Thoracic positioning

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  • PA Standard investigation carried out in the x-ray dept Cassette anterior to chest, x-rays shot post-ant from 2 metres away, shoulders abducted to remove scapula Carried out in standing therefore better inspiration
  • AP Cassette placed behind the patient, portable machine Patient could be sitting in a chair, semi erect in bed, supine in bed. NOTE the patient position will affect the CXR Marked AP on film Heart enlarged often poorer expansion
  • Thoracic positioning

    1. 1. By Dr Kushagra V Garg
    2. 2.  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.
    3. 3.  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
    4. 4.  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 } } Pre-read }
    5. 5.  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
    6. 6.  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
    7. 7. Overpenetrated Film • Lung fields darker than normal—may obscure subtle pathologies • See spine well beyond the diaphragms • Inadequate lung detail
    8. 8. Underpenetrated Film •Hemidiaphragms are obscured •Pulmonary markings more prominent than they actually are
    9. 9.  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
    10. 10.  6. Inspiration  Should be able to count 9-10 posterior ribs  Heart shadow should not be hidden by the diaphragm 1 2 3 4 5 6 7 8 9 10
    11. 11. 9-10 posterior ribs are 9 About 8 posterior ribs are showing 8 With better inspiration, the “disease process” at the lung bases has cleared
    12. 12.  7. Rotation  Medial ends of bilateral clavicles are equidistant from the midline or vertebral bodies
    13. 13. 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
    14. 14.  8. Angulation  Clavicle should lay over 3rd rib 1 2 3
    15. 15. Pitfall Due to AngulationPitfall Due to Angulation A film which is apical lordotic (beam is angled upA film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart andtoward head) will have an unusually shaped heart and the usually sharp border of the left hemidiaphragm willthe usually sharp border of the left hemidiaphragm will be absentbe absent Apical lordotic Same patient, not lordotic
    16. 16.  9. Soft tissue and bony structures  Check for  Symmetry  Deformities  Fractures  Masses  Calcifications  Lytic lesions
    17. 17.  10. Mediastinum  Check for  Cardiomegaly  Mediastinal and Hilar contours for hilar masses
    18. 18.  11. Diaphragms  Check sharpness of borders  Right is normally higher than left  Check for free air, gastric bubble, pleural effusions
    19. 19.  Posteroanterior – PA(erect)  Anteroposterior – AP(mostly supine)  Lateral  Decubitus  Lordotic  Thoracic Inlet View
    20. 20.  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
    21. 21.  Intervertebral disc spaces upto T4 should be ideally visualised
    22. 22.  Chest PA Expiration study  Expiratory view demonstrates air trapping and diaphragm movement  Exp : pneumothorax, interstitial shadowing, obstructive emphysema (foreign body)
    23. 23.  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
    24. 24.  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
    25. 25. Normal AP
    26. 26.  upper edge of cassette just above the lung apices  arms laterally rotated  Central beam is directed towards sternal notch  FFD of 120cms.
    27. 27.  Level of diaphragm is on a higher level
    28. 28.  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
    29. 29.  Used to visualize ribs  Used for non ambulatory patients  Used for pediatric age group
    30. 30.  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.
    31. 31.  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
    32. 32.  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.
    33. 33.  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.
    34. 34.  Antero-posterior radiograph of trachea showing paratracheal lymph node mass.
    35. 35.  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.
    36. 36.  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
    37. 37.  Radiographic positioning by clarks  Wikipedia  Radiographic positioning and procedures by Greathouse  Valuble inputs by Dr Kirti and Dr Gandhi
    38. 38. Thank You for The long and ?? BoringThank You for The long and ?? Boring presenTaTionpresenTaTion
    39. 39.  CT  Hrct  MRI  Angiography But due to limitation of time and topic these modalities will be covered in subsequent presentations

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