Transcript Helen Murphy SCC Allied Health Radiology Program Views:  PA Upright/ Left Lateral Upright (already talk about)  AP upright chest  Supine chest  Cross-Table Left Lateral  AP/PA Lordotic chest  Decub Chest  Portable.

Helen Murphy
SCC Allied Health
Radiology Program
Views:
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PA Upright/ Left Lateral Upright (already talk about)
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AP upright chest
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Supine chest
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Cross-Table Left Lateral
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AP/PA Lordotic chest
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Decub Chest
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Portable Chest
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Dual Energy Chest (SHMC)
On all CXRS….
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The lung markings, diaphragms, heart borders, hilum,
greater vessels, and bony cortical outlines are
sharply defined. So use high KVP (sufficient to
penetrate the chest structures and provides the contrast
scale necessary to visualize the lung details.) and a grid
( to absorb scatter).
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Sharply defined recorded details are also obtained when
patient respiration and body movements are halted(So
NO MOTION!!!)
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The least amount of object “image receptor distance
(OID) is maintained. This why PA is better than AP
(patient’s heart is closer to IR).

Use a 72-inch (183-cm) source “image receptor distance”
(SID) to decrease the magnification of the heart.
72 inch SID
40 inch SID
CONT…
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The time of examination, degree of patient elevation(
supine semi-upright…) and if done AP should be on
the image.
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Indicating the time of day on the image is
especially important if the patient's progress is
being followed and multiple chest images are to
be taken on the same day. This is done
automatically on CR and DR( but is the time
right?). Knowledge of the degree of elevation
helps the reviewer determine the exact amount
of fluid in the patient's lungs.
Structures shown: Entire lung
field

An AP projection is somewhat similar to
the PA projection. AP being farther from
the IR, the heart and great vessels are
magnified as well as engorged, and the
lung fields appear shorter because
abdominal compression moves the
diaphragm to a higher level. The clavicles
are projected higher, and the ribs assume
a more horizontal appearance
PA
AP
Scapulas are in the way!
Upright
Supine
Heart appears larger
Portable Chest: AP Upright
Why take a portable CXR?
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Patient is not stable or too sick to come
down stairs
Check for position of lines and tubes
Check for complications from lines and
tubes
Sudden onset of chest pain and or
shortness of breath
To check for a Pneumothorax (upright is
best!)
Air embolism from line

Another way to show air-fluid levels: To
demonstrate precise air-fluid levels when
pleural effusion is suspected, chest
images should be taken with the patient
upright and the x-ray beam horizontal.
With this position, the air rises and the
fluid gravitates to the lowest position,
creating an air-fluid separation. This
separation is identified as a decrease in
density on the image wherever the dense
fluid is present in the lung field. The true
amount of fluid cannot be discerned on
an image unless the fluid is level; in the
slanted position the chest may appear to
have no fluid. When the patient is supine,
the fluid is evenly spread throughout the
lung field, preventing visualization of fluid
levels.
The same patient with tube
angle and without
With 25 degrees
Without
Please:

Remove all patient monitoring lines that can be
removed or shift them out of the lung field! When
patient monitoring lines remain within the lung field,
they may obscure lung details or the one line we are
looking for.

Use a grid whenever possible, especially on larger
patients. A grid is not always employed in portable
imaging. Why? because it is difficult to ensure that the
grid and central ray are aligned accurately, which
could lead to grid cutoff. When no grid is used, a lower
kVp technique is needed to prevent excessive scatter
radiation from reaching the IR and hindering contrast.
Although the lower kVp will sufficiently penetrate the
lung field, it seldom provides enough penetration to
allow visualization of structures within and behind the
heart shadow
Same patient demonstrating a
fluid-type pathologic condition
Non grid
Grid
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When a chest x-ray is used to evaluate the
placement of apparatus positioned within
the mediastinal region, the heart shadow
should be penetrated. The accurate
placement of these lines cannot be
evaluated without heart penetration.
Accomplish this penetration by increasing
the kVp. The resulting image will
demonstrate a penetrated heart shadow
with the thoracic vertebrae, posterior ribs,
and chest lines, clearly demonstrated
through it. The amount of scatter radiation
reaching the IR will also increase, resulting
in overall lower image contrast (Gray
&UGLY!!) So grid use would be helpful!!!!
X-Table Lateral Chest
X-table Lateral
Just like a lateral chest just done x-table
 Still need the entire lung field on
 Use for post pacemaker patients and
babies
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Pulmonary Apices Positions:
o
AP axial projection -Lordotic position -Lindbolm
method (pt leans backwards to the film)
o
AP axial projection ( pt AP angle tube 15-20 up)
o
PA axial projection ( pt PA angle tube 15-20 up)

PA axial projection- Lordotic position- Fleischer
method (pt leans backwards away from film)

Not shown (no pictures in book)
Structures shown:

Demonstrate the apices free from
superimposion of clavicles.
AP Axial
Lordotic Position
AP Axial
PA axial
Positions:
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Rt lateral Decubitus (right side down)
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Lt lateral Decubitus (left side down)
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*For fluid: place patient on affected side
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* For air: place patient on the unaffected
side
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*Trendelenburg helps show fluid levels
better
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* Can be done AP or PA
What does it show:
Demonstrates the change in fluid
position and reveals any previously
obscured pulmonary areas or, in the
case of pneumothorax (air or gas in the
pleural space), the presence of any free
air.
 Done on pts with chest tubes to check
fluid levels

Right lateral decub chest xray
AP projection, left lateral
decubitus position .The arrows
indicate the air-fluid level (air
on the side up).
I would show both sides
AP projection, right lateral
decubitus position. Arrows
showing a fluid level (the down
side) . Note the fluid in the lung
fissure (arrowhead)
Obliques of the Chest

RAO/LAO: 45 degree obliques
demonstrate the side farthest from the
IR (LAO shows right side)

RPO/LPO:45 degree obliques
demonstrate the side closest from the IR
(LPO shows the left side)
LAO Chest : Demonstrate the side farthest
from the IR (right side)
RT side demonstrated
LPO Chest: demonstrate the side closest
from the IR (left side)
Left side is demonstrated
Dual energy Chest
Done at SHMC on all PICC Line patients
 One exposure (long one) but three
images!
 First image normal chest
 Second image ribs blurred
 Third image just bones
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1
2
3
No dual energy try inverting
the image (image processing)
Stuff in the chest
Some lines found in the in chest:
Central venous (CV line) catheters also known as
Peripherally inserted central catheters (PICC) or
Ports , pulmonary arterial line also known as a
Swan-Ganz catheter
o Central venous catheters are inserted into the
subclavian vein or a more peripheral vein in the upper
extremity are extremely useful for measurement of
the central venous pressure (CVP) and for providing a
conduit for the rapid infusion of fluid or chronic
hyperalimentation. They allow for infusion of
substances that are too toxic for peripheral infusion,
such as for chemotherapy, total parenteral nutrition,
dialysis, or blood transfusions.
o So that the CVP may be correctly measured, the
catheter must be located with in the true central
venous system, beyond all the valves, which
interfere with direct transmission of the right arterial
pressure to the catheter.
o We would like it to be where the brachiocephlic
veins join to form the superior vena cava or within
the superior vena cava itself approximately 2 to 3
cm above the right atrial junction
o Medial to the anterior border of the first rib
Tip Here

Images taken for CV line placement should
demonstrate adequate density and
penetration to visualize the line and lung
conditions that may result if perforation
occurs during line insertion, such as
pneumothorax or hemothorax.
Complications:
Pneumothorax
 Infections
 Air embolism
 Hemorrhage
 Arrhythmia

pneumothorax
Catheter with it’s tip in the pleural space. A right subclavian catheter,
perforated the superior vena cava and eroded into the right pleural
space. Note the tip of the catheter projecting beyond the right border of
the mediastinum (arrow). The direct infusion of parenteral fluid into the
pleural space has led to a large right hydrothorax
This is why it is very important to have a x-ray before use!
Catheter in the right internal jugular vein.

Broken PICC catheter. The sheared-off portion of the
catheter (arrow) is located in the left lower lobe.

Pulmonary arterial line (Swan-Ganz
catheter): The pulmonary arterial line is
similar to the Central venous line but is
longer. It is used to measure atrial
pressures, pulmonary artery pressure,
and cardiac output. The measurements
obtained are used to diagnose ventricular
failure and monitor the effects of specific
medication, exercise, and stress on heart
function. The pulmonary arterial line is
inserted in the subclavian, internal or
external jugular, or femoral vein and is
advanced through the right atrium into the
pulmonary artery . Images taken for
pulmonary arterial line placement should
demonstrate adequate density and
penetration to visualize the line and
mediastinal structures to determine
adequate placement and lung conditions
that may result if perforation occurs
during line insertion, such as
pneumothorax or hemothorax.
AP CXR demonstrating accurate pulmonary arterial(PA) line placement
.
More things put into a chest:
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Endotracheal tube (ET): The ET is a stiff, thick-walled
tube that is used to inflate the lungs: They are inserted
through the mouth into the trachea as a means of
establishing or opening an air way
It should be 5-7 cm above the tracheal bifurcation(carina)
Why take a cxr? To check for proper placement of tube and
to check for pneumonia or pneumothorax
20% go into right main bronchus this will cause collapse of
the left lung
A tube to high will cause air to enter the stomach, this could
cause regurgitation of gastric contents into the lungs, which
could lead to aspiration pneumonia.
Films taken daily to check for movement
Patient could get a tension pneumothorax from the
pressure of the ventilation machine.
A, Adult endotracheal tube.
Distal end of endotracheal
tube with cuff deflated (1)
side hole
end hole
Tracheotomy tube.
(
C, Pediatric endotracheal tube; note the
absence of cuff.
Anteroposterior mobile chest
projection showing trachea (dotted line)
endotracheal tube
nasogastric tube
carina
cardiac monitor
wires
Carina
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Proper position of the endotracheal tube
5-7 cm above Carina or
Old school 2 inches
superior to the carina
Poor placement :Intubation of right main-
stem bronchus with complete occlusion of
the left bronchus causing left lung
atelectasis.
Check for:
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Head and neck in the neutral position
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With flexion or extension of the neck the
tube will move about 2cm
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The patient is not rotated
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The patient is breathing okay
Still more things put into the chest:
Thoracostomy tube (chest tubes)
○ Thoracostomy tube (chest tube): The chest tube is a 1.25-
cm diameter, thick-walled tube that is used to remove fluid
or air from the pleural space when it is preventing
negative pressure in the intrapleural space from aiding in
lung expansion. Failure to remove the fluid or air may
result in collapse of the lung. For drainage of air the tube
is placed anterosuperiorly within the pleural space,
typically at the level of the second or third intercostal
space at the midclavicular line . For drainage of fluid the
tube is typically placed within the pleural space laterally at
the midaxillary line at the level of the fifth or six intercostal
space. The side hole of the thoracostomy tube, which is
marked by an interruption of the radiopaque identification
line, should be placed within the thoracic cavity, medial to
the inner ribs. Images taken for (chest tubes)
thoracostomy tube placement should demonstrate
adequate density and penetration to visualize the
radiopaque identification line.
Chest tubes
radiopaque identification line
Pacemaker: The pacemaker is used to regulate the heart rate
by supplying electrical stimulation to the heart. This electrical
signal will stimulate the heart the needed amount to maintain an
effective rate and rhythm. On a PA or anteroposterior (AP) chest
image the pacemaker catheter tip should be seen at the apex of
the right ventricle . Care should be taken when positioning a
patient whose pacemaker was inserted within 24 hours of the
examination. Elevation of the left arm should not be done unless
surgeon or nurse have given there okay, this is done to prevent
dislodging of the pacemaker and catheter. Two views should be
done to show tip placement. On a frontal radiograph, the tip
often appears to be well positioned. A lateral projection is
required to show that the tip is directly posterior in the coronary
sinus, rather than in its proper position anterior in the right
ventricle. They can be done supine (x-table lateral) if patient is
still to sleepy from surgery.
Post pacemaker
Left arm

Fracture of a cardiac pacemaker wire
(arrow)
Perforation of the myocardium by an intravenous electrode usually
occurs at the time of insertion or during the first few days
thereafter. Perforation should be suspected when the pacemaker
fails to sense or elicit a ventricular response. Plain radiographs
show the electrode tip lying outside the right ventricular cavity