Bontrager Chapter 2 Positioning

The traditional CR centering technique for the chest is to place the top or the IR ______ inches above the shoulders

1.5 - 2"

What is the minimum number of ribs that should be demonstrated above the diaphragm on a PA radiograph of an average adult chest with full inspiration?

10 ribs

Chest radiography for the adult patient usually uses a kilovoltage range of ______ to ______ kV.

110 to 125 kV

Which of the following set of exposure factors is recommended for a chest examination of a young pediatric patient? A. 70 to 85 kV, short exposure time B. 90 to 100 kV, medium exposure time C. 100 to 120 kV, short exposure time D. 120 to 150 kV, long exposure time

A. 70 to 85 kV, short exposure time

A radiograph of a PA and a left lateral projection of the chest show the mediastinum of the chest is under-penetrated. The technologist used the following factors: 72" SID, upright Bucky, full-inspiration exposure, 75 kV, 600 mA, and a 1/60-second exposure time. A. Which of these factors is the most likely cause of the problem? Briefly explain. B. How can the technologist improve the image when making the repeat exposure?

A. 78 kV is too low; recommended kV range is 110-125 B. Increase the kV and reduce the mAs for the repeat exposure

To prevent the clavicles from obscuring the apices on an AP projection of the chest, the central ray should be angled (A) _________ so that it is perpendicular to the (B) ___________.

A. Caudad (+/- 5 degrees) B. Sternum

A. Should the 14 x 17" IR be aligned in portrait or landscape orientation for a PA chest projection of a hypersthenic patient? B. For an asthenic patient?

A. Landscape B. Portrait

For patients with the following clinical histories, which lateral position would you perform - right or left? A. Patient with severe pains in left side of chest B. Patient with no chest pain but recent history of pneumonia in right lung C. Patient with no chest pain or history of heart trouble

A. Left B. Right C. Left

Which of the following objects should be removed (or moved) before chest radiography? (Choose all that apply.) A. Necklace B. Bra C. Religious medallion around neck D. Dentures E. Pants F. Hair fasteners G. Oxygen lines

A. Necklace B. Bra C. Religious medallion around neck F. Hair fasteners G. Oxygen lines

A. Which anterior oblique projection would best demonstrate the left lung - RAO or LAO? B. Which posterior oblique projection would best demonstrate the left lung - RPO or LPO?

A. RAO B. LPO

List four possible pathologic conditions that suggest the need for both inspiration and expiration PA chest radiographs

A. Small pneumothorax B. Fixation or lack of normal diaphragm movement C. Presence of a foreign body D. Distinguishing between opacity in rib or lung

List and explain briefly the three reasons chest radiographs should be taken with the patient in the erect position (when the patient's condition permits).

A. To allow diaphragm to move down farther B. To show possible air and fluid levels in the chest C. To prevent engorgement (becoming over-filled with fluid) and hyperemia (an excess of blood in the vessels) of the pulmonary vessels

What position/projection would be used for a patient who is too ill or weak to stand for an AP lordotic projection?

AP semiaxial projection, central ray 15-20 degrees cephalad

Situation: A patient with a possible neoplasm in the right lung apex comes to the radiology department for a chest examination. The PA and lateral projections do not clearly demonstrate the neoplasm because of superimposition of the clavicle over the apex. The patient is unable to stand or sit erect. Which additional projection can be taken to demonstrate the neoplasm clearly and to eliminate the superimposition of the clavicle and the left lung apex?

AP semiaxial projection; CR is angled 15-20 degrees cephalad to project the clavicles above the apices and to demonstrate clearly the possible tumor.

Clinical indication described? Collapse of all or portion of lung

Atelectasis

Situation? A patient with a clinical history of advanced emphysema comes to the radiology department for a chest x-ray. AEC will not be used. How should the technologist alter the manual exposure settings for this patient? A. Do not alter them. Use the standard exposure factors. B. Decrease the kV moderately (--). C. Increase the kV slightly (+). D. Increase the kV moderately (++).

B. Decrease the kV moderately (--).

Clinical indication described? Irreversible dilation of bronchioles

Bronchiectasis

Situation: A patient with a history of pleurisy comes to the radiology department. Which of the following radiographic series should be performed? A. Soft tissue lateral of the upper airway B. Right and left lateral decubitus C. Erect PA and lateral D. CT scan of the chest

C. Erect PA and lateral

Why do the lungs tend to expand more with the patient in an erect position than in a supine position?

Erect position allows abdominal organs to drop, allowing the diaphragm to move farther down and the lungs to aerate more fully.

Which positioning tip will help prevent the patient's chin and neck from being superimposed over the upper airway and apices of the lungs for a PA chest radiograph?

Extend the neck upward

True/False: Echocardiography and electrocardiography are basically the same procedure.

False

True/False: Generally, you do not need to use radiographic grids for adult patients for PA or lateral chest radiographs.

False

True/False: No lead shielding is necessary for male patients or women greater than age 65 during radiographic imaging of the chest.

False

True/False: CR centering for the PA chest projection on an obese patient is 1 to 2" lower than for a sthenic patient.

False (centering for obese patient is at the same location - T7)

True/False: The height, or vertical dimension, of the average-to-large person's chest is greater than the width, or horizontal dimension.

False (greater width)

True/False: Because the heart is always located in the left thorax, the use of anatomic side markers on a PA chest projection may not be necessary.

False (heart may be located in right thorax)

How much separation of the posterior ribs on a lateral chest projection indicates excessive rotation from a true lateral position?

Greater than 1 cm (1/2-3/4")

Which type of body habitus is associated with a broad and deep thorax?

Hypersthenic

Situation: A patient with a possible small pneumothorax. Routine chest projections (PA and lateral) fail to show the pneumothorax conclusively. Which additional projections could be taken to rule out this condition?

Inspiration and expiration PA projections and/or a lateral decubitus AP chest with affected side up

Which specific position would be used if a patient were unable to stand but the physician suspected that the patient had fluid in the left lung?

Left lateral decubitus

What is the name of the condition characterized by free air entering the pleural cavity?

Pneumothorax

Why is it important to raise the patient's arms above the head for lateral chest projections?

Prevents upper arm soft tissues from being superimposed over upper chest fields

Clinical indication described? Condition most frequently associated with congestive heart failure

Pulmonary edema

Explain the primary purpose and benefit of performing chest radiography using a 72" SID.

Reduces distortion and magnification of the heart and other chest structures

Which specific position would be used if the patient were unable to stand but the physician suspected that the patient had free air in the left pleural cavity?

Right lateral decubitus (affected side up)

Situation: A patient enters the ER with a possible hemothorax in the right lung caused by a motor vehicle accident. The patient is unable to stand or sit erect. Which specific projection would best demonstrate this condition, and why?

Right lateral decubitus; in a patient with hemothorax (fluid), the side of interest should be down.

What circumstances or clinical indications suggest that an AP lordotic projection should be ordered?

Rule out calcifications or masses beneath the clavicles

The shoulders need to be rolled forward for the PA projection to allow the _________ to move laterally and be clear of the lung fields.

Scapulae

Careful collimation during a chest radiograph will improve image quality by decreasing _________ radiation to the IR.

Scatter

The CR is placed at the level of the _____ vertebra for a PA chest projection.

T7

A radiograph of a PA view of the chest shows that the SC joints are not the same distance from the spine. The right SC joint is closer to the midline than is the left SC joint. What is the positioning error?

The patient is rotated into a slight RAO position.

True/False: Long hair may produce an artifact when imaging with digital radiographic systems.

True

True/False: Single-photon emission computed tomography (SPECT) is frequently used to diagnose myocardial infarction.

True

True/False: With most digital chest units, the question of IR placement into either the portrait or the landscape position is eliminated because of the larger IR.

True

Clinical indication described? A contagious disease caused by an airborne bacterium

Tuberculosis

Change in manual exposure factors? Left lung atelectasis

increase (+)

Change in manual exposure factors? Respiratory distress syndrome (RDS) or adult respiratory distress syndrome (ARDS), known as hyaline membrane disease (HMD) in infants

increase (+)

Change in manual exposure factors? Severe pulmonary edema

increase (+)

Change in manual exposure factors? Advanced asbestosis

none (0)

Change in manual exposure factors? Large pneumothorax

none (0)

Change in manual exposure factors? Lung neoplasm

none (0)

Change in manual exposure factors? Primary tuberculosis

none (0)

Change in manual exposure factors? Pulmonary emboli

none (0)

Why should a left lateral be performed unless departmental protocol indicates otherwise?

A left lateral better demonstrates the heart region

Situation: A young child enters the ER with a possible foreign body in one of the bronchi of the lung. The foreign body, a peanut, cannot be seen on the PA and lateral projections of the chest projection. Which additional projection(s) could the technologist perform to locate the foreign body?

AP and lateral upper airway projections

Situation: A routine chest series indicates a possible mass beneath a patient's right clavicle. The PA and lateral projections are inconclusive. What additional projection(s) could be taken to rule out this condition?

AP lordotic

Which of the following is not a form of occupational lung disease? A. Anthracosis B. Emphysema C. Silicosis D. Asbestosis

B. Emphysema

Which of the following bony landmarks is palpated for centering of the AP chest projection? A. Vertebra prominens B. Jugular notch C. Thyroid cartilage D. Sternal angle

B. Jugular notch

Situation: PA and left lateral projections demonstrate a suspicious region in the left lung. The radiologist orders an oblique projection that will best demonstrate or "elongate" the left lung. Which specific oblique projections will best elongate the left lung? (More than one oblique projection will accomplish this goal.)

Both the LPO and RAO positions will best demonstrate or elongate the left lung.

Clinical indication described? Acute or chronic irritation of bronchi

Bronchitis

Situation: A patient with severe pleural effusion comes to the radiology department for a chest x-ray. AEC will not be used. How should the technologist alter the manual exposure settings for this patient? A. Do not alter them. Use the standard exposure factors. B. Decrease the kV moderately (--). C. Increase the kV slightly (+). D. Increase the kV moderately (++).

C. Increase the kV slightly (+).

Which of the following devices should be used for the erect PA and lateral chest projections for an infant? A. Upright chest device B. Supine table Bucky C. Pigg-O-Stat D. Plexiglas restraint board

C. Pigg-O-Stat

Which of the following anatomic structures must be examined to determine rotation on a PA chest radiograph? A. Appearance of ribs B. Shape of heart C. Symmetric appearance and location of sternoclavicular joints D. Symmetric appearance and location of costophrenic angles

C. Symmetric appearance and location of sternoclavicular joints

A radiograph of a PA projection of the chest shows the top of the apices is cut off and a wide collimation border can be seen below the diaphragm. In what way can this be corrected during the repeat radiograph?

Center the CR higher (T7); make sure the IR is centered to the CR and the top collimation light border is at the vertebra prominens.

Clinical indication described? Most common form of emphysema

Chronic obstructive pulmonary disease (COPD)

Clinical indication described? One of the most common inherited diseases

Cystic fibrosis

Which of the following chest projections/positions is recommended to detect calcifications or cavitations within the upper lung region beneath the clavicles? A. Left lateral decubitus B. PA C. RPO and LPO D. AP lordotic

D. AP lordotic

What is a common radiographic sign seen on a chest radiograph for a patient with respiratory distress syndrome (RDS)? A. Enlargement of heart B. Fluid in apices C. Sail sign D. Air bronchogram

D. Air bronchogram

Which of the following types of body habitus may cause the costophrenic angles to be cut off if careful vertical collimation is not used? A. Hypersthenic B. Hyposthenic C. Sthenic D. Hyposthenic and asthenic

D. Hyposthenic and asthenic

A radiograph of a lateral projection of the chest shows the posterior ribs and costophrenic angles are separated more than 1/2" indicating excessive rotation. Describe a possible method for determining the direction of rotation.

Determine which hemidiaphragm (right or left) is more posterior/anterior. The left hemidiaphragm can frequently be identified by visualization of the gastric air bubble or the inferior heart shadow.

Clinical indication described? Shortness of breath

Dyspnea

Optimal technical factor selection ensures proper penetration of the: A. Heart B. Great vessels C. Lung regions D. Hilar region E. All of the above

E. All of the above

Clinical indication described? Accumulation of pus in pleural cavity

Empyema

An erect chest PA radiograph aids the patient to achieve full inspiration and helps to prevent _____ and _____ of the pulmonary vessels.

Engorgement; hyperemia

Situation: A patient comes to the radiology department for a pre-surgical chest examination. The clinical history indicates a possible situs inversus of the thorax (transposition of structures within the thorax). Which positioning step or action must be taken to perform a successful chest examination?

Ensure placement of the correct R or L anatomic side marker on the IR, because the heart and other thoracic structures may be transposed from right to left.

True/False: Ultrasound is not an effective modality to detect pleural effusion.

False

True/False: A grid is not recommended for a LPO projection of the adult chest.

False (a grid is recommended)

True/False: In general for an average patient, more collimation should be visible on the lower margin of the chest image than on the top for a PA or lateral chest projection.

False (should be equal)

For certain studies of the heart, the _____ (right or left) anterior oblique requires a rotation of _____ degrees.

Left; 60 degrees

Where is the CR placed for a lateral projection of the upper airway?

Level of C6-C7, midway between thyroid cartilage and jugular notch

What are the recommended patient instructions when performing an erect PA chest on a female with large pendulous breasts?

Lift the breasts up and outward and them remove her hands as she leans against the chest board (IR) to keep them in position

Why is a PA chest preferred to an AP projection?

Places the heart closer to the IR to reduce magnification of the heart

What is the name of the condition characterized by fluid entering the pleural cavity?

Pleural effusion

Clinical indication described? Inflammation of pleura

Pleurisy

Clinical indication described? Accumulation of air in the pleural cavity

Pneumothorax

Describe the way optimum density (brightness) of the lungs and mediastinal structures can be determined on a PA chest radiograph

Should be able to see faint outlines of at least middle and upper vertebrae and ribs through heart and other mediastinal structures.

Clinical indication described? A form of occupational lung disease

Silicosis

What is another term for the condition termed visceral inversion?

Situs inversus

A radiograph of a PA projection of the chest shows only seven posterior ribs above the diaphragm. What caused this problem, and how could it be prevented on the repeat exposures?

The lungs are under-inflated. Explain the need for a deep inspiration, and take the exposure on the second deep inspiration.

True/False: Because they have shallower (superior-inferior dimension) lung fields, the CR is often centered higher for geriatric patients.

True

True/False: Chest radiography is the most commonly repeated radiographic procedure because of poor positioning or exposure factor selection errors.

True

True/False: Multi-detector CT can produce high-resolution images of the heart on one breath-hold.

True

A recommended CR centering technique for a PA chest projection requires the technologist to palpate the __________ and measure down from that bony landmark ______ inches for a male and ______ inches for a female patient.

Vertebra prominens; 8"; 7"

Change in manual exposure factors? Advanced emphysema

decrease (-)

To ensure better lung inspiration during chest radiography, exposure should be made during the _________ inspiration.

second

Change in manual exposure factors? Reactivation (secondary) tuberculosis

slight increase (+)