Chest X-ray quality

Tutorial introduction Before interpreting a chest X-ray it is important to assess the quality of the image. Without this step you may diagnose disease that is not genuine or you may be wrongly reassured. This tutorial covers the principles of chest X-ray quality and discusses the limitations of sub-optimal images. Anatomical inclusion, projection, rotation, inspiration/lung volume, penetration and artifact all contribute to image quality. Each are discussed in turn Discarding/repeating images If the image is not of best quality but the clinical question can still be answered, a chest X-ray need not be repeated. If you are not sure if a repeat image will be of use then discuss the case with a radiographer or radiologist. Do not discard a chest X-ray because it is not perfect. Even suboptimal images demonstrate life-threatening abnormalities, which may require your immediate attention.

Tutorial Key Points

Image quality influences interpretation Check the image for - Inclusion, Projection, Rotation, Inspiration, Penetration and Artifact Quality is influenced by radiographic technique and patient factors Does a poor quality X-ray answer the clinical question? Does a poor quality X-ray demonstrate a life threatening abnormality?

Inclusion
Key points Is all necessary anatomy included? Can the clinical question still be answered? Image quality - anatomy inclusion First ribs? Costophrenic angles? Lateral edges of ribs?

Inclusion
A chest X-ray should include the entire thoracic cage. Occasionally, important anatomical structures are not included. If the clinical question can still be answered then acquiring another image is not always necessary.

Inclusion
Image quality - anatomy inclusion First ribs? Costophrenic angles? Lateral edges of ribs?

Projection
Key points Posterior-Anterior (PA) is the standard projection PA projection is not always possible Both PA and AP views are viewed as if looking at the patient from the front PA views are of higher quality and more accurately assess heart size than AP images If an AP projection is performed, ask yourself if the clinical question can still be answered

Posterior-Anterior (PA) projection The standard chest radiograph is acquired with the patient standing up, and with the Xray beam passing through the patient from Posterior to Anterior (PA). The chest X-ray image produced is viewed as if looking at the patient from the front, face-toface. The heart is on the right side of the image as you look at it.

Projection

PA projection X-rays pass from the posterior to the anterior of the patient - hence Posterior-Anterior (PA) projection. The image is viewed as if looking at the patient face-to-face.

Projection

AP projection X-rays pass from the anterior to the posterior of the patient - hence Anterior-Posterior (AP) projection. The image is still viewed as if looking at the patient face-toface. This is usually because the patient is too unwell to stand

Projection

AP v PA - Heart size The heart, being an anterior structure within the chest, is magnified by an AP view. Magnification is exaggerated further by the shorter distance between the X-ray source and the patient, often required when acquiring an AP image. This leads to a more divergent beam to cover the same anatomical field. As a rule of thumb, you should never consider the heart size to be enlarged if the projection used is AP. If however the heart size is normal on an AP view, then you can say it is not enlarged AP v PA projection The upper diagram shows an AP projection. Heart size is exaggerated because the heart is relatively farther from the detector, and also because the X-ray beam is more divergent as the source is nearer the patient. The lower diagram shows a conventional PA projection. The apparent heart size is nearer to the real size, as the heart is relatively nearer the detector. Magnification of the heart is also minimised by use of a narrower beam, produced by the increased distance between the source and the patient.

Projection

AP v PA - Scapular edges Radiographers will often label a chest X-ray as either PA or AP. If the image is not labelled, it is usually fair to assume it is a standard PA view. If, however, you are not sure, then look at the medial edges of each scapula. AP projection - example AP projection images are of lower quality than PA images. Compare this image with the PA view below. The image has been acquired by a mobile X-ray unit in the resuscitation room. Note the AP SITTING label. The scapulae are not retracted laterally and they remain projected over each lung. Heart size is exaggerated (cardiothoracic ratio approximately 50%). If seen on a PA image this would be at the borderline for cardiac enlargement. The radiograph was repeated - see below. PA projection - example This PA X-ray is of the same patient as the image above. The edges of the scapulae are retracted laterally with only a small portion projected over each lung. The lungs are therefore more easily seen. The cardiothoracic ratio is clearly well within the normal limit of 50%.

Rotation
Key points Check for rotation If there is rotation ask does it matter? Rotation may lead to misinterpretation of heart contours, tracheal position and lung appearances

Rotation If the patient is very rotated and you do not recognise this, certain appearances may become misleading. Principles of rotation The spinous processes of the thoracic vertebrae are in the midline at the back of the chest. They should form a vertical line that lies equidistant from the medial ends of the clavicles, which are at the front of the chest. Rotation of the patient will lead to off-setting of the spinous processes so they lie nearer one clavicle than the other. Does rotation matter ? If the patient is rotated then interpretation may become difficult. Firstly, it may be difficult to know if the trachea is deviated to one side by a disease process. It also becomes difficult to comment accurately on the heart size. Changes in lung density due to asymmetry of overlying soft-tissue may be incorrectly interpreted as lung disease.

Rotation
Well centred PA chest X-ray Find the medial ends of the clavicles Find the vertebral spinous processes The spinous processes should lie half way between the medial ends of the clavicles

Inspiration and lung volume

Key points Always assess inspiration and lung volumes Incomplete inspiration can lead to exaggeration of lung markings and heart size Lung hyperexpansion is a sign of obstructive lung disease Assessing inspiration To assess the degree of inspiration it is conventional to count ribs down to the diaphragm. The diaphragm should be intersected by the 5th to 7th anterior ribs in the midclavicular line. Less is a sign of incomplete inspiration.

Inspiration and lung volume Chest X-rays are conventionally acquired in the inspiratory phase of the respiratory cycle. The radiographer asks the patient to, 'breathe in and hold your breath!' Patients who are short of breath, or those who are unable to follow the instructions may find this difficult. When interpreting a chest X-ray it is important to recognise if there has been incomplete inspiration. If the image is acquired in the expiratory phase, the lungs are relatively airless and their density is increased. Also, the raised position of the diaphragm leads to exaggeration of heart size, and obscuration of the lung bases.

Inspiration and lung volume

Expiration
Anteriorly only the third rib intersects the diaphragm at the mid-clavicular line The lung bases are white - Is there consolidation? How big is the heart?

Inspiration and lung volume

Inspiration Anteriorly the sixth rib intersects the diaphragm at the midclavicular line The lungs are not consolidated The heart size is clearly normal

Assessing for hyperexpansion

Normal expansion

Assessing for hyperexpansion While checking for adequate inspiration you may notice that a patient's lungs are hyperexpanded (>7th anterior rib intersecting the diaphragm at the mid-clavicular line). This is a sign of obstructive airways disease. It is possible to assess for hyperexpansion by counting ribs, or by checking for flattening of the hemidiaphragms. Normal expansion This patient has taken a good breath in such that the diaphragm is intersected by the 6th rib in the mid-clavicular line. The hover over image shows an imaginary line (dotted) between the costophrenic and cardiophrenic angles. The distance between this line and the diaphragm (green line) should be greater than 1.5cm(asterisk) in normal individuals. In practice this is rarely measured and a quick assessment of diaphragm shape is all that is necessary.

Assessing for hyperexpansion

Hyperexpansion

Hyperexpansion It is often quicker to assess for hyperexpansion by looking at the hemidiaphragms. These are clearly flattened (red line) in this patient. The ribs are difficult to count as they have lost density. This is due to long term steroid treatment for the patient's emphysema. There is also consolidation of the lung bases due to pneumonia.

Penetration
Penetration is the degree to which X-rays have passed through the body Digital correction may compensate for an incorrectly penetrated X-ray Always check the structures behind the heart A well penetrated chest X-ray is one where the vertebrae are just visible behind the heart The left hemidiaphragm should be visible to the edge of the spine

Penetration Penetration is the degree to which X-rays have passed through the body. Assessment of penetration is traditionally a standard part of assuring chest X-ray quality. With modern digital systems over or under penetrated/exposed images are rarely a problem. Image data can be 'windowed' to optimise visibility of anatomical structures. This is often performed by radiographers after they have acquired the image or can be performed using web-based imaging software on the wards. A well penetrated chest X-ray is one where the vertebrae are just visible behind the heart. Although X-rays are still occasionally over or under exposed, a discussion of penetration now best serves as a reminder to check behind the heart. The left hemidiaphragm should be visible to the edge of the spine. Loss of the hemidiaphragm contour or of the paravertebral tissue lines may be due to lung or mediastinal pathology.

Penetration
Under penetration The left hemidiaphragm is not visible to the spine Lung tissue behind the heart cannot be assessed Re-windowing the image using digital software can compensate

Penetration
Re-windowing The diaphragm (long arrows) is visible to the spine. The left paravertebral soft tissues are visible (short arrows) , and the right side of the spine is clear (arrowheads). There is no abnormality of lung tissue behind the heart.

Artifact
Key points Some artifacts are unavoidable Kind of artifact : Radiographic artifact, Patient artifact, Medical/surgical artifact A chest X-ray may be obtained to assess position of medical devices Ask yourself if artifact limits image interpretation Can the question clinical question still be answered?

Artifact The appearance of anatomical structures may be artifactual because of radiographic technique, patient factors, or the presence of external or internal non-anatomical objects. Artifact is often unavoidable, but some artifact can lead to misinterpretation of the image. Medical equipment may obscure anatomical structures, to the detriment of image interpretation, or conversely may be vital to image assessment. Artifact is acceptable if the clinical question can still be answered. An image need only be repeated if artifact prevents the clinical question from being answered confidently. Radiographic artifact This is spurious or unclear appearance of an anatomical structure due to radiographic technique. As previously discussed, examples include rotation, incomplete inspiration and incorrect penetration. Other radiographic artifact includes clothing or jewelry not removed. Patient artifact Artifact may be due to patient factors such as poor co-operation with positioning or movement. Very often obesity exaggerates lung density. Occasionally normal anatomical structures such as hair or skin folds can cause confusion Medical/surgical artifact Some chest X-rays are performed solely to assess the position of medical devices. It is a common task of a junior doctor to be asked to assess the position of such devices on a chest X-ray. External medical devices not part of the X-ray assessment should be removed by radiographers prior to image acquisition, unless it is dangerous to do so. .

Artifact

Neck surgical emphysema?

Medical/surgical artifact NGT)