Pharos university
faculty of Allied medical sciences
Clinical Practice I (RSCP-201)
Department of Radiological Sciences and Medical
Imaging Technology
Prof. Dr. Hesham Badawy
Dr.Mohamed El Safwany
1
Intended Learning Outcomes
The student should be able to learn
how to perform adequate chest
radiograph at the end of this lecture.
2
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
3
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.
8
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.
9
Lateral Chest
• Measure: Lateral midchest
• 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
10
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.
11
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.
12
Lateral Chest Film
• Should see apical area
of chest.
• Respiratory effort down
to tenth ribs.
• No rotation: ribs
superimposed.
• Evidence of collimation
13
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.
14
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
15
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.
16
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.
17
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.
19
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
20
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.
21
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.
22
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.
23
Right Anterior Oblique Chest
• Make exposure.
• Have patient breathe
and relax.
24
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.
25
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
26
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.
27
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.
28
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.
29
Left Anterior Oblique Chest
• Make exposure.
• Have patient breathe
and relax.
30
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.
31
Locating an Abnormality
• An abnormality was seen on the A-P thoracic
spine.
• The P-A and Lateral Chest were requested.
32
Locating an Abnormality
• If was felt that the abnormality was cardiac so
oblique views were ordered to confirm location
of nodule.
33
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.
34
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.
35
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.
36
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
37
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.
38
Clinical History
• Malignancy that may metastasize to
osseous structures. i.e. prostate
cancer
• Unexplained weight loss, prolonged
hormonal therapy or corticosteriod
therapy or abuse.
39
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
40
Physical Examination
• Active or progressive neurologic or
neuromotor deficits
• Suspicion of possible peripheral joint
or spinal instability
• A significant or progressing scoliosis
41
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?
42
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.
43
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.
44
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.
45
Assignment
One student will be selected for
assignment.
46
Suggested Readings
Clark’s radiographic positioning and
techniques.
47
Question
What are the technical aspects for
optimal chest PA radiograph?.
48
Thank You
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