CHEST RADIOGRAPHY

Speaker:
Mr. Aditya Thakur
2nd Year B.Sc
RADIODIAGNOSIS AND Moderator:
IMAGING Mr. S.R CHOUDHRY
Department of Radiodiagnosis &
Imaging
P.G.I.M.E.R., Chandigarh.
 INTRODUCTION

Chest x-ray is the most commonly performed

diagnostic x- ray examination. Approximately half of all
x-rays obtained in medical institutions are chest x-rays.
A chest x-ray is usually done for the evaluation of lungs,
heart and chest wall.
Pneumonia, heart failure, emphysema, lung cancer and
other
medical conditions can be diagnosed or suspected on a
chest
x-ray. Traditionally, chest x-ray have been taken prior to
employment, prior to surgery or during immigration. The
use of routine chest x-ray is being re-evaluated because
there is a lack of evidence for their usefulness. Routine
x-rays are obtained in absence of specific signs
symptoms or Medical conditions.
 ANATOMY
 The trunk of body is divided by the diaphragm into
an upper
and lower part. Upper part is called thorax and
lower part is called abdomen.
 Thorax is formed by following bones
: Anteriorly by sternum
: Posteriorly by the 12 thoracic
vertebra and inter vertebral disc
: On each side by 12 ribs
THORACIC CAVITY:
The cavity of the thorax contains the right
and left pleural cavities which are
completely invaginated and occupied by
the lung. The right and the left pleural
cavities are separated by a thick median
portion called the mediastinum. The heart
lies in the middle mediastinum.

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 Structure lies inside the mediastinum
1 Trachea and its bronchus
2 Oesophagus
3 Muscles
4 Heart enclosed in pericardium
5 Aorta
Trachea: It is fibro elastic tube about 11cm
long extending from the larynx at the level
of 6th cervical vertebra to lower border of
4th thoracic vertebra where it is divided in
the
right & left bronchi one for each lung.
Lung: The lungs are pair of respiratory
organs and spongy in texture. Each lung
is conical in shape. The right lung is
divided into 3 lobes
a) Superior
b) Middle
c) Inferior by the two fissure a) Oblique b)
Horizontal

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 Structure lies inside the
mediastinum Contd…
Left lung is divided into two lobes by the oblique
fissure.
A. Superior
B. Inferior
Heart: The heart is a conical, hollow muscular organ
situated into the middle mediastinum. It is enclosed with in
pericardium.
The heart is placed obliquely behind the body of
the sternum so that 1/3 of its lies the right and 2/3 to the
left of the median plane.
 Indications of the Chest
Radiography
1. Pulmonary diseases such as
 Koch’s disease.

2. Pleural disease – Pleuritis.

 Pleurisy - inflammation of plural.
 Pleural effusion - fluid in pleural cavity..
3. Pericarditis
4. Chest x-ray are done for follow up pts.
5. Pre-operative and post-operative cases
6. To see the heart disease like cardiomegally
7. To see diaphragm movement.
8. Blunt Trauma Chest
9. Bronchial asthma
10. Bronchial pneumonia
 Equipment and Accessories
 X-ray Unit
 High Power Generator
 Chest stand or vertical bucky, Air Gap
Stand
 Cassettes
- X-Ray Unit: The heart cycle is completed in
about 0.08 second. So the exposure time
should be lesser than 0.08 sec to prevent the
blurring of heart shadow due to involuntary
movement of heart. This type of exposure can
be achieved by high mA and high KV X-ray
units with output in the range.
800mA – 1000mA
40KV - 150 KV
 Exposure time can be reduced further by the

use of high speed screen faster film

combination.
 It can also be achieved with the added
advantage of selecting a smaller focal spot
within the tube rating.
 - High Power Generators:
The essential function of H.T generator
in x-ray tube is to provide such power
which is needed by X-ray tube so an
important specification in the description
of any generator is a statement on its
power out put. Unit 70KW – 100KW
generator is used which can give 1000-
1250mA and upper voltage limit 150KV.
- CHEST STAND OR VERTICAL BUCKY
The chest stand is a holder for
cassettes that is used to examine
patients in erect position, for chest or
other radiography. It must hold the
size of cassette used for chest
examination and rigidly.
 Preparation For The Chest
Radiography
This procedure requires no special preparation. But
a brief
explaination to patients with a rehearsal of the
procedure should ensure a satisfactory result.
Respiratory movement should be repeated several
times before the performance Is considered to be
satisfactory.
Patients will also be asked to remove all metallic
jewellery or undergarments that may contain metal
that may interfere with x-rays.
 Basic Projections
 PA (Postero -anterior) Erect
 AP ( Antero –posterior ) Erect or supine
 Lateral (Erect or sitting)
 Additional Projections

OBLIQUE
a. PA Oblique
- Left PA Oblique
- Right PA Oblique
b. AP Oblique
- Left AP Oblique
- Right AP Oblique
2. Apicogram
3. Lordotic
4. Decubitus
 PA View

Position of patient :
 Patient is made to stand in PA position, facing the
cassette, in front of vertical chest stand.
 Chin of the patient is placed over the cassette
 The cassette is adjusted 1 ½” above the upper border
of the shoulder.
Position of part :
 Hands of the patient should be placed on waist level
below the hips , so that they will not be superimposed
on CP angles.
 Palms should face upwards and arms are rotated
internally to throw out the scapula out of lungs.
 Shoulders sould lie in the same transverse plane and
depressed to carry the clavicles below the apices.
Cassette Size: The cassette size is chosen so
that it must include the apices and lower
region of the diaphragm and chest wall. It
must includes the costophrenic angle (CP)
Central Ray: C.R. is directed at right angle to
the film at the Junction of 4th & 5th thoracic
vertebra,
FFD: generally 5 feet (6 feet for Heart size).
Breathing Instructions: The exposure is given
in arrested inspiration phase, to show the
greatest possible area of lung structure.
P.A Position
 L

P.A. Resultant Image

 Structures shown

 Air filled trachea

 Lungs
 Diaphragmatic domes
 Heart
 Aortic knob
 Evaluation Criteria
Position wise: It must include whole of the
lung field.
 Apices
 C.P. Angle
 Any rotation is easily detected by the position of
medial end of the clavicle.
 Scapula should not over shadow the lung field

Exposure Wise
a. Trachea & bifurcation of trachea must be seen
in the midline.
b. Vertebral bodies should be faintly visible but not
inter vertebral space.
c. Heart & diaphragm show a sharp outline.
d. Peripheral lung vessels must be seen.
Processing wise: Put a finger
under the darkest
area of the film. If finger is not
seen properly, then
it is properly developed.
 PA in expiration

This view is done in two conditions.

 For pneumothorax, PA is done in expiration

to confirm the disease. This has effect of

intra pleural pressure which result in
compression of lung making a
pneumothorax bigger.
 This technique also demonstrates the

effect of inhaled foreign body obstructing

the passage of air in lung segment and
extent of diaphragmatic movement.
 AP Projection (Erect or sitting)

This view is done as an alternative to

PA erect projection. When the
patient’s shape or medical condition
makes it difficult or unsafe for the
patient to stand or sit for basic
projection. For the latter, the patient
is usually supported sitting erect on a
trolley or bed side.
 Positioning of patient & film for AP
erect projection
 The patient may be standing or sitting with their back against the
cassette which is supported vertically with the upper edge of the
cassette above the lungs apices.
 The median sagittal plane is adjusted at right angle to the center of the
film.
 The shoulders are brought downward & forward with the back of the
hands below the hip & elbow forward
Central ray: Is directed at right angle to the film and
towards the sternal notch. The central ray is then angled
until it is coinciding with the middle of the film. The
exposure is taken on normal full inspiration
 AP Supine projection (on
bedside)
Positioning of patient & film:
With assistance, a cassette is carefully positioned
under the pt’s back with the upper edge of
cassette above the lung apices. The median
sagittal plane is adjusted at right angle to the
middle of the film & pt’s pelvis is checked to
ensure that it is not rotated. The arms are laterally
rotated. Chin slightly raised.
Central Ray : Is same as erect AP projection
Exposure: is taken on normal full inspiration
 Lateral projection
Positioning of patient and film: Patient is made to stand
in lat position in front of the vertical cassette holder with
side to be examined touching the film. Both arms are raised
over the head. Distance between film & xiphisternum equal
to the distance between line joining spinous process.
 Mid axillary line should be 2” posterior to midline of grid.
Central Ray: Is directed through axilla at the level of D5.
FFD is generally 40.” Grid is used because KVP is more
than 70. To prevent the scatter Rad”.
Note: For diaphragmatic abscess (to see the movement of
diaphragm)
 Two exposures are given on single film.
 1st in inspiration 2/3mAs.
 2nd in expiration 1/3 mAs.
 Alternate procedure - Fluoroscopy
 Lateral projection Cont…
Lateral view is done to see the:
 Depth of tumors.
 Part of the lungs overlapped by heart.
 To demonstrate the inter lobar fissures
 To localize the pulmonary lesion.
Evaluation Criteria:
 Posterior rib superimposed
 Sternum should not be rotated
 C.P. Angle and apices should be included.
 Hilum should approx in centre.
 Exp. Should penetrate the lung field of heart.
Lat. Position
Resultant Image
 Penetrating View Of Chest
 It is done to see rib & heart.
 It is done when one side appears opaque on normal
chest radiograph.
Opacity due to hydrothorax or pyothorax. Thus to
penetrate through these densities more exposure
is required. Grid is used one side which is normal
will be over exposed so wedge filters can be used
to see both sides with same opacity.
 Oblique projection

Mediastinum & lung fields, incase of

asbestosis pleural plaques not seen in PA
projection.
 Rt. Middle lobe – Ant. oblique

 Both lower lobe - Post oblique

a. Right anterior oblique: The patient in PA position & the
Rt. Side of the trunk is kept in contact with the cassette &
patient is rotated to bring the left side away from the films so
that the coronal plane is at an angle at 450 to the film.
Central rays: Directing at right angle to the middle of film.
or at the level of 6th thoracic vertebra.
b. Left anterior oblique: The patient in PA position & the
left side of the trunk is kept in contact with cassette & the
patient is rotated to bring the right side away from the film so
that the coronal plane is at an angle of 450 to the film.
Central Ray: Is directing at right angle to the middle of film
or
at the level of 6th thoracic vertebra.
Structure shown: Lung field usually
appear shorter due to
magnification of diaphragm.

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Left posterior oblique: The patient in AP position
&
the left side of the trunk is kept in contact with the
cassette. Patient is rotated to bring the right side
away from the film. So the coronal plane is an angle
of 450 to the film.
Central Ray: at right Angle to the middle of the
film or
at the level of 6th thoracic vertebra.
Structure shown:
 The maximum area of lung.

 Trachea & its bifurcation.

 Heart descending aorta and arch of Aorta.

Right posterior oblique: The patient in AP
position
and right side of the trunk is kept in contact with
the
cassette and patient is rotated to bring the left
side
away from the film so the coronal plane is an
angle of
450 to the film
Central ray at right angle to the middle of the
film or at
the level of 6th thoracic vertebra.
Structure shown:
 Maximum area of right lung &

mediastinal content.
 Also shown trachea & entire left

branch of bronchial tree.

 Left atrium, left main branch of the

pulmonary artery.

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 APICOGRAM
Apicogram is done when there is doubt of T.B. T.B mostly
begins in apex region where the lesion is superimposed by
clavicle.
Apicogram can be done in two ways:
 Tube angle, patient straight

 Patient angle, tube straight

Tube angle, patient straight (Axial projection) patient in AP

position. Patient is made to stand in front of tube & back
touching to the film. Film is placed 4”-5” above the upper
border of shoulder
Central ray is directed just below sternal notch with
150 to 200 angulation towards head.
Patient in PA Position : Patient is made to stand in PA
position in front of vertical cassette holder. A cassette is
placed 4 to 5” above the border of shoulder.
Central ray is directed at level of C7 with 15-20
angulation
toward the feet.
Patient angle & tube straight method :
The patient is made to stand facing the tube “6 to 8” away
from the film. Patient is asked to lean backward touching
the
head and neck on the cassette. So the clavicle is thrown
away from the apex of the lung.
Central ray: is directed at the sternal notch.
Structure shown :
The apices lying below the shadow of clavicles.
Evaluation criteria:
 The clavicles should lie superior to

the apices.
 Sternal ends of clavicle should

equidistance from the vertebral

column.
 The apices should be included.

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Apicogram Axial Projection
 LL
Clavicle

Apex

Resultant Image
 Lordotic View
This projection is done to see
 Middle lobe collapse of R Lung
 Demonstrate the magnified interlobular effusions

Positioning of patient & Cassette:

Patient is made to stand in PA position in front
of a vertical cassette holder, patient is asked to
hold stand with hand and he is made to lean back
Ward i.e. approx – 300 inclination.
Central ray: is directed at level of D5
Lordotic Position
 L

Resultant Image
 Decubitus Projection

Lat Decubitus: Patient is made to lie in lateral position

on affected side, Film is placed either touching to anterior
or posterior aspect. Tube is brought horizontal. Both
Decubitus should be done. Fluid will come to the side
which is lowered.
Cassette Position: The cassette is placed posteriorly or
anteriorly in contact with the chest and adjusted
approximately 2” above the shoulder. Central ray is
directed at right angle to D5 Make the exposure at the
end of full inspiration.
Structures shown : This projection
demonstrates the
change in fluid position and reveals any
previously
obscured pulmonary areas or in case of
suspected
pneumothorax, presence of any free air.
Evaluation criteria
 The patient should not be rotated from a
true frontal position.
 The affected side should be included.

 The apices should be included.

 Proper identification should be visible.

Decubitus Position
Resultant Image
 Ventral or dorsal Decubitus
position
Patient is made to lie down in prone or supine
position. Elevate the thorax 2-3” on foam pad.
Arms are kept over the head, cassette is placed
against the affected side. The cassette is adjusted
so that it extends to the level of laryngeal
prominence.
Make the exposure at the end of full
inspiration
Central ray: is directed center to the mid axillary
line at the level of the 6th thoracic vertebra.
 PEDIATRIC CHEST
RADIOGRAPHY
Although there are many similarities in pediatric and Adult
chest radiography in basic positioning and image quality. To
maintain the proper positioning and image quality, it is
essential to immobilize the child by using immobilization
devices.
 Some time we have to take help by parents for
immobilization of patient during radiography.
 We have to provide radiation protection by using lead apron,
thyroid shielding to the child’s parent as well as child.
 If patient is cooperative then immobilization device is not
used.
 Basic positioning of child is as adult PA. AP. LAT.

 Exposure time should be lesser about 0.08 sec.

AP Projection
 L

Resultant Image
 Selection Of Kilovoltage

In general 60-70kvp is adequate for the Posterio-

anterior projection. In which case there will be
minor penetration of the mediastinum and heart.
An increase in kilovoltage however is necessary
for penetration of the denser mediastinum and
heart to show the lung behind those structures and behind the
diaphragm as well as the lung bases in a very larger or heavy
breasted patient
 High KV Technique
We used KV in the range of 90-140. Which reduce contrast
between the lung field and mediastinum. However, using
this technique there is loss of inherent contrast and
visualization small lesion of soft tissue density because
possibility of photoelectric effect is decreased at the same
time possibility of Compton effect is increase. The purpose
of high KV technique, we make use of Compton effect
which is independent of atomic number.
Purpose: The application of high kilovolgate technique is
primarily with a view to obtaining exposure time in the
region of milliseconds. The effect control to blur the image
by involuntary movement.
 Airgap Technique

The technique of leaving a gap between the patient and

film during radiography is called air gap technique.
AIM : The aim of this technique like grid, is also reduce the
effect of scattered radiation produced on the film.
Principle : The scatter radiation arising in the patient, from
compton scattering travels in all directions. When an air
gap is left between the patient. Some of scatter radiation
will not be able to reach the film. Some will be reduced in
intensity due to inverse square law, some will be deflected
in other direction before reaching the film e.g. in chest
x- ray, cervical spine lateral projection.
 Newer Developments

Due to higher radiation dose and cost

involved as bigger size of films are being
used. There is growing need to look into
this aspect. Thus newer developments
have taken place as following
Mass miniature radiography (Odelca
camera)
To reduce the cost of film because a small
film is used (100to 70mm) for follow up
cases at T.B. in specialized T.B. Hospitals.
Advantage Disadvantage
a. It is less costly a. High radiation dose
b. Storage problem b. Information is less
solved
c. It is done for TB
screening
2. High KV Technique
3. Image intensifier system (D.F. System)
4. Digital chest radiography
This is done by two methods.
 Flat panel detector system
 Using imaging plate system
F.P.D. System: There is detection at the outer
end which picks up signal and passes to
analog convertor. In this analogue data is
converted as:
Imaging plate Method:
Advantage :
 Post processing.
 Radiation dose less.
 Tele radiography.
 Image can be store.
 Cost reduce.
 Better edge enhancement.

Disadvantage : Initial investment cost high.

Computed tomography
After development of CT technology CT is done
for chest to visualize the mass lesion in the lung
field as well as mediastinal mass, so we can
distinguish, The tumour or pleural effusion,
cavitation by giving intravenous contrast media
to enhance the lesion for better visualization for
diagnosis whether it is malignant or benign
tumor.
Bronchography is replaced by the
development of HRCT chest it is done to
visualize the bronchiactasis, as well as the
interstitial parenchymal lung lesion.
 Radiation protection
The radiation protection can be achieved by
applying ALARA Principle As low as
reasonably achievable)
 Distance
 Time
 Shielding

1. Limitation of filed size by using collimators.

2. Directing the beam.
3. Use of gonad shields.
4. Careful preparation of the patient.
5. Use of the high speed film, screen, high mA
and short exposure time.
6. Presence of essential staff only.
7. Use of protective apron or protective screen
 Conclusion
Chest x-ray is the basic investigation
which may reveal more information about
the patients disease.
Approximately ½ of the all x-ray
examination is obtained in medical
institution are chest x-ray. The quality of
Chest x-ray is of utmost importance but it
is difficult to maintain it as slight variation
in exposure factors, processing time and
slight rotation due to malpositioning may
result into loss of the information. So the
chest radiography is to be done very
carefully.
we can say in other words that proper
chest radiography is a challenge for
Radiological technologist. This
challenge is met more effectively with
the help of digital radiography and
more information is being gathered by
other new modalities like CT scan,
MRI etc

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