Chest X-ray quality

Projection

Posterior-Anterior (PA) projection

The standard chest radiograph is acquired with the patient standing up, and with the X-ray 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-to-face. The heart is on the right side of the image as you look at it.

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

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.

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Anterior-Posterior (AP) projection

Sometimes it is not possible for radiographers to acquire a PA chest X-ray. This is usually because the patient is too unwell to stand.

The chest X-ray image is still viewed as if looking at the patient face-to-face.

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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-to-face.

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.

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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.

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.

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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.

In order to take a PA view the patient places his or her arms around the side of the detector plate, or stands with hands on hips. This ensures the scapulae are rotated laterally and no longer overlap the lungs.

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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%.

©Radiology Masterclass 2007 -