Week 3 Chest Positioning & Indications 50

1

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

2

Chest Radiography

• On patients older than 40 years old that

have a thoracic spine for full spine series

will have a P-A chest routinely. This is

done at no charge to the patient.

• On patients older than 60 years, they will

have a P-A and lateral chest. The patient

is charged for the chest x-ray.

3

6.5 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

4

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.

5

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.

6

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.

7

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.

Digital P-A Chest

8

9

6.6 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.

10

Lateral Chest

• Measure: Lateral mid-

chest

• Protection: Half apron



I.D. up Portrait

• Top of film two inches

above shoulder.

• Center horizontal

central ray to film

11

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.

12

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.

13

Lateral Chest Film

• Should see apical area

of chest.

• Respiratory effort down

to tenth ribs.

• No rotation: ribs

superimposed.

• Evidence of collimation

Digital Chest Series

PA Chest Good RespirationLateral Chest Good

Collimation

14

15

Chest Supplemental Views

• Chest oblique views should be taken as

anterior oblique projections.

• 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.

16

6.7 Apical Lordotic Chest


chest



• Tube Angle: 10 to 20

degrees cephalad

• Film: 14” x 17” Portrait or

12” x 10” regular I.D. up

Landscape Preferred

• Marker: Anatomical

17

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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• 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.

19


• Collimation: slightly less

than film size.

• Breathing Instructions:

“Take a deep breathe

and hold it” Inspiration.

• Make exposure

• Assist patient out of

position.

20

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.

21

6.8 Right Anterior Oblique

Chest• Measure: P-A at mid

chest



• No Tube Angle



wider than 35 cm


22

Right Anterior Oblique Chest


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.

23


• 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.

24


• 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.



and hold it.

25


• Make exposure.

• Have patient breathe

and relax.

26


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.

27

6.9 Left Anterior Oblique Chest


chest



• No Tube Angle



wider than 35 cm


28

Left Anterior Oblique Chest


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.

29


• 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.

30


• 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.



and hold it.

31


• Make exposure.

• Have patient breathe

and relax.

32

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.

33

Locating an Abnormality

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

• The P-A and Lateral Chest were requested.

34

Locating an Abnormality

• If was felt that the abnormality was cardiac so

oblique views were ordered to confirm location

of nodule.

35

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.

36

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.

37

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.

• What if I don’t want to take x-rays in my

office?

38

Why Do I Need This Class?

• If you plan on referring your patient out for

radiography, you may need to train the

technologist at the referral office about

weight bearing radiography.

• If you refer out, the patient may not come

back.

• May delay treatment.

39

Who needs X-rays?

• How do I determine if x-rays are

indicated?

• Will X-rays help me determine what is

wrong with the patient?

• Has the patient improved with my current

treatment plan?

40

Where do I start?

• The best tools for determining

the need for any test are:

–Patient’s clinical history

–Physical exam finding

41

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

42

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.

43

Clinical History

• Malignancy that may metastasize to

osseous structures. i.e. prostate

cancer

• Unexplained weight loss, prolonged

hormonal therapy or corticosteroid

therapy or abuse.

44

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

45


• Active or progressive neurologic or

neuromotor deficits

• Suspicion of possible peripheral joint

or spinal instability

• A significant or progressing scoliosis

46


• No response to conservative care or

worsening of condition after two to

four weeks of conservative care.

– May indicate need for re-exam.

• Lack of physical, historical or

mechanical finding to explain the

patient’s symptoms.

47

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?

48

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.

49


• Your ability to take films must be

factored. This will include the quality

of the x-ray equipment as well as your

skills.

– Are you going to refer out very large

patients or children?

50


• Does the patient have a bio-

mechanical problem?

• Does the patient have a block

vertebra?

• Does the patient have sacralization?

• Are these factor going to impact your

treatment plan for the patient?

51


• Cost of the exam must be considered.

– Will plain films give me the information

that I need or should I get a CT scan or

MRI?

• CT and MRI will detect insignificant disc

herniations.

– What does my provider charge for these

studies?

52

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.

53

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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End of Lecture

Documents

Week 3 Chest Positioning & Indications 50