CHEST CHAPTER 2 95

LATERAL DECUBITUS POSITION (AP PROJECTION): CHEST

Clinical Indications Chest

Evaluation Criteria
• Small pleural effusions are demon- SPECIAL

strated by air-fluid levels in pleural space. • AP supine or Anatomy Demonstrated: • Entire lungs, including apices,
semierect
• Small amounts of air in pleural cavity both costophrenic angles, and both lateral borders of ribs,
• Lateral decubitus
may demonstrate a possible pneumotho- (AP)
should be included.
rax (see Notes). Position: • No rotation: Should show equal distance from
43 the vertebral column to the lateral borders of the ribs on both
Technical Factors sides; sternoclavicular joints should be the same distance from

R
• Minimum SID—72 inches (183 cm) the vertebral column. • Arms should not superimpose upper
35
• IR size—35 × 43 cm (14 × 17 inches), lungs. • Collimation field (CR) should be centered to the area
of T7 on average-sized patients.
crosswise (with respect to patient position)
• Grid Exposure: • No motion; diaphragm, rib, and heart borders
• Analog and digital systems—110 to 125 kV range and lung markings should appear sharp. • Optimal contrast
• Use decubitus (decub) marker scale and exposure should result in faint visualization of
vertebrae and ribs through heart shadow.
2
Shielding Shield radiosensitive tissues outside region interest.

Patient Position
• Cardiac board on the cart or radiolucent pad under patient
• Patient lying on right side for right lateral decubitus and on left
side for left lateral decubitus (see Notes)
• Patient’s chin extended and both arms raised above head to
clear lung field; back of patient firmly against IR; cart secured to
prevent patient from moving forward and possibly falling; pillow
under patient’s head
• Knees flexed slightly and coronal plane parallel to IR with no
body rotation

Part Position
• Adjust height of IR to center thorax to IR (see Notes).
• Adjust patient and cart to center midsagittal plane and T7 to CR Fig. 2-67 Left lateral decubitus position (AP projection).
(top of IR is approximately 1 inch [2.5 cm] above vertebra
prominens).

CR
• CR horizontal, directed to center of IR, to level of T7, 3 to 4
inches (8 to 10 cm) inferior to level of jugular notch. A
horizontal beam must be used to show air-fluid level or
pneumothorax.

Recommended Collimation Collimate on four sides to area of

lung fields (top border of light field to level of vertebra prominens)
(see Notes).

Respiration Make exposure at end of second full inspiration.

Alternative Positioning Some department protocols state that the

head be 10° lower than the hips to reduce the apical lift caused Fig. 2-68 Left lateral decubitus (fluid evident in left lung).
by the shoulder, allowing the entire chest to remain horizontal
(requires support under hips).
NOTES: Place appropriate decub marker and R or L to indicate which side
of chest is down.
Radiograph may be taken as a right or left lateral decubitus. To produce Lung
the most diagnostic images, both lungs should be included on the image.
For possible fluid in the pleural cavity (pleural effusion), the suspected
side should be down. Do not cut off that side of the chest. The anatomic
side marker must correspond with the patient’s left or right side of the
body. The marker must be placed on the IR before exposure. It is unac-
ceptable practice to indicate the side of the body either digitally or with a Heart
marking pen after the exposure.
For possible small amounts of air in the pleural cavity (pneumothorax), Air
the affected side should be up, and care must be taken not to cut off this fluid
level
side of the chest.

Fig. 2-69 Left lateral decubitus.

 96 C H A PT E R 2 CHEST

AP LORDOTIC PROJECTION: CHEST

Clinical Indications Chest

• Rule out calcifications and masses SPECIAL
• AP supine or
beneath the clavicles. semierect
• Lateral decubitus
Technical Factors (AP)
• Minimum SID—72 inches (183 cm) • AP lordotic

• IR size—35 × 43 cm (14 × 17 inches),

35
lengthwise or crosswise
R
• Grid
• Analog and digital systems—110 to 125 kV range 43

Shielding Shield radiosensitive tissues outside

region of interest.

Patient Position
2 Fig. 2-70 AP lordotic.
• Patient standing about 1 foot (30 cm) away from IR and leaning
back with shoulders, neck, and back of head against IR
• Both patient’s hands on hips, palms out; shoulders rolled forward

Part Position
• Center midsagittal plane to CR and to centerline of IR.
• Center cassette to CR. (Top of IR should be about 3 inches
[7 to 8 cm] above shoulders on an average patient.)

CR
• CR perpendicular to IR, centered to midsternum (3 to 4 inches
[9 cm] below jugular notch)

Recommended Collimation Collimate on four sides to area of

lung fields (top border of light field to level of vertebra
prominens).
Fig. 2-71 Exception: Semiaxial AP.
Respiration Make exposure at end of second full inspiration.

Exception If patient is weak and unstable or is unable to assume

the erect lordotic position, an AP semiaxial projection may be taken
with the patient in a supine position (Fig. 2-71). Shoulders are
rolled forward and arms positioned as for lordotic position. The CR
is directed 15° to 20° cephalad, to the midsternum.

Evaluation Criteria
Anatomy Demonstrated: • Entire lung fields and clavicles
should be included.
Position: • Clavicles should appear nearly horizontal and
above or superior to apices, with medial aspects of clavicles
superimposed by first ribs. • Ribs appear distorted, with
posterior ribs appearing nearly horizontal and superimposing
anterior ribs. • No rotation: Sternal ends of the clavicles
should be the same distance from the vertebral column on
each side. The lateral borders of the ribs on both sides should Fig. 2-72 AP lordotic.
appear to be at nearly equal distances from the vertebral
column. • Center of collimation field (CR) should be
midsternum with collimation visible on top and bottom.
Exposure: • No motion; diaphragm, heart, and rib outlines
should appear sharp. • Optimal contrast scale and exposure
should allow visualization of the faint vascular markings of
lungs, especially in area of the apices and upper lungs.
 CHEST CHAPTER 2 97

ANTERIOR OBLIQUE POSITIONS—RAO AND LAO: CHEST

Clinical Indications Chest

• Investigate pathology involving the lung SPECIAL
• AP supine or
fields, trachea, and mediastinal semierect
structures. • Lateral decubitus
• Determine the size and contours of the (AP)
heart and great vessels. • AP lordotic
• Anterior oblique
Technical Factors
35
• Minimum SID—72 inches (183 cm)
L
• IR size—35 × 43 cm (14 × 17 inches),
RAO LAO
lengthwise 43
• Grid
• Analog and digital systems—110 to 125 kV
range
Fig. 2-73 45° RAO position. 2
Shielding Shield radiosensitive tissues outside region of interest.

Patient Position
• Patient erect, rotated 45° with left anterior shoulder against IR
for LAO and 45° with right anterior shoulder against IR for RAO
(see Notes for 60° LAO)
• Patient’s arm flexed nearest IR and hand placed on hip, palm
out
• Opposite arm raised to clear lung field and hand rested on head
or on chest unit for support, keeping arm raised as high as
possible
• Patient looking straight ahead; chin raised

Part Position
As viewed from the x-ray tube, center the patient to CR and to IR,
with top of IR about 1 inch (2.5 cm) above vertebra prominens. Fig. 2-74 45° LAO position.
CR L
• CR perpendicular, directed to level of T7 (7 to 8 inches [8 to
10 cm] below level of vertebra prominens)

Recommended Collimation Collimate on four sides to area of

lung fields (top border of light field to level of vertebra
prominens).

Respiration Make exposure at end of second full inspiration.

NOTES: For anterior obliques, the side of interest generally is the side
farthest from the IR. Thus, the RAO provides the best visualization of the
left lung.
Certain positions for studies of the heart and great vessels require
oblique positions with an increase in rotation of 45° to 60°. See Figs 2-77
and 2-78.
Less rotation (15° to 20°) may be valuable for better visualization of
the various areas of the lungs for possible pulmonary disease.

Exception Either erect or recumbent posterior obliques can be

taken if the patient cannot assume an erect position for anterior
obliques, or if supplementary projections are required.

Fig. 2-75 45° RAO position.

Evaluation Criteria farthest from the IR should be approximately two times the
Anatomy Demonstrated: • Both lungs from the apices to the distance of the side closest to the IR. • CR centered at level of
costophrenic angles should be included. • Air-filled trachea, T7.
great vessels, and heart outlines are best visualized with 60° Exposure: • No motion; outline of the diaphragm and heart
LAO position. should appear sharp. • Optimal exposure and contrast allow
Position: • To evaluate for a 45° rotation, the distance from the visualization of vascular markings throughout the lungs and rib
outer margin of the ribs to the vertebral column on the side outlines except through the densest regions of the heart.
 98 C H A PT E R 2 CHEST

L
L

Fig. 2-76 45° LAO position. Fig. 2-77 45° RAO position.

L
L

Fig. 2-78 60° LAO position. Fig. 2-79 60° RAO position.