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C
hest radiography is the most common radiographic pro- cedure performed in medi- cal imaging departments, and one of the most often repeated exams.1-3^ It is estimated that in the United States 68 million chest radio- graphs are performed each year. 4 Chest radiography is performed to evaluate the lungs, heart and thoracic viscera. Additionally, disease processes such as pneumonia, heart failure, pleurisy and lung cancer are common indications. The American College of Radiology (ACR) and others suggest that daily chest radio- graphs are indicated for critically ill patients. 5-7^ This includes patients on venti- lators, as well as those with acute cardio- pulmonary problems. According to the ACR Practice Guidelines for the Performance of Pediatric and Adult Chest Radiography, there are several indications for a chest radiograph. 5 Some of these indications include: ■ Evaluation of signs and symptoms potentially related to the respira- tory, cardiovascular and upper gas- trointestinal systems, as well as the
Chest Radiography for
Radiologic Technologists
DAN L. HOBBS, M.S.R.S., R.T.(R)(CT)(MR)
After completing this article, the reader should be able to: ■ Identify the basic anatomy seen on a chest radiograph. ■ Describe the anatomical relationships of various organs in the chest. ■ Describe the basic positioning requirements for a chest exam. ■ List the criteria used to critique a chest radiograph. ■ Identify radiologists’ requirements for interpreting a chest radiograph. ■ Discuss several common disease processes of the lungs and their radiographic appearances. ■ Evaluate a chest radiograph for various devices such as endotracheal tubes, chest tubes and central venous catheters. ■ Describe several pathologies of the chest.
The chest exam is performed more frequently than any other exam in the imaging department. It is important for radiographers to under- stand the standards for imaging the chest because good chest radiographs are critical in managing patient care. This article provides an overview of chest radiography from the perspective of both the radiologist and the tech- nologist. Readers will gain an understanding of several pathologic processes involv- ing the chest and can use this information to perform opti- mal radiographic imaging.
This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your area of interest. For access to other quizzes, go to www.asrt .org/store.
musculoskeletal system of the tho- rax. The chest radiograph also can help to evaluate thoracic disease processes, including systemic and extrathoracic diseases that second- arily involve the chest. Because the lungs are a frequent site of metasta- ses, chest radiography can be useful in staging extrathoracic, as well as thoracic, neoplasms. ■ Follow-up of known thoracic disease processes to assess improvement, resolution or progression. ■ Monitoring of patients with life-sup- port devices and patients who have undergone cardiac or thoracic sur- gery or other interventional procedures. ■ Compliance with government regu- lations that mandate chest radiogra- phy. Examples include surveillance posteroanterior chest radiographs for active tuberculosis or occupa- tional lung disease or exposures and other surveillance studies required by public health law. ■ Preoperative radiographic evalu- ation when cardiac or respiratory
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symptoms are present or when there is significant potential for thoracic pathology that could com- promise the surgical result or lead to increased perioperative morbidity or mortality. 5 The radiographer’s role is to provide the physician with an image of the chest that is diagnostic and aids in the treatment of the patient. This cannot be accom- plished satisfactorily without adequate knowledge of chest anatomy, pathology and consistent positioning in both the ambulatory and bedridden patient.
Normal Chest Anatomy The Bony Thorax The bony thorax of the chest is composed of the sternum anteriorly and 12 pairs of ribs that surround the lungs. Each pair of ribs connects to a corresponding thoracic vertebra posteriorly. The posterior rib attach- ments connect at the costovertebral and costotransverse joints. Each rib wraps around the lung and descends approximately 3 to 5 inches from its highest point poste- riorly. 2 (See Figure 1.) The anterior portion of each rib connects by way of costocartilage to the sternum. The costocartilage usually does not show up on a radiograph unless it is calcified. The true ribs, numbers 1 though 7, connect anteriorly to the sternum by way of this cos- tocartilage. (See Figure 2) The false ribs are numbers 8 through 12. Ribs 8 through 10 connect to the sternum by way of the costocartilages of the seventh ribs. False ribs 11 and 12 are short and do not wrap around the body; they also are called floating ribs. The ribs collec- tively provide a protective framework for the lungs.
The Respiratory System The respiratory system is composed of the larynx, trachea, bronchi and lungs. The larynx, commonly referred to as the voice box, is the most superior struc- ture in the respiratory system and houses the vocal cords. In close proximity to the larynx are the thyroid cartilage, laryngeal prominence or Adam’s apple, and the cricoid cartilage. The epiglottis also is located nearby and acts as a covering for the trachea when food is swallowed. The trachea descends inferiorly begin- ning at about the level of C5 to approximately T5 or T6, where it bifurcates at the carina into the right and left primary bronchi. The bronchi then subdivide into several branches. Three secondary branches feed the right lung and 2 secondary branches feed the left lung. These branches divide into tertiary levels and smaller segments, eventually ending in the terminal bronchioles where the alveoli exchange oxygen and carbon dioxide. 2
The Lungs The lungs are composed of a spongy material called the parenchyma. The parenchymal tissue contains the fine structures of the bronchial trees and pulmonary circula- tion. The exchange of oxygen and carbon dioxide takes
Figure 1. Sagittal CT image of the chest. This reformatted image demonstrates the posterior (P) to anterior (A) descent of the ribs as they wrap around the body. The distance between the 2 lines represented by the arrow is approximately 3 to 5 inches in most individuals.
Figure 2. Coronal CT image of the anterior chest. This reformatted image of the anterior chest demonstrates the sternum (A). The stars indicate a few of the anterior ribs, which are composed of costocarti- lage. The anterior ribs do not visualize on chest radiographs unless they are calcified. Note the calcifications that have formed on the proximal and distal segments of the costocartilages in this example.
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left hemidiaphragms. The right hemidia- phragm is higher on a chest radiograph because of the location of the liver, which is immediately inferior to it. The term cardiophrenic angles is sometimes used to describe the area where the heart’s border comes in contact with the diaphragm. There are both right and left cardiophrenic angles, which should be visualized on a normal chest radiograph. (See Figure 4.)
Pleura Each lung is surrounded by a thin- walled sac called the pleura. The pleura completely encases the lung with an inner layer called the pulmonary or visceral layer and an outer layer called the parietal layer. The potential space between these 2 layers is called the pleu- ral space. Radiographically, this space is important because it can fill with air (pneumothorax) or blood (hemotho- rax), which can be seen on a chest radio- graph. A chest tube can be placed within the pleural space to drain accumulated fluid or air.
The Mediastinum The mediastium is the space between the lungs that houses the heart and great vessels, including the proximal pulmonary arter- ies and aortic root. Additionally, the proximal bronchial trees, pulmonary veins, a portion of the esophagus and lymphatic vessels are important structures found in the mediastinum. The hilum “is the central area of each lung, where the bronchi, blood vessels, lymph vessels and nerves enter and leave the lungs.”^2 (See Figure 4.) Furthermore, the thymus gland is located above the heart in the superior mediastinal compartment.
Patient Preparation for the Chest Exam All Patients Prior to proceeding with the exam, all women of child-bearing age should be asked if there is any possi- bility of pregnancy. The ACR guidelines 5 suggest that all imaging facilities should have policies and procedures in place that identify patients who might be pregnant prior to exposing them with ionizing radiation. Additionally, clothing that interferes with the exam should be
removed. This includes items such as bras, jewelry, but- tons or any metal objects that could interfere with the study. 5 T-shirts with prominent logos also should be removed because they can show up on the study and can interfere with the diagnosis. Long hair that is in braids or tightly held together with rubber bands should be moved from the upper lung fields. 2 Figure 5 shows sev- eral artifacts that resulted in repeat radiographs. Body piercings and especially nipple piercings are common metallic foreign bodies that can interfere with interpretation and diagnosis. This can be a delicate and embarrassing subject for patients. The question should be phrased sensitively to avoid offending the patient. It is not appropriate to ask a patient if he or she has a nipple piercing. However, simply inquiring if all metal has been removed from the chest area is appropriate. Some body piercings have been welded closed and cannot be removed unless cut. Likewise, some patients will not remove a body piercing because piercings can be difficult or impossible
Figure 5. Radiographic collage of the chest. Each of these images required repeat expo- sures due to carelessness in screening patients for artifacts.
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to reinsert. In fact, the Association of Professional Piercers on its Web site stated, “Even momentary removal of jew- elry from a healing piercing can result in amazingly rapid closure of the piercing and make reinsertion difficult or impossible.”^10 This site also claimed that metal piercings will not interfere with or obstruct the visibility of pathol- ogy on a thoracic radiograph. The decision to remove a piercing should rest with the patient. However, the radiog- rapher should explain that the patient might be asked to remove the piercing on subsequent radiographs if it does indeed interfere with a diagnosis. The choice to do this would still rest with the patient.
Inpatients and Portable Exam Preparation Part of preparing a patient for the exam includes removing irrelevant material from the area of interest. Radiographers performing inpatient chest exams in the radiology department and portable chest exams through- out the hospital should be particularly aware of this. Extra time should be taken to ensure that external tubes and lines are redirected from the imaging area. Inpatient gowns frequently contain snaps that can interfere with the study. Sometimes these gowns can be removed and replaced with snapless gowns. If not, the snaps should be repositioned away from the field of view. Likewise, oxygen tubing, electrocardiogram (ECG) leads, the external por- tions of nasogastric tubes, enteral feeding tubes, tempo- rary pacemakers and telemetry devices should be directed to an appropriate area outside of the collimated field. Care should be taken to avoid disconnecting or inadver- tently extracting these devices. Figure 6 demonstrates how distracting they can be if not removed from the field of view. Time should be taken to move these items because they interfere with the visibility of pertinent anatomy. When they remain in the field of view they diminish the quality of the exam, resulting in poor patient care and sometimes missed diagnoses.
Radiography of the Chest Conventional radiography of the chest has been described in several positioning textbooks. 2,11^ The basic radiographs include a posteroanterior (PA) projec- tion and lateral position. For acutely ill patients, an anteroposterior projection (AP) often is obtained. If the patient is in the emergency room (ER) or intensive care unit (ICU), AP portable chest radiography usually is performed. It is interesting to note that it has been estimated that in many medical centers up to 50% of chest radiographs are performed with a portable x-ray machine.^12 AP projections obtained with portable units
have several disadvantages compared with PA projec- tions. These include magnification of the heart and thoracic viscera, inability to obtain adequate inspira- tion because of difficulty obtaining the study erect and technique variations caused by inadequate placement of grids and screens. Several authors have suggested that chest radiog- raphy should be performed with a 72-inch source-to- image-receptor distance (SID) to reduce magnification of the heart. 2,11^ Some medical centers use a 120-inch SID for this reason. Quite often, an erect view is difficult to obtain when performing chest radiography because of the patient’s condition. However, erect studies are preferred because they better demonstrate pleural effu- sions and pulmonary edema. Furthermore, when the patient is in an erect position the abdominal structures descend, allowing the patient to take in a deeper breath. This results in a better radiograph, with the lung paren- chyma better visualized.
The PA Projection The PA is performed by positioning the patient against the upright Bucky. (See Figure 7.) First, adequate radia- tion protection should be provided to the patient when- ever possible. This means that the radiographer should provide a wraparound apron or other shielding devices as deemed appropriate. Next, the patient should stand in a relaxed position facing the Bucky with the shoulders
Figure 6. Radiographs demonstrating extraneous tubes and lines. These 2 radiographs demonstrate poorly placed ECG lines that interfere with the chest exam. The lines should have been redirected from the field of view prior to making an exposure.
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habitus often require centering between 8 and 9 inches from the vertebra prominens. Conversely, a patient with a hypersthenic body habitus should be centered between 6 and 7 inches from the vertebra prominens. Next, the top of the collimated light field is put at the level of the vertebra prominens. This corresponds to the level of the pulmonary apices. Because of the divergent nature of the x-ray beam, when the upper collimated beam reaches the IR all of the apices will be included on the radiograph, thus precluding clipping important tho- racic anatomy. Likewise, by using this method the col- limation at the bottom of the radiograph includes the lung bases, thus providing equal collimation at the top and bottom of the IR. This is an interesting method and with practice can result in better-centered radiographs of the chest. The exposure is made with high kVp, high mA and short exposure time. The patient should be instructed to hold his or her breath on the second inspiration. This allows for a better inspiratory effort and, as a consequence, a radiograph with fully inflated lungs.
The Lateral Position The lateral radiograph of the chest is performed by placing the left hemithorax against the IR. The arms should be raised above the head. Occasionally, an intravenous (IV) pole or other support can be used to help maintain this position. The left lateral position is routine because it places the heart closer to the IR. The shoulder is in close contact with the IR superi- orly; however, depending on body habitus, this often results in greater object-film distance inferiorly. This can be as much as 2 or 3 inches. Care should be taken to ensure that the patient is standing straight and that the body does not tilt toward the IR. It is tempting for new radiographers to tilt the patient to reduce the object-film distance. However, this is incorrect and should be avoided because the radiograph will appear distorted. Tilt “may be evident by closed disk spaces of thoracic vertebrae” on the radiograph. 2 To ensure that the patient is standing in a true lateral position, some radiographers place a hand on the patient’s lower back, where the ribs are easy to pal- pate. The radiographer can ensure superimposition of the right and left rib cages by rotating the patient if necessary while feeling the posterior ribs. When the radiographer’s hand is perpendicular to the IR, unwanted rotation generally is eliminated. (See Figure 7, lower right image.) Again, the exposure is made with high kVp, high mA and short exposure time. As in the
PA projection, the exposure is made upon the second inspiration.
The Portable AP The portable exam is performed whenever the patient cannot come to the department for traditional PA and lateral radiographs of the chest. Sometimes a portable chest radiograph can be performed only with the patient in the supine position. Whenever possible, however, it should be performed with the patient erect or erect “to the greatest angle tolerated by the patient.”^11 Patients who are on ventilators or have had recent sur- gery present a challenge when trying to position for the AP, and the examination often must be performed with the patient supine. As stated previously, care should be taken to reposition ECG wires and tubes overlying the chest that interfere with physician interpretation. Radiographers always should keep this in mind because portable studies are performed on critical patients who present with all sorts of paraphernalia. Semierect films often appear lordotic when per- formed with the portable x-ray machine. This happens when the x-ray tube and IR are not properly aligned. The x-ray tube should be perpendicular to the IR to avoid a lordotic appearance. However, if fluid levels are a concern, the x-ray tube should remain in a horizontal position. In this scenario, to avoid a lordotic appearance, a decubitus position should be considered. These deci- sions are made by the radiographer and are paramount in providing good patient care. This means that the radiographer should evaluate the reason for the chest radiograph and then determine the best method to use. For example, if the exam was ordered to demonstrate possible pleural effusions, it should be performed with the patient fully erect with a horizontal beam. If the patient’s condition does not allow for an erect exami- nation, a lateral decubitus projection provides similar information. On the other hand, if the portable exam is ordered to demonstrate a line placement and the patient presents in a semierect position, the x-ray tube should be tilted caudally to avoid a lordotic appearance. This generally places the x-ray tube at a 90° angle to the IR. Other factors such as the placement of grids and screens require additional forethought on the radiogra- pher’s part.
Consistency in Positioning It is not unusual for patients in the ICU to have portable chest radiography performed daily. In these scenarios, similar positions should be employed each
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day. This means that radiographers making these exposures should check previous radiographs to ensure they are providing uniformity in positioning and technique. Subtle changes often are noted on daily radiographs when they are compared with each other. Such findings could prompt changes in patients’ medical treatment,7,13^ as a study performed by Marik and Janower confirmed.^14 They found that 66% of intu- bated patients and 25% of nonintubated patients in an ICU had modifications in treatment based on results of daily chest radiographs. As a result, it is important that radiographers pro- vide consistency when performing chest radiography. Subtle changes seen on chest radiographs should be the direct result of the patient’s condition and not a result of variations in positioning. Consistent position- ing can be accomplished only by providing adequate documentation on the radiograph. To do this, some radiology departments use a sticker to record this information. Newer digital technologies provide a way to add electronic annotations to images. At a minimum, the sticker or annotation should include the date and time of the exam, the distance used, the patient’s position and the technique employed. This permits consistency when follow-up studies are performed by multiple radiographers working differ- ent shifts. Regardless of which method is employed to record this data, it is crucial that the information is retrievable in some format. It is also crucial that radiographers review this information prior to per- forming subsequent chest radiography. The exposure for the AP portable chest radiograph should be made on the second inspiration if possible. For patients who are unresponsive or require mechanical ventilation by a respiratory therapist or anesthesiologist, a coordinated effort will be necessary to ensure that there is sufficient inspiration prior to making the exposure. Likewise, if the patient is on a ventilator “... carefully watch the patient’s chest to determine the inspiratory phase for the exposure.”^11
Technical Evaluation Of a Chest Radiograph Once the film has been exposed and processed, the responsibility of reviewing it does not rest solely with the radiologist. The film first should be evaluated by the radiographer. In a conversation with D. Madden, M.D., (October 2006), he said “The technologist is responsible for the technical excellence of the study.” This statement emphasizes the importance of obtaining a quality exam
and reinforces the fact that radiographers play an inte- gral role in the care of patients. A radiograph cannot be interpreted adequately by the radiologist unless it is tech- nically adequate. The following considerations should be evaluated by the radiographer prior to submitting the radiograph for review: ■ Correct demographic information. ■ Correct marker placement. ■ Correct exposure. ■ Adequate position. ■ Sufficient inspiration. ■ Pertinent anatomy demonstrated.
Correct Demographic Information This information should include the patient’s name and any other identifying information deemed neces- sary by the institution. The ACR guidelines suggest that each image be permanently marked with the patient’s name, the x-ray number or some other identifying number, the date and time the exam was performed and the patient’s date of birth. 5
Correct Marker Placement The correct anatomical side marker, right or left, should be visible on the final radiograph. Care should be exercised by the radiographer to ensure that the marker will not interfere with interpretation by cover- ing pertinent anatomy. Additional care should be exer- cised to make sure that the marker is placed on the correct side. Conditions such as situs inversus show the importance of correct marker placement. Situs inver- sus is a reversal of anatomy. As Wilhelm explained: “In situs inversus, the morphologic right atrium is on the left and the morphologic left atrium is on the right. The normal pulmonary anatomy is reversed so that the left lung has 3 lobes and the right 2 lobes. In addi- tion, the liver and gallbladder are located on the left, while the spleen and stomach are located on the right. The remaining structures also are a mirror image of the normal.”^15 Markers are often color coded, which helps to reduce errors. Nonetheless, radiographers always should check prior to making an exposure to ensure that the correct marker is placed on the correct side. Writing “R” or “L” on the radiograph after the expo- sure is generally not acceptable because of legal issues associated with mismarkings. 2 This also could hold true for annotating an image after exposure with newer digital technologies.
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Pertinent Anatomy Demonstrated The chest radiograph should demonstrate all of the anatomy of the lungs from the apices to the lung bases. (See Figure 10.) This means that both hemidiaphragms should be seen in their entirety. Student radiographers often question how close the costophrenic angles can be clipped without requiring a repeat. In response, an experienced radiographer might explain that pleural effusion is a frequent finding on chest radiographs and sometimes blunting of the costophrenic angle is the only radiographic sign. Therefore, all of the costophrenic angles should be visualized.
Densities on a Chest Radiograph The amount of blackening on a chest radiograph is a direct result of the amount of radiation that passes through the thorax and reaches the imaging receptor. Specific terminology is used to describe the differences in tissue attenuation when this happens.^19 Radiolucency describes the ability of the x-ray beam to pass through a body part. For example, the lungs are radiolucent because they are composed mainly of air, allowing for easy passage of the x-ray beam through the parenchyma. Likewise, fat
is radiolucent compared with bone, but not quite as radio- lucent as air. Conversely, in comparison with the lungs, the spine is radiopaque. The term radiopaque describes how the x-ray beam is attenuated as it interacts with the calcium in the thoracic spine.^19 Radiolucent structures are captured on the recording media as black or very dark shades of gray. Radiopaque structures are captured as white densities. Additionally, the atomic number of an element determines its radiopacity. Higher atomic-numbered elements have increased radiopacity, or the ability to attenuate the x-ray beam more; therefore, these densi- ties appear white on radiographs. See Table 1 for a list of common elements encountered in radiology and their corresponding atomic numbers. Understanding these concepts is crucial when evaluating the different densities seen on a chest radiograph. The structures within the chest are composed of 5 basic densities. Four of these densities are inherent to the organism; the last is metal, which is man-made. Each can be evaluated on a chest radiograph. They are listed in order from the most radiolucent to the most radiopaque:
Figure 10. Radiograph demonstrating sufficient inspiration. The patient has provided sufficient inspiration on a PA projection of the chest if 10 ribs can be visualized above the diaphragm. The posterior ribs are numbered from 1 to 10 and the white dotted line represents the right hemidiaphragm. The frontal projection also should include all of the anatomy from the apices to the lung bases.
Figure 9. Lateral chest radiograph demonstrating rotation. No more than one-quarter to one-half inch rotation is acceptable for a lateral projection of the chest.
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■ Air. ■ Fat. ■ Soft tissue. ■ Bone. ■ Metal.
Air Air is the most radiolucent substance visible on a radiograph. The lungs are black on a radiograph because they are filled mainly with air.
Fat Fat by itself appears as very dark shades of gray on a radiograph. However, it can vary in appearance depending on the location, thickness and the collective effect of composite tissues. Quite often fat densities appear in the axilla on a PA radiograph of the chest as thin dark radiolucencies.
Soft Tissue Soft tissue structures in the thorax include the heart and great vessels. These structures have a greater radi- opacity than the lungs; therefore, they appear white. Likewise, if the bronchi become plugged with mucus or filled with fluid, the resulting appearance on a radio- graph resembles tissues of water density, such as the heart. Radiologists commonly refer to these types of den- sities as “tissues of water densities” because, regardless of their composition, they are represented by various shades of white on the radiograph.
Bone Bone is composed primarily of calcium. It is the cal- cium that makes the bones appear white on a radiograph. The composition of bone varies, resulting in various shades of densities on the radiograph from gray to white. For example, trabecular bone is more porous than com- pact bone and is represented on a radiograph with shades from gray to white. Impenetrable compact bone is repre- sented as white. As a result, the ribs, clavicles, scapulae and vertebrae are visualized as white on a chest radiograph.
Metal Metal is included in this discussion because it is com- monly seen in the body. Metal absorbs more radiation than any of the other 4 basic densities and thus appears white on radiographs. Examples related to the chest include shoulder joint replacements; metallic sutures, such as those seen in patients who have had open heart surgery; surgical clips; pacemakers; and stents.
Differences in Densities And Radiographic Signs Anatomy on a chest radiograph is visible because of the different densities discussed above. For example, the left ventricle of the heart can be seen because the left lung is in close proximity to the left ventricle and the radiopacities of these 2 structures are strikingly dif- ferent. Hence, the border of the heart is visible. Occasionally, the heart border cannot be seen on a chest radiograph. This happens when the lungs, bronchioles or interstitium become full of secretions, such as blood or pus from infection, or filled with tumors. The lung then is composed of tissues that are like water densities, making it similar in density to the heart. When this happens, the border of the heart cannot be seen because the adjoining lungs now have the same density. According to Siela, “If 2 structures of equal density are adjacent to each other, the border of neither structure can be detected.” 21 This is called the silhouette sign. This sign is very helpful and often used by radiologists to evaluate disease processes of the thorax.
Example of the Silhouette Sign When a pathologist microscopically views a tissue sample from a normal lung and then compares it with a tissue sample from an abnormal lung that is full of fluid, they appear drastically different. (See Figure 11.) This holds true of their radiographic appearances, as well. Air-filled alveoli appear black, and fluid-filled alveoli appear white on a radiograph. As Chandrasekkar explained, “Most of the disease states replace air from alveoli with a pathological process, which usually is a liquid density and appears white.”^22 Radiologists use radiographic signs such as this to help them identify
Table 1 Atomic Numbers of Common Elements In the Radiographic Sciences 20 Element Atomic Number Hydrogen 1 Oxygen 8 Calcium 20 Iodine 53 Barium 56 Lead 82
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they are present, the hilum will appear bulky. Dick then suggests study- ing the lungs apart from the pulmonary arteries and veins. They should appear black because they are full of air. It is important to scan both of the lungs. She accom- plishes this by starting at the apices and mov- ing inferiorly, compar- ing the left and right lungs at the same level. Furthermore, she empha- sizes the importance of looking at the lung tissue that extends behind the heart. Additionally, when comparing the periph- ery of the lungs to the mediastinal area, lung markings are considerably less identifiable. However, if lung markings are absent, then disease of the airspace, such as atelectasis, should be considered. Likewise, while looking in the periphery of the lung Dick suggests assessing the radiograph for a pneumothorax. If pres- ent, a distinct line will be evident on the edge of the lung field. Finally, she reviews the surface of the hemidia- phragms. They should curve downward, and the cos- tophrenic and cardiophrenic angles should not be blunted. If they are blunted, this suggests effusion. Air beneath the diaphragm might be noticed at this point, suggesting a perforated hollow viscus. To finish, the radiograph should be evaluated for changes in soft tis- sues and bony structures. A mastectomy or rib fracture can be seen when performing this step. A similar approach can be used to evaluate the lat- eral chest radiograph. It is beyond the scope of this Directed Reading to discuss evaluation any further. Suffice it to say that radiographers should ensure that the technical aspects of the exam are completed appro- priately so that the systematic review by the radiologist is easier to perform.
Locations of Tubes and Lines In addition to performing adequate chest exams, radiographers should be able to recognize correct
placement of lines and tubes in the chest. Frequently, it is necessary to know where these lines and tubes are located and be familiar with their radiographic appearance. Some radiographers mistakenly believe that this could result in an ethical violation by tempt- ing the radiographer to interpret the radiograph or provide a diagnosis. However, the Code of Ethics of the American Society of Radiologic Technologists and the American Registry of Radiologic Technologists states: “The radiologic technologist acts as an agent through observation and communication to obtain pertinent information for the physician to aid in the diagnosis and treatment of the patient and recognizes that interpretation and diagnosis are outside the scope of practice for the profession.”^26 Providing a diagnosis is in direct conflict with the Code of Ethics and should be avoided. However, knowing the correct location of specific tubes and lines will result in better patient care by enabling the radiographer to provide correct posi- tioning and adequate technique, both of which can be crucial in the care of the patient. A list and description of commonly placed tubes and lines visualized on chest radiographs are shown in Table
- They include: ■ Endotracheal tube (ETT). ■ Tracheostomy tube. ■ Central venous catheter (CVC).
Table 2 Location of Tubes and Lines Tube or Line Desired Position ETT Tip > 5 cm from carina Tracheostomy tube tip Halfway between stoma and carina Central venous catheter Tip in superior vena cava PICC line Tip in superior vena cava Swann-Ganz catheter Tip in proximal right or left pulmonary artery Pleural drainage tube Anterosuperior for pneumothorax; posteroinferior for effusion Pacemaker Tip at apex of right ventricle; other(s) in right atrium and/or coronary sinus AICD One lead in superior vena cava; other in right ventricle NG tube At least 10 cm of tube into the stomach Feeding tube Tip in the duodenum (Reprinted with permission from William Herring M.D., Tubes and Lines: What Where and Whoops. www.learningradiology.com.)
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■ Peripherally inserted central catheter (PICC line). ■ Swann-Ganz catheter. ■ Pleural drainage tube.
■ Pacemaker. ■ Automatic implantable cardioverter defibrillator (AICD). ■ Nasogastric (NG) tube.
Endotracheal Tube An ETT is used with mechanical ventilators to manage the patient’s airway. The tubes come in various sizes and are inserted more commonly through the mouth, but also can be inserted through the nose. The insertion can be made with the aid of a laryngoscope, which is a medical instrument used to guide the tube through the glottis and into the trachea. Stewart et al 27 suggested that correct positioning places the distal end of the tube approxi- mately 5 cm above the carina. Portable chest radiography is a reliable method of demonstrating ETT placement, especially in ICU patients. (See Figure 13.)
Tracheostomy Tube A tracheostomy tube is inserted in the anterior por- tion of the patient’s neck just above the suprasternal notch directly into the trachea by an incision or by a percutaneous technique. 28 These patients often have undergone an ETT placement and now require longer- term ventilation. Herring suggested that the desired location of the tracheostomy tube tip on a chest radio- graph is halfway between the stoma and the carina. 23 (See Figure 14.)
Central Venous Catheter The CVC is a catheter that is placed into the subcla- vian, jugular or femoral vein that leads to the heart. Two types of CVCs include tunneled and nontunneled cath- eters. Nontunneled catheters are inserted directly into the vein for short-term venous therapy. Tunneled CVCs are inserted in the vein via a tunnel under the skin for extended access. 29 Some common types of CVCs are the Hickman, Broviac and Groshong catheters (Bard Access Systems Inc, Salt Lake City, Utah). A different catheter called a Port-a-Cath (Smiths Medical Inc, St. Paul, Minnesota) is a more permanent CVC usually placed under the skin in the chest that can be accessed via a Huber needle to administer medications. “A chest radio- graph is the easiest way to verify central line position.”^29 (See Figure 15.) When visualizing a CVC on a chest radiograph, the tip of the catheter should be placed in the superior vena cava just above the right atrium. 30 Some reasons for inserting a CVC include: ■ To obtain access to the venous system when peripheral veins are not available.
Figure 13. Radiograph demonstrating an endotracheal (ET) tube placement. A normally positioned ET tube should be located about 5 cm above the carina. The pencil mark in the center of this radiograph indicates the carina. The pencil mark at mid-T2 indicates the end of the ET tube.
Figure 14. Radiograph demonstrating a tracheostomy tube. Herring^23 suggested that the tracheostomy tube tip (middle arrow) should be located halfway between the carina (lower arrow) and the stoma (upper arrow). (Reprinted with permission from W. Herring, Albert Einstein Medical Center, Philadelphia, PA. LearningRadiology.com Web site. www.learningradiology.com.)
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Pacemaker The pacemaker is a medical device that stimulates the beating of the heart when the heart’s natural pace- maker is not working properly. The 2 types of pacemak- ers commonly used are the temporary pacemaker and the permanent pacemaker. The temporary pacemaker is placed via a CVC approach, and the tip of the wire is directed to the right atrium or the right ventricle. The proximal end of the wire is connected to a small battery- powered generator located outside of the patient’s body. With a permanent pacemaker, this generator is surgical- ly implanted. It usually is implanted in the subcutaneous fat in the patient’s anterior chest wall. Pacemakers can have different numbers of leads. For example, a single- lead pacemaker paces only the ventricles and a 2-lead pacemaker can pace both the ventricles and the atria. 33 (See Figure 19.) Additionally, biventricular pacemakers can be implant- ed to treat patients who are experiencing heart failure.
This is called cardiac resynchronization therapy. The biventricular pacemaker allows synchronization between both sides of the heart. This pacemaker has 3 leads that are positioned in the right atrium, right ventricle and left ventricle by passing them through the coronary sinus vein. 34 Portable chest radiography can demonstrate the position of pacemaker leads in the heart.
Automatic Implantable Cardioverter Defibrillator An AICD, also called an ICD, is a device that is slight- ly larger than a pacemaker and is implanted in the chest wall in a similar way. This device is used to detect heart arrhythmias and then deliver an electrical shock to the heart to convert it to a normal rhythm. “The lithium bat- teries provide a projected monitoring life of 3 years, or the capability of delivering about 100 discharges.”^35 An AICD also can go into a pacing mode after defibrilla- tion and act as a pacemaker if the needs of the patient warrant it. Bardy et al stated that “most cardioverter- defibrillators now require only a single lead that can be placed transvenously.”^36 Portable chest radiography can be used to demonstrate an AICD. (See Figure 20.)
Figure 18. Radiograph demonstrating a pleural drainage tube. Herring^23 pointed out that the tip of the drainage tube (top arrow) lies in the apex of the right hemithorax. (Reprinted with permission from W. Herring, Albert Einstein Medical Center, Philadelphia, PA. LearningRadiology.com Web site. www.learningradiology.com.)
Figure 19. Radiograph showing a 2-lead pacemaker. The upper arrow points to the lead in the right atrium; the lower arrow points to the lead in the right ventricle. The generator is circled. (Reprinted with permission from W. Herring, Albert Einstein Medical Center, Philadelphia, PA. LearningRadiology.com Web site. www.learningradiology.com)
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Nasogastric Tube and Feeding Tube The NG tube is a long, flexible tube that is placed through the nose into the stomach. It is included in this discussion because a chest radiograph often is ordered for NG tube placement. When this is the case, the chest should be positioned low enough to include the end of the tube or an abdominal radiograph should be suggest- ed. An NG tube can be used to decompress the gastroin- testinal tract to relieve abdominal distention. It also can be used for feeding; administering barium or medication; and lavage, such as when active bleeding or poisoning is a concern. 37 Kolbitsch et al 38 reported a case of an NG feed- ing tube inadvertently placed into the respiratory system in a tracheostomized patient, causing a pneumothorax. As a result of such situations, routine chest radiography is mandatory to confirm the position of NG tubes. 38 Herring suggested that at least 10 cm of the tube’s tip should be in the stomach. Ideally, the tip should rest in the duodenum. 23 (See Figure 21.)
Common Radiographic Findings in the Chest Radiographers should be familiar with common radio- graphic findings in the chest. Seven such findings are: ■ Pneumonia. ■ Congestive heart failure. ■ Pneumothorax. ■ Pleural effusion.
■ Cardiomegaly. ■ Pneumoperitoneum. ■ Emphysema.
Pneumonia Pneumonia is an illness that shows up as a white den- sity on a chest radiograph. (See Figure 22.) Sometimes radiologists refer to these opacities as consolidations. Consolidations occur when the lung’s alveoli fill with fluid, simulating soft-tissue densities on the radiograph. There are several causes of pneumonia, including bac- teria, viruses, chemicals and injury. Additionally, aspira- tion pneumonia can occur when the patient aspirates oral or gastric contents, such as when a stroke patient aspirates barium during a swallowing study.
Figure 20. Radiograph demonstrating an AICD pacemaker. This is a 2-lead automatic implantable cardiac defibrillator.
Figure 21. Radiograph demonstrating NG tube placement. Herring^23 stated that at least 10 cm of the distal portion of the NG tube should be in the stomach. The arrow is pointing to the distal tip of the tube, which has curled into the fundus of the stomach. Furthermore, when a feeding tube is placed it should be positioned in the duodenum. (Reprinted with permission from W Herring, Albert Einstein Medical Center, Philadelphia, PA. LearningRadiology.com Web site. www.learningradiology.com.)
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of the costophrenic angles. (See Figure 25A.) This is a good argument for the necessity of including both angles when performing chest radiography. In the bedridden patient, a lateral decubitus position can be used to visual- ize pleural effusions. Pleural effusions are best visualized in the dependent side or side that is down. For example, if the patient is positioned in a left lateral decubitus, the fluid would descend to the dependent side, thus visualiz- ing a left pleural effusion. (See Figure 25C.)
Cardiomegaly Cardiomegaly is an enlarged heart, which is not a problem in and of itself; however, it is a symptom of an underlying problem. 40 (See Figure 26.) Some of the conditions that lead to cardiomegaly include high blood pressure, heart valve disorder and cardiomyopathy. 40 A radiologist evaluates the size of the heart by measuring the transverse dimension of the heart and comparing it with the transverse dimension of the thorax. “The nor- mal heart will occupy slightly less than 50% of the trans- verse dimension of the thorax.”^17 (See Figure 27.)
Pneumoperitoneum Air within the abdominal cavity is referred to as pneumoperitoneum. Typically, it is seen after surgi- cal procedures; however, it also can be caused by a
perforation of the bowel or can occur spontaneously from a bowel obstruction. During trauma, a penetrat- ing injury to the abdomen can introduce air into the peritoneal cavity. A recent report discussed a case of pneumoperitoneum caused by intercourse. 41 Regardless of the cause, the air rises to the level of the diaphragms in an erect position. This black air density can be visu- alized on a PA chest radio- graph because it comes in close contact with the white soft-tissue density of the dia- phragm. (See Figure 28.)
Emphysema Emphysema ranks as the fourth leading cause of death in the United States. 42 It is a disease of the lungs that often is caused by smok- ing. Patients who suffer from emphysema experience shortness of breath and often require oxygen therapy. Sometimes this disease is described as a chronic obstructive pulmonary disease, which also includes other diseases such as chronic bronchitis and asthma. With emphysema, the alveoli lose their elasticity and are unable to hold their shape. Patients with emphy- sema have a flattening appearance of the diaphragms and a barrel-shaped chest. (See Figure 29.) Gay and associates 43 noted that patients with emphysema often also have chronic bronchitis with associated bronchial wall thickening.
Conclusion Chest radiography is performed thousands of times each day in the United States. Because of this frequency, radiographers sometimes become careless when performing the exam. This should be avoided because the chest exam is often critical in determin- ing a patient’s course of treatment. Radiographers play an essential role in the process, and their goal always should be to provide an image that is diagnostic and helps in the patient’s overall treatment. Every patient deserves this type of care, whether in an ambulatory or inpatient setting. Quality chest radiographs cannot
Figure 24. Radiographs demonstrating bilateral pneumothoraces. The image labeled A was taken on inspiration and shows subtle lines bilaterally (arrows) demonstrating air in the pleural space. The radiograph labeled B also shows bilateral pneumothoraces; however, the exposure was made on expira- tion. This decreases the lung volume, but the air in the pleural space remains the same, thus accentuat- ing pneumothoraces. (Images courtesy of G. Aben, Michigan State University Department of Radiology, East Lansing).
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be obtained without adequate knowledge of basic chest anatomy, pathology and consistent positioning.
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Figure 25. A. Erect PA and B. lateral chest radiographs dem- onstrating pleural effusion. There is bilateral blunting of both costophrenic angles. C. Left lateral decubitus chest radiograph demonstrating pleural effusion. The arrows in this radiograph demonstrate how the fluid migrates to the dependent side.
A
C
B
