Radiographic Positioning of the Thoracic Spine, Chest and Ribs

Section objectives:
At the conclusion of this course the student doctor should;
1. Be able to efficiently conduct all parts of a thoracic spine series, chest series, rib series and ancillary views including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2. Be able to identify the significant anatomy demonstrated on each view of the series.
Standard Thoracic Spine Series - 3 views
	A-P thoracic
	Lateral thoracic
	P-A chest

Standard Chest Series - 2 views
	P-A chest
•	Lateral chest

Standard Rib Series - 5 views
	A-P
	30, and 60 oblique
	Below diaphragm view
	P-A expiratory chest

Optional Thoracic Spine, Chest, and Rib Views
	Apical lordotic chest view
	Swimmer's lateral if C7/Tl junction is not seen

Radiographic Positioning #5822	10	last updated: May, 99
Radiographic Positioning of the Thoracic Spine, Chest and Ribs

A-P Thoracic

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	72" FFD (preferred), no tube tilt
Technique:	80 kVp, large focal spot
Measure:	Slide calipers over shoulder to rest on sternum and midline of the
back at about the level of T6 with patient in full inspiration
Filter/shield:	A-P thoracic filter on upper 1/3 (1/2)
breast shields if non-scoliotic
gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing facing the x-ray tube with the midsagittal plane centered to the central ray.
Central ray:	Top of the cassette should be placed about 1 above the vertebra prominens, with central ray at mid sternum (T6 level)
Collimation:	Open to full cassette vertically, side-to-side to mid-clavicular line
Marker:	R or L

EXPOSURE
Patient directions: "Take a breath in, hold it. Hold still, don't move" - expose.

EVALUATION CRITERIA: A-P Thoracic
	The spinal column from C7 to T12 should be seen centered in the midline of the film.
	Good collimation will include side collimation borders medial to female breast shadows.
	Sternoclavicular joints should be seen equidistant from the spine indicating no rotation.
	Optimum exposure including the use of a wedge filter in addition to the correct use of the anode-heel effect should clearly visualize the lower thoracic vertebral body margins and intervertebral joint spaces without overexposing the upper thoracic vertebra.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

Lateral Thoracic

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	72" FFD (preferred), no tube tilt
Technique:	90 kVp, small focal spot. Small WA is required to make the time greater than 1.0 second (1-2 second exposure), this allows for blurring of the ribs. 
Measure:	From axilla to axilla.
Filter/shield:	Lateral thoracic filter on bottom ½ of film, may require additional filters.
gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing in lateral position with mid-coronal plane centered to the bucky.
If patient has a lateral thoracic curve, place convexity to film, otherwise place left lateral against bucky.
Have patient place hands on top of the head, tuck elbows together. 
Central ray:	Top of the cassette should be placed about I" above the vertebra prominens. Set vertical portion of CR to posterior axillary line.
Collimation:	Open to fill cassette vertically, laterally posterior ½ of the chest.
Marker:	L (usually).

EXPOSURE
Patient directions for breathing technique: "Take a deep breath in, now slowly blow it out".  Expose during exhale.
	Precise timing is required as the exposure is taken while the patient is exhaling, to blur the ribs out of the x-ray.

EVALUATION CRITERIA: Lateral Thoracic
	The spinal column from C7 to T12 should be seen centered in the midline of the film.
	For some patients, the upper vertebra may be underexposed due to superimposition of the shoulders, this may require a lateral cervicothoracic spot shot.
	Intervertebral disc spaces should be open.
	Vertebral bodies should be in lateral profile without rotation as indicated by superimposed posterior ribs.
	Optimum exposure should demonstrate the thoracic spine with blurring of the ribs and lung markings.
	Patient identification and L marker (usually) should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs
P-A Chest

PREPARE THE ROOM
Cassette:	Insight, 14" x 17",	lengthwise (tall, flash up) for females
		crosswise (wide, flash up) for males and obese pts.
Tube:	72” FFD, no tube tilt
Technique:	110 kVp, small focal spot, time < 0.1 second to minimize heart motion
Measure:	Slide calipers over shoulder to rest on sternum and midline of the
back at about the level of T6
Filter/shield:	gonad (½ apron)

THE INSIGHT CASSETTE
The front and back screens are different; the front screen is designed to see the lungs, the rear screen is designed to see the mediastinum, retrocardiac and subdiaphragmatic areas. The film is specialty film identified by a double notch in one corner.
	The front screen identifies where the notches fit into the cassette.
	If reversed, it makes an undiagnostic radiograph.
	350 speed film/screen combination.

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing facing the bucky with backs of hands on waist, head extended (preferred) or head turned to right.
If female, have her pull breast tissue laterally, get as close as possible to the bucky, then place hands on waist.
Patients should roll the shoulders forward to move the scapula laterally and out of the way.
Central ray:	Top of the cassette should be placed about 1'~ above the vertebra prominens.
Collimation:	Open to full chest size vertically and laterally.
Marker:	R or L

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Another deep breath in and hold it. Hold still, don't move" - expose.
	Timing is crucial, expose at the peak of the second inspiration.

EVALUATION CRITERIA: P-A Chest
	The larynx and trachea should be filled with air and well visualized.
	There should be no rotation as evidenced by the symmetrical appearance of the sternoclavicular joints.
	Collimation borders should appear on all four sides with minimal borders on top and bottom.
	Optimum exposure should be dark enough to visualize the air filled trachea through the cervical and thoracic vertebra.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

P-A Expiratory Chest

Expiratory chest views accentuate a pneumothorax (if present) by decreasing the intrapulmonary pressure. Technique is identical to usual P-A chest except expose on expiration instead of 2nd
deep inspiration.

Lateral Chest

PREPARE THE ROOM
Cassette:	Insight, 14" x 17", lengthwise (tall, flash up)
Tube:	72" FFD, no tube tilt
Technique:	115 kVp, small focal spot
Measure:	From latissimus dorsi bilaterally through the central ray.
Filter/shield:	gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing with left side against bucky (heart closest to film) and weight evenly distributed on both feet.
Raise arms and place on top of head, keep chin up.
Central ray:	Top of the cassette should be placed about 1" above the vertebra prominens. Set vertical portion of CR to mid-axillary line.
Collimation:	Open to full cassette size vertically and side-to-side thoracic cavity.
Marker:	L.

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Another deep breath in and hold it. Hold still, don't move" - expose.
	Timing is crucial, expose at the peak of the second inspiration.

EVALUATION CRITERIA: P-A Chest
	No rotation, ribs posterior to vertebral column should be directly superimposed; costophrenic angles should be aligned and superimposed.
	Chin and arms should be elevated sufficiently to prevent excessive soft tissues from superimposing lung apices.
	Images should include lung apices at the top, and costophrenic angles on the lower margin of the film.
	Collimation margins should appear on all four sides with T7 in center of film.
	No motion, should be evidenced by sharp outlines of the diaphragm and lung markings.
	Optimum exposure should demonstrate lung markings through the heart shadow and upper lung areas, without overexposing other regions of the lungs.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

A-P Lordotic Chest

PREPARE THE ROOM
Cassette:	Insight, 14" x 17
Tube:	72" FFD, no tube tilt
Technique:	110 kVp, small focal spot
Measure:	Slide calipers over shoulder to rest on sternum and midline of the back at about the level of T6.  Same as P-A chest.

Filter/shield:	gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing facing the tube about one foot away from the bucky. Have patient lean back with shoulders, neck and back of head against the bucky.
Rest both hands on hips, palms facing out, roll shoulders forward. 
Central ray:	Perpendicular to the film, centered to mid sternum (3-4 "below jugular notch) with the cassette about 3-4" above the shoulders.
Collimation:	Collimate to include area of interest.
Marker:	R or L

EXPOSURE
Patient directions: "Take a deep breath in, now blow it all the way out. Another deep breath in and hold it. Hold still, don't move" - expose.
	Timing is crucial, expose at the peak of the second inspiration.

EVALUATION CRITERIA: A-P Lordotic Chest
	Clavicles should appear nearly horizontal and above or superior to apices.
	No rotation, sternal ends of the clavicles should be the same distance from vertebral column on each side.
	Lateral borders of the ribs on both sides should be near equidistant from the vertebral column.
	Center of collimation field should be mid-sternum with more collimation visible on the bottom.
	The ribs should appear distorted with the posterior portion nearly horizontal.
	No motion, diaphragm, heart and rib outlines should appear sharp.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

A-P (or P-A) Ribs
(Above Diaphragm)

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	70 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing (preferred) or supine facing the x-ray tube with mid-clavicular line centered to the bucky.
Raise chin and look straight ahead.
Central ray:	To T7 (3-4"below jugular notch) at approximately mid-clavicular line. Center cassette to central ray.
Collimation:	Open to outer margins of the thorax. We should see entire vertebral body and outer margins of the ribs.
Marker:	R or L

EXPOSURE
Patient directions: "Take a deep breath in, hold it. Hold still, don't move" expose.

EVALUATION CRITERIA: A-P Rib
	The first through tenth ribs should be seen above the diaphragm.
	No motion is seen on the radiograph (blurring).
	No rotation of the thorax is evident.
	Optimum exposure should visualize ribs through the heart shadow without overexposing mid-posterior ribs through the lung fields.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

30, 60" Oblique Rib

PREPARE THE ROOM
Cassette:	black, 14" x 17", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	70 kVp, small focal spot
Measure:	through central ray at appropriate angle
Filter/shield:	gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is standing (preferred) or supine with patient rotated into oblique position at appropriate angle.
	Injury to right anterior ribs perform RAO views.
	Injury to right posterior ribs perform RPO views.
	Injury to left anterior ribs perform LAO views.
	Injury to left posterior ribs perform LPO views.
Position patient arm so humerus does not obscure ribs. 
Central ray:	Top of the cassette about 1.5 "above the shoulders, CR to T7 and about hallway between spine and lateral margin of affected side.
Collimation:	Open to outer margins of the thorax. We should see entire vertebral body and outer margins of the ribs.
Marker:	R or L.

EXPOSURE
Patient directions: "Take a deep breath in, hold it. Hold still, don't move" expose.

EVALUATION CRITERIA: 30,60 Oblique Rib
	The first through eighth or ninth rib should be seen above the diaphragm.
	No motion is seen on the radiograph (blurring).
	Optimum exposure should visualize ribs through the heart shadow without overexposing mid-posterior ribs through the lung fields.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Thoracic Spine, Chest and Ribs

Below Diaphragm (A-P) Ribs

PREPARE THE ROOM
Cassette:	black, 10" x 12", crosswise (wide, flash opposite side being imaged)
Tube:	40" FFD, no tube tilt
Technique:	90 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad (½ apron)

PREPARE THE PATIENT
Position:	Patient is fully gowned with no jewelry, hairpins, glasses, bra, etc.
Patient is erect or supine with mid-clavicular line centered to bucky.
Central ray:	Midway between xiphoid and lower rib cage in mid-clavicular line.
Center the cassette to the central ray.
Collimation:	To cassette size with four sides of collimation.
Marker:	R or L

EXPOSURE
Patient directions: "Take a breath in, blow it all the way out. Hold still, don't move" expose.

EVALUATION CRITERIA: Below Diaphragm Rib
	The eighth through twelfth ribs and vertebra should be clearly seen.
	No motion is seen on the radiograph (blurring).
	No rotation of the thorax is evident.
	Optimum exposure should visualize ribs through the liver/visceral shadows.
	Patient identification and R/L marker should be clearly visible without blocking anatomy.

Radiographic Positioning #5822	18	last updated: May, 99