COLLEGE OF ALLIED HEALTH PROFESSIONS

WEEK 8 ACTIVITY COURSE MODULE

Radiographic Positioning and Radiologic Procedures II
Bachelor of Science in Radiologic Technology

ANATOMY
BODY HABITUS
The general shape of the human body, or
the body habitus, determines the size,
shape, position, and movement of the
internal organs.

RESPIRATORY SYSTEM
Respiratory system consists of the
• pharynx
• trachea
• bronchi
• two lungs
-The air passages of these organs communicate
THORACIC CAVITY with the exterior through the pharynx, mouth,
The thoracic cavity is bounded by the and nose, each of which, in addition to serving
walls of the thorax and extends from the other described functions, is considered a part
superior thoracic aperture, where struc- of the respiratory system.
tures enter the thorax, to the inferior tho-
racic aperture TRACHEA
• Diaphragm separates the thoracic cavity from • is a fibrous, muscular tube with 16 to 20 C-
the abdominal cavity. shaped cartilaginous rings embedded in its walls
for greater rigidity.
It contains: • approximately ½ inch (1.3 cm) in diameter and
• Heart 4 ½ inches (11 cm) in length, and its posterior
• Lungs aspect is flat
• Organs of the respiratory Carina last tracheal cartilage is
• cardiovascular elongated and has a hooklike process which extends
• lymphatic systems posteriorly on its inferior surface.
• inferior portion of the esophagus • Two lesser tubes
• thymus gland
Primary Bronchi
THREE SEPARATE CHAMBERS INSIDE THE CAVITY Right primary bronchus is shorter, wider, and
1. Single pericardial cavity more vertical than the left primary bronchus.
2. Right pleural cavity Because of the more vertical position and
3. Left pleural cavity greater diameter of the right main bronchus,
These cavities are lined by shiny, foreign body entering the trachea are more
slippery, and delicate serous membranes likely to pass into the right bronchus than the
left bronchus.
MEDIASTINUM- space between the two pleural • After entering the lung, each primary bronchus
cavities divides, sending branches to each lobe of the
lung: three to the right lung and two to the left
lung.

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The pleura consists of two layers:
Secondary Bronchi
• divide further and decrease in caliber. Visceral pleura (inner) covers the lung and extends into
fissures.
Tertiary bronchi
• bronchi continue dividing into tertiary bronchi Parietal pleura (outer) lines the thoracic cavity and
and then into smaller bronchioles, and end in diaphragm.
minute tubes called the terminal bronchioles
The pleural cavity between them contains serous fluid,
Bronchial tree preventing friction during respiration.
• extensive branching of the trachea because it
resembles a tree trunk Each lung has lobes divided by fissures:

Right lung: 3 lobes (superior, middle, inferior) with

horizontal and oblique fissures.

Left lung: 2 lobes (superior and inferior) with only an

oblique fissure. The lingula, a small projection,
corresponds to the right middle lobe.

Lungs are further divided into bronchopulmonary

segments, then primary lobules, which contain terminal
bronchioles, alveolar ducts, and alveolar sacs, where gas
exchange occurs.

ALVEOLI
The terminal bronchioles connect to alveolar ducts,
which lead to alveolar sacs lined with alveoli. The lungs
contain millions of alveoli, where oxygen and carbon
dioxide exchange occur through diffusion.

LUNGS
The lungs are the organs of respiration, responsible for
oxygen intake and carbon dioxide removal. They are
made of light, spongy, and elastic tissue (parenchyma)
and covered by a serous membrane (pleura). Each lung
has a rounded apex extending above the clavicles and a
broad base resting on the diaphragm. The right lung is
MEDIASTINUM
shorter and broader than the left lung due to the liver
The mediastinum is the thoracic area between the
and heart's position.
sternum, spine, and lungs. The esophagus, a 9-inch
muscular tube, connects the pharynx to the stomach
During breathing, the lungs move downward
and passes through the mediastinum and diaphragm.
(inspiration) and upward (expiration). The costophrenic
Positioned in front of the vertebral column, it is close to
angle in radiology marks the deepest part of the lung's
the trachea, aortic arch, and heart, making it useful in
lateral recess. The mediastinal surface has a hilum,
heart examinations when filled with barium sulfate for
where bronchi, blood vessels, and nerves enter, and the
imaging.
left lung has a cardiac notch accommodating the heart.

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The thymus gland, part of the lymphatic system,
produces thymosin, a hormone essential for immune
system development. It consists of two lobes located in
the lower neck and superior mediastinum, anterior to
the trachea and great vessels. The thymus grows until
puberty, then shrinks and is replaced by fat in older
individuals. In infants, an enlarged thymus can cause
respiratory issues by pressing on nearby structures. AP
and lateral radiographic exams are used to assess the
thymus, with optimal imaging taken at full inspiration.

The structures associated with the mediastinum are

Heart, Great vessels, Trachea, Esophagus, Thymus,
Lymphatics, Nerves, Fibrous tissue, and Fat.

COMPUTED TOMOGRAPHY
At the present time, computed tomogra
phy (CT) is used almost exclusively to
image the anatomic areas of the thorax
including the thymus gland. CT is exceled
lent at showing all thoracic structures.

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RADIOGRAPHY
GENERAL POSITIONING CONSIDERATION
Radiography of the heart and lungs requires the patient
to be placed in an upright position to prevent
engorgement of pulmonary vessels and allow gravity to
depress the diaphragm. The left lateral chest position is
commonly used to place the heart closer to the IR,
resulting in a less magnified heart image. To prevent
distortion of the heart shadow, the body must be
carefully positioned and immobilized. Procedures for PA
and lateral projections include placing the side of
interest against the IR holder, standing with equal
weight distribution, raising the patient's arms, and
examining the posterior aspects of the ribs. In oblique
projections, the patient rotates the hips with the thorax
and points the feet directly forward.

BREATHING INSTRUCTIONS
During normal inspiration, the costal muscles pull the
anterior ribs, the shoulders rise, and the thorax
expands. Deep inspiration causes the diaphragm to
move inferiorly, resulting in heart elongation.
Radiographs of the heart should be obtained at the end SECTION 1. TRACHEA
of normal inspiration to prevent distortion. When AP PROJECTION
pneumothorax is suspected, one exposure is made at PP: Supine/upright; neck slightly extended; MSP
the end of full inspiration and another at the end of full perpendicular to IR; Adjust pt. shoulders to lie in the
expiration to show small amounts of free air in the same transverse plane; Center IR at the level of the
pleural cavity. Inspiration and expiration radiographs manubrium; exposure during slow inspiration;
are used to show the diaphragm movement, the
presence of a foreign body, and atelectasis. RP: Manubrium
CR: Perpendicular through the manubrium to the center
TECHNICAL PROCEDURE of the IR
Involves projections required by the attending physician SS: Outline of the Air-filled trachea; Area from the
and the patient's clinical history. The exposure factors midcervical to the midthoracic region.
and accessories depend on the radiographic CI: Aspiration/Foreign body
characteristics of the individual patient's pathologic
condition.

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SECTION 1.1 TRACHEA AND SUPERIOR CR: Perpendicular CR enters at the level of T7
MEDIASTINUM SS: Entire lung field
LATERAL PROJECTION
• Sharp outline of heart
PP: Seated/upright lateral position; hands clasped
behind the body; shoulder rotated posteriorly (prevents • Sharp outline of diaphragm (expiration)
superimposition of arms & superior mediastinum); neck
extended slightly; exposure during slow inspiration • Ten posterior ribs above diaphragm
RP: Midway b/n jugular notch & midcoronal plane (for
Upright Position Rationale:
trachea); 4-5 in. lower (for superior mediastinum)
CR: Horizontal through a point of midway bet. The • Diaphragm at its lowest position
jugular notch and the MCP
SS: Air-filled trachea & trachea and superior • Air-fluid levels are seen
mediastinum free from superimposition by the • Avoid engorgement of the pulmonary vessels
shoulders
ER: described by Eisleberg & Sagiltzer CI: Pleural effusion, Pneumothorax, Atelectasis

• Used to demonstrate retrosternal extensions of

the thyroid gland

• Thymic enlargement in infants (recumbent

position)

• Opacified larynx & upper esophagus

Outline of trachea & bronchi

CI: Aspiration/For foreign body localization

LATERAL PROJECTION
PP: Upright/seated-upright; left side against the IR (for
heart & left lung) or right side against the IR (for right
lung); MSP ∥ to IR; MCP perpendicular to IR; arms
extended directly upward; elbow flexed; forearm
resting on elbows
RP: T7
CR: Perpendicular to IR, CR enters on the MCP at the
level of T7
SS: Heart, aorta & left-sided pulmonary lesions (left
lateral)

SECTION 2. CHEST • Right-sided pulmonary lesions (right lateral)

PA PROJECTION
ER:
PP: Upright/seated-upright (always); chin extended
upward; arms hanging at the side and flex arms and to • Employed to demonstrate the interlobar
the rest of the back the hands low on the hips; depress fissures
the shoulders and adjust to lie in the same transverse
plane; exposure after second full inspiration (general) or • To differentiate the lobes
end of full inspiration & expiration (for presence of
• To localize pulmonary lesions
pneumothorax & foreign body)
RP: T7

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• RAO:

o Maximum area of left lung

o Trachea

o Entire left branch of bronchial tree

o Best image of left atrium, anterior

portion of apex of left ventricle & right
retrocardiac space

o Esophagus (if barium filled)

• Medial part of right middle lobe & lingula of the

left upper lobe free from hilum (CR 10-20°)

CI: Pleural effusion, Pneumothorax, Atelectasis

PA OBLIQUE PROJECTION
PP: Upright/seated-upright; LAO/RAO (affected side
up); body rotated 45° toward unaffected side; 55-60°
(for cardiac series); 10-20° (for study of pulmonary
diseases); shoulder of unaffected side against IR; weight
of pt must be equally distributed on both feet
RP: T7
CR: Perpendicular
SS: Entire lungs, Trachea filled with air

• LAO:

o Maximum area of right lung

o Trachea & carina

o Entire right branch of bronchial tree

o Heart, descending aorta & aortic arch

o Esophagus (if barium filled)

AP OBLIQUE PROJECTION
PP: Upright/supine; LPO/RPO (affected side down);
body rotated 45° toward affected side; shoulder of
affected side against IR; flex elbows and place hands on
the hips with palms facing outward or pronate hands
beside hips; raised hands closer to IR

RP: 3 in. inferior to jugular notch

CR: Perpendicular to IR at a level 3 inch below jugular
notch
SS: Both lungs and its entirety; Trachea filled with air;
Visible identification markers

LPO: Maximum area of left lung; similar to RAO

RPO: Maximum area of right lung; similar to LAO

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ER:

• Used when patient is too ill to be turned in

prone position

• Supplementary position in investigation of

specific lesions

• Used with recumbent patient in contrast studies

of the heart & great vessels

SECTION 3. PULMONARY APICES

AP AXIAL PROJECTION/LINDBLOM
METHOD/LORDOTIC POSITION
AP PROJECTION PP: Upright; step 1 foot in front; lean backward in
PP: Supine/upright; back against IR; place hands on extreme lordosis; elbow flexed; pronate hands beside
hips; elbow flexed; hand pronated the hips; shoulder against IR
RP: 3 in. inferior to jugular notch RP: Midsternum
CR: Perpendicular CR: Perpendicular or 15-20° cephalad (no leaning
SS: Somewhat similar to PA but magnified backward)
SS: Lung apices inferior to shadow of clavicles; clavicles
• Magnified heart & great vessels
lying superior to the apices
• Lung fields appear shorter
• Demonstrate interlobar effusions
• Clavicle projected higher
ER: Used in preference to PA axial projection in
• Ribs assume horizontal position hypersthenic patient & whose clavicles occupy a high
position
Resnick Recommendation:
CI: Rule out calcifications and masses beneath the
• CR 30° caudad to midsternal region clavicles

• Rationale: To free basal portions of the lung

fields from superimposition by anterior
diaphragmatic, abdominal & cardiac structures

CI: Pleural effusion, Pneumothorax, Atelectasis

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SECTION 4. LUNGS AND PLEURAE

PA AXIAL PROJECTION
AP/PA PROJECTION R or L Lateral
PP: Upright; chin rested against the IR; elbow flexed; Decubitus
pronate hands on hips; depress shoulder & protract
forward; exposure at end of full inspiration PP: Lateral decubitus; patient lie on affected side (for
RP: T3 pleural effusion) or unaffected side (pneumothorax);
CR: 10-15° cephalad (expiration optional) or body elevated 2-3 in.; arms well above the head; remain
perpendicular to IR and centered at the level of T7 in position for 5 minutes before exposure
SS: Lung apices superior to shadow of clavicles; Apices RP: 3 in. inferior to jugular notch (AP) or T7 (PA)
in their entirety; Clavicles lying below the apices CR: Horizontal and perpendicular to the center of the IR
CI: Pleural effusion, Pneumothorax, Atelectasis at a level of 3 inch
SS: Apices; affected side in its entirety; demonstrates
the change in fluid position and reveals any obscured
pulmonary areas
CI: Pleural effusion, Pneumothorax, Atelectasis

AP AXIAL PROJECTION
PP: Upright/supine; flex pt elbows and place hands on
hips with the palms out; place shoulders back against
the grid

RP: Midsternum
CR: 15-20° cephalad to the center of IR
SS: Apices lying below the clavicles; Clavicles lying
superior to the apices; Superior lung region adjacent to
the apices
CI: Pleural effusion, Pneumothorax, Atelectasis

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LATERAL PROJECTION R or L Position SCENARIOS:
Ventral/Dorsal Decubitus Position SECTION 1. TRACHEA
PP: Supine/prone; thorax elevated 2-3 in.; remain in AP PROJECTION
position 5 minutes before the exposure; extend arms
A 45-year-old male patient presents to the emergency
well above the head; affected side against the IR
RP: 3 in. inferior to jugular notch (ventral decubitus) or department with progressive hoarseness, difficulty
T7 (dorsal decubitus) breathing, and a harsh, barking cough. He has a history
CR: Horizontal of smoking and occasional acid reflux. The attending
SS: Shows a change in position of fluid and reveals physician suspects an upper airway obstruction and
pulmonary areas that are obscured by fluid in standard orders an X-ray AP projection of the trachea to assess
projection for possible narrowing, foreign body, or tracheal mass.
• Entire lung fields; Upper lung fields not
obscured by the arms; no rotation of thorax
CI: Pleural effusion, Pneumothorax, Atelectasis SECTION 1.1 TRACHEA AND SUPERIOR
MEDIASTINUM
LATERAL PROJECTION
A 6-year-old child is brought to the pediatric emergency
department with a sudden onset of stridor, difficulty
breathing, and a fever. The child’s parents report a
history of recent upper respiratory infection. The
attending physician suspects croup or epiglottitis and
orders a lateral X-ray of the trachea to assess for upper
airway narrowing or swelling.

SECTION 2. CHEST
PA PROJECTION
A routine chest X-ray is requested for a patient with a
persistent cough to check for infections or lung disease.

LATERAL PROJECTION
A patient with a known lung nodule requires a lateral
chest X-ray to evaluate its size and location.

PA OBLIQUE PROJECTION
A 55-year-old male presents to the radiology
department with a history of chronic cough, possible
right hilar lymphadenopathy seen on a prior PA chest x-
ray, and suspected bronchiectasis. He is complaining of
mild right-sided chest pain. The physician has ordered a
PA chest oblique projection to better visualize the right
lung and mediastinum, specifically the hilar region.

AP OBLIQUE PROJECTION
A bedridden patient with pneumonia requires an AP
oblique chest X-ray to assess lung involvement.

AP PROJECTION
A patient in the ICU on a ventilator requires an AP chest
X-ray to monitor lung condition and tube placement.

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SECTION 3. PULMONARY APICES radiologist orders an AP projection of the lungs and
pleurae in the right lateral decubitus position.
AP AXIAL PROJECTION/LINDBLOM
METHOD/LORDOTIC POSITION LATERAL PROJECTION R or L Position
A 58-year-old male presents to the outpatient clinic Ventral/Dorsal Decubitus Position
with a persistent cough, night sweats, and unexplained
weight loss over the past three months. He has a history A 62-year-old female patient presents to the emergency
of smoking and was recently exposed to a coworker department with progressive shortness of breath, a dry
diagnosed with tuberculosis (TB). The physician cough, and right-sided chest discomfort. She has a
suspects pulmonary tuberculosis, which commonly
history of congestive heart failure (CHF) and
affects the apical regions of the lungs, and orders an AP
Axial Projection (Lordotic View) of the Pulmonary Apices pneumonia. On auscultation, decreased breath sounds
to evaluate for cavitary lesions or fibrosis. are noted in the right lower lung field, raising suspicion
of a pleural effusion. The physician orders a right lateral
PA AXIAL PROJECTION decubitus X-ray to assess fluid accumulation in the
A 58-year-old male patient presents to the outpatient pleural space.
clinic with persistent shoulder pain, tingling in his left
hand, and unexplained weight loss over the past three GROUP 5:
months. He has a 30-year history of smoking. The Concha, Norilyn
physician suspects a possible Pancoast tumor (superior De Belen, Lea
sulcus tumor) and orders a PA Axial projection of the Guting, Xyhr
pulmonary apices to evaluate the lung apices for any Pineda, Kenneth Mico
mass or lesion compressing nearby structures. Santiago, Lyka
Villamayor, Ivan

AP AXIAL PROJECTION
A 60-year-old female patient presents to the outpatient
radiology department with progressive shortness of
breath, a dry cough, and occasional chest discomfort
over the past six months. She has a history of long-term
exposure to environmental pollutants due to her
occupation in textile manufacturing. Her pulmonologist
suspects early signs of pulmonary fibrosis and orders an
AP Axial Projection of the Pulmonary Apices to evaluate
the upper lung fields for fibrosis, scarring, or other
interstitial lung abnormalities.

SECTION 4. LUNGS AND PLEURAE

AP/PA PROJECTION R or L Lateral
Decubitus

A 65-year-old female patient with a history of

congestive heart failure and chronic obstructive
pulmonary disease (COPD) presents to the emergency
department with worsening shortness of breath and a
dry cough. A recent chest X-ray in an upright position
suggested possible pleural effusion on the right side. To
confirm the presence and mobility of the fluid, the

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