TB X-Ray Training Module PDF

for a healthy Zambia TBLON PROJECT: TRAINING ON RADIOLOGICAL DIAGNOSIS OF TB Facilitators: Dr Nteeni Mutinta Siachami Mr Malunga Chipulu MODULES 1. Chest x-ray technique & safety 2. Assessing quality of chest x-ray 3. Chest anatomy 4. Chest interp...

for a healthy Zambia TBLON PROJECT: TRAINING ON RADIOLOGICAL DIAGNOSIS OF TB Facilitators: Dr Nteeni Mutinta Siachami Mr Malunga Chipulu MODULES 1. Chest x-ray technique & safety 2. Assessing quality of chest x-ray 3. Chest anatomy 4. Chest interpretation I 5. Chest interpretation II 6. Tuberculosis and chest x-ray 7. Post treatment changes on chest x-ray 8. Disseminated tuberculosis imaging- spine, abdomen and other parts 9. Cases and practical exercises Module 1 ; Technique Technique: Introduction  X-rays are a form of energy, similar to visible light, microwaves and radio waves.  Unlike visible light, x rays have enough energy to pass through body tissues.  As the x-rays move through the body tissues, they are absorbed differently by bone, lungs, air etc allowing an image to be formed.  The image formed is displayed in a film/on a screen. https://nl.123rf.com/photo_25301700_volledige-lengte-van-de-verpleegkundige- aanpassen-xray-machine-voor-vrouwelijke-pati%C3%ABnt-in-het-onderzo.html Electromagnetic Wave Spectrum  Postero-anterior view  -The standard position for obtaining a routine adult chest radiograph.  -Patient faces the image receptor  -Dorsum of hands placed behind and below the hips (pushes the scapulae away from the lung fields)  -Image taken in full normal arrested inspiration.  Postero-anterior view: essential image characteristics.  Full lung fields are seen.  Scapulae projected away from the lung fields.  Medial ends of the clavicles symmetrical and equidistant from the spinous processes.  -Sufficient inspiration: visualizing 6th anterior ribs/10 ribs posteriorly.  Sharply defined costophrenic angles, diaphragm, mediastinum, lung markings and heart.  Anteroposterior (AP) view  Used when patient unable to cooperate for the routine PA procedure (very sick patient, infants)  May be done with the patient seated or lying flat on a bed, with the cassette/detector behind the patient.  The heart is at a greater distance from the film hence appear more magnified than PA view.  Scapulae are usually visible in the lung fields.  Anteroposterior view: Image characteristics.  The heart may appear magnified.  The scapula are seen within the lung fields.  The clavicles are seen above the apex of the lung fields.  Lateral chest radiograph  Typically used in conjunction with the posteroanterior view.  Allows the viewer to see behind the heart and diaphragmatic dome and the hilar.  The side of the patient under investigation is brought in contact with the image receptor.  Lateral chest radiograph: essential image characteristics  Image should include the apices and costophrenic angles and lung margins anteriorly and posteriorly.  Image processing optimized to visualize the heart and lung tissue with particular regard to any lesions if appropriate.  NB: not a routine projection, to avoid increased patient dose  Done to confirm position and size of a lesion seen in another projection.  Apical/lordotic View  Clavicles project superiorly, clear of the lung fields.  This improves evaluation of the lung apices  Variety of techniques: PA/AP, erect/supine/prone.  Cephalic angulation of the central beam: 20-450  Shoulders rolled forward away from the lung field. Apical/Lordotic view: essential image characteristics Apical/Lordotic view: essential image characteristics RADIATION SAFETY  RADIATION SAFETY  Radiation sources can be grouped into 2:  -Natural  -Man- made.  X-rays involve use of man-made ionizing radiation to evaluate internal body structures.  Ionizing radiation can have harmful effects on body tissues.  The effects can be deterministic (surpassing a radiation threshold) or stochastic (none dose dependent)  A single view CXR has 0.02 mSv average effective radiation dose. (= 4 days background radiation; 7 hour flight= 0.05mSv)  Stochastic vs deterministic effects of radiation Deterministic effects: Stochastic effects:  Occurs when the radiation  Not dependent of dose of dose surpasses a threshold. radiation.  Below that level, no effects  There is damage to the DNA of seen. cells.  Eg. Cataracts, erythema,  May result in cancer or damage transient oligospermia. to germ cells (effect for cause  Radiation induced genetic effects in future offspring.) killing/malfunction of cells.  There is a latency of 2- 20 years  Effects are seen immediately before effects are seen. or within 3 weeks. (Leukemia 2 years; 10-20 years for solid tumors. RADIATION SAFETY  PATIENT  HEALTH WORKERS & OTHER CAREGIVERS Patient safety.  Justified examination: clinical summary.  Confirm patient identity: At least 2 identifications.  Correct technique and preparation. Avoid unnecessary repeats; optimum exposure factors and beam energy.  Collimation and shielding: Radiation exposure only to body part being evaluated.  **No limit on diagnostic radiation exposure levels. Safety of health workers and other caregivers.  Standardized waiting bay, patient flow and buildings.  Limit access to radiation areas. Only persons directly involved with the procedure should be allowed in the rooms.  Use shielding for caregivers who must be present at the radiation area. (Lead aprons, goggles, radiation barriers)  Radiation exposure monitoring for workers (TLDs; max 50 mSv/year)  Use of alternative imaging modality where applicable e.g. ultrasound for evaluation of pleural and pericardial effusion.  Safety in Pregnancy.  Asking patient if they are pregnant/suspect if they are pregnant.  Enquire about last normal menstrual period/ Pregnancy test.  If clinical reasons for the examination override, proceed with the examination using dose reduction strategies.  Shielding the patient’s belly from radiation using a lead apron/shield.  Collimation (Only expose the body parts being investigated to the x-ray beam.)  Taking the minimum number of exposures needed to establish a diagnosis.  Use of views that give the lowest radiation dose. Royal Australian and New Zealand College of Radiologists, Inside Radiology: Radiation Risk of Medical Imaging During Pregnancy, Available URL: www.insideradiology.com.au Additional measures of safety. The further away from the source of radiation one is, the safer they are from radiation. Inverse square law: Regular quality assurance assessment to ensure equipment is working at optimum level.  Mobile unit: special precautions  Used in less than ideal conditions.  Special emphasis should be made on radiation protection.  Maintain distance away from source of radiation for persons not directly involved in the imaging.  Reduce number of exposures per patient.  Protective equipment/gear should always be used. Radiation safety: summary ALARA= AS LOW AS REASONABLY ACHIEVABLE  TAKE HOME MESSAGE  Radiography involves use of ionizing radiation, that may have harmful effects.  All radiologic examinations should be justified.  Ensure the correct technique and positioning of the patient to obtain the best quality images to help in diagnosis.  Care should be taken to protect the health workers and other caregivers.  Special care should be taken to protect pregnant women. Module 2; Quality of chest x- ray Introduction  Most CXRs normal  Need to know what a normal CXR looks like Courtesy of professor pitcher  Technical Quality of a CXR  Evaluate the following before CXR interpretation  Patient details  At least two identifiers  Name  Date  Facility where X ray done  View RIP  Supine, PA, AP, lateral  The main qualities determining quality of a CXR  Rotation  Inspiration  Penetration Courtesy of professor pitcher Assessing Quality of CXR  Clavicular heads  Spinous processes  Vertebra bodies  Ribs  Anterior ribs  Posterior ribs View PA Scapula Periphery of the lungs AP Over the lung fields Clavicles Project over lung fields Above the lung apices Ribs Posterior ribs well visualized Anterior ribs well visualised Gastric Well visualized Not well visualized Bubble Rotation  Observe the clavicular heads (medial ends) and spinous  Clavicular heads should be equidistant from the spinous processes of the thoracic vertebrae  The spinous process should be between the clavicular heads  Rotation is important in determining  Tracheal deviation  Heart size Normal rotation Courtesy of professor pitcher Courtesy of professor pitcher Courtesy of professor pitcher Courtesy of professor pitcher  Inspiration  CXR should be taken with full inspiration  “Breath in and hold your breath”  Diaphragm should be observed at  Count the ribs to the diaphragm  8th to 10th rib posteriorly or  5 to 6th rib anteriorly Courtesy of professor pitcher Inspiration Expiration Inspiration Inspiration Courtesy of professor pitcher  Normal Expansion Normal Expansion Hyper-Expansion  Flattened hemidiaphragms  Penetration  Penetration is the degree to which the X-rays pass through the body  In normal penetration  4 Lower thoracic vertebra should be visible through the heart Spin e  Left hemidiaphragm should be visible at the of the spine Hemidiaphra gm  The bronchovascular Image Courtesy of drbeen structures behind the heart https://www.drbeen.com/blog/the-basics-of-chest-x- ray-interpretation/) should be seen  Under exposure  Makes structures radio- opaque (darker)  May cause “overcalling” some findings  Features Spi 