Lecture 3 - Chest Radiography 2020 with Videos.pdf

ANATOMY & POSITIONING I CHEST RADIOGRAPHY LECTURE 3  BODY CAVITIES ! There are three large internal spaces which occupy the trunk of the body: ◦ Thoracic Cavity ◦ Abdominal Cavity ◦ Pelvic Cavity ! The thoracic and abdominal cavities are separated by a la...

ANATOMY & POSITIONING I CHEST RADIOGRAPHY LECTURE 3  BODY CAVITIES ! There are three large internal spaces which occupy the trunk of the body: ◦ Thoracic Cavity ◦ Abdominal Cavity ◦ Pelvic Cavity ! The thoracic and abdominal cavities are separated by a large muscular partition called the Diaphragm ! There is no structural division between abdomen and pelvis ◦ May collectively be called the Abdominopelvic cavity  THORACIC CAVITY ! The Thoracic Cavity occupies the upper portion of the trunk, located between the neck and abdomen ! It is separated from the Abdominal Cavity by the Diaphragm ! The Diaphragm can be subdivided into the Right and Left Hemidiaphragm  BONY THORAX ! The Bony Thorax encloses the Thoracic Cavity and provides a protective framework for the organs contained within ! The Bony Thorax consists of the: ◦ Sternum ◦ Clavicles ◦ Scapulae ◦ 12 Pairs of ribs ◦ 12 Thoracic Vertebrae  RESPIRATORY SYSTEM ! The Respiratory System provides vital functions for the body: ! It introduces oxygen to the cells, which is needed to carry out metabolic activities under aerobic conditions ! It removes carbon dioxide, produced by cellular activities, as a waste product of metabolism  RESPIRATORY SYSTEM ! The Respiratory System consists of the: ◦ Pharynx ◦ Larynx ◦ Trachea ◦ Bronchi ◦ Lungs  RESPIRATORY SYSTEM ! Air enters the nasal cavity, which is divided into right and left chambers by the cartilaginous and bony nasal septum ! The nasal cavity communicates with the Pharynx  PHARYNX ! The Pharynx is commonly referred to as the throat ◦ It may also be called the upper airway or upper respiratory tract ! The Pharynx is common to both the Digestive and Respiratory Systems ◦ It aids in deglutition or swallowing  PHARYNX ! The Pharynx is 5 inches (125 cm) in length and lined with mucous membrane ! It is located anterior to the Cervical Spine ! The Pharynx extends below the Sphenoid bone in the base of skull to the level of the disc space between C6- C7, where it becomes continuous with the Esophagus  PHARYNX ! The Pharynx is divided into three parts: ! Nasopharynx ◦ Communicates with the Nasal Cavity ! Oropharynx ◦ Communicates with the Oral Cavity ! Laryngopharynx or Hypopharynx ◦ Communicates with both the Larynx and Esophagus  LARYNX ! The Larynx is the organ of voice (voice box) and is the most proximal portion of the Respiratory System ! It is located below the root of the tongue and anterior to the Laryngopharynx  LARYNX ! The Larynx is 1½-2 inches (4-5 cm) in length and extends from C3-C6 ! It is suspended by ligaments from a small bone in the anterior neck called the Hyoid Bone just below the tongue or floor of the mouth  LARYNX ! The Epiglottis is a flap of elastic cartilaginous tissue covered with a mucous membrane, attached to the entrance of the Larynx ! It acts as a lid for the slanted opening of the Larynx ! During swallowing, the Epiglottis flips down and covers the Laryngeal opening, preventing food and fluid from entering the Larynx, Trachea and Bronchi of the Lungs  LARYNX ! The Larynx consists of nine pieces of cartilage ! The major cartilages include the: ◦ Thyroid Cartilage ◦ Cricoid Cartilage  LARYNX ! Thyroid Cartilage ◦ Largest cartilage located at the level of C5 ◦ Two fused plates that form the anterior wall of the Larynx ! Cricoid Cartilage ◦ Ring of cartilage which forms the inferior and posterior margin of Larynx ◦ Attached to the first ring of the Trachea ◦ Tracheotomies are performed just below the cricoid cartilage  LARYNX ! The Vocal Cords of the Larynx are located posteriorly on either side of the Thyroid Cartilage ! The Glottis is a slit-like opening between the Vocal Cords ! Sounds are made as air passes between the Vocal Cords along with numerous muscles and ligaments, which connect the Laryngeal Cartilages to assist in sound- making  TRACHEA ! The Trachea is commonly referred to as the windpipe ! It is 4½ inches by 1inch in diameter ! The Trachea extends from its junction with the Larynx at the level of C6 to the level of T4-T5  TRACHEA ! The Trachea is a fibrous, muscular tube formed by sixteen to twenty C- shaped rings of cartilage that keep it from collapsing when the airway is open during inspiration ! It is lined with ciliated cells which beat upward to carry foreign particles and excessive mucous secretions away from the Lungs  TRACHEA ! At the inferior margin of the Trachea is a bony spur of cartilage called the Carina which bifurcates or splits the trachea into two lesser tubes called the Right and Left Main Stem Bronchus ! The bifurcation occurs at the level of T5  MAIN STEM BRONCHI ! The 3rd division of the respiratory system is the Main Stem Bronchi ! They are two primary tubes which enter the Lung at a slit called the Hilum ! The Right Main Stem Bronchus is shorter, wider and more vertical ◦ Foreign bodies lodge in the Right Main Stem Bronchus more commonly than in the left  MAIN STEM BRONCHI ! Upon entering the Lungs at the Hilum, the Main Stem Bronchi branch into Secondary Bronchi to supply each lobe of the Lungs: ! There are 3 Secondary Bronchi in the Right Lung (corresponding to the 3 lobes of the Right Lung) ! There are 2 Secondary Bronchi in the Left Lung (corresponding to the 2 lobes of the Left Lung)  BRONCHIOLES ! The Secondary Bronchi further subdivide into smaller tubes called Bronchioles ! The Bronchioles spread to all parts of the Lung as many smaller branches ◦ They are referred to as lung markings on a Chest image ! The Bronchiole walls are made of smooth muscle ◦ If they spasm, they may close off, causing an Asthma Attack  BRONCHOGRAM ! To demonstrate the Bronchial Tree, a Bronchogram may be performed ! A Bronchogram is a specialized radiographic procedure of the bronchial tree using radiopaque contrast medium  ALVEOLI ! The Bronchioles terminate into very small tubes called Terminal Bronchioles and attach to small sacs called Alveoli ! The Alveoli are the functional unit of the Lungs, where exchange of oxygen and carbon dioxide occurs ! Each Alveoli consist of a Alveolar Duct and Sac  ALVEOLI ! The Alveoli receive deoxygenated blood from the Pulmonary Arteries ! Once oxygenated, blood returns to heart via the Pulmonary Veins  PULMONARY CIRCULATION ! The Pulmonary Circuit of the Cardiovascular System is unique in the way that veins and arteries differ from the rest of the body ! The Systemic Circuit of the Cardiovascular System works in the following way: ◦ Arteries in the body bring oxygenated blood from the Heart to the rest of the body ◦ Veins in the body bring deoxygenated blood back to the Heart from the rest of the body  PULMONARY CIRCULATION ! The Superior and Inferior Vena Cava are the major veins which bring deoxygenated blood back to the heart ! The deoxygenated blood flows through the Right Atrium and Right Ventricle of the Heart ! The deoxygenated blood then flows through the Pulmonary Arteries to the Alveoli in the Lungs for removal of carbon dioxide and replenishment of oxygen  PULMONARY CIRCULATION ! The Pulmonary Veins bring oxygenated blood back to the left side of the heart, where it is pumped through the Left Atrium and Ventricle ! The oxygenated blood is then sent back through the body by way of the Aorta and Arteries  LUNGS ! The Lungs are the 4th and last division or distal portion of the Respiratory System ! They are located on either side of the Thoracic Cavity ! The Lungs are composed of spongy elastic material called parenchyma, which allows the Lungs to expand and contract  LUNGS ! The Lungs bring oxygen in and remove carbon dioxide from the blood through the thin walls of the alveoli ! There is a capillary network from the Pulmonary Arteries for exchange of oxygen and carbon dioxide  LUNGS ! Each Lung consists of: ! An Apex: Pointed superior portion approximately 1inch superior and posterior to the Clavicle ! A Base: Broad, concave portion resting on the convex surface of the Diaphragm  LUNGS ! A depression or slit on the medial surface of each Lung is called the Hilum, where the Bronchi, Pulmonary Arteries, and Nerves enter the Lung and the Pulmonary Veins Lymphatic Vessels exit  LUNGS ! Where the Base of each Lung meets the ribs of the Bony Thorax at its outermost corner, an angle is formed called the Costophrenic Angle ! Where the Base of each Lung meets the Heart at its innermost corner, an angle is formed called the Cardiophrenic Angle  LUNGS ! The Lungs are divided into lobes by deep Fissures, which lie in an oblique plane, allowing the lobes to overlap  LUNGS ! There are three Lobes in the Right Lung and two Lobes in the Left Lung  LUNGS ! The Oblique Fissures divides the Right and Left Lungs into Superior and Inferior Lobes ! The Right Superior Lobe is further divided by a Horizontal Fissure, creating the Right Middle Lobe ! The Left Lung has no Horizontal Fissure – thus there are only two lobes in the Left Lung  RIGHT LUNG ! The Right Lung is one inch shorter than the left lung due to the large space occupied by the Liver in the abdomen, which pushes up on Right Hemidiaphragm ! The Right Lung is also broader than the Left because of the position of the Heart  RIGHT LUNG ! The Right Lung has a larger volume because it has 3 lobes (corresponding to the number of Secondary Bronchi) ! The Lobes of the Right Lung are named according to their location and include: ◦ Upper or Superior Lobe ◦ Middle Lobe ◦ Lower or Inferior Lobe  LEFT LUNG ! The Left Lung is longer than the Right Lung and has a smaller volume due to having only 2 lobes ! On the medial side of the Left Lung is an indentation called the Cardiac Notch to accommodate the Heart ! The Left Lung is divided into 2 lobes (with corresponding Secondary Bronchi) named according to their location: ◦ Upper or Superior Lobe ◦ Lower or Inferior Lobe  PLEURA ! The Pleura is a double walled sac of membrane that encloses the Lungs and the Thoracic Cavity ! Visceral Pleura: The inner lining that adheres to the Lungs – the textbook also refers to this as the Pulmonary Pleura ! Parietal Pleura: The outer lining that adheres to the walls of the Thoracic Cavity  PLEURAL CAVITY ! The Pleural Cavity is a small space between the Visceral and Parietal linings ! It is filled with pleural fluid which acts like a lubricant to reduce friction between the layers during respiration  PLEURAL CAVITY ! The Pleural Cavity is only demonstrated radiographically when there is an abnormality within the Lung ! Two abnormalities include: ! Pneumothorax ! Pleural Effusion  PNEUMOTHORAX ! When a lung collapses, it is called Atelectasis ! Air collects between the Parietal and Visceral layers in the Pleural Cavity, resulting in a condition called Pneumothorax ! Radiographically, a Pneumothorax is visualized by a lack of lung markings (Bronchioles)  PLEURAL EFFUSION ! Pleural effusion is an abnormal accumulation of fluid in the pleural cavity ! It is demonstrated on this Decubitus Chest image by the presence of fluid on the right side (arrows) ! There is also fluid accumulation in the Horizontal Fissure (arrowhead)  MEDIASTINUM ! The Mediastinum is a vertical partition located in the Midsagittal Plane of the Thoracic Cavity ! It contains all of the Thoracic organs except the Lungs ! The Mediastinum is bounded anteriorly by the Sternum and posteriorly by the Thoracic Spine ! It consists of superior, anterior, and posterior sections  MEDIASTINUM ! The Mediastinum includes the following organs: ◦ Trachea ◦ Esophagus ◦ Bronchi ◦ Thymus Gland (in children) ◦ Heart ◦ Great Vessels  TRACHEA / ESOPHAGUS ! The Trachea lies anterior to the Esophagus and is visualized as an air-filled radiolucent tube leading to the hilum on a Lateral Chest image ◦ The Main Stem Bronchi and Trachea are superimposed on each other on the Lateral image ! The Esophagus collapses on itself when it is not filled with food or fluid, but will often appear if filled with air on a Lateral Image  THYMUS GLAND ! The Thymus Gland is located behind the upper sternum, above and anterior to the Heart ! It is often referred to as a temporary organ ! It is prominent in children until the age of puberty, where it gradually diminishes and almost disappears in adults  THYMUS GLAND ! The Thymus Gland functions primarily during childhood to aid with the body’s immune system and contributes to the body’s ability to produce antibodies ! Arrow on Lateral Chest image demonstrates an enlarged thymus gland in a pediatric patient  HEART ! The Heart and roots of the Great Vessels are enclosed in a double- walled sac called the Pericardial Sac ! The Heart is located posterior to the Sternum and anterior to the fifth- eighth Thoracic Vertebrae ! It lies in an oblique plane within the Mediastinum, with approximately 2/3rds to the left of the Midsagittal plane  GREAT VESSELS ! The Great Vessels of the Mediastinum include the following: ! Aorta ! Superior Vena Cava ! Inferior Vena Cava ! Pulmonary Arteries ! Pulmonary Veins  AORTA ! The Aorta is the largest artery in the body, carrying blood to all parts of the body through its various branches ! It is divided into three parts: ! Ascending Aorta (coming from the heart) ! Aortic Arch (where it turns on itself) ! Descending Aorta (passes downward through the diaphragm where it becomes the abdominal aorta)  AORTA ! At the Arch of the Aorta, there are three branches: ◦ Brachiocephalic Artery ◦ Left Common Carotid Artery ◦ Left Subclavian Artery  VENA CAVAS ! The two major Veins of the Mediastinum are the: ! Superior Vena Cava ! Inferior Vena Cava ! Superior Vena Cava ◦ Large vein that returns blood to the heart from the upper half of body ! Inferior Vena Cava ◦ Large vein returning blood to the heart from the lower half of the body  PULMONARY VESSELS ! The remaining Great Vessels of the Mediastinum include the: ! 2 Pulmonary Arteries ◦ Bring deoxygenated blood from the Heart to the Lung ! 2 Pulmonary Veins ◦ Bring oxygenated blood from the Lungs to the Heart REVIEW  RESPIRATORY CYCLE ! The pressure inside the lungs is in constant balance with outside atmospheric pressure ! The balance between negative and positive pressure is achieved through the Respiratory Cycle (inspiration / expiration) ! Respiration occurs 16-18 times per minute  RESPIRATORY CYCLE ! The Thoracic Cavity is airtight, with flexible side walls (Ribs) and a flexible floor (Diaphragm) for expansion and contraction during the Respiratory Cycle  THE DIAPHRAGM ! The Diaphragm is the dome- shaped sheet of muscle that separates the Thoracic Cavity from the Abdominal Cavity ! It is also referred to the Thoracic Diaphragm because it’s located in the Thoracic Cavity ! It is attached to the spine, ribs and sternum and is the main muscle of respiration, playing a very important role in the breathing process  THE DIAPHRAGM ! The location of the Diaphragm depends upon: ! A person’s physique or body structure ! Whether they are inhaling or exhaling ! Whether they are recumbent or erect  RESPIRATORY EXCURSION OF THE DIAPHRAGM ! On Inspiration: Air moves into the Lungs ! The Diaphragm contracts, flattens and is lowered ! The volume and dimension of the Thoracic Cavity increases in 3 dimensions: ◦ Vertical ◦ Transverse ◦ Anteroposterior  RESPIRATORY EXCURSION OF THE DIAPHRAGM ! On Expiration: Air moves out of the Lungs ! The Diaphragm relaxes and rises ! The volume and dimensions of the Thoracic Cavity decrease  BODY HABITUS ! Body Habitus describes variations in the general form and shape of the body between individuals ! The type of Body Habitus is determined by the: ◦ Size, shape and position of organs ◦ Muscle tone ◦ Motility of the internal organs ! The organs most affected by Body Habitus are: ◦ Lungs ◦ Heart ◦ Gallbladder ◦ Stomach ◦ Large Intestine  BODY HABITUS ! There are four distinct Body Habitus: ◦ Hypersthenic ◦ Sthenic ◦ Hyposthenic ◦ Asthenic  HYPERSTHENIC ! The Hypersthenic individual has a stocky “massive” build ! The Thoracic Cavity is wide and deep from front to back, short vertically ! The Ribs lie in a horizontal plane ! The Diaphragm is high ! The Lungs are short and narrow at the Apices and broad at the Bases ! The Heart is short and wide ! 5% of population  STHENIC ! The Sthenic individual is considered “average” though leans slightly to heavy-set ! The Thoracic Cavity is moderately deep from front to back, average vertically ! The Ribs lie in a more vertical plane ! The Diaphragm is moderately high ! The Lungs are longer, slightly narrower at the Apices than at the Bases ! The Heart is moderately transverse ! 50% of population  HYPOSTHENIC ! The Hyposthenic individual is considered leaner and slightly taller than “average” ! The Thoracic Cavity is shallower from front to back, longer vertically ! The Ribs lie in a vertical plane ! The Diaphragm is lower ! The Lungs are longer, almost equal width at the Apices and the Bases ! The Heart is vertical and more toward the midline ! 35% of population  ASTHENIC ! The Asthenic individual is considered very slender and is the extreme to the Hypersthenic individual ! The Thoracic Cavity is narrow and shallow but longer vertically ! The Ribs slope downward sharply and lie in a vertical plane ! The Diaphragm is very low with most of the abdominal organs lying within the pelvis ! The Lungs are longer, with the Apices extending way above the Clavicles, equal width at the Bases ! The Heart is vertical and at the midline ! 10% of population HYPERSTHENIC / STHENIC COMPARISON STHENIC / HYPOSTHENIC COMPARISON HYPOSTHENIC / ASTHENIC COMPARISON HYPERSTHENIC / ASTHENIC COMPARISON BODY HABITUS COMPARISON Name each Body Habitus as represented by the above images: ! A. ! B. ! C. ! D.  CLINICAL INDICATIONS ! There are a wide variety of clinical indications for ordering a Chest X-ray that will diagnose abnormalities of the Respiratory and Cardiovascular Systems ! The more common indications include: ◦ Chronic Obstructive Pulmonary Disease ◦ Pneumonia ◦ Pulmonary Edema / Congestive Heart Failure ◦ Pleurisy ◦ Tuberculosis ◦ Malignant and Benign Tumors ◦ Asbestosis ◦ Respiratory Distress Syndrome  COPD ! There are two main types of COPD (chronic obstructive pulmonary disease) ◦ Chronic Bronchitis ◦ Emphysema ! The main cause of COPD is long-term exposure to substances that irritate and damage the lungs, like cigarette smoking ! Air pollution, chemical fumes, or dust can also cause it  EMPHYSEMA ! Emphysema is an irreversible and chronic lung disease ! There is alveolar wall destruction and loss of elasticity ! Air tends not be expelled during expiration, resulting in labored breathing  EMPHYSEMA ! Emphysema is evident on Chest images by increased lung dimensions, as in a barrel-shaped chest ! The Diaphragm appears flattened with loss of the Costophrenic Angles ! The Lung fields appear radiolucent because of trapped air within the Alveoli  PNEUMONIA ! Pneumonia is an inflammation of the lung resulting in accumulation of fluid within a segment of the lung ! It appears as an area of increased density and will demonstrate an air fluid level ! The image on the right demonstrates Right Lower Lobe Pneumonia  PULMONARY EDEMA ! Pulmonary Edema is often caused by Congestive Heart Failure ! When the heart is not able to pump blood to the body efficiently, it can back up into the veins that take blood through the Lungs to the left side of the Heart ! As the pressure in these blood vessels increases, fluid is pushed into the Alveoli in the Lungs ! This fluid reduces normal oxygen movement through the Lungs  PULMONARY EDEMA ! Pulmonary Edema is demonstrated on a Chest image as diffuse radio-densities in the Hilar regions of the Lung, fading toward the periphery ! If Congestive Heart Failure is present, the Heart shadow will be enlarged  PLEURISY ! Pleurisy (also known as pleuritis) is an inflammation of the Pleura ! There are many possible causes of pleurisy but viral infections spreading from the lungs to the pleural cavity are the most common ! The inflamed pleural layers rub against each other every time the lungs expand when inhaling ! This can cause sharp pain when breathing, also called pleuritic chest pain  TUBERCULOSIS ! Tuberculosis (TB) is a disease caused by a bacterium called Mycobacterium tuberculosis that is spread through the air from one person to another ! The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain  TUBERCULOSIS ! Tuberculosis causes inflammation, the formation of tubercules and other growths within tissue, and can cause tissue death ! Pulmonary tuberculosis is making a comeback with new resistant strains that are difficult to treat  BENIGN NEOPLASMS ! Benign lung nodules and tumors usually cause no symptoms ! They are almost always found accidentally on a chest X-ray or CT scan  BENIGN NEOPLASMS ! The more common types of benign lung tumors include: ! Hamartomas are the most common type of benign lung tumor and the third most common cause of solitary pulmonary nodules ◦ These firm marble-like tumors are made up of tissue from the lung's lining as well as tissue such as fat and cartilage ◦ They are usually located in the periphery of the lung. ! Bronchial Adenomas make up about half of all benign lung tumors ◦ They are a diverse group of tumors that arise from mucous glands and ducts of the Trachea  LUNG CANCER ! Lung cancer (also known as Carcinoma of the Lung) is a disease characterized by uncontrolled cell growth in tissues of the lung ! If left untreated, this growth can spread beyond the lung in a process called metastasis into nearby tissue or other parts of the body ! Most cancers that start in Lung, known as primary lung cancers, are carcinomas that derive from epithelial cells  LUNG CANCER ! The main types of Lung Cancer are Small-Cell Lung Carcinoma (SCLC), also called Oat Cell cancer, and Non-small-cell Lung Carcinoma (NSCLC). ! The most common symptoms are coughing (including coughing up blood), weight loss, shortness of breath and chest pains  ASBESTOSIS ! Asbestosis is a chronic lung disease characterized by a scarring of lung tissues, which leads to long-term breathing complications ! The disease does not have a cure ! It is caused exclusively by exposure to Asbestos, but may not be diagnosed until decades after the exposure occurred RESPIRATORY DISTRESS SYNDROME ! Respiratory Distress Syndrome (RDS) is a breathing disorder that affects newborns ! The disorder is more common in premature infants born about 6 weeks or more before their due dates ! RDS is more common in premature infants because their lungs aren't able to make enough surfactant  RESPIRATORY DISTRESS SYNDROME ! Surfactant is a liquid that coats the inside of the Lungs ◦ It helps keep them open so that infants can breathe in air once they're born ◦ Without enough surfactant, the lungs collapse ! Classic respiratory distress syndrome (RDS) appears as a Bell-shaped thorax due to generalized under- aeration of the lungs  CHEST RADIOGRAPHY ! Chest Radiography should be performed upright or erect whenever possible when the patient’s condition permits ! The Upright or Erect position is performed for three reasons: 1. It allows the diaphragm to move to its lowest position, causing the abdominal organs to drop, so the lungs can fully aerate 2. It demonstrates possible air / fluid levels within the chest cavity or Lungs 3. It prevents engorgement of the Pulmonary Vessels  CHEST RADIOGRAPHY ! Chest Radiography should be performed at a minimum of 72 inch SID ◦ Some radiologists / department protocols require SID of 10 feet ! 72 inch SID minimizes enlargement of the Heart and Great Vessels by decreasing magnification  CHEST RADIOGRAPHY ! Chest Radiography is performed on inspiration to demonstrate the greatest possible area of lung tissue ! The degree of inspiration is determined by number of ribs showing within lungs ! The appearance of 10 ribs above the Diaphragm demonstrates full inspiration  CHEST RADIOGRAPHY ! Occasionally both Inspiration and Expiration Images may be taken on the same patient for comparison to: 1. R/O pneumothorax 2. Localize Foreign Body 3. Evaluate the respiratory excursion of the Diaphragm  CHEST RADIOGRAPHY ! The Routine Projections performed of the Chest are: ! Posteroanterior ! Left Lateral  ARTICLES NECESSARY ! 2 14x17 Image Receptors for Adult patients ! Pediatric Image Receptor sizes 10x12 CR – Newborns to 10 years old 14x17 – 10+ years old ! Right / Left Lead Anatomic Markers ! Gonadal Shielding ! Most Chest Units have a bar attached for the patient to hold on raising their arms above their head ◦ IV Pole - used for lateral so patient can raise their arms only if handle bar is not available  EQUIPMENT PREPARATION ! Clean X-ray room ! Place the X-ray Tube in the horizontal position ! 72 inch to 10 feet SID ! Center the X-ray Tube to center of the Upright Bucky or Chest unit ! Place 14x17 image receptor lengthwise in upright bucky ◦ Hypersthenic men will need to have Image Receptor placed crosswise to accommodate for broader lungs if using an Upright bucky  EQUIPMENT PREPARATION ! DR (Direct Radiology) does not use Image Receptors  SET CONTROL PANEL ! High kVp (110-125) is used to ensure penetration of the Heart and provide a low contrast image (lots of shades of gray termed long scale) ! If not using a grid or bucky, lower kV is used ◦ 80 kV for Portable Chest X-ray ! mAs: High mA and low exposure time to reduce the chance of motion caused by heart contractions ! Select Large Focal Spot  SET CONTROL PANEL ! Most Routine Chest Projections use AEC (Automatic Exposure Control) when using an Upright Bucky, Chest Unit or DR Unit ! When selecting the AEC Photocells: ◦ Outer Chambers for PA – lungs will overly the photocells ◦ Center Chamber for Lateral  PATIENT PREPARATION ! Greet patient and establish correct identification ! Provide instructions for undressing ◦ Everything off from waist up with the gown tied in the back ◦ Ensure that no artifacts are worn by the patient including bra, necklaces, chains, piercings ! Assess patient condition to determine how to proceed ! Explain procedures and obtain clinical information ! Question female patients about the possibility of pregnancy  PA PROJECTION ! The patient should be facing the Upright bucky, with their weight equally distributed ◦ The shoulders should be in the same transverse plane ! Raise the chin and place on the chin rest to avoid superimposing neck soft tissue over Apices of the Lungs ! Place the top of the Image Receptor 1-2” above the top of the shoulders, depending upon the patient’s body habitus  PA PROJECTION ! Center the patient’s Midsagittal plane to the midline of the Upright bucky ! Roll the patient’s shoulders forward to remove the Scapulae from the Lung field and to project the Clavicles below the Apices of the Lungs ! Direct the Central Ray perpendicular to midline of the Image Receptor – it will enter at approximately T7  PA PROJECTION ! Collimate the X-ray beam to the size of the Image Receptor – light shadow should be visible on either side of the patient and above the shoulders ! Mark the Image Receptor with the Right anatomic side marker on the outside of the Upright Bucky ! Place the gonadal shielding at waist level facing the X-ray tube  PA PROJECTION ! Instruct the patient to take a deep breath in and hold their breath – the exposure is made with the patient taking a full inspiration ! Make the exposure from behind the control panel while observing the patient ! After the exposure, make sure to tell the patient to breathe! ADJUSTMENT FOR BODY HABITUS ! When performing the PA Projection on the majority of patients, placement of the top of the Image Receptor 1-2 inches above the shoulders will direct the Central Ray to approximately T7 ! For the Hypersthenic individual, place the top of the Image Receptor one inch higher as these individuals have shorter lungs  TEXTBOOK VARIATION ! The textbook recommends locating the Vertebral Prominens (Spinous Process of Cervical Spine #7) at the base of the neck and measuring an 8 inch hand spread for males and a 7 inch hand spread for females for centering point of the Central Ray  LATERAL PROJECTION ! The Left Lateral Projection is most commonly performed ! It will place the Heart closer to the Image Receptor, reducing OID and magnification  LATERAL PROJECTION ! Replace 14X17 Image Receptor in the Upright bucky lengthwise ! Turn the patient so their left side is against the bucky surface, weight evenly distributed, shoulders in the same transverse plane ! Place the Midsagittal plane parallel to the plane of the Image Receptor  LATERAL PROJECTION ! Check for rotation of the spine and hips - no leaning into the bucky or forward bending ! Lower the bucky so that the top of the Image Receptor is 1 inch above the shoulders ! Because of the increase in the OID of the lower right lung field, the Right Costophrenic Angle will be projected lower due to the divergence of the X-ray beam  LATERAL PROJECTION ! Instruct the patient to extend their arms above their head – they may grasp their forearms or hold on to the handle bar above their head ! Center the patient’s Midaxillary line to center of Upright Bucky ! Direct the Central Ray perpendicular to the center of the Image Receptor at the level of the midthorax (T7)  LATERAL PROJECTION ! Place the Left anatomic side marker placement on outside of Upright Bucky in light field away from anatomical structures ! Collimate to size of the Image Receptor or use Automatic Collimation ◦ Light field should be seen on anterior and posterior aspects of the Chest  LATERAL PROJECTION ! Turn the gonadal shielding so it is facing the X-ray tube if using a apron shield ! Adjust AEC on the control panel to the Center Chamber ! Expose on inspiration ADJUSTMENT FOR BODY HABITUS ! For Hyposthenic and Asthenic patients with longer lungs, lower the Bucky 1 inch from the PA Projection because the lungs will be projected lower due to the divergence of the X-ray beam  COMPLETING THE EXAM ! Provide the patient with post-examination instructions ! The patient should remain in waiting area until images have been analyzed for medicolegal aspects, anatomical structures, positioning and exposure factors ! Once cleared, the images are transmitted for radiologist reading and other areas of the hospital through PACS ! Complete patient data entry into the computer and charging of examination to patient account ! Clean and stock the room in preparation for the next patient  IMAGE ANALYSIS MEDICOLEGAL ! For all radiographic images – the first step is to make sure that the medicolegal aspects of the image are included: ◦ Patient Identification ◦ Appropriate Right or Left anatomic side marker  IMAGE ANALYSIS – PA PROJECTION ANATOMICAL STRUCTURES ! The entire lung field should be included from the Apices to the Costophrenic Angles ! The air-filled Trachea should be located within the midline of the image ! Lung and hilar markings on either side of the Thoracic spine ! 10 Ribs demonstrated above the Diaphragm, indicating the exposure was made on full inspiration  IMAGE ANALYSIS – PA PROJECTION ANATOMICAL STRUCTURES ! The anatomical structures on the PA Projection of the Chest include: ! Air-filled Trachea ! Apices of Lung ! Clavicles ! Scapulae ! Aortic Arch ! Hilum  IMAGE ANALYSIS – PA PROJECTION ANATOMICAL STRUCTURES ! The anatomical structures on the PA Projection of the Chest include: ! Heart Shadow ! Lung Bases ! Costophrenic Angles ! Cardiophrenic Angles ! Gastric Air Bubble in the Fundus of Stomach ! A slight shadow of the Thoracic Vertebrae behind Heart  IMAGE ANALYSIS – PA PROJECTION POSITIONING ! Rotation on the PA Projection is determined by examining the Sternoclavicular (SC) Joints ◦ If symmetrical – No rotation ◦ If not symmetrical – Rotation of the Chest ! The anatomical structures are centered ! The Scapula are removed from the Lung field ! Chin soft tissue is not overlying the Apices of the Lung  IMAGE ANALYSIS – PA PROJECTION POSITIONING ERROR ! The SC Joints aren’t symmetrical on this image, indicating that the patient is rotated ! Rotation is caused by: ◦ The patient’s weight not being evenly distributed ! The direction of the rotation can be determined by which sternal end of the Clavicle is closest to the spine ◦ This patient is in a slight LAO position because the sternal end of the Left Clavicle overlies the spine  IMAGE ANALYSIS – PA PROJECTION POSITIONING ERROR ! The Shoulders were not rolled forward enough indicated by the Scapula within lung field ! The Shoulders were also not in same transverse plane indicated by the Left Scapula located higher than the Right ! The errors in positioning on this image are slight and would not require a repeat exposure  IMAGE ANALYSIS – PA PROJECTION EXPOSURE FACTORS ! Adequate penetration is demonstrated by a faint shadow of Thoracic Spine behind the Heart Shadow ! Evidence of radiation protection – light field on all sides of anatomy ! No evidence of motion by sharp outlines of rib margins, diaphragm and Heart borders ! Long-scale contrast for visualization of vascular markings within the lung field  IMAGE ANALYSIS – PA PROJECTION EXPOSURE FACTOR ERROR ! The Note SC joints aren’t symmetrical on this image, caused by the scoliosis of the spine ! Because of the scoliosis, the spine is placed over the right photocell ! The image is overexposed and should be repeated using manual exposure factors  IMAGE ANALYSIS – LATERAL ANATOMICAL STRUCTURES ! The Apices through Costophrenic Angles are included and superimposed ! The Intervertebral Disc spaces of Thoracic Spine open ! Hilum of the Lung in the center of the image ! Sternum in lateral position ! Esophagus behind Trachea  IMAGE ANALYSIS – LATERAL ANATOMICAL STRUCTURES ! The anatomical structures on the Lateral Projection of the Chest include: ! Lateral Sternum ! Air-filled Trachea ! Air-Filled Esophagus ! Lateral Scapula ! Aortic Arch ! Hilum  IMAGE ANALYSIS – LATERAL ANATOMICAL STRUCTURES ! The anatomical structures on the Lateral Projection of the Chest include: ! Heart Shadow ! Superimposed Costophrenic Angles ! Superimposed Cardiophrenic Angles ! Gastric Air Bubble in Fundus of Stomach ! Bodies and Intervertebral Disk Spaces of Thoracic Vertebrae  IMAGE ANALYSIS – LATERAL POSITIONING ! The Posterior Ribs are examined for superimposition ◦ No space between the Right and Left Posterior Ribs indicates no rotation ! No shadow of the arm or soft tissue overlying Apices ! No forward or backward leaning ! The Sternum is in the lateral position  IMAGE ANALYSIS – LATERAL POSITIONING ERROR ! The Posterior Ribs aren’t superimposed on this image ! Rotation is caused by: ◦ The patient’s weight is not evenly distributed ◦ The shoulders and hips not in the same transverse plane ! ¼ to ½ inch between the Posterior is acceptable – any more rotation would require a repeat exposure  IMAGE ANALYSIS – LATERAL POSITIONING ERROR ! The Posterior ribs on the right side (farthest from the Image Receptor) will be magnified slightly due to OID and will be projected slightly posterior to the Left Posterior Ribs (closest to the Image Receptor)  IMAGE ANALYSIS – LATERAL POSITIONING ERROR ! The Posterior ribs aren’t superimposed on this image ! There is more than ½ inch space between the Right and Left Posterior Ribs ! This is a repeatable error  IMAGE ANALYSIS – LATERAL POSITIONING ERROR ! The soft tissue of the arm is overlying the Apices of the Lungs ! The patient did not raise the arms high enough ! This is a repeatable error  IMAGE ANALYSIS – LATERAL EXPOSURE FACTORS ! Adequate penetration is demonstrated by visualization of Rib outlines and Lung markings through the Heart shadow and upper lung region ! Long scale contrast ! Evidence of radiation protection – light field on all 4 sides of anatomy ! No evidence of motion by sharp outlines of the Diaphragm and Lung vascular markings  DECUBITUS POSITIONS OF THE CHEST ! Decubitus positions of the Chest are performed when the patient can’t stand or sit upright – the patient will lie recumbent on either their right or left side depending upon the pathology to be visualized ! The technologist should check the patient’s requisition form for clinical indications to determine which decubitus position is to be performed ◦ When in question – check with the referring physician ! A horizontal X-ray beam is used to demonstrate the presence of air fluid levels  DECUBITUS POSITIONS OF THE CHEST ! If Pleural Effusion is suspected: Fluid will gravitate to the lowest position because of its weight and the effect of gravity ! The patient lies on the affected side or with the affected side down ! If Pneumothorax is suspected: The air outside the lungs (Pneumothorax) will rise to the highest position ! The patient lies on the unaffected side or affected side up  DECUBITUS POSITIONS OF THE CHEST ! The equipment used to perform a Decubitus position of the Chest depends upon what is available in the department and the patient’s condition: ◦ Upright Bucky with a cart ◦ Decubitus Bucky attached to the X-ray table ◦ Portable X-ray unit ! A 14x17 inch Image Receptor is placed in the bucky crosswise – it will be lengthwise with respect to the patient’s body position  LEFT LATERAL DECUBITUS ! The patient is placed on a radiolucent sponge, lying on left side ! The patient’s back IS against the bucky surface, knees together and flexed slightly, shoulders and hips parallel ! The patient’s arms should be raised above their head, away from the Lung field  LEFT LATERAL DECUBITUS ! The X-ray tube is placed in the horizontal position at 72 inch SID ! The height of the bucky or table is adjusted so that the patient’s Midsagittal plane is centered to midline of the Image Receptor ! The top of the Image Receptor is placed 2 inches above the patient’s shoulders  LEFT LATERAL DECUBITUS ! The Central Ray is directed perpendicular to midline of the Image Receptor to the patient’s midthorax ! Collimate to size of the Image Receptor ! Place the anatomical marker on the elevated side, with an arrow pointing up ! Shield the patient and expose on inspiration  IMAGE ANALYSIS LEFT LATERAL DECUBITUS ! The entire Lung field should be included from Apices to both Costophrenic Angles and lateral borders of the Thoracic Cavity ! Sternoclavicular Joints should be symmetrical ! Arms should not superimpose the upper Lung field ! No motion – sharp borders of the Heart and Lung markings ! Proper exposure factors: Faint visualization of the Thoracic Vertebrae behind the Heart shadow  IMAGE ANALYSIS DECUBITUS CHEST ! If the anatomy of interest is the side up – it is not a repeatable image if the side down is not included in its entirety on the image ! Pneumothorax of the Right Lung as indicated by arrows  ADAPTING THE EXAM TO THE PATIENT ! The patient’s condition may require a modification of the routine positions / projections ◦ Inability to stand ◦ Unstable condition ◦ Pediatrics ! Any change from the routine must be noted on the image (Place a position lead marker on Image Receptor or annotate on image during post- processing) PA PROJECTION - CART PATIENT ! Lock cart for patient’s safety ! Patient’s Midsagittal Plane centered to midline of Upright Bucky / Chest Unit ! Top of Image Receptor placed 1-2 inches above shoulders ! Light field above shoulders to ensure that the Apices are included PA PROJECTION - CART PATIENT ! Hypersthenic Males = 1 cross- wise or 2 Lengthwise Image Receptor’s to ensure the entire Lung field is included ! Make sure chin is elevated ! Roll the shoulders forward ! No rotation of body ! Watch marker placement so it is not overlying anatomical structures  LATERAL PROJECTION CART PATIENT ! Ensure that patient is in the True Lateral Position ! Check for rotation - no leaning into the bucky or forward bending ! Make sure the arms are raised high enough to avoid loose soft tissue from obscuring Lung field ! Midaxillary line centered to center of Upright Bucky or Chest Unit ! Make sure marker is not overlying anatomical structures  LATERAL PROJECTION CART PATIENT ! If the patient is unable to sit completely erect, the head of the cart can be raised as high as possible and a radiolucent sponge placed behind the patient’s back ! Follow previous positioning instructions AP PROJECTION OF THE CHEST ! AP Projections of the Chest are performed when the patient is unable to stand or sit upright against the Upright bucky ! AP projections can be performed in the Radiology Department, ER or on patient floors within the hospital ! When going to other departments, a portable (mobile) X-ray unit is used AP PROJECTION OF THE CHEST ! AP Projections of the Chest may be performed either Semi-upright or Supine depending upon the patient’s condition ! SID varies according to whether the Semi-upright or supine position is performed ! SID should be as long as the equipment allows to avoid magnification – use the tape measurer on the X-ray tube to confirm SID AP PROJECTION OF THE CHEST ! Raise the patient’s bed or cart into a Semi-upright position ! The technologist will usually have to slide the patient up towards the head end of the bed or cart with the patient supine, prior to raising the head end of bed or cart ! Place a 14x17 Image Receptor behind the patient’s back - crosswise orientation for most patient’s, unless they are very thin AP PROJECTION OF THE CHEST ! Make sure the top of the Image Receptor is at least 2 inches above the shoulders ! Check to make sure that there is an equal amount of the Image Receptor on either side of the patient ! Center the patient’s Midsagittal Plane to the midline of the Image Receptor AP PROJECTION OF THE CHEST ! Ensure that the patient is not rotated toward either side ! Place patient’s hands on their hips if possible and roll their shoulders forward, making sure that their arms are out of the Lung field ! Place the X-ray tube parallel to the patient’s Sternum and to the plane of the Image Receptor - angling the X-ray tube caudad will be necessary AP PROJECTION OF THE CHEST ! Direct the Central Ray perpendicular to the Sternum and to the midline of the Image Receptor at level of the midthorax ! Make sure there is light above the shoulders to avoid clipping the Apices of the Lungs ! Manually set control panel ◦ 3-8 mAs (depending on the size of the patient) at 80 kV ! Mark the Image Receptor, shield the patient and expose on inspiration  IMAGE ANALYSIS AP PROJECTION OF THE CHEST ! On completed radiographic image, annotate the image as an AP Semi-upright ! Time of day, Exposure factors, and SID may also be annotated on the image post-processing ! Lateral Projections are rarely performed portably  IMAGE ANALYSIS AP PROJECTION OF THE CHEST ! Evaluate the AP projection as previously discussed for routine PA projection ! The differences in the AP image will be: ◦ The Heart will appear magnified and engorged due to being farther from the Image Receptor (OID) ◦ The Clavicles will be projected higher and more horizontal on the AP image ◦ If the patient is not fully upright with a horizontal X-ray beam, air / fluid levels will not be clearly visible  IMAGE ANALYSIS - AP PROJECTION POSITIONING ERROR ! If the Central Ray is not placed perpendicular to the Sternum or angled enough on a Portable AP Projection of the Chest performed with the patient in a Semi-Upright position, the resultant image will: ◦ The Clavicles will be projected above the Apices ◦ The Ribs will lie in a horizontal plane ◦ There will be distortion of the thoracic organs ! The Central Ray angle is incorrectly angled on this image (not angled caudad enough) ! This is a repeatable error ! Intravascular lines, tubes and catheters, and electrical devices are placed in the chest cavity and vessels that supply the heart for a variety of reasons ! These include: ◦ Endotracheal tube ◦ Central Venous Catheter (CVC) ◦ Peripherally inserted Central Catheter (PICC) ◦ Swan-Ganz Catheter ◦ Port-a-Cath ◦ Chest Tubes ◦ Pacemakers ! AP Portable Chest Projections are performed frequently to evaluate the location of these devices  LINE PLACEMENT ! The purpose and correct location for the following tubes / lines / catheters are: ! Endotracheal tube: Assists in ventilation and isolates the trachea to control the airway; avoids gastric distension and provides a direct route for suctioning ◦ Correct location is 3-5 cm above the Carina ! Central Venous Catheter (CVC): Measurement of central venous pressure and to maintain and monitor intravascular blood volume ◦ The tip should lie within the Superior Vena Cava ! Peripherally inserted Central Catheter (PICC): For long-term venous access and to administer medications such as chemotherapy or antibiotics ◦ The tip should lie in the Superior Vena Cava or Axillary Vein  LINE PLACEMENT ! The purpose and correct location for the following tubes / lines / catheters are: ! Swan-Ganz Catheter: Pulmonary artery catheter to monitor hemodynamic status of critically ill patients; Helps to differentiate cardiac from non-cardiac pulmonary edema ◦ The tip should be about 2 cm from the Hilum in either the right or left Pulmonary Artery ! Port-a-Cath: Implanted venous access device for patients who need frequent or continuous administration of chemotherapy; implanted under the skin in the upper chest ◦ The tip is placed in the Internal Jugular Vein  CHEST TUBES ! A Chest Tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum ! It is used to remove air (pneumothorax) or fluid (pleural effusion) blood (hemothorax), or pus (empyema) from the Pleural Space  PACEMAKERS ! Pacemakers are used for cardiac conduction abnormalities ! A pacemaker is a small device that is implanted subcutaneously in the left anterior check wall, with at least one electrode into the Subclavian Vein ! This device uses electrical pulses to prompt the Heart to beat at a normal rate  PACEMAKERS ! Pacemakers are used to treat arrhythmias ! Arrhythmias are problems with the rate or rhythm of the heartbeat ! During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm  PACEMAKERS ! A PA Chest X-ray make be performed to check the lead placement to see if they have become dislodged from the Apex of the Right Ventricle  AP PROJECTION OF THE CHEST SUPINE ! If the patient is in trauma or is too critically ill to be positioned in a Semi-upright position, AP supine projections of the Chest are performed ! The table bucky is used if the patient is brought to the Radiology Department at 40 inch SID ! The Image Receptor orientation will depend on the patient’s body habitus  AP PROJECTION OF THE CHEST SUPINE ! If the AP Projection supine position is performed portably, the patient is lifted up and the Image Receptor is placed behind the patient’s back ! The SID should be as long as the equipment allows to avoid magnification – use the tape measurer on the X- ray tube to confirm SID ! Follow AP Projection positioning procedures  IMAGE ANALYSIS AP PROJECTION – SUPINE ! The differences in the AP Supine image will be: ◦ The Heart will appear magnified and engorged due to being farther from the Image Receptor (OID) ◦ The Clavicles will be projected higher and more horizontal on the AP image ◦ Air-fluid levels will not be visualize ◦ Frequently not a complete inspiration (8 to 9 ribs) 165  PEDIATRIC RADIOGRAPHY OF THE CHEST ! An AP Projection (supine position) is always performed on infants until they are old enough to lift head ! The Lateral Projection may be routine at some clinical sites (St. Paul Children’s Hospital) PEDIATRIC RADIOGRAPHY OF THE CHEST ! The age of the child will determine the type of immobilization equipment used ! The Tame ‘Em Board immobilization device looks like an Indian papoose, which secures the infant into the AP supine recumbent position with Velcro strips  PEDIATRIC RADIOGRAPHY OF THE CHEST ! The Pig-o-Stat immobilization device is used to secure a child over 2 years old, who can lift their head up ! Two plastic molds surround the child while they sit on a small bicycle seat, legs dangling, in the Upright position PEDIATRIC RADIOGRAPHY OF THE CHEST ! Portable AP projections of the Chest are performed on premature babies in the NICU (Neonatal Intensive Care Unit) ! Frequent CXR’s are performed and compared to previous images to evaluate the Lungs ! The Lungs are one of the last organs to develop in the fetus, which makes them vulnerable when a premature delivery occurs  PEDIATRIC RADIOGRAPHY OF THE CHEST ! The baby is in an isolette ! The Image Receptor is warmed so not to reduce the baby’s body temperature ! The NICU nurse will usually lift the baby while the technologist places the Image Receptor under baby ! During the exposure, the nurse will usually hold the baby arm’s and legs to hold the baby in position  SPECIAL POSITIONS / PROJECTIONS OF THE CHEST ! Special positions of the Chest are performed to demonstrate specific anatomical structures or pathological processes ! Typically, Routine Projections (PA and Left Lateral) are performed first, followed by Special Positions ordered by the radiologist: ◦ Apical Lordotic Position: For demonstration of the Apices of the Lungs  APICAL LORDOTIC CHEST ! The purpose of the Apical Lordotic Chest position is to evaluate the Apices of the Lung if a suspected tumor, mass or lesion is obscured by the clavicles on the Routine PA Projection ! The AP Upright Projection is most commonly performed  APICAL LORDOTIC CHEST ! The X-ray Tube is placed in the horizontal position at 72 inch / 10 Feet SID ! A 14X17 Image Receptor is placed in the Upright bucky in the crosswise orientation ◦ If the Department protocol is to include the entire lung field, place the Image Receptor lengthwise ! The patient stands with their back toward the Upright bucky, 1 foot away from the surface  APICAL LORDOTIC CHEST ! Make sure that the patient’s weight is evenly distributed over their feet ! With assistance from the technologist, the patient leans back until their shoulders and the back of their head is resting on bucky surface ! The patient’s Midsagittal plane is centered to the midline of the Upright Bucky  APICAL LORDOTIC CHEST ! The patient’s shoulders are rolled forward to remove the Scapulae from the Lung field ! The Central Ray is angled 15-25 degrees cephalad to the Mid-sternum, approximately 3-4 inches below the Jugular of Sternal Notch ! The variation in the Central Ray Angulation depends upon how far the patient can lean back against the Upright bucky  APICAL LORDOTIC CHEST ! If the patient can’t lean backward at all, the Central Ray is angled 25 degrees cephalad ! Make sure there is at least 3-4 inches of light shadow above shoulders ! Mark the Image Receptor in the light field and shield the patient ! Expose on inspiration using outer AEC photocells  IMAGE ANALYSIS APICAL LORDOTIC CHEST ! The Apices of the Lungs should be included in entirety free from superimposition of the Clavicles ! The Clavicles will be projected above the Apices and appear in a horizontal position ! The Ribs will appear distorted and horizontal in position ! Check for rotation by the symmetrical appearance of the SC Joints  POSITIONING REVIEW - PA ! Position the patient so the Midsagittal plane is centered to the center of the Upright Bucky ! Place the top of the Image Receptor 1-2 inches above shoulders ◦ Light field above the shoulders to ensure that the apices aren’t clipped ! Raise the patient’s chin to avoid superimposition of soft tissue of neck over apices of lung ! Roll the shoulders forward to remove Scapula from lung field ! Place Right anatomic side marker placement on outside of Upright Bucky in the light field way from anatomical structures ! Shield patient ! Expose on inspiration  IMAGE ANALYSIS REVIEW PA PROJECTION OF THE CHEST ! Patient ID and anatomic side markers included ! All anatomical structures included on the image ! Full inspiration ! Correct position ! No rotation ! Scapulae removed from lungs ! Proper exposure factors ! Equal collimation top and bottom ! No evidence of motion POSITIONING REVIEW - LATERAL ! Position the patient so they are in a true Lateral Position – no rotation of the hips or spine ◦ Make sure that the patient is not leaning into bucky or forward bending ! Shoulders in same transverse plane ! Raise the patient’s arms high enough to avoid loose soft tissue from upper arms obscuring the Lung field ! Midaxillary line centered to center of bucky ! Make sure Left marker is not overlying anatomical structures ! Shield patient ! Change AEC chamber to Center photocell on control panel ! Expose on inspiration CHEST RADIOGRAPHY IMAGE ANALYSIS REVIEW  IMAGE ANALYSIS ! List two reasons why this image needs to be repeated:  IMAGE ANALYSIS ! List the reason why this image needs to be repeated:  IMAGE ANALYSIS ! List the reason why this image needs to be repeated: ANATOMY REVIEW ANATOMY REVIEW  REVIEW EXERCISES ! Complete following review exercises for this lecture: ! A. Read assigned reference pages in textbook ! B. Complete Review Exercises – Lecture Three (in course packet) ! C. Images are located on the D2L course site under Materials / Content under Lecture Review Images – Lecture 3 Chest Radiography  REVIEW EXERCISES ! Review the following Utube Videos for this lecture: ! Routine Chest: https://youtu.be/pIpEwWRlsY0 ! Wheelchair Chest: https://youtu.be/rvjBo_s7_c4 ! Stretcher Chest: https://youtu.be/NZ5AyMpI6fs ! Decubitus Chest: https://youtu.be/ 9X6JSg0zOjk REVIEW VIDEO – ROUTINE CHEST REVIEW VIDEO – WHEELCHAIR CHEST REVIEW VIDEO – STRECHER CHEST REVIEW VIDEO – DECUBITUS CHEST