Malignancy that may metastasize to osseous structures. i.e. prostate cancer

• Unexplained weight loss, prolonged hormonal therapy or corticosteriod therapy or abuse.

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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

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Physical Examination

• Active or progressive neurologic or neuromotor deficits

• Suspicion of possible peripheral joint or spinal instability

• A significant or progressing scoliosis

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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?

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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.

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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.

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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.

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Assignment

One student will be selected for assignment.

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Suggested Readings

Clark’s radiographic positioning and techniques.

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Question

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

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Thank You