Chapter 2 Chest (1030)
What are the 4 divisions of the respiratory system?
1. Pharynx 2. Trachea 3. Bronchi 4. Lungs
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?
Both LPO and RAO oblique positions will best demonstrate or elongate the left lung
A radiograph of a lateral projection of the chest shows the posterior ribs and costophrenic angles are separated more then 1", indicating excessive rotation. Describe a possible method for determining the direction of rotation.
Determine which hemidiaphragm is more A or P. The left hemidiaphragm frequently identified by gastric air bubble or inferior heart shadow.
Should a 14x17 IR be aligned in a portrait or landscape orientation for a PA chest projection of an asthenic patient?
Portrait
Why do the shoulders need to be rolled forward for a PA projection?
to allow the scapulae to move laterally and be clear of the lung fields
What important parts of the lungs are important in a radiograph?
*Apex* rounded upper area above the level of the clavicles *Carina* Lowest margin of the separation of the trachea into the right/left bronchi *Base of each lung* lower concave area of each lung that rests on the diaphragm *Costophrenic angle* the extreme outermost lower corner of each lung, where diaphragm meets the ribs *Hilum (root)* central area of each lung, where bronchi, blood vessels, lymph vessels, and nerves enter and leave the lungs
what are the 4 digital imaging considerations?
1. Collimation critical for patient dose reduction, improved image quality, preventing scatter radiation 2. Accurate centering 3. Exposure factors Using the highest possible kVp and lowest mAs for optimal image quality 4. Post-processing evaluation of exposure indicator
How is a supine/semierect AP chest shown differently than a PA chest?
1. The heart appears larger as a result of increased manification from a shorter SID and increased OID of the heart 2. Possible pleural effusion for this type of patient often obscures vascular lung markings compared with a fully PA chest projection. Without a horizontal beam, fluid levels may not be demonstrated. 3. Usually inspiration is not as full, and only 8-9 posterior ribs are visualized.
What are the 4 important structures in the mediastinum?
1. Thymus gland 2. Heart and great vessels 3. Trachea 4. Esophagus
What are the correct anatomical terms for the following? 1. Adam's apple 2. Voice box 3. Breastbone 4. Shoulder 5. Collarbone
1. Thyroid cartilage 2. Larynx 3. Sternum 4. Scapula 5. Clavicle
What are 3 reasons chest projections should be taken with the patient in the erect position when their condition allows?
1. To allow diaphragm to move further down 2. To show possible air and fluid levels in the chest 3. To prevent engorgement and hyperemia of the pulmonary vessels
What are the 3 parts of the aorta?
1. ascending aorta 2. aortic arch 3. descending aorta
How many ribs should be showing above the diaphragm on a PA chest radiograph on deep inspiration?
10
What exposure factors is recommended for a chest exam of a young pediatric patient?
70-85 kVp, short exposure time
A radiograph of a PA and a left lateral projection of the chest demonstrates the mediastinum of the chest is under penetrated. The tech used the following factors for the radiograph: 72in SID upright buckey full inspiration exposure 75 kVp and 800mA short exposure time Which of these factors is the most likely cause of the problem?
75kVp is too low. Recommended range is 110-125 kVp
What chest projection/position is recommended to detect calcifications or cavitations within the upper lung region beneath the clavicles?
AP Iordotic
What kind of radiographs of the upper airway allow visualization of the air-filed trachea and larynx?
AP and lateral of upper airway
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
A patient with a possible neoplasm in the right lung apex comes to the radiology department for a chest exam. The PA and lateral projections do not clearly demonstrate the neoplasm because of the 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 cephalic to project the clavicles above apices and to clearly demonstrate possible tumor.
Pneumothorax
Accumulation of air in the pleural space that causes partial or complete collapse of the lung. Radiograph will show no lung markings. Radiograph should be taken erect. If not erect, lateral decubitus with affected side up
what is a common radiographic sign seen on a chest radiograph for a patient with respiratory distress syndrome (RDS)?
Air bronchogram sign
What is the term for the small air sacs located at the distal ends of the bronchioles, in which O2 and CO2 are exchanged in the blood?
Alveoli
upper, rounded portion of lungs above the level of the clavicles
Apex
What anatomy should be included on PA chest?
Apices Costophrenic angles air filled trachea from T1 down Hilum region markings heart great vessels bony thorax
What are the major arterial branches from the aortic arch?
Brachiocephalic Left common carotid Left subclavian arteries
Where is the CR placed for a lateral projection of the upper airway?
C6-C7, midway between thyroid cartilage and jugular notch
The two important bony landmarks of the thorax that are used for locating the CR on a PA and AP chest projection are:
C7 and jugular notch
What is the name of the ridge seen when looking down into the bronchus where it divides into the right and left bronchi? It is approximately at the level of which vertebrae?
Carina T4-5
What bone is seen in the anterior portion of the neck and is found just below the tongue or floor of the mouth?
Hyoid
Pleurisy
Inflammation of the pleura surrounding the lungs. The cause is visceral and parietal pleura rubbing during respiration.
Why do the lungs tend to expand more with the patient in an erect position than in a supine position?
It allows organs to drop, allowing the diaphragm to move further down and the lungs to aerate more fully
Which posterior oblique projection would best elongate the left thorax?
LPO
Should a 14x17 IR be aligned in a portrait or landscape orientation for a PA chest projection of a hypersthenic patient?
Landscape
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
In general, what kind of contrast is used for chest radiography?
Low contrast, described as long-scale contrast, with more shades of gray. Requires high kVp of 110-125
cystic fibrosis
Most common inherited disease Secretions of heavy mucus cause progressive clogging of bronchi and bronchioles
List the three divisions of the structure located proximally to the larynx that serve as a common passageway for both food and air.
Nasopharynx Oropharynx Laryngopharynx
The outer layer of the pleura adhering to the inner surface of the chest wall and diaphragm is
Parietal pleura
What are the clinical indications of an AP chest projection (supine or semi erect)
Pathology involving the lungs, diaphragm, and mediastinum.
What are the clinical indications for a lateral chest position?
Pathology situated posterior to the heart, great vessels, and sternum
Describe the patient position for a lateral decubitus chest
Patient lying on right side for right lateral decubitus Patient lying on left side for left lateral decubitus Patient's chin extended arms raised above head Back firmly against IR Knees flexed slightly and coronal plane parallel to IR
Describe the patient position for an AP lordotic chest projection
Patient standing 1 foot away from IR Leaning back with shoulders, neck, and black of head against IR Both hands on hips, palms out shoulders rolled forward
What is the passageway fo food, fluids, and air?
Pharynx
What device should be used for the erect PA and lateral chest projections for an infant?
Pigg-O-Stat
What are the clinical indications for an erect, PA chest projection?
Pneumothorax, atelectasis, and signs of infection
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
The inner layer adhering to the surface the lungs
Pulmonary (visceral) pleura
Is RAO or LAO best for visualization of the left lung?
RAO
Which anterior oblique projection would best elongate the left thorax--right anterior oblique or left anterior oblique?
RAO
What is the primary purpose and benefit of performing chest radiography using a 72in SID?
Reduces distortion and magnification of the heart and other chest structures
What are clinical indications?
Represent conditions that are encountered more commonly, and knowledge and understanding of these clinical indications should be considered routine and essential for all technologists
What 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
A patient enters the ER with a possible hemothorax in the right lung caused by a car 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 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 clavicles
What are the technical factors for an AP projection of the upper airway?
SID 40 inches (to minimize magnification) IR 10x12, portrait Grid 75-85 kVp
What are the technical factors for a lateral position of the upper airway?
SID 72 inches IR 10x12, portrait grid 75-85 kVp
What are the technical factors for a lateral chest position?
SID 72 inches IR 14x17, portrait Grid kVp 110-125
What are the technical factors for an RAO or LAO?
SID 72 inches IR 14x17, portrait grid 110-125 kVp
What are the technical factors for a PA chest projection?
SID 72in IR zise 14x17, portrait or landscape Grid kVp 110-125
What is frequently used to diagnose myocardial infarction?
SPECT Single-photon emission computed tomography
To ensure better lung inspiration during chest radiography, when should exposure be made?
Second inspiration
Dyspnea
Shortness of breath
The CR is placed at which vertebra for a PA chest projection?
T7
why is the right lung smaller than the left lung and the right hemidiaphragm is positioned higher than the left hemidiaphragm?
The liver is on the right
Which side is best demonstrated on the finished radiograph?
The patient's side closest to the IR
If a person accidentally inhales a food particle, which bronchus is it most likely to enter and why?
The right bronchi because it is larger in diameter and more vertical
For RAO or LAO chest, which side is closest to the IR?
The side that is NOT of interest
Why should a left lateral be performed unless departmental protocol indicates otherwise?
To better demonstrate the heart region
What connects the larynx to the main bronchi? Is also called the windpipe?
Trachea
What divides the carina into the left and right primary bronchi?
Trachea, level of T4-T5
True or False: The width of the average PA or AP chest is greater than the vertical dimension
True
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?
Underinflated ribs; explain the need for a deep breath and take the image on the second deep inhalation
Should the CR be centered higher for geriatric patients?
Yes, they have shallower lung fields
Pleural effusion and 2 types
abnormal accumulation of fluid in the pleural space 1. Empyema-fluid is pus 2. Hemothorax- fluid is blood
bronchitis
acute or chronic condition in which excessive mucus is secreted into the bronchi, causing cough and shortness of breath
respiratory distress syndrome (RDS)
alveoli and capillaries of the lung are injured or infected, resulting in leakage of fluid and blood into spaces between alveoli
The trachea is located _________ to the esophagus
anteriorly
Asbestosis
caused by inhalation of asbestos fibers and results in pulmonary fibrosis
Atelectasis
collapse of all or a portion of a lung occurs as the result of obstruction of the bronchus or puncture or "blowout" of an air passageway
pulmonary edema
condition of excess fluid within the lung that most frequently is caused by a backup in pulmonary circulation commonly associated with congestive heart failure
Extreme, outermost lower corner of the lungs
costophrenic angle
What type of body habitus is associated with a broad and deep thorax?
hypersthenic
Epiglottitis
inflammation of the epiglottis Most common in children ages 2-5
Bronchiectasis
irreversible dilation or widening of bronchi or bronchioles that may result from repeated pulmonary infection or obstruction
Lung neoplasm
new growth or tumor - benign (noncancerous) -malignant (cancerous)
What are the clinical indications for a lateral decubitus chest position (AP projection)?
pneumothorax
What condition is characterized by free air entering the pleural cavity?
pneumothorax
Chest radiography for the adult patient usually uses a kilo voltage rang of
110-125 kVp
Tuberculosis (TB) and its 2 types
A contagious disease caused by an airborne bacterium 1. Primary - Patient never had it before 2. Reactivation (secondary) -
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 projections could the tech perform to locate the foreign body?
AP and lateral upper airway projections
What should happen if a patient is too weak for an AP lordotic chest projection?
AP semi axial projection with patient in supine position. Shoulders rolled forward. CR directed 15-20 degrees cephalad.
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, CR 15-20 degrees cephalad
How is the CR angled for an AP chest projection in a supine or semierect position?
Caudid to be perpendicular to long axis of sternum to prevent clavicles from obscuring apices
Anthracosis (black lung pneumoconiosis)
Caused by deposits of coal dusts
A radiograph of a PA projection of the chest demonstrates the top of the apices is cut off and a wide collimation border can be seen below the diaphragm. How can this be corrected during the repeat radiograph?
Center CR higher to T7, make sure IR is centered to IR and top collimation light border is at vertebra prominens
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?
Decrease the kVp moderately
What are the clinical indications for posterior oblique positions (RPO, LPO)
Determine the size and contours of the heart and great vessels
What is the primary muscle of inspiration?
Diaphragm
When is exposure made during a lateral position of the upper airway?
During a slow, deep inspiration to ensure filling trachea and upper airway with air
For a lateral of the upper airway, should it be taken in Right or Left lateral?
Either
A patient comes to the radiology department for a presurgical chest exam. The clinical history indicates a possible situs inverses of the thorax. Which positioning step or action must be taken to perform a successful chest exam?
Ensure placement of the correct Right/left anatomic side marker on IR because the heart may be transposed from Right to Left
What is the name of the structure that acts as a lid over the larynx to prevent foreign objects from entering the respiratory system?
Epiglottis
A patient with a history of pleurisy comes to the radiology department. What radiographic series should be performed?
Erect PA and lateral
What method can you use to determine the distance from the vertebra prominence for CR placement?
Hand spread method
In general, what king of mA and exposure time is required for chest radiography?
High mA and short exposure time to minimize the chance of motion and resultant loss of sharpness.
Which types of body habitus may cause the costophrenic angles to be cut off if careful vertical collimation is not used?
Hyposthenic and asthenic
A patient with severe pleural effusion comes to the radiology department for a chest X-ray. Automatic exposure control (AEC) will not be used. How should the tech alter the manual exposure settings for this patient?
Increase kVp slightly
Pneumonia and its 4 types
Inflammation of the lungs that result in accumulation of fluid within certain sections of the lungs 1. Aspiration pneumonia 2. Bronchopneumonia- bronchitis of lungs caused by Staph 3. Lobar pneumonia- confined to 1 or 2 lobes of the lungs 4. Viral (interstitial) pneumonia- inflammation of the alveoli and connecting lung structures
A patient has 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
What are the clinical indications for an anterior oblique position (LAO, RAO)?
Investigate pathology involving the lung fields, trachea, and mediastinal structures. Determine the size and contours of the heart and great vessels
Emphysema
Irreversible disease in which air spaces in the alveoli become greatly enlarged as a result of alveolar wall destruction and loss of alveolar elasticity and results in labored breathing Evident on chest radiographs by increased lung dimensions, barrel chest with depressed and flattened diaphragm obscuring costophrenic angles, and an elongated heart shadow. Lung fields appear very radiolucent, requiring signficant decrease in exposure factors from a normal chest
What bony landmark is palpated for centering of the AP chest projection?
Jugular notch
What anatomy is demonstrated for a lateral position of the upper airway?
Larynx and trachea filled with air
Which kind of lateral should be performed and why?
Left lateral More accurately demonstrates the heart region without much magnification because the heart is located primarily in the left thoracic cavity
What does the vertebra prominence correspond to?
Level of T1 and uppermost margin of the apex of the lungs
What are the recommended patient directions when performing an erect PA chest on a female patient with large pendulous breasts?
Lift breasts up and out, remove her hands as she leans against the IR to keep them in position
What is the distance for CR placement from the vertebra prominence for men and women?
Men-8 inches Women-7 inches
Should the CR centering for the PA chest projection on an obese patient be 1-2 inches lower than a sthenic patient?
No. Centering is the same
The delicate, double walled sac or membrane that contains the lungs
Pleura
Which lung is shorter and why?
Right lung because of the liver, which pushes up on the right hemidiaphragm
Describe the patient position for a lateral position of the upper airway
Rotate shoulders posteriorly Arms hanging down Hands clasped behind back Top of IR is at the level of the EAM (ear canal meatus)
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?
Rotation; patient is rotated into a slight RAO position
What are the clinical indications for an AP lordotic chest projection?
Rule out calcifications and masses beneath the clavicles
The bony thorax consists of:
Sternum 2 clavicles 2 scapulae 12 pairs of ribs 12 thoracic vertebrae
Describe patient position for an AP chest projection in a supine or semi erect position
Supine on cart. Head should be raised into semi erect position. Roll patient's shoulders forward by rotating arms medially
What anatomic structures are examined to determine rotation on a PA chest radiograph?
Symmetric appearance and location of sternoclavicular joints
Where should the CR be for an AP projection of the upper airway?
T1-T2, about 1in above the jugular notch
Compare the right and left primary bronchi
The right primary bronchus is wider and shorter and more vertical. This makes it more probable for foreign objects to enter and lodge into the right rather than the left
Can long hair produce an artifact when imaging with digital radiographic systems?
Yes
What anatomy is included in a lateral chest?
apices costophrenic angles from the sternum anteriorly to the posterior ribs and thorax posteriorly
Lower, concave portion of the lungs
base
To prevent the clavicles from obscuring the apices on an AP projection of the chest, the central ray should be angled _________ so that it is perpendicular to the ___________
caudal +/- 5 sternum
An erect chest PA radiograph aids the patient to achieve full inspiration and helps to prevent ___ and ____ of the pulmonary vessels.
engorgement hyperemia
aspiration
foreign objects are swallowed or aspirated into the air passages
Chronic Obstructive Pulmonary Disease (COPD)
form of persistent obstruction of the airways that usually causes difficulty in emptying the lungs of air
What is each half of the diaphragm called?
hemidiaphragm
Central area in which bronchi and blood vessels enter the lungs
hilum
For certain studies of the heart, the ________ anterior oblique requires a rotation of _________ degrees
left 60
Parenchyma
light, spongy, highly elastic substance that makes up the lungs. Allows for breathing
The heart is enclosed in a double walled membrane called the
pericardium
Silicosis
permanent condition of the lungs that is cause by inhalation of silica (quartz) dust Patients are 3x more likely to develop TB
Why is a PA chest preferred to an AP projection?
places heart closer to IR to reduce magnification of the heart
The potential space between the parietal pleura and pulmonary pleura is
pleural cavity
What is the condition characterized by fluid entering the pleural cavity?
pleural effusion
Careful collimation during a chest radiograph will improve image quality by decreasing _____ radiation to the IR.
scatter
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
What is another term for the condition visceral inversion?
situs inversus
