Dr.

Pankaj agarwal
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a good radiograph to be produced a set of exposures factors are to be selected

. The miliampere seconds(mAs) The kilo voltage The focus to film distance

Region being examined Thickness Density Pathology Types of screens and films used Grid

Product of x ray tube current(mA)and time(s) indicates amount of radiation being used Determines film blackening mA should be larger to reduce exposure time mAs underexposed film mAs overexposed film

Determines Max As

contrast of the film

contrast can be obtained if lowest kVp possible is used

kVp is increased not only is radiation more penetrating but more radiation is produced
Thus

increased kV allows mAs and thus exposure time to be reduced

For a given kVp and mAs greater the FFD less the intensity of radiation reaching the film FFD should not be too less, so as to prevent radiation damage to skin. And should not be to large to prevent high tube loading . FFD is sometimes increased to reduce geometrical unsharpeness, magnification, and distortion

In trying to determine if pathology is present in a chest radiograph following factors are to be considered on all chest x-rays: Inspiration Penetration Rotation Angulation Orientation
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The vascular pattern in the lung fields will be accentuated with a shallow inspiration since the same amount of blood flow is now distributed to a smaller volume of lung. The level of inspiration can be estimated by counting ribs. Visualization of nine posterior ribs, or seven anterior ribs on an upright PA radiograph projecting above the diaphragm would indicate a satisfactory inspiration.

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The lack of penetration renders the area whiter and can simulate pneumonia or effusion. In an ideal radiograph the thoracic spine(T8/9) should be barely viewing through the cardiac silhouette.

On the lateral view, we can look for proper penetration and inspiration by observing that the spine appears to be darker as we move caudally. This is due to more air in lung in the lower lobes and less chest wall. The sternum should be seen edge on and posteriorly we should see two sets of ribs.
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Rotation of the patient distorts mediastinal anatomy and makes assessment of cardiac chambers and the hilar structures especially difficult. Chest wall tissue also contributes to increased density over the lower lobe fields simulating disease. Rotation of the radiograph is assessed by judging the position of the clavicle heads and the thoracic spinous process. Ideally the clavicle heads should be equidistant from the spinous process.
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In this we are making reference to the position of the patient and the x-ray beam. A PA radiograph is obtained with the x-ray traversing the patient from posterior to anterior and striking the film. Similarly an AP radiograph is positioned with the x-ray traversing the patient from anterior to posterior striking the film. The cardiac border or silhouette will appear larger on an AP radiograph due to the magnification effect of the more anteriorly located heart relative to the film
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With the patient in a more lordotic projection the clavicles will project superiorly relative to the upper thorax With the lordotic projection of the ribs assume a more horizontal orientation. Occasionally a lordotic xray can be obtained intentionally to better visualize structures in the thoracic apex obscured by overlying bony structures.
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Posterio anterior (PA view) Anterio posterior (AP view) Lateral projection(R or L position) PA Oblique projection(RAO and LAO) AP Oblique projection (RPO and LPO) AP axial (lordotic view) Lateral decubitus (R or L) Dorsal decubitus(R or L)

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If possible, always examine patients in upright position. Place the patient ,with arms hanging at sides, before a vertical grid device. Adjust the height of IR so that its upper border is about 1.5 to 2 inches above relaxed shoulders. Center the midsagittal plane of the patients body to midline of IR.
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Extend the patients chin upward and adjust head so that midsagittal plane is vertical. Ask the patient to flex the arms and to rest back of hands low on hips below level of costophrenic angles. In female patients ask her to pull breast upward and laterally.

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Exposure is made after second full inspiration to ensure max.expansion of lungs. Central ray should be centered at T7, perpendicular to center of IR.

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Entire lung fields from apices to cpa There should be no rotation Scapulae projected outside lung fields 9 posterior ribs or 7 anterior ribs visible Sharp outlines of heart and diaphragm Faint shadow of ribs and superior thoracic vertebrae visible through heart shadow

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Patient is in supine or upright position with back against grid. Center midsagittal plane of chest to IR Upper border of IR should be 1.5 to 2 inches above relaxed shoulders. Adjust the shoulders to lie in the same transverse plane.

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Exposure is made after second full inspiration to ensure max. expansion of lungs. Perpendicular to the long axis of sternum and center of IR. Central ray should enter 3 inches below jugular notch.

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Magnified and engorged heart and great vessels. Lung fields appear shorter. Clavicles are projected higher. Ribs assume horizontal position.

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Entire lung fields from apices to cpa. Medial portion of clavicles equidistant from vertebral column. Trachea in midline. Faint shadow of ribs and superior thoracic vertebrae visible through heart shadow Equal distance from vertebral column to lateral border of ribs on each side.

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If possible always examine in upright standing position. Turn the patient to true lateral position , midsagittal plane being parallel to IR. Midcoronal plane being perpendicular to grid. Extend the arms directly upwards ,flex the elbows, and with forearms resting on elbows hold the arms in position.IR should be 1.5 to 2 inches above shoulder.
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Exposure is made after second full inspiration to ensure max. expansion of lungs. Central ray should enter the patient on midcoronal plane at level of T7 or inferior aspect of scapula , perpendicular to center of IR

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Lateral projection (R or L)-Exposure

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LUL

LLL

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Superimposition of ribs posterior to vertebral column Arm or soft tissue not overlapping the superior lung field Lateral sternum with no rotation Open thoracic IV disc spaces and intervertebral foramina hilum in the center of radiograph

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Place the patient on either affected or unaffected side, as indicated, for at least 5 minutes before exposure. Extend the arms well above head and adjust thorax in a true lateral position. Adjust IR so that it extends approx. 1.5 to 2 inches beyond shoulders.

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After second full inspiration Central ray is horizontal and perpendicular to the center of IR at a level 3 inches below jugular notch for AP or at T7 for PA. This view helps in demonstrating any change in fluid level and reveals obscured pulmonary areas.

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No rotation of patient Affected side is shown completely Patients arm not visible in field of interest

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Arrows showing pleural effusion

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keep patient in prone or supine position ,centering thorax to grid , keeping for at least 5 min. in the same position. Extend arms well above head. Place the affected side against a vertical grid ,adjusting it so that top of IR extends to level of thyroid cartilage.

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After second full inspiration Central ray is horizontal and perpendicular to the center of IR at a level of midcoronal plane and 3 inches below jugular notch for dorsal or at T7 for ventral decubitus. This view helps in demonstrating any change in fluid level and reveals obscured pulmonary areas.

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Place the patient in upright position ,facing Xray tube and standing 1 feet in front of vertical grid, with midsagittal plane centered to midline of grid. Adjust the IR so that its upper margin is about 3 above upper border of shoulders (when the patient is adjusted in lordotic view. For oblique lordotic positions rotate the patient 30 degrees away from the position used for AP position, with affected side towards the grid.
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After second full inspiration. Central ray being perpendicular to the center of IR at level of midsternum. This view helps in demonstrating the apices and interlobar effusions.

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Clavicles lying horizontaly and superiorly to apices. Sternal end of clavicles equidistant from vertebral column. Apices and lungs completely. Ribs distorted with anterior and posterior end somewhat superimposed.

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clavicle

Lung apex

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Maintain the patient in the position used for PA projection. Have the patient turn approx. 45 degrees towards left side for LAO ,towards right side for RAO. The side of interest being the farther from the IR. Top of IR should be placed 1.5 to 2 inches above vertebral prominence. Exposure is done in full inspiration with central ray perpendicular to center of IR at level of T7

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Maximum area of right lung along with thoracic viscera . Left lung superimposed by the spine. Trachea and its bifurcation(carina) Right branch of bronchial tree. Heart Descending aorta (lying in front of spine) Arch of aorta .

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Maximum area of left lung along with thoracic viscera . Right lung superimposed by the spine. Trachea and left branch of the bronchial tree. Right retrocardiac region . Anterior portion of apex . Left atrium

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Trachea R main bronchus

carina Left lung

heart

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One point to remember is that RPO corresponds to LAO position and LPO corresponds to RAO position The side of interest being closest to IR. With the patient in supine position ,adjust the IR so that upper border is about 1.5 to 2 inches above vertebral prominence or about 5 inches above jugular notch.
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Rotate the patient toward the correct side ,adjust the body at a 45 degree angle ,and center thorax to the grid. Adjust the shoulders to lie in the same transverse plane in a position of forward rotation. Exposure is made in second full inspiration perpendicular to center of IR at a level 3 inches below jugular notch .

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This view presents AP oblique projection of thoracic viscera similar to corresponding PA oblique projection . RPO being comparable to LAO ,LPO to RAO.

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