Chest and Thorax X-ray: Supplementary.pptx

The Most requested Examinations in Radiology Department

1. RADIOGRAPHIC TECHNIQUES OF THORAX (LUNG ); SUPPLEMENTARY VIEWS    RADIOLOGY DEPARTMENT ABUBHAKAR TAFAWA BALEWA UNIVERSITY TEACHING HOSPITAL, BAUCHI   BY BUHARI RABIU ABUBAKAR STUDENT RADIOGRAPHER (400 LV), BAYERO UNIVERSITY, KANO SUPERVISOR: Ahmed, USMAN  JUNE, 2022

2. OUTLINE BACKGROUND BRIEF ANATOMY GENERAL INDICATIONS LIST OF ABBREVIATIONS PATIENT PREPARATION EQUIPMENT AND ACCESSORIES RADIOGRAPHIC TECHNIQUES CONCLUSION REFERENCES

3. BACKGROUND The chest radiograph (CXR) is thought to be the most frequently-performed radiological investigation globally although no published data is known to corroborate this (Jones, J. & Murphy, A. 2011). The frequency of routine chest x-ray request in our teaching hospital is very high, as it is considered a prerequisite in preadmission, pre-employment and pre-operative cases (Akinola, R. A., 2014). It is an x-ray of the chest, lungs, heart , large vessels, ribs, and diaphragm that requires a low radiation exposure . ( Jones, J. & Murphy, A. 2011)

4. BACKGROUND (CON’T) Why supplementary views? S ome patients such as paediatrics, geriatrics and/or very ill patients as well as inconclusive diagnoses from the PA view require the additional views.

5. BRIEF ANATOMY The thorax is the part of the body between the neck and abdomen ( M oore, K.L., et al 2010) It is the sub part of chest consisting of bony and visceral thoraces. The bony thorax is the skeletal framework that forms the ribcage which protects and supports the viscera within its cavity The visceral thorax includes the primary organs of the respiratory and cardiovascular systems ( Akinola, R. A., 2014).

6. BRIEF ANATOMY… The thoracic cavity is divided into three major spaces: the mediastinum , the right and left pulmonary cavities housing the lungs . (Moore , K.L., et al 2010) Each lung has an apex that projects into the neck and a concave base that sits on the diaphragm . The right lung Is larger and heavier than the left lung, but is shorter and wider (Chung, K. W ., et al 2015) The right lung Is divided into upper, middle, and lower lobes by the oblique and horizontal (accessory) fissures ,

7. BRIEF ANATOMY CONT.. The oblique fissure usually begins at the head of the 5 th rib and follows roughly the line of the 6 th rib The horizontal fissure runs from the oblique fissure in the midaxillary line at the 6 th rib level and extends forward to the fourth costal cartilage level The left lung Contains the lingula , a tongue-shaped portion of the upper lobe that corresponds to the middle lobe of the right lung, cardiac notch , and grooves for various structures (e.g., aortic arch, descending aorta , left subclavian artery). (Chung, K. W., et al 2015)

8. BORDERS AND SURFACES OF THE LUNGS Anterior border : is sharp, thin and overlaps the heart, a left lung presents a cardiac notch at its lower end and a lingula. Posterior border : is rounded, thick and lies beside the vertebral column. Costal surface: is convex, covered by costal pleura which separates lung from ribs, costal cartilages & intercostal muscles. Medial surface : It is divided into 2 parts: anterior (mediastinal) part: contains a hilum in the middle Posterior (vertebral) part: i t is related to bodies of thoracic vertebrae, intervertebral discs, posterior intercostal vessels & sympathetic trunk.

9. THE LUNGS AP VIEW LATERAL VIEW Superior lobe Superior lobe Inferior lobe Inferior lobe Middle lobe Middle lobe Moore, K.L., et al 2010) Superior lobe Superior lobe Inferior lobe Inferior lobe

10. GENERAL INDICATIONS The chest radiograph is performed for a broad content of indications, including but not limited to the following; Respiratory disease Cardiac disease Suspected metastasis/neoplasms Trauma Follow-up of known disease to assess progress (Jones , J. & Murphy, A. 2011)

11. GENERAL INDICATIONS P neumoperitoneum E valuation of symptoms that could relate to abdominopelvic pathology M onitoring of patients in intensive care units P ost-operative imaging P re-employment medical fitness I mmigration screening (Jones, J. & Murphy, A. 2011).

12. TOPOGRAPHIC LANDMARKS Accurate radiographic positioning requires appropriate knowledge of land marks that can be used to center the image receptor correctly. For chest positioning; sternal notch, sternal angle, vertebral and xiphoid processes are the usual marks used in this regard. FIG: 3

13. THE SUPPLEMENTARY VIEWS These are forms of the chest radiographs that are performed in a variety of clinical scenarios: ​ Lateral Lordotic (apical) Decubitus- right, left or dorsal Expiratory- PA erect or AP supine Oblique (for ribs #) Semi-recumbent/erect (rare) (Jones, J. & Murphy, A. 2011)

14. ABBREVIATIONS AP: Anteroposterior PA: Posteroanterior MSP: Mid sagittal plane MAL: Midaxillary line IR: Image receptor SID: Source to image distance CR: Central ray PT: Patient COPD: Chronic obstructive pulmonary disease

15. PT PREPARATION Remove all radio-opaque objects around the region of interest and dress in a hospital gown Long hair should be worn up Remember to explain clearly the procedure to your patient Rehearse breathing instruction with the patient for many times. Tubings and lines must be remained insitu and intact in ward radiography unless otherwise

16. EQUIPMENT AND ACCESSORIES X-ray machine Cassettes; (43cm x 35cm)/(35cm x 35cm) or detector Stationary grid (when applicable) Foam pads and other positioning aid devices

17. LATERAL (ERECT) INDICATION L ocalising suspected chest pathology when assessed in conjunction with a PA view E xamines the retrosternal and retrocardiac spaces I t allows assessment of the posterior costophrenic recesses CONTRAINDICATION Unjustified pregnant woman Infants Unfit patients

18. LATERAL POSITIONING OF PATIENT AND IR The erect patient is turned to bring the affected side in contact with the IR. The median sagittal plane is adjusted parallel to the image receptor . (Weight should be evenly distributed on both feet) The arms are folded over the head or raised above the head to rest on a horizontal bar support The mid-axillary line is coincident with the middle of the Bucky CR is centered to mid-thorax at the level of T7 or 4 inches below the Jugular notch SID 72 inches ( 180cm) Collimate on four sides to include the entire lung fields Exposure is made on full arrested inspiration (Bontrager, K.L. & Lambignano, J.P., 2010) FIG. 2.1

19. ESSENTIAL IMAGE CHARACTERISTICS Entire lungs from apices to the costophrenic angles Retrosternal and retrocardiac spaces clearly outlined Heart and great vessels

20. LATERAL THORAX SALIENT POINTS G astric bubble is under the left hemidiaphragm L eft hemidiaphragm is less distinct anteriorly due to the cardiac silhouette R ight hemidiaphragm appears higher and more complete (as the right is closer to the beam) T he radiation dose from a lateral chest radiograph is substantially higher than that of a PA projection and should probably not be routinely performed for this reason

21. APICAL LORDOTIC INDICATION: To evaluate suspicious areas within the lung apices. POSITIONING OF PATIENT AND IR Patient stand about 30cm away from IR and leaning back with shoulders, neck and back of head against IR Place patients hand on hips with palms out and rolled shoulders forward Align MSP to perpendicular to the IR CR is centered 3 inches below jugular notch Alternatively; Supine with CR 15-30 degrees cranial angulations

22. APICAL LORDOTIC DIRECTION AND CENTRING OF THE X-RAY BEAM With the patient in the position for the; PA projection ; CR is angled 30° caudally and centred over the 7th cervical spinous process coincident with the sternal angle AP projection; the central ray is angled 30° cranial towards the sternal angle . AP PT reclining at 30 to IR; central ray is perpendicular and centred 3” below the SSN

23. ESSENTIAL IMAGE CHARACTERISTICS Entire lung fields and clavicle should be included Clavicles seen superior to the apices and in the same horizontal level Sternoclavicular ends of the clavicles are equidistant from the vertebral spines and projected above the lung Ribs appears distorted, with post. ribs nearly horizontal and superimposing anterior ribs PA APICAL

24. LATERAL DECUBITUS INDICATION : P roblem-solving film, used to evaluate air-fluid levels, pneumothorax vs. pleural effusion; pneumothorax vs. pneumomediastinum A ir trapping due to inhaled foreign bodies and showing and quantifying pleural effusions NB: Position is required when the patient is too ill to stand erect (McKerrow, M. & Murphy, A., 2016)

25. POSITIONING OF PATIENT AND IR T he patient laying on either side on a trolley, supported on top of a firm foam pad Patient adjusted so that MAL is coincident with and perpendicular to the center of the coach IR is placed lengthwise posterior to the patient running parallel with the long axis of the thorax. T he patient’s hands should be raised to avoid superimposing on the region of interest, legs may be flexed for balance Beam is collimated with correct marker placed (Bontrager, K.L. & Lambignano, J.P., 2010)

26. DIRECTION AND LOCATION OF THE X-RAY BEAM The collimated horizontal beam is directed perpendicularly and to a point 4” below the suprasternal notch along MSP

27. ESSENTIAL IMAGE CHARACTERISTICS Entire lung fields, including apices and costophrenic angles clearly outlined No rotation No motion; diaphragm, ribs , and lung markings appear sharp

28. APICAL LORDOTIC RADIOLOGICAL CONSIDERATIONS should the patient unable to achieve the aforementioned positioning , supine position can be used to accomplish it A combination of positions can also be utilized, with the patient’s back arched as much as possible and the central ray angled cephalically patients with a long-standing history of emphysema or COPD will have abnormally long lungs compared to the general population, remember this when collimating superior to inferior side marker placement is imperative; patients can have congenital conditions (McKerrow, M. & Murphy, A. 2016)

29. EXPIRATORY VIEW An expiratory chest radiograph can be taken in either a PA or AP projection, and can also be taken with a mobile/portable unit. INDICATION : Used to assess small pneumothorax, emphysema (air trapping) or bronchial obstruction (?COPD) Subphrenic abscess ( Knipe , H. & Murphy, A. 2016)

30. EXPIRATORY VIEW.. POSITIONING OF PATIENT AND IR - AS in basic PA/AP view Collimation : - superiorly 5 cm above the shoulder joint to allow proper visualization of the upper airways - inferiorly to the inferior border of the 12th rib laterally to the level of the acromioclavicular joints PITFALLS : the cardiac silhouette appearing enlarged, and spurious basal opacities being the most common false positive findings ( Knipe , H. & Murphy, A. 2016)

31. ESSENTIAL IMAGE CHARACTERISTICS The entire lung fields should be visible from the apices down to the lateral costophrenic angles.  T he chin should not be superimposing any structures M inimal to no superimposition of the scapulae borders on the lung fields Sternoclavicular joints are symmetrical T he clavicle are in the same horizontal plane T he ribs and thoracic cage are seen only faintly over the heart  C lear vascular markings of the lungs should be visible ( Knipe , H. & Murphy, A. 2016)

32. GENERAL RADIOLOGICAL CONSIDERATIONS S ide marker placement is imperative; patients can have congenital conditions that mimic a mirrored image Same positioning but different collimation is used to better visualization of middle lobe and lingual lobe pathologies as they get the maximum thickness for X-ray beam to pass in this positioning Exposure is made in full arrested inspiration in all the views except for the expiratory view SID 72 inches (180cm ) and 40 inches for supine ( Knipe , H. & Murphy, A. 2016)

33. GENERAL RADIATION PROTECTION Justification of the examination in view Good communication Collimate on four sides to include the entire lung fields Adequate selection of exposure parameters in conformity with ALARAP principle Appropriate use of grid must be ensured Pregnancy screening must be ensured, and if exposure is justified on pregnant woman, the embryo/fetus must be shielded Shielding/distancing of gonads against the primary beam

34. GENERAL PATIENT CARE Establish good communication Reassure the patient and his relatives patient’s comfort should be prioritized Reduce patient waiting time as much as possible Be empathic, sympathetic and smart

35. CONCLUSION Radiographic supplementary views of thorax (lungs) require adequate communication between the radiology staff and the physicians.

36. REFERENCES Akinola, R. A. Evaluation of Routine Chest X-rays Performed in a Tertiary Institution in. International Journal of Cardiovascular System, vol ¾, 2014 . Bontrager, K. L., Lambignano, J. P., ( 2014). Handbook of Radiographic Positioning and Techniques. 8 th Edition, p. 92. Chung, K . W ., Chung, Harold M., Halliday , N. (2015). Gross Anatomy. 8 th Edition,. W olters Shower Publishers (BRS), P.68. Fauber , T. L.,. (2006). Radiographic Imaging and Expopsure , 5 th Edition. Aelsevier 5 th edition. Jones, J ., Murphy A. (2021). Chest Radiograph. Radiopaedia.org .. https:// doi.org/10.53347 Knipe , H., Murphy, A., Chest (Expiratory View). 2021. Radiopaedia.org .. https:// doi.org/10.53347/rlD-43328 McKerrow, M., Murphy, A. Chest AP (Lordotic View). (2016). Radiopaedia.org .. https://doi.org/10.53347 .

37. REFERENCE CONT. Moore, K.L., Dalley , II., Arthur, F. Agur , Anne M. R. ( 2015). Clinically Oriented Anatomy, 6 th Edition. ISBN; 978-0-7817-7525-0 Sharma, O. P. ( 2018). Radiology Positioning for Technician. (2nd edition). Peepee Publishers and Distributors (P) LTD. ISBN: 978.81-8445-239-6 Whitely, A. S., Jefferson, G., Holmes, Ken., Sloane, Charles., Anderson, Craig., Hoadley , Graham., ( 2019). Clark’s Positioning in Radiography. Taylor and Francis Group, LLC, CRC Press, 2016. p. 231-248. ISBN: 13: 978-1-4441-6505-0 (e-book-pdf)

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