X ray

1. CHEST

2.  Anatomy of
the chest
 Heart, Ribs,
lungs, aorta,
Trachea,
oesophagus
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3.  The main position of the chest:
1. PA position
2. Lateral position
▪ The additional positions of the chest:
1. AP supine or semierect
2. Lateral decubitus
3. AP Lordotic
4. Anterior oblique
5. Posterior oblique
 Upper airway (Routine)
• Lateral
• AP
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4. Chest PA projection
➢ Pathology demonstrated:
Plural effusion, pneumothorax, ......., etc.
1. Patient preparation: the radiographer should remove all the
opaque object from chest and neck region, including clothes
with button, necklace or any object that would be visualized
on the radiograph as a shadow.
2. Film size: 35x43 cm. C.W. Or L.W.
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5. Patient position:
▪ Patient erect, feet spread slightly.
▪ Chin raised resting against IR to prevent superimpose to apices.
▪ Hand on hips with palms facing back and elbows partially flexed.
▪ Shoulders rotated forward against IR to move shadow of scapula.
▪ Shoulders depressed downward to show lung apices.
Part position:
 Align midsagittal plane to CR and to midline of IR.
 Ensure no rotation of thorax (shoulders should be in same plane).
 Top of film about 4 cm above the shoulders.
 Very ill patient puts arms around the IR (S. Bukey).
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6.  CR: perpendicular to IR & the cantered to midsagittal plan at
level of T7 (18-20 cm below vertebra prominence) or inferior
angle of scapula.
 SID: 72 inches (180cm): to avoid magnification of the heart
shadow
 Breathing Instruction: exposure made at full inhalation by
holding the second full inhalation with no motion.
 Notes:
1. we used high kV to provide sufficient penetration to visualize
well the fine lung marking in the areas behind the heart & the
lung bases.
2. Increase density increase Ma.
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7. 7

8. Structure shown:
 Lungs at full inhalation
 Heart
 Trachea
 Diaphragm
 Ribs
 Clavicles
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9. Image quality:
In good chest radiograph you can see:
 lung apex
 Costophrenic angles
 Show minimum of 9-10 ribs.
 Both Rt & Lt sternal end of the
clavicles will be the same distance
from the centre line of the spine &
in the same plane.
 Distance from lateral rib margin to
vertebral column the same on each
side from upper to lower rib cage.
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10.  How to determine the heart size:
The cardiothoracic ratio (CTR) is
the ratio between the maximum
transverse diameter of the heart &
the maximum transverse diameter
of the chest, it is usually expressed
as the ratio of these measurements
in centimetres.CTR of greater than
0.5 is said to indicate cardiac
enlargement.
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11. PA chest patient cannot stand
The same step of the PA chest for erect position Expect on:
- Patient seated on cart.
- Arms around IR depend on patients position.
- Shoulders rotated forward & downward.
- No rotation of thorax.
- Top of film about 4cm above the shoulders.
- CR at T7.
- If portable IR is used because patient cannot be placed up against
chest board, place pillow on lap to raise & support the IR at 4 cm
above the shoulders.
- Keep the IR against chest for minimum object image distant (OID).
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12. Lateral position
 Pathology demonstration: the pathology situated posterior to
heart, great vessel, & sternum can be demonstrated. FB.
- Lt Lat to show heart & lung
- Rt Lat show pathology in Rt lung
 Film size: 35x43 cm. L.W.
 Patient position:
 Erect: Prevent engorgement of vessels.
 Weight evenly distributed on both feet
 Lt sides against the film.
 Arms above head, chin up.
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13. Part position:
 Lift arms up
 Mid sagittal plan parallel to IR.
 Shoulders close together in the same plane.
 Bend elbow with forearm on the head.
 For ill patient lean hands on I.V pull.
Notes: 1. there should be no tilt or leaning side, the sagittal plan
must parallel to film.
2. chin and arm elevated sufficiently to prevent excessive
soft Tissue from superimposing apices.
▪ C.R.: Directed at level T7(8-10 cm below the jugular notch.
▪ SID: 72 in (180cm). ???
13

14.  Breathing Instruction: exposure made at full inhalation by
holding the second full inhalation with no motion.
 Structure shown:
- Lt Lat: heart & left lung
- Rt Lat: Rt lung.
 Image quality
- Entire lung from apices to costophrenic angles.
- Sternum anteriorly to posterior ribs & thorax.
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15. Lateral position (with wheelchair)
The same step of the lateral chest
for erect position expect on:
 Patient position on cart
 Patient seated on cart.
 Arms crossed above head or hold
on arm support.
 Chin kept up.
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16. Patient position in wheelchair:
 Remove armrest or place pillow under the
patient to avoid superimpose the armrest with
lower lung.
 Turn patient in wheelchair to lateral position.
 Place blocks behind back.
 Raise arms above head & have patient hold on to
support bar
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17. AP projection: Chest (supine or semierect)
 Pathology demonstrated: this projection demonstrate pathology
involving the lung, diaphragm and mediastinum.
 Film size: 35x43cm (14x17in) C.W.
Patient position:
 Patient is supine on cart or semierect
position.
 Place IR under or behind patient.
 IR. 4-5 cm above shoulders.
 Centre patient to CR & to IR.
 Mid sagittal plane perpendicular with mid film.
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18.  CR: angled caudal to be perpendicular to long axis of sternum
(about 5o caudad angle to prevent clavicles from obscuring the
apices).
At the level of T7 (8 -10 cm) below jugular notch.
 Breathing Instruction: exposure made at full inhalation by
holding the 2nd full inhalation with no motion.
 SID: 72 inches (180 cm) for semierect,
& 40 in (100cm) for supine.
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19.  Notes:
The heart will be appear larger as a
result of increased magnification from
a shorter SID & increase OID of the
heart.
• Structures shown:
- Magnified Heart.
- Magnified vessels.
- Lungs, .......etc.
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20. Lateral Decubitus (AP projection)
Pathology demonstrate
➢For pleural effusion the affected side should be down.
➢For pneumothorax the affected side should be up.
➢Care must be taken not to cut off the affected side.
➢Place appropriate marker to indicate which side of chest up.
➢IR size: 35x43cm (14x17in) C.W.
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21. Patient position:
 Elevate thorax on sponge or sheets.
 Patient lying on Rt side for Rt lateral decubitus & on Lt side for
Lt lateral decubitus.
 Patient’s chin & both arm raised above head to clear lung field.
 Back contact with IR.
 Knees flexed slightly & coronal
plane parallel to IR.
 Ensure no rotation of thorax
(shoulder should be in same plane)
 IR about 2.5 cm above vertebra
prominent.
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22.  CR.: horizontal directed to centre of IR to level T7
(about 8-10cm inferior to level of jugular notch)
 Breathing Instruction: exposure made at full inhalation by
holding the second full inhalation with no motion.
 SID: 72 inch (180cm).
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23. Structures shown:
 Entire lungs including apices & both
costophrenic angles.
 Both lateral border of ribs should be
included.
Image quality:
 Distance from lateral rib margin to
vertebral column the same on each side
from upper to lower rib cage.
 Sternoclavicular joint should be the
same distance from vertebral column.
 Arms should not superimpose on the
upper lungs.
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24. AP Lordotic projection
Pathology:
 Determine the masses beneath the clavicles.
 Tuberculosis
Film size: 35x43cm. lengthwise.
Patient position:
 Patient standing about 30 cm away from IR.
 Shoulder tilt back ward in contact with IR.
 Both patient hands on hips, palm out & shoulder rolled forward.
 Centre midsagittal plane to CR & to centre of IR.
 Ensure no rotation of thorax
 Top of IR about 7-8 cm above the shoulders.
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25.  CR.: perpendicular to IR, central to midsternum (9cm below
jugular notch).
 Breathing Instruction: exposure made at full inhalation by
holding the second full inhalation with no motion.
 SID: 72in (180cm).
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26. Exception: Ap semiaxial projection
 If patient is weak & unstable or is
unable to assume the erect lordotic
position, an AP semiaxial projection
may be taken with the patient in a
supine position.
 Shoulders are rolled forward & arms
positioned as for lordotic position.
 CR.: is directed 15° to 20° cephalad,
to the midsternum.
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27. Structures shown
 Entire lung field
 Clavicles
Image quality
 Clavicles should appear nearly horizontal
& superimposed by 1st ribs.
 Distorted ribs posterior, ribs superimpose with anterior ribs.
 Sternal ends of the clavicles should be the same distance from
vertebral column on each side.
 The lateral border of ribs on both sides should
appear to be near distances from vertebral
column.
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28. Anterior oblique positions: Chest
Pathology demonstrated:
▪ Pathology involved lung, trachea & mediastinal structures.
▪ Size & contours of heart & great vessels.
Film size: 35 x 43cm. Lengthwise.
Patients position:
 Patient erect, rotated 45o with Lt anterior shoulder against IR for
the LAO; & 45o with Rt anterior shoulder against IR for the RAO
 In some cases for certain position for heart study require an LAO
with increase in rotation to 60o.
 For lungs pulmonary disease it best to decrease the rotation to 15o
to 20o.
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29.  Patients arm flexed nearest IR & hand placed on hip, palm out.
 Opposite arm raised to clear lung & hand rest on head, keeping
arm raise as high as possible.
 Chin raised up.
 Centre the patient to CR & to IR.
 Top of IR about 2.5cm above the
vertebra prominence.
CR: directed to level of T7 (18-20 cm,
below level of vertebra prominence)
toward unaffected side.
SID: 72in (180 cm).
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30. Breathing Instruction: exposure made at full inhalation by
holding the second full inhalation with no motion.
Structures shown
 lung apex, Costophrenic angles, Trachea. & Heart.
Note: the interest side is the side farthest from the IR.
ex. RAO → visualize Lt lung.
Image quality
 The distance from outer margin of
the ribs to the vertebra column on
the side farthest from the IR should
be approximately two times the
distance of the side closest to the IR.
RAO 30

31. 45° LAO position
45° RAO position
60° LAO position
60° RAO position
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32. Posterior oblique positions
Pathology demonstrated:
 Pathology involved lung fields, trachea & mediastinal structures.
 The size & contours of the heart & great vessels.
Film size: 35x43cm. L.W.
Patient position:
 Patient erect, rotated 45o with Lt posterior
shoulder against IR for the LAO; & 45o with Rt
posterior shoulder against IR for the RAO.
 Arm closest to the IR raised & head supported,
other arm placed on hip with palm out.
 Chin raised.
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33.  Top of IR about 2.5 cm above vertebra
prominens or about 12 cm above level
of jugular notch / 5 cm above shoulders
 Thorax centred to CR & to IR.
Note:
 If patient can not stand or sit, take
posterior oblique on table.
 Place support under elevated hip &
shoulders.
 Place support under patients head.
CR: Directed to the level T7.
SID: 72 in (180 cm). 45° RPO position.
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34. Breathing Instruction: exposure made at
full inhalation by holding the second full
inhalation with no motion.
Note: The LPO position shows the same
anatomy as the RAO
& the RPO the same as LAO.
Structures shown
 Lung field appear shorter than AO
because the magnified of diaphragm.
 The heart & great vessels appear larger
because they are farther from the IR.
45° LPO position. 34

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37. Lateral position: upper Airway
Demonstrated Pathology in larynx, trachea & upper esophagus.
- Epiglottitis, which may be life-threatening for a young child.
Film size: 24x30cm. L.W.
Patient position:
 Patient seated or standing in lateral position.
 Position patient to centre upper airway to
CR & centre of IR.
 Rotate patient posteriorly with arm hanging
down, clasping hand behind back.
 Chin raised up.
 Top IR at the level of the opening external ear canal (EAM).
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38. CR: Directed the CR at the level C6 or
C7 (midway between the laryngeal
prominence & jugular notch).
SID: 72in (180cm) to minimize the
magnification.
Breathing Instruction: exposure made
during a slow, deep inspiration to
insure the trachea filling with ear.
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39. Structures shown:
 Larynx and trachea filled with ear.
Image quality:
 For neck region: the of image should include the area from
external ear canal to T2 or T3.
 For distal larynx & trachea: the image should include the area
from C3 to T4.
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40. AP projection: upper airway
 Demonstrate the pathology in larynx & trachea with air filled.
 Demonstrate the pathology in upper esophagus if object is given
contrast media.
Film size: 24x30 cm L.W.
Patient position:
 Patient upright, seating or standing.
 Back, head & shoulder against the IR
 Midsagittal plane perpendicular to the IR.
 Raise chin so that acanthiomeatal line is perpendicular to the IR;
have a patient look directly ahead.
 Top IR about 3-4 cm below EAM.
CR: Directed to T1-2, about 2.5cm above jugular notch.
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41. Breathing Instruction: exposure made during a slow, deep
inspiration to insure the trachea filling with ear.
Structure shown:
 The larynx & trachea from C3 to T4 should be
filled with air & visualized through the spine.
Image quality:
 No rotation: symmetric of sternoclavicular joints.
 Mandible should superimpose the base of the skull with the spine
aligned with the center of the film.
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