Modified Chest X-Ray Radiography through Glass Window for Imaging COVID-19 Pneumonia: Techniques and Radiation Dose

REVIEW
Ibrahim I. Suliman, Ghada A. Khouqeer, Nada A. Ahmed, Mohamed M. Abuzaid, Abdelmoneim Sulieman

 
International Journal of Biomedicine. 2023;13(2):194-201.
DOI: 10.21103/Article13(2)_RA2
Originally published June 5, 2023

Abstract: 

The requirement for infection control during the COVID-19 pandemic led to modifying the exposure parameters in conventional radiography for performing chest X-ray radiography (CXR) through-the-glass (TTG) for imaging COVID-19 pneumonia. Herein, we reviewed and reported the current experiences with the TTG protocol, and summarized the current implementation strategies and modified technique factors. For implementing TTG techniques, measurements are required in a simulated environment using a patient equivalent phantom, and a certain number of investigations must be performed before the patient examination. However, the TTG technique requires modification due to the decrease in photon intensity caused by the attenuation in the glass barrier. This study discussed factors affecting CXR and some related radiation dose terminology required for implementing the TTG technique. Moreover, it summarized the exposure factors of CXR using the TTG technique compared with the standard CXR. Radiation exposure to the patient and the staff using the TTG technique remains within the recommended limits for safe practice. Image quality issues arose following the implementation of the TTG technique, mainly related to suboptimal positioning; image artifacts resulted due to glass attenuation, the increased source-to-image distance (SID), and patient movement. Overall, the reviewed results in this study could help formulate international guidelines and recommendations for the TTG technique for COVID-19 patient imaging, thereby minimizing the cost and time required for setting up the protocol.

Keywords: 
X-ray radiography • glass window • COVID-19 • radiation dose
References: 
  1. Centers for Disease Control and Prevention. COVID-19. Available from: https://www.cdc.gov/coronavirus/2019-ncov/index.html
  2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-513. doi: 10.1016/S0140-6736(20)30211-7. 
  3. WHO. Coronavirus disease (COVID-19) pandemic. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
  4. Wong HYF, Lam HYS, Fong AH, Leung ST, Chin TW, Lo CSY, Lui MM, Lee JCY, Chiu KW, Chung TW, Lee EYP, Wan EYF, Hung IFN, Lam TPW, Kuo MD, Ng MY. Frequency and Distribution of Chest Radiographic Findings in Patients Positive for COVID-19. Radiology. 2020 Aug;296(2):E72-E78. doi: 10.1148/radiol.2020201160.
  5. Auffermann WF, Kraft CS, Vanairsdale S, Lyon GM 3rd, Tridandapani S. Radiographic imaging for patients with contagious infectious diseases: how to acquire chest radiographs of patients infected with the Ebola virus. AJR Am J Roentgenol. 2015 Jan;204(1):44-8. doi: 10.2214/AJR.14.14041.
  6. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. Updated March 22 2020. Available from: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recom...
  7. Rai A, Ditkofsky N, Hunt B, Dubrawski M, Deva D, Mathur S. Portable Chest Radiography Through Glass During COVID-19 Pandemic-Initial Experience in a Tertiary Care Center. Can Assoc Radiol J. 2021 Feb;72(1):175-179. doi: 10.1177/0846537120942885.
  8. Benacerraf BR, McLoud TC, Rhea JT, Tritschler V, Libby P. An assessment of the contribution of chest radiography in outpatients with acute chest complaints: a prospective study. Radiology. 1981 Feb;138(2):293-9. doi: 10.1148/radiology.138.2.7455106. 
  9. Wong HYF, Lam HYS, Fong AH, Leung ST, Chin TW, Lo CSY, Lui MM, Lee JCY, Chiu KW, Chung TW, Lee EYP, Wan EYF, Hung IFN, Lam TPW, Kuo MD, Ng MY. Frequency and Distribution of Chest Radiographic Findings in Patients Positive for COVID-19. Radiology. 2020 Aug;296(2):E72-E78. doi: 10.1148/radiol.2020201160. 
  10. Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, Lucarini S, Busoni S, Mazzoni LN, Miele V. Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome. Radiol Med. 2020 Aug;125(8):730-737. doi: 10.1007/s11547-020-01232-9. 
  11. Dennie C, Hague C, Lim RS, Manos D, Memauri BF, Nguyen ET, Taylor J. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Consensus Statement Regarding Chest Imaging in Suspected and Confirmed COVID-19. Can Assoc Radiol J. 2020 Nov;71(4):470-481. doi: 10.1177/0846537120924606. 
  12. Moirano JM, Dunnam JS, Zamora DA, Robinson JD, Medverd JR, Kanal KM. Through-the-Glass Portable Radiography of Patients in Isolation Units: Experience During the COVID-19 Pandemic. AJR Am J Roentgenol. 2021 Oct;217(4):883-887. doi: 10.2214/AJR.20.23367.
  13. Chan J, Auffermann W, Jenkins P, Streitmatter S, Duong PA. Implementing a Novel Through-Glass Chest Radiography Technique for COVID-19 Patients: Image Quality, Radiation Dose Optimization, and Practical Considerations. Curr Probl Diagn Radiol. 2022 Jan-Feb;51(1):38-45. doi: 10.1067/j.cpradiol.2020.12.003. 
  14. ICRP, 2007. Radiological Protection in Medicine. ICRP Publication 105. Ann. ICRP 37 (6).
  15. Brady Z, Scoullar H, Grinsted B, Ewert K, Kavnoudias H, Jarema A, Crocker J, Wills R, Houston G, Law M, Varma D. Technique, radiation safety and image quality for chest X-ray imaging through glass and in mobile settings during the COVID-19 pandemic. Phys Eng Sci Med. 2020 Sep;43(3):765-779. doi: 10.1007/s13246-020-00899-8. 
  16. McKenney SE, Wait JMS, Cooper VN 3rd, Johnson AM, Wang J, Leung AN, Clements J. Multi-institution consensus paper for acquisition of portable chest radiographs through glass barriers. J Appl Clin Med Phys. 2021 Aug;22(8):219-229. doi: 10.1002/acm2.13330.
  17. Rai A, MacGregor K, Hunt B, Gontar A, Ditkofsky N, Deva D, Mathur S. Proof of Concept: Phantom Study to Ensure Quality and Safety of Portable Chest Radiography Through Glass During the COVID-19 Pandemic. Invest Radiol. 2021 Mar 1;56(3):135-140. doi: 10.1097/RLI.0000000000000716. 
  18. Schelleman A, Boyd C. X-rays through the Looking Glass: Mobile Imaging Dosimetry and Image Quality of Suspected COVID-19 Patients. Journal of Radiation Protection and Research. 2021;46(3):120-126.
  19. England A, Littler E, Romani S, Cosson P. Modifications to mobile chest radiography technique during the COVID-19 pandemic - implications of X-raying through side room windows. Radiography (Lond). 2021 Feb;27(1):193-199. doi: 10.1016/j.radi.2020.07.015.
  20. Gange CP, Pahade JK, Cortopassi I, Bader AS, Bokhari J, Hoerner M, Thomas KM, Rubinowitz AN. Social Distancing with Portable Chest Radiographs During the COVID-19 Pandemic: Assessment of Radiograph Technique and Image Quality Obtained at 6 Feet and Through Glass. Radiol Cardiothorac Imaging. 2020 Nov 12;2(6):e200420. doi: 10.1148/ryct.2020200420. 
  21. NCRP National Council on Radiation Protection and Measurements. Structural shielding design for medical x-ray imaging facilities. NCRP Report No. 147, National Council on Radiation Protection and Measurements, Bethesda, Maryland, 2004
  22. ICRP, 2004. Managing Patient Dose in Digital Radiology. ICRP Publication 93. Ann. ICRP 34 (1).
  23. Jenkins D. Exposure Factor Manipulation and Control. In: Radiographic Photography and Imaging Processes. Springer, Dordrecht. 1980. doi: 10.1007/978-94-009-8692-3_7
  24. Ahmed NA, Basheir EH, Farah AB, Mohammedzein TS, Suliman II. Proposed national diagnostic reference levels for standard radiographic X-ray procedures in Sudan. Radiat Prot Dosimetry. 2020 Oct 16;190(4):419-426. doi: 10.1093/rpd/ncaa114. 
  25. Suliman II. Estimates of Patient Radiation Doses in Digital Radiography Using DICOM Information at a Large Teaching Hospital in Oman. J Digit Imaging. 2020 Feb;33(1):64-70. doi: 10.1007/s10278-019-00199-y. 
  26. ICRU (2005) Patient Dosimetry for X-Rays Used in Medical Imaging, 2005. ICRU Report No. 74, International Commission on Radiation Units and Measurements, Bethesda.
  27. International Atomic Energy Agency (2007) Dosimetry in Diagnostic Radiology: An International Code of Practice. IAEA TRS. No 457, IAEA, Vienna.
  28. IEC 62494-1:2008 Medical electrical equipment - Exposure index of digital X-ray imaging systems - Part 1: Definitions and requirements for general radiography. International Standard, ISBN 2-8318-9944-3
  29. Shepard SJ, Wang J, Flynn M, Gingold E, Goldman L, Krugh K, Leong DL, Mah E, Ogden K, Peck D, Samei E, Wang J, Willis CE. An exposure indicator for digital radiography: AAPM Task Group 116 (executive summary). Med Phys. 2009 Jul;36(7):2898-914. doi: 10.1118/1.3121505. Erratum in: Med Phys. 2010 Jan;37(1):405. 
  30. Hart D, Hillier MC, Shrimpton PC. Doses to patients from radiographic and fluoroscopic X-ray imaging procedures in the UK: 2010 review. HPA-CRCE-034.2012.  Available from:http://www.hpa.org.uk/Publications/Radiation/CRCEScientificAndTechnicalR...
  31. European Commission. Diagnostic reference levels in thirty-six European countries, Radiation Protection N° 180. Luxembourg: Publications Office of the European Union; 2014.
  32. ACR–AAPM–SPR Practice parameter for diagnostic reference levels and achievable doses in medical X-ray imaging. Revised 2018 (Resolution 40). Available from: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/diag-ref-level...
  33. Yeung P, Pinson JA, Lawson M, Leong C, Badawy MK. COVID-19 pandemic and the effect of increased utilisation of mobile X-ray examinations on radiation dose to radiographers. J Med Radiat Sci. 2022 Jun;69(2):147-155. doi: 10.1002/jmrs.570.

Download Article
Received March 13, 2023.
Accepted May 12, 2023.
©2023 International Medical Research and Development Corporation.