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Slide 1

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Slide 2

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Slide 3

Welcome to the online educational module “Image Gently: Steps to Manage Radiation Dose During the
Examination.” The goal of this module is to provide the medical imaging professional with sufficient
information to create diagnostic quality images while properly managing radiation dose during pediatric
fluoroscopy. This goal will be achieved if the user is knowledgeable about the operation and controls
found on most state-of-the-art fluoroscopes. Operational differences in interventional, general purpose
and mobile C-arm fluoroscopes are addressed. For example, the image is a drawing of a typical control
panel for a general purpose fluoroscopic unit. Each rectangle, circle, or lever shown controls a unique
feature of the fluoroscope. Some of the discussion in this module is beyond the scope typically found in
texts currently used in many radiologic technologist training programs. It may be necessary for the
experienced radiologic technologist to guide users of new equipment or those with less experience in
pediatric fluoroscopy. These training modules underscore the important role of the radiologic
technologist in clinical practice when performing diagnostic imaging examinations of children.

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Slide 4

At the completion of this module, the participant will be able to:

1) Explain the basic operation of fluoroscopic equipment.
2) Identify areas of fluoroscopic practice that can reduce radiation dose to the pediatric patient
during fluoroscopy.
3) List equipment configuration adjustments that affect dose to pediatric patients during
fluoroscopy.
4) Discuss the relationship between fluoroscopic image quality and patient dose.

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Slide 5

Anatomical programs allow the operator to correctly select the type of exam and patient size, which in
turn selects the appropriate multiple controls of the fluoroscope. The anatomical programs are presets
programmed into the fluoroscope by the manufacturer or end user. These programs influence the air
kerma rate of the fluoroscope for preconfigured clinical exams such as the abdomen, kidney,
mesenteric artery or pelvis as a function of patient size in the drop down menu illustrated in the figure.
The filter type and thickness, voltage across the x-ray tube, x-ray tube current, and pulse width all affect
the amount of radiation production by the fluoroscope and the radiation reaching the patient and image
receptor. While radiologic technologists typically think of variations between two fluoroscopes as
“differences in calibration,” these differences are actually a result of unique design choices made by
different manufacturers.

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Slide 6

It is critical that the radiologist and radiologic technologist work with the QMP to establish consensus for
the appropriate default settings of the fluoroscopic unit for pediatric examinations. Because of the large
combination of pediatric patient sizes and types of examinations, most state-of-the-art fluoroscopes
allow multiple configurations to be placed into the fluoroscope’s anatomical programs in an organized
fashion. This feature allows operators to choose appropriate settings and radiographic techniques for a
given patient and examination with one or two simple selections.

However, the fluoroscope’s labeling of default settings can be confusing. For example, what do “small,
medium and large” indicate? Does this indicate a “small, medium or large adult” or a “small, medium or
large child”? The default settings may have been configured in the factory, so they may not be properly
adjusted for children. The illustration shows different patient sizes from one manufacturer that are more
descriptive than most. In this case, by default, one can probably safely assume that the “small”
selection indicates a small adult-sized patient. The radiologic technologist should work with the

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physician and QMP to reach a consensus in evaluating proper setup and labeling of default settings to
eliminate ambiguities and to ensure good pediatric patient care.

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Slide 7

It is probably not possible to use the same technique settings for a patient of the same size and for the
same exam on two different fluoroscopes and deliver the same radiation dose to the patient. However,
the operator may be able to select similar anatomical programs on two separate fluoroscopes for a
given patient. For example, the figure shows that the operator could select the subclavian artery in the
drop down menu on two different machines provided both machines offered this anatomical choice.
However, this does not ensure that the two machines will use similar technique factors. Due to unique
designs by manufacturers, variations between models by the same manufacturer, or software revisions
on identical models by the same manufacturer, two fluoroscopes probably will not use the same
technique factors for patients of the same size, nor would identical technique factors result in the same
radiation dose to the patient. The fluoroscope with higher technique factors may actually be delivering a
lower radiation dose to the patient.

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Slide 8

A single fluoroscopic image, such as a last-image-hold (LIH) image, is noisier than a radiographic
image, but it’s also achieved at a lower dose. The radiation dose to the patient from an LIH image is
approximately one-tenth of the dose from a radiographic image. The radiographic image, with less
noise, provides better image quality, particularly of soft tissues.

The image on the left of a rabbit thorax is a last-image-hold image. There is more noise and less detail
displayed than in the image on the right acquired with a radiographic technique, which delivers
approximately 10 times more radiation dose to the patient and the image receptor.

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Slide 9

The maximum entrance air kerma rate to the patient during fluoroscopy is capped at approximately 88
mGy/min in the normal fluoroscopy mode. However, the actual air kerma rate is very dependent on the
thickness of the child as illustrated in the diagram. The air kerma rate for the smallest neonate is
approximately 25 times less than the air kerma rate for an average-sized adult on a properly configured
fluoroscope.

There are no regulations that limit how much radiation a patient can receive from a fluoroscopic
examination. The direct medical benefit from the fluoroscopy study should outweigh any risk from
ionizing radiation associated with the examination. The operator should understand the design features
of the fluoroscope, which either reduce the fluoroscopic air kerma rate or the dose of each image
acquisition. They also should be competent in the use of these features in order to manage the total
radiation dose delivered to the entire range of pediatric patient sizes.

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Even with optimized fluoroscopic equipment, there may be a clinical need that justifies and results in a
substantial radiation dose to the patient. The Joint Commission (TJC) defines a sentinel event as the
delivery of 15,000 mGy to a patient’s skin over a time span of 6 months to a year. While this does not
prevent the operator from exceeding this dose level during complex interventional examinations that
may address life-threatening situations, the TJC’s rule is a strong deterrent to exceeding this dose level.

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Slide 10

Default settings determine the rate of radiation production at the beginning of the examination. The goal
is to provide a diagnostic quality image at a properly managed radiation dose as illustrated in the figure.
These control settings should be carefully selected to provide dose rate levels appropriate to the
physical size of the child and the complexity of the examination. If the image quality provided by the
default is unacceptable to the operator, the operator will adjust the controls to provide the necessary
image quality. Using this approach, the operator properly manages both image quality and patient
radiation dose. If the default settings provide better image quality than necessary at the start of the
exam, the operator receives no visual prompt to adjust the fluoroscope's control settings to manage
either the patient dose or image quality. The radiologic technologist should check the fluoroscope prior
to the beginning of each study to ensure that the appropriate default settings are activated. The
department’s quality assurance program should include default-setting guidelines.

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Slide 11

The operator uses the foot or hand switch on the fluoroscopy machine to turn the x-ray beam “on or off.”
When the switch is depressed, radiation is continuously emitted by the fluoroscope as shown in the
figure, which illustrates radiation output over time for continuous fluoroscopy. The tube current typically
ranges from 0.5 to 6 mA according to the patient’s size. The continuously acquired image data is
divided into 30 separate images (frames) each second. Since the frame rate is not adjustable in this
mode, the length of time the beam is “on” for each image is approximately 33 msec. This time period is
too long to properly freeze involuntary patient motion of the pediatric patient. Therefore, using
continuous fluoroscopy creates blur from moving objects. This is called motion unsharpness.
Historically, all fluoroscopy was continuous until the introduction of pulsed fluoroscopy in the late 1990s.

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Slide 12

In pulsed fluoroscopy, the x-ray beam is rapidly started and stopped (pulsed) to produce each
fluoroscopic image. The number of images per second is equal to the number of pulses per second.
The figure shows that three pulses of radiation have occurred, resulting in the creation of three
fluoroscopic images. On most modern fluoroscopes, the operator can select the pulse rate within the
range from 1 pulse/sec to 30 pulses/sec. The pulse width, defined as the duration of each pulse is
ideally less than or equal to 6 msec for children and less than or equal to 10 msec for adults. Because
these pulse widths are much shorter than the 33 msecs used in continuous fluoroscopy, unsharpness of
moving objects in the fluoroscopic image is significantly reduced.

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Slide 13

The tube current during each pulse of fluoroscopy is increased compared to continuous fluoroscopy, so
the number of x-rays used to generate each fluoroscopic image is the same for either mode of
operation. This is necessary to maintain similar levels of noise in the fluoroscopic image for either mode
of fluoroscopy. This is illustrated in the figure where the product of tube current (mA) and pulse duration
are equal for each image acquired in both continuous (A) or pulsed (B) fluoroscopy. The tube current for
continuous fluoroscopy is relatively low. Each image is acquired over a 33 msec period. The product of
the two, current x time (mAs), associated with each fluoroscopic image is represented by the area of the
yellow, dotted rectangles, horizontal for continuous mode and vertical for the pulsed mode. Because the
area of the horizontal and vertical rectangles is equal, the dose per image in both modes is similar
resulting in similar noise characteristics in the final images.

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Slide 14

Pulsed fluoroscopy at 30 pulses per second does not reduce the radiation dose to the patient compared
to continuous fluoroscopy. In both types of fluoroscopy, 30 images are generated each second. If the
patient size, exam, image noise and mAs are constant, the radiation dose rate to the patient will be
essentially unchanged. The image illustrates the position of the child relative to the major components
of a general fluoroscope found in a typical radiology department.

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Slide 15

The figure illustrates that pulsed fluoroscopy at 15 pulses per second generates half as many images
as 30 pulses per second. Because the dose of each pulse is the same, patients receive half as much
radiation dose. Further reductions in pulse rate will result in lower patient dose rates.

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Slide 16

While lower pulse rates deliver less radiation dose to the patient, fewer fluoroscopic images per second
are also created. This reduces temporal resolution in the image, that is, the ability to image moving
objects continuously and clearly. Therefore, during dynamic studies where clinical objects of interest are
in continual motion, such as an infant’s heart, the operator must weigh the desire to reduce patient dose
against the need for satisfactory temporal resolution.

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Slide 17

Pediatric cardiac studies require frame rates of 30 pulses/second while adult cardiac studies are
typically imaged at 15 pulses per second. The pediatric studies require 30 pulses/second because
infants and children have a more rapid heartbeat than adults. Non-cardiac interventional studies
typically require 15 pulses/second for pediatrics and 7.5 pulses/second for adults. General fluoroscopic
studies of the gastrointestinal tract or bladder can typically be performed with frame rates from 1 to 4
pulses per second for either pediatric or adult patients.

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Slide 18

The voltage (kV) applied across the x-ray tube determines the amount of energy carried by each x-ray,
which determines the ability of the x-ray to penetrate the child’s tissues. The kV setting determines the
maximum energy x-ray within the beam. In the x-ray beam spectrum in the figure, an 80 kV setting
created a few maximum energy x-rays of 80 keV. This fluoroscopic x-ray beam contains a continuum of
x-ray energies below the maximum value. In this example the most frequent x-ray energy present in the
beam, the effective energy, is approximately 36 keV. The higher energy x-rays, greater than the
effective energy, tend to exit the patient and contribute to the formation of the x-ray image. The lower
energy x-rays, less than the effective energy, tend to be absorbed by the patient. These low energy x-
rays increase patient dose without contributing to image formation.

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Slide 19

Because higher voltage (energy) x-rays more efficiently penetrate the patient, an increase in the voltage
reduces the number of x-rays required to produce an x-ray image. Therefore, patient dose and subject
contrast in Figure B, are reduced compared to Figure A. Figures A and B were created with 50 and 120
kV respectively with the same dose to the image receptor. The inherent contrast in the phantom for both
images is the same since the aluminum objects are identical and the phantom thickness is constant at 7
cm thick. As described previously, for a given image, objects 1, 3, 4, 6, 7 and 9 are the same contrast.
Objects 8 is double the thickness of object 5, which is double the thickness of the object 2. Again the
objects in the first group of 6 objects are at a contrast level greater than object 5, but less than the
object 8. In Figure B objects 2 and 5 are difficult to see along with some of the missing corners to the
squares in the outer two columns. The loss of subject contrast with an increase in voltage prevents
increases in voltage with the intent of reducing patient dose. During pediatric interventional fluoroscopy,
the iodine in contrast agents improves tissue contrast in the image to a greater degree when the voltage
does not exceed 80 kV. Higher voltages, up to 100 kV, may be used when barium is the contrast agent
for upper or lower GI studies in pediatric patients.

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Slide 20

The tube current determines the rate of x-ray production or number of x-rays per unit time. The number
of x-rays produced by the x-ray tube and reaching the image receptor is directly proportional to the tube
current if all other technique factors are equal. An increase in tube current reduces the amount of noise
in the image, but increases the patient dose. Eight hundred and 10 mA were used to produce Figures A
and B, respectively, with all other technique factors held constant. As the patient dose increased
eightyfold, a reduction in noise in the image improves the visibility of detail of the 9 objects. Since the
tube current and patient dose increase more rapidly than the noise falls, this is not an effective way to
improve image quality while managing patient dose. The contrast level of the objects in the two images
are identical, but the objects in Figure B are more difficult to see than A because of the increase in
quantum mottle (noise) in the image.

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Slide 21

Pulse width is the length of time x-rays are produced during the creation of a single image. Increasing
the tube current or the pulse width during a pulse of radiation increases the number of x-rays used to
create an image. Eight hundred and 10 msec were used to produce Figures A and B, respectively, with
all other technique factors held constant. In this case, the patient dose increased 80-fold in the
improved image, Figure A, with noticeably reduced noise levels. Any increase in the tube current or
pulse width has the same effect on the management of patient dose and image quality; image
degradation in this and the previous question is similar. But this is only true because the phantom used
to produce the two images is stationary. The tube current should be increased to its maximum before
increasing the pulse width when imaging patients because an increase in pulse width also results in
more motion unsharpness especially in pediatric patients who are constantly moving.

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Slide 22

Beam filtration is achieved by positioning a sheet of material (a filter) within the tube housing to
intercept the x-ray beam to remove low-energy x-rays. Adding filtration changes the shape of the
bremsstrahlung curve. Because the maximum energy of the x-rays in the beam is determined by the
selection of the high voltage, the maximum energy x-ray is not altered by additional filtration. However,
the effective energy, the energy corresponding to the peak of the curve, is shifted to the right with
additional filtration. In addition, the area under the curve is reduced, which represents the intensity or
the total amount of energy that is carried by the x-ray beam. If the low-energy x-rays are not removed
by the filter, their energy is deposited in the child’s tissues, increasing the radiation dose without
improving image quality. Historically, the filter material was aluminum.

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Slide 23

Today, most fluoroscopes can interchange filters of different thicknesses composed of material with an
atomic number higher than aluminum. These added filters more effectively remove low-energy x-rays
and allow the higher-energy x-rays to reach the patient. Copper is a common example. Copper filters on
interventional fluoroscopes range from 0.1 to 0.9 mm copper. General fluoroscopic units typically
provide 0.1 and 0.2 and sometimes 0.3 mm copper filter. Mobile fluoroscopes typically have a fixed
copper filter thickness of 0.1 or 0.2 mm of copper.

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Slide 24

For any sized patient, as the added filter thickness increases, the entrance dose to the patient
decreases relative to the entrance dose to the image receptor. This results in equal or slightly better
image quality at a reduced patient dose. However, as a child’s size increases, added filter thicknesses
must be reduced. The fluoroscope can only produce a finite number of x-rays per second. As patient
size increases and attenuates more x-rays, a thinner filter, which attenuates fewer x-rays, must be used
to ensure the appropriate number of x-rays reach the image receptor. This phenomenon is illustrated in
the image, which plots the filter thickness used by one manufacturer as a function of patient thickness
simulated by the thickness of a plastic phantom constructed of PMMA, a synthetic resin. Note that 0.9
mm copper is used for patient’s body parts less than 3 inches thick. For patients in the 3-to 6- inch
range of thickness, 0.6 mm of copper is used. The copper thickness is reduced to 0.3 mm for patient
thicknesses in the 7-to 8-inch range. For patients greater than 8 inches in thickness, a 0.2 mm copper
thickness is selected.

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Slide 25

State-of-the-art fluoroscopes automatically adjust voltage, tube current, pulse width and added filtration
within specified ranges as more or fewer x-rays are needed to penetrate the patient. The order in which
the fluoroscope changes these parameters affects the management of patient dose and image quality
for pediatric patients. As illustrated in the chart on the left, if the filtration increases, the voltage should
be reduced to limit the loss of subject contrast in the image in the patient thickness range of 0 to 6
inches, which is the size of the smaller pediatric patients. The chart on the right demonstrates that after
the added filtration and high-voltage combination is selected, the tube current and pulse width should
increase to deliver the correct number of x-rays to the image receptor in the 0- to 6- inch range of
patient thickness. The tube current rather than the pulse width should be increased when more x-rays
are needed, provided the x-ray tube has not reached the maximum allowed tube current. If the
technologist or operator suspects that the fluoroscope is not following the hierarchy described above
when changes in radiation output are necessary, he or she should contact the QMP or service engineer
to investigate the fluoroscope’s programming.

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Slide 26

Fluoroscopes with aluminum filtration should increase the voltage from 65 to 120 kV as patient size
increases from the smallest to largest patients as illustrated in this chart. The minimum allowed voltage
for the smallest patients should be about 65 kV. While voltages from 40 to 60 kV for the smallest
patients or body parts can be used, these lower voltages result in significantly higher patient doses with
little improvement in image quality. The default setting for the minimum voltage with a standard filtration
of 3 mm of aluminum during pediatric imaging is approximately 65 kV. Despite the loss of subject
contrast in the image, the largest patients must be imaged in the 110- to 120-kV range to obtain
adequate penetration without exceeding the maximum fluoroscopic dose rate of 88 mGy/min. If the
fluoroscope is not operating within these recommended ranges, the technologist should contact the
service engineer to investigate the operation of the unit.

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Slide 27

When copper or other higher atomic number filters are used, the voltages used for the largest patients
are the same because the copper filters are removed by the fluoroscope. When smaller children are
imaged, the added thickness of copper dictates the appropriate voltage to maintain contrast in the
image. For example, a mobile C-arm or tilting table general purpose fluoroscope that provides a fixed
0.1- or 0.2-mm copper filter should not use voltages less than 65 kV for the smallest patients. An
interventional fluoroscope should increase the added filtration as patient width decreases from 18 to 10
cm. As the added copper filtration increases from 0.1 to 0.9 mm, a decrease in voltage from
approximately 70 to approximately 55 kV restores some of the contrast in the image that was lost when
the copper filtration was added. These three images illustrate this concept. Figure A is created without
copper filtration at 70 KV. One can detect the object because its subject contrast is different than its
background. Figure B is created at 70 kV with 0.9-mm copper added in the x-ray beam; note the loss of
contrast in the image. Figure C is created with the 0.9 mm copper filtration in the beam and a reduction
of the high voltage to 56 kV. While all of the subject contrast of A is not recovered in C, the subject

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contrast of C is significantly improved relative to B. Unless the fluoroscope is equipped with an
appropriate pediatric configuration, these recommended voltages and filter thicknesses will probably not
be used automatically, which may needlessly increase the patient dose rate. If the technologist or
operator suspects that the fluoroscope is not functioning within these recommendations, he or she
should contact the QMP or service engineer to investigate the fluoroscope’s programming.

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Slide 28

Most modern fluoroscopes allow the operator to select from a number of dose rate settings typically
labeled low, medium or high. This control determines the radiation dose rate at the image receptor,
which affects the amount of noise in the image. A task with inherently low contrast such as
differentiating soft tissues requires a higher dose to the image receptor and less noise. One example
would be evaluating tracheomalacia or collapse of tracheal cartilage on inspiration. For this task, a dose
rate of medium or high should be selected. An examination with high inherent contrast, such as a bone
biopsy, angiogram of a large vessel or upper GI with barium, is less affected by the dose to the image
receptor and a low or medium dose rate should be selected.

The operator should select the dose rate level appropriate to the imaging task. The low dose setting is
typically half of the medium setting, which is typically half of the high dose level setting. The first image
contains more noise and less detail than the second image because the first image was obtained on the
low setting at 25% of the dose used for the second image obtained on the high setting. The operator

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should select the lowest dose level setting that provides adequate image quality for the clinical task. As
noted earlier, the default setting at the beginning of the examination should be low.

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Slide 29

The dose rate control setting directly affects the radiation dose to the image receptor, which affects the
child’s radiation dose. Any change of the dose to the image receptor changes the child’s radiation dose.
This image shows three buttons provided by one manufacturer at the table side of an interventional
fluoroscope used to select the dose rate to the image receptor. The choice on the left produces an air
kerma rate that is 25% of the choice on the far right.

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Slide 30

Frame averaging is the process of averaging multiple fluoroscopic image frames together to produce a
final image with less noise. When successive fluoroscopic images are added together, the level of noise
in the processed image is reduced due to an averaging effect. While this reduces noise, temporal
resolution, that is the ability to clearly see objects in motion across the image, is diminished. These
three images illustrate this concept. The first image contains no frame averaging, and the tip of the
moving guide wire is properly imaged. The second image is four frames averaged together; note that
the tip of the moving guide wire is displayed with four different ends. The third image is the composite of
16 frames averaged together; the tip of the moving guide wire is not imaged. The first image is noisier
than the last image. Frame averaging is most commonly found in mobile fluoroscopic systems.

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Slide 31

Frame averaging allows reduction of patient dose as illustrated in this graph. Sixteen and 4 averaged
frames allow the dose to the image receptor to be reduced by a factor of four and two, respectively.
Because frame averaging reduces the noise in the image, the radiation dose to the image receptor can
be reduced without affecting the original image quality. While this is attractive with respect to patient
dose management, the loss of temporal resolution in pediatric imaging due to frame averaging is
typically unacceptable. When verifying default settings before a case begins, the radiologic technologist
should ensure that frame averaging settings are minimized or turned off for pediatric cases.

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Slide 32

A feedback control loop called automatic brightness control or automatic exposure rate control allows
the tube current, voltage, pulse width and/or added filtration in the beam to be automatically adjusted in
response to patient thickness and attenuation changes. During a typical pediatric fluoroscopic
examination, the path length of the x-rays through the patient continually changes. In addition,
attenuation properties of lung, soft tissue and bone are dramatically different. The differing attenuation
properties and patient thicknesses significantly change the number of x-rays required (air kerma rate) to
penetrate the patient and maintain consistent image quality throughout the examination. In the two
charts, the PMMA thickness on the horizontal axis is the thickness of phantom used during performance
testing of the fluoroscope. The figures illustrate the change in tube voltage, filter thickness, pulse width
and tube current that occurs in response to changing simulated patient thickness.

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Slide 33

Anatomical programming organizes the many types of clinical examinations and pediatric patient size
ranges into presets. This figure Illustrates typical presets found on an interventional fluoroscope
configured for adults. These adult presets typically do not include examinations specific to pediatric
imaging nor as a range of patient thickness. However, each program setting is given a unique name
and includes the correct tube current, voltage, pulse rate, pulse width, added filter thicknesses, focal
spot size and other control parameters as determined by the medical imaging team. A more appropriate
pediatric preset, for example, a voiding cysto-urethrogram (VCUG), might be assigned 1 of 4 patient
size ranges (e.g., 10–15, 15–20, 20–25 and 25–30 cm). All other types of exams would also be
programmed for the four size ranges above. This is a valuable feature. If set up properly, anatomical
programming takes the guesswork out of choosing the correct settings for various exams and different
sized patients.

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Slide 34

Last image hold (LIH) is an equipment feature that retains the last image of a fluoroscopy sequence on
the monitor after the fluoroscopic pedal is released. Prior to the introduction of LIH, fluoroscopic images
only appeared on the display monitor while the fluoroscopy pedal was depressed and the patient was
irradiated. LIH allows the operator to study the displayed static fluoroscopic image like the one here as
long as necessary without further irradiation to the patient. Proper use of this feature reduces the
patient’s total radiation dose from fluoroscopy.

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Slide 35

Fluoro save (FS), sometimes called “fluoro-grab,” allows the operator to select the LIH image displayed
on the monitor or ‘grab’ a fluoroscopic image during live fluoroscopy and store the image to the
fluoroscope’s memory. This image is stored permanently with any radiographic images acquired for
archival purposes. In the absence of FS, a digital radiographic image must be acquired to create an
archived image. While the recorded digital radiographic image has significantly better image quality
than the FS image, it also results in a radiation dose to the patient at least 10 times greater. If the
archived FS image provides the necessary clinical information, the patient can be spared the radiation
dose of the digital radiographic image.

This is an example of the difference in appearance of a fluoro save image (Image A) from an upper GI
on an infant with congenital heart disease. The spot film (Image B) demonstrates greater anatomic
detail but the radiation dose to the patient is approximately 10 times higher. If the radiologist does not
need anatomic detail, then the lower dose fluoro save image should be used.

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Slide 36

Last fluoro loop replay (LFLR) allows the operator to save to memory the last fluoroscopic sequence by
pushing a button when the fluoroscopic pedal is released. LFLR images are noisier than digital
radiographic acquisitions. However, if they provide the necessary clinical information, the additional
radiation dose associated with an acquired digital angiography sequence can be avoided. As with FS,
the radiation dose to the patient from the LFLR sequence will be at least 10 times less than a digital
angiographic sequence. This movie clip is representative of a LFLR sequence that can be replayed
during the procedure.

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Slide 37

Manufacturers ship their units with image processing presets that typically work well for adult anatomy,
which typically contains higher subject contrast and larger objects than a pediatric image. Image
processing designed for pediatric patients may allow the acquisition of images with less radiation dose
to the patient. All acquired digital images are mathematically manipulated prior to their presentation on
the monitor. If the manufacturer has presets designed for image processing of pediatric images, the
fluoroscope should be configured to use these presets. The radiation dose to the subject in the two
images here is the same. Image B uses image processing designed to reduce the noise in the image,
which should allow for the reduction of radiation dose and obtain clinically useful images. If the
manufacturer does not have these types of presets available, the medical imaging team should explore
whether the manufacturer has image processing presets other than their standard adult settings, which
may be more suitable for pediatric fluoroscopy.

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Slide 38

All fluoroscopes have a normal mode of fluoroscopic operation; the maximum air kerma rate to the
patient is limited by the FDA to 88 mGy/min (10 R/min). Some fluoroscopes also have a high dose
mode, called high-level control mode, with a maximum air kerma rate of 176 mGy/min (20 R/min).
When the fluoroscopy pedal is depressed in the high-level control mode, the FDA requires that the
fluoroscope emit an audible tone during fluoroscopy to alert the operator that the machine is operating
in high-level control mode. This mode should not be used during the examination unless the additional
dose is essential; it is typically needed only in very large patients. High-level control mode should not be
used during fluoroscopy of pediatric patients unless the pediatric patient is much larger than an
average-sized adult. The tone you hear is typical of the continuous tone emitted by a fluoroscope when
operated in the high-dose mode.

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Slide 39

Fluoroscopy time is the total elapsed time during the examination when fluoroscopic x-rays are
produced. The radiologic technologist should monitor the timer and alert the operator when agreed
upon milestones of fluoroscopy time have elapsed. This image is a reproduction of the fluoroscope’s
display at the control panel in the control room. In this case the total fluoroscopy time during the
procedure was 7 minutes, 38 seconds.

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Slide 40

The continuous use of fluoroscopy maximizes the radiation dose to the patient. The patient’s total
radiation dose will be lower if the operator uses fluoroscopy intermittently and for the shortest time
needed to make the required observations. An example of intermittently depressing the fluoroscopic
footswitch is illustrated in the short movie clip.

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Slide 41

Fluoroscopy time provides no information concerning the radiation dose the child received from
recorded images acquired during the examination. In addition, the exposure rate to the child varies
dramatically based upon the attenuation of the child’s tissues and the child’s thickness, as illustrated in
the figure. Fluoroscopy time does not account for these variances.

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Slide 42

Within the procedure room, typically near the display monitors, an amber-colored indicator light is
provided. When this light is on, radiation is being produced. The images show the amber light off and on
respectively.

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Slide 43

Stray radiation dissipates immediately when the foot switch is released by the operator. X-rays travel at
the speed of light, so while stray x-rays may be scattered several times within the walls of the procedure
room before they are completely absorbed, it occurs almost instantly due to their high speed.

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Slide 44

The source-to-skin distance (SSD) is indicated by the vertical arrow in the figure. SSD is the distance
between the focal spot within the x-ray tube and the entrance plane of the patient’s body, represented
here with the stacked saline bags. The radiation delivered to the patient depends on how far the patient
is located from the source of the x-rays (the SSD). The inverse square law states that as one moves
away from the focal spot, the radiation decreases as 1/SSD2. This means that small increases in the
SSD result in significant decreases in the radiation dose rates. For example, doubling the SSD results
in a 25% decrease in the radiation dose rate to the patient.

Page 49 of 81
Slide 45

For mobile C-arm fluoroscopes, the focal spot should be placed as far away from the patient as the size
of the C-arm and image receptor allow. Mobile C-arms typically have spacers that prevent the SSD
from being less than 30 cm. For most general fluoroscopic units, the SSD is typically fixed at
approximately 50 cm. If your general fluoroscopic table allows adjustment of SSD, perform all pediatric
imaging at the largest available SSD. For interventional fluoroscopy units like the one shown in the
illustration, the x-ray tube is typically located beneath the table, so the operator should raise the patient
table when possible to move the patient farther away from the focal spot and close to the image
receptor.

Page 50 of 81
Slide 46

The source-to-image receptor (SID) is the distance between the focal spot of the fluoroscope and the
entrance plane of the image receptor as illustrated by the vertical arrow in the figure. Since the inverse
square law applies to SID as well as SSD, small decreases in the SID result in a significant decrease in
the radiation output necessary to deliver the correct number of x-rays to the image receptor. Any
decrease in the radiation output of the fluoroscope as a result of a smaller SID results in a smaller
radiation dose to the patient provided the SSD has been properly maximized.

Page 51 of 81
Slide 47

For a mobile C-arm, the patient should be positioned as close to the image receptor as possible, since
this increases the SSD on a fluoroscope with a fixed SID. For a general fluoroscopic system, such as a
GI room, the SSD is typically fixed, so the image receptor should be moved as close to the patient as
possible. For an interventional C-arm fluoroscope as shown in the figure, the table should be raised
appropriately to maximize the SSD and then the image receptor should be moved as close to the
patient as possible. For small children (and some claustrophobic adults) being adjacent to the image
receptor may be scary. However, achieving this goal significantly decreases the patient’s radiation
dose.

Page 52 of 81
Slide 48

Field of view (FoV) describes the size or area of the x-ray field at the entrance plane of the image
receptor. In the normal mode, there is no electronic magnification, and the x-ray beam irradiates the
entire surface area of the image receptor as shown in the drawing on the left. Magnification modes
(e.g., mag 1, mag 2, and mag 3) result in successively smaller area x-ray beams to the image receptor.
The smaller FoV (area) is enlarged to completely fill the area of the display monitor of the fluoroscope
as shown in the drawing on the right. As the FoV decreases, the electronic magnification of the image
on the monitor increases.

Page 53 of 81
Slide 49

Displayed images on the monitor are enlarged as illustrated in Figure B compared to Figure A and may
be sharper when a smaller FoV is selected. For image intensifiers, the image sharpness and resolution
always improve for smaller FoVs. On the small-format flat-panel detectors, those with a field of view
less than 20 cm found in cardiac catheterization labs and on mobile fluoroscopes, the sharpness and
resolution are unchanged as the FoV changes. However, details are somewhat easier to see with
smaller FoVs because the patient anatomy is enlarged on the display monitor. Large-format flat-panel
detectors, those with a field of view more than 20 cm found in interventional labs or on general
fluoroscopic tables, perform similarly to the small-format detectors as the FoV is reduced with the added
bonus of significantly improved sharpness and resolution when the FoV is decreased below 20 cm.

Page 54 of 81
Slide 50

The radiation dose rate to the patient increases as smaller FoVs are selected. On older fluoroscopes,
the patient radiation dose rate quadrupled when the selected FoV diameter was halved. However, on
state-of-the-art fluoroscopes, the increase in patient dose rate is less pronounced. On these newer
machines, as the size of the FoV is halved, the patient dose rate is typically doubled. The graph
illustrates the relative dose rate increase as the dimension of the FoV decreases from its largest size.

Page 55 of 81
Slide 51

When selecting the FoV, the operator must weigh the need for better image quality against the cost of
more radiation dose to the patient. Organs of infants and toddlers are small and difficult to image. For
this reason, small children are typically imaged using the smallest FoV to improve sharpness and
resolution (e.g., a newborn child with subtle posterior urethral valves blocking outflow of urine from the
bladder). If larger FoVs provide adequate image quality for some portions of the study, the operator
should use them instead, with appropriate manual collimation. This image of a rabbit thorax, which is
approximately the size of a newborn child’s, illustrates that the smallest FoV of the fluoroscope is still
capable of imaging the entire thorax.

Page 56 of 81
Slide 52

At the beginning of the examination, the largest FoV should be the default setting (green arrow)
because it reduces the radiation dose rate to the patient. The section of the control panel that allows
this selection is shown in the figure. If this large FoV does not provide adequate image quality, the
operator may select a smaller FoV. If the selected FoV with good image quality irradiates a larger area
of the patient than necessary, the collimator should be closed part way to reduce the area of patient
anatomy to only that required for the image. The indicator light that is lit (yellow arrow) indicates that the
smallest FoV has been selected.

Page 57 of 81
Slide 53

Recall that electronic magnification occurs when the operator selects a smaller FoV. Geometric
magnification occurs when the patient is positioned closer to the focal spot than normal with a gap
between the patient and the image receptor. For example, if the patient is located halfway between the
focal spot and the image receptor (SID) as illustrated in the image by the blue arrow, the patient’s
anatomy will be enlarged on the display monitor by a factor of approximately two. Geometric
magnification occurs any time the image receptor is moved away from the patient.

Page 58 of 81
Slide 54

From a practical standpoint, small amounts of geometric magnification may be unavoidable during
pediatric fluoroscopy. If a sterile field must be maintained or the child is small relative to the size of the
image receptor, an air gap between the patient and image receptor may be necessary, which will
automatically result in some geometric magnification. This should be minimized, however. Geometric
magnification is strongly discouraged for pediatric fluoroscopy. First, geometric magnification reduces
the SSD and increases the SID. Recall that this causes patient dose rates to increase. Second,
improvement in image quality from geometric magnification does not occur unless the focal spot size is
smaller than the focal spots found on the majority of fluoroscopes. Typically, the patient should be
positioned close to the image receptor as shown in this figure.

Page 59 of 81
Slide 55

Collimation is the reduction of the area of the x-ray beam arriving at the patient by blocking the outer
portions of the x-ray field with attenuating blades inside the collimator. State-of-the-art fluoroscopes
provide a graphical display of the position of the edge of the collimator blade superimposed on an LIH
image of the patient’s anatomy shown in the figure at the left. This allows the operator to reposition the
collimator blades without subjecting the patient to additional radiation dose during the adjustment. All
unnecessary regions of patient anatomy outside the area of interest should be collimated out of the
image. Image B illustrates the result of subsequent fluoroscopy after the collimator blades are
positioned as indicated by the graphical lines in image A.

Page 60 of 81
Slide 56

When the volume of patient's tissues irradiated is reduced by collimation, less scatter radiation is
generated. Less scatter results in a slight improvement in subject contrast in the images. Image A was
created with a collimated area significantly larger than the square object. Image B was created with a
collimated field area slightly larger than the square object. Image B presents slightly better contrast,
which improves delineation of rounded corner of the object due to the decreased scatter in the field of
view.

Page 61 of 81
Slide 57

A 12-year-old girl was born with one forearm longer than the other. The orthopedic surgeon fused the
growth plate of the distal radius under fluoroscopic guidance. The patient's skin dose at the center of
the x-ray field, the region of the patient’s wrist, is unchanged by collimation. Because the radiographic
technique factors are unchanged by collimation, the dose to the patient’s wrist is unchanged. However,
the radiation field should have been limited to the area of the box. Proper collimation would decrease
patient dose to patient anatomy outside the box. In addition, the primary radiation dose to the
surgeon’s hands essentially would have been eliminated by proper collimation.

Page 62 of 81
Slide 58

The occupational exposure that the operator and staff receive during a fluoroscopic procedure should
be primarily determined by the amount of scatter radiation emitted from the patient. Therefore,
everything else being equal, the occupational dose of the operator and staff will be reduced by proper
collimation. The graph illustrates that a FoV with a 37-cm dimension (large FoV) will generate scatter
radiation at a rate six times greater than the scatter radiation rate from the smallest FoV with a
dimension of 15 cm. Please note that all other radiographic technique factors being equal, the small
field of view image receptors to the left of the vertical dashed line, which are typically found in
catheterization labs, generate scatter rates that are two to three times less than the large-format image
receptors found in radiology interventional fluoroscopic labs.

Page 63 of 81
Slide 59

If proper collimation is lacking during a fluoroscopy procedure, lack of collimation can result in the
hands of the fluoroscopist being placed in the primary radiation beam. An infant had abdominal
distention soon after birth resulting in a concern for bowel obstruction. This fluoroscopic image
demonstrates two suboptimal practices in pediatric fluoroscopy: First, the image is not collimated to the
area of interest. Only the region of the rectum should be included on the exam, which is indicated by the
box. Second, the hands of the operator are included in the fluoroscopy beam, which would not occur
with appropriate collimation.

Page 64 of 81
Slide 60

The risk to the patient from ionizing radiation is believed to be proportional to the kerma area product.
The kerma area product can be cut in half by either reducing the air kerma (patient dose) or the area of
the x-ray beam by half. Tighter collimation that reduces the area of the x-ray beam to half of its original
value reduces risk to the patient to the same degree as reducing the air kerma by half. While either
tighter collimation or dose reduction can be used to reduce patient risk, tighter collimation avoids the
increase in noise that occurs with dose reduction and also results in a small improvement to subject
contrast in the image.

Image A on first pass may appear to be reasonably collimated. Image B is the same image with tighter
collimation, but adequate anatomy is included. However, the area of the collimated beam in Image B is
one-half the area of the image on Image A. The dimension of the collimated field only needs to be
divided by 1.4 as opposed to 2 to cut the area of the beam in half. This illustrates that relatively small
reductions in the dimension of the field can have a significant impact on reducing the risk to the patient.

Page 65 of 81
Slide 61

The operator should first select the FoV that offers the necessary image quality with the understanding
that less image quality will be achieved with larger FoVs. Selecting the larger FoV reduces the radiation
dose rate to the patient. This image suggests the operator reduced the patient dose rate by selecting
the largest FoV for the study. For most pediatric cases, this large FoV will include patient anatomy in
the image that is unnecessary. Next, the operator should collimate the x-ray beam to reduce the kerma
area product. Unfortunately, instead of using this two-step process, many operators simply select a
smaller FoV with better image quality. While this may result in a reasonable x-ray beam area for most
children, the dose rate to the child will be unnecessarily high.

Page 66 of 81
Slide 62

Due to the small size of children, proper collimation may result in an x-ray beam area at the image
receptor less than 20 cm2. The ABS/AERC feedback system, which is designed to respond to changes
in thickness and attenuation of the patient, will not work properly if the area of the x-ray beam, the
dimension of the square area in the figure is smaller than the diameter of the ABS/AERC’s round
sensor. When this occurs, the fluoroscope will incorrectly increase radiation production and deliver a
higher radiation rate to the patient than necessary. This can be avoided by asking the service
representative of the fluoroscope, in consultation with the QMP, to reduce the area of the ABS/AERC’s
small circular sensor. The figure illustrates the smallest collimated square x-ray field that can be used
correctly with the circular area of the sensor.

Page 67 of 81
Slide 63

The antiscatter grid used during adult fluoroscopy attenuates the majority of the scatter radiation before
it reaches the image receptor. If the grid is not used for adults, the image quality is unacceptable
because of the loss of subject contrast as illustrated in the image of the lateral lumbar spine of an adult
patient on the left. The image on the right was produced using a good-quality grid designed for use with
adult patients. The removal of the majority of scatter radiation dramatically improves the subject
contrast in the image. Small children (and the distal extremities of adults) generate much less scatter
radiation than adult trunks. For body part thicknesses less than 10 cm, the small amount of scatter
radiation reaching the image receptor when a grid is not used does not significantly reduce subject
contrast. The radiation dose rate without a grid is approximately 60% of the radiation dose rate with a
grid for thicknesses less than 10 cm. Therefore, the antiscatter grid should be removed when imaging
portions of the patient with thicknesses less than 10 cm. Note that grids on all general tilt table units and
most interventional fluoroscopy units are designed to be removed by the operator, while most mobile C-
arm fluoroscopes do not allow the operator to remove the grid.

Page 68 of 81
Slide 64

The operator should position the detector over the area of anatomic interest prior to depressing the
fluoroscopy pedal. For example, if an upper GI is being performed on an adolescent, the experienced
user will avoid turning the x-ray beam on over the pelvis of the patient. There is no need to radiate the
patient as the detector is moved from the pelvis to the esophagus. This practice is strongly discouraged.

Page 69 of 81
Slide 65

Operators may better manage their patients’ radiation dose during a procedure if they receive periodic
notifications during the examination when agreed-upon milestones of the patient's cumulative air kerma
have been reached. For example, the protocol within a department might be notification of the operator
every time 25% of the total expected dose is reached during an examination. For example, if the total
expected air kerma was 2,000 mGy for a given interventional procedure on a given sized patient, the
radiologic technologist would notify the operator at 500-mGy intervals. The target total air kerma for a
diagnostic or complex interventional case would probably be some multiple of 100 or 1,000 mGy,
respectively. The total target air kerma for a routine GI or VCUG study would be some multiple of 10 or
1 mGy, respectively.

Page 70 of 81
Slide 66

This concludes Image Gently: Steps To Manage Radiation Dose During the Examination. You should
now be able to:
1) Explain the basic operation of fluoroscopic equipment.
2) Identify areas of fluoroscopic practice that can reduce radiation dose to the pediatric patient
during fluoroscopy.
3) List equipment configuration adjustments that affect dose to pediatric patients during
fluoroscopy.
4) Discuss the relationship between fluoroscopic image quality and patient dose.

Page 71 of 81
Slide 67

Page 72 of 81
Page 73 of 81
Slide 68

It is easy for a radiologic technologist to earn category A credit after successfully viewing all three of the
modules and completing the quiz for these courses. To take the quiz that is for all three courses, go to
the courses in the ASRT Store and follow the checkout instructions to add the courses and quiz to your
personal learning area for free. You will be able to print off a certificate of completion after successfully
passing the quiz.

Page 74 of 81
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Suggested Additional Reading

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exposure and image quality in pediatric fluoroscopy. Pediatr Radiol 2000, 30:236-242.
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radiation exposure in pediatric imaging. Pediatr Radiol 2000, 30:229-235.
7. Campbell RM, Strieper MJ, Frias PA, Jeager G, Balfour G, Costello L, Sullivan KM. Quantifying
and minimizing radiation exposure during pediatric cardiac catheterization. Pediatr Cardiol 2005,
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 8. Chambers CE, Fetterly KA, Holzer R, Lin PJ, Blankenship JC, Balter S, Laskey WK. Radiation
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 23.Lederman HM, Khademian ZP, Felice M, Hurh PJ. Dose reduction fluoroscopy in pediatrics.
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