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By Dr Kushagra V
Garg
Most common radiological investigation
Standard component of a pulmonary examination
Systematic review is vital in interpretation of chest x-rays
Chest radiographs are one of the most difficult X Rays to interpret because of subject to subject variation.
2 dimensional image of a 3 dimensional structure
X-ray findings may lag behind other clinical features
Normal x-ray does not rule out pathology Dependent on good quality image
1: Name 2: Date 3: Old films 4: What type of view(s) 5: Penetration 6: Inspiration 7: Rotation 8: Angulation 9: Soft tissues / bony structures 10: Mediastinum 11: Diaphragms 12: Lung Fields
Quality Control
Findings
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Pre-read}
1. Check the name 2. Check the date/Side 3. Obtain old films if available
4. Which view(s) do you have? PA / AP, lateral, decubitus, AP lordotic
5. Penetration
Should see ribs through the heart
Barely see the spine through the heart
Should see pulmonary vessels nearly to the edges of the lungs
Overpenetrated Film
• Lung fields darker than normal—may obscure subtle pathologies
• See spine well beyond the diaphragms
• Inadequate lung detail
Underpenetrated Film•Hemidiaphragms are obscured
•Pulmonary markings more prominent than they actually are
Should be kept minimum to decrease/minimize motion unsharpness
For faster cassette we have to compromise on the kV and penetration but exposure time is minimized
6. Inspiration
Should be able to count 9-10 posterior ribs
Heart shadow should not be hidden by the diaphragm
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9-10 posterior ribs are showing
9
About 8 posterior ribs are showing
8
With better inspiration, the
“disease process” at the lung bases has
cleared
7. Rotation
Medial ends of bilateral clavicles are equidistant from the midline or vertebral bodies
If spinous process appears closer to the right clavicle (red arrow), the patient is rotated toward their own left side
If spinous process appears closer to the left clavicle (red arrow),
the patient is rotated toward their own right side
8. Angulation
Clavicle should lay over 3rd rib
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2
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Pitfall Due to AngulationPitfall Due to Angulation
A film which is apical lordotic (beam is angled up A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart toward head) will have an unusually shaped heart
and the usually sharp border of the left and the usually sharp border of the left hemidiaphragm will be absenthemidiaphragm will be absent
Apical lordotic Same patient, not lordotic
9. Soft tissue and bony structures Check for
Symmetry Deformities Fractures Masses Calcifications Lytic lesions
10. Mediastinum Check for
Cardiomegaly Mediastinal
and Hilar contours for hilar masses
11. Diaphragms
Check sharpness of borders
Right is normally higher than left
Check for free air, gastric bubble, pleural effusions
Posteroanterior – PA(erect) Anteroposterior – AP(mostly supine) Lateral Decubitus Lordotic Thoracic Inlet View
Standard, radiology dept X-rays posterior to anterior Standing position Cassette in the front FFD of 180 cms Centring inferior angle of scapula(T7) kV,mAs and cassette selection depends
on the patient
Intervertebral disc spaces upto T4 should be ideally visualised
Chest PA Expiration study Expiratory view demonstrates air trapping and diaphragm movement Exp : pneumothorax, interstitial shadowing,
obstructive emphysema(foreign body)
Cassette placed behind patient X-rays anterior to posterior Sitting in chair, semi-erect in bed, supine AP marked on film Heart enlarged, poor inspiration Collimation
Cassette above lung apices.
MSP perpendicular to cassette
Shoulder brought downwards, hand behind the back and elbows way forward
The central ray is then angled until it is coincident with the
middle of the film
Normal AP
upper edge of cassette just above the lung apices
arms laterally rotated
Central beam is directed towards sternal notch
FFD of 120cms.
Level of diaphragm is
on a higher level
Cassette should be parallel to the coronal plane
Central ray is angled till it is coincidental with middle of the cassette
Centring is at sternal notch
Used to visualize ribs Used for non ambulatory patients Used for pediatric age group
The patient is turned to bring the side under investigation in
contact with the cassette. The median sagittal plane is
adjusted parallel to the cassette.
The arms are folded over the head or raised above the head
to rest on a horizontal bar. The mid-axillary line is
coincident with the middle of the film, and the cassette is adjusted to include the apices and the lower lobes to the level of the first lumbar vertebra.
Direct the horizontal central ray at right-angles to the middle of the cassette at the mid-axillary line.
With the patient in the position for the postero-anterior projection, the central ray is angled 30 degrees caudally towards the seventh cervical spinous process coincident with the sternal angle.
With the patient in the position for the antero-posterior projection,
the central ray is angled 30 cephalad head towards the sternal angle
The patient is placed for the postero-anterior projection.
he clasps the sides of the vertical Bucky, the patient bends backwards at the waist.
The degree of dorsiflexion varies for each subject, but in general it is about 30–40 degrees.
The horizontal ray is directed at right-angles to the cassette and towards the middle of the film.
The patient lies supine, with the median sagittal plane adjusted to coincide with the central long axis of the imaging couch.
The chin is raised to bring the radiographic baseline to an angle of 20 degrees from the vertical.
The cassette is centred at the level of the sternal notch.
Central beam is directed at the midline at the level of the sternal notch.
Exposure is made on forced expiration.
Antero-posterior radiograph of trachea showing paratracheal lymph node mass.
The patient stands or sits with either shoulder against a vertical Bucky.
The median sagittal plane of the trunk and head are parallel to the cassette.
The cassette should be large enough to include from the
lower pharynx to the lower end of the trachea at the level of the sternal angle.
The shoulders are pulled well backwards to enable the visualization of the trachea.
This position is aided by the patient clasping their hands
behind the back and pulling their arms backwards.
The cassette is centred at the
level of the sternal notch.
Patient lie semi prone on the affected side. Arms over the head Upper edge of the cassette is placed just above the lung
apices Centering is at the middle of the cassette or at the level of
T7. AP setup should be made. Knee flexed and should be on top of one another The affected side should be supported by some radiolucent
material so that the affected side completely comes in the xray.
Marker Decubitus - useful for differentiating pleural effusions from
consolidation (e.g. pneumonia) ; Loculated effusions from free fluid in the pleura. Abscess
Radiographic positioning by clarks Wikipedia Radiographic positioning and procedures
by Greathouse Valuble inputs by Dr Kirti and Dr Gandhi
Thank You for the long and ?? Boring Thank You for the long and ?? Boring presentationpresentation
CT Hrct MRI Angiography
But due to limitation of time and topic these modalities will be covered in subsequent presentations