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
1

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.

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

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.

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.
5

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.
6

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

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.
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

Digital Chest Series

PA Chest Good Respiration

Lateral Chest Good

Collimation

14

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.

15

6.7 Apical Lordotic Chest

Measure: P-A 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
16

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.
17

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.

18

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.

19

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.

20

6.8 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

21

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.
22

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.
23

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.

24

Right Anterior Oblique Chest

Make exposure.
Have patient breathe
and relax.

25

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.
26

6.9 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

27

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.
28

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.
29

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.

30

Left Anterior Oblique Chest

Make exposure.
Have patient breathe
and relax.

31

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.
32

Locating an Abnormality

An abnormality was seen on the A-P thoracic

spine.
The P-A and Lateral Chest were requested.
33

Locating an Abnormality

If was felt that the abnormality was cardiac so

oblique views were ordered to confirm location
of nodule.
34

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.
35

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.
36

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 dont want to take x-rays in my
office?
37

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.

38

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?

39

Where do I start?
The best tools for determining
the need for any test are:
Patients clinical history
Physical exam finding

40

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

41

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.
42

Clinical History
Malignancy that may metastasize to
osseous structures. i.e. prostate
cancer
Unexplained weight loss, prolonged
hormonal therapy or corticosteroid
therapy or abuse.

43

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
44

Physical Examination
Active or progressive neurologic or
neuromotor deficits
Suspicion of possible peripheral joint
or spinal instability
A significant or progressing scoliosis

45

Physical Examination
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
patients symptoms.
46

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?
47

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.
48

Other factors to be considered

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?

49

Other factors to be considered

Does the patient have a biomechanical 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?
50

Other factors to be considered

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?
51

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.
52

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.
53

End of Lecture

54