1. International Atomic Energy Agency Patient Dose Management - Equipment & Physical Factors L 5

2. Radiation Protection in Cardiology Lecture 5: Patient dose management2 Educational Objectives 1.Physical factors & challenge to dose management 2.Understanding the role of operator in patient dose management 3.How to manage patient dose using equipment factors

3. Radiation Protection in Cardiology Lecture 5: Patient dose management3 Physical factors and challenges to radiation management To create image some x rays must interact with tissues while others completely penetrate through the patient. Spatially uniform beam enters patient X rays interact in patient, rendering beam non-uniform Non-uniform beam exits patient, pattern of non-uniformity is the image Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

4. Radiation Protection in Cardiology Lecture 5: Patient dose management4 Because image production requires that beam interact differentially in tissues, beam entering patient must be of much greater intensity than that exiting the patient. Beam entering patient typically ~100x more intense than exit beam As beam penetrates patient, x rays interact in tissue causing biological changes Only a small percentage (typically ~1%) penetrate through to create the image. Physical factors and challenges to radiation management Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

5. Radiation Protection in Cardiology Lecture 5: Patient dose management5 Lesson: Entrance skin tissue receives highest dose of x rays and is at greatest risk for injury. Beam entering patient typically ~100x more intense than exit beam in average size patient As beam penetrates patient x rays interact in tissue causing biological changes Only a small percentage (typically ~1%) penetrate through to create the image. Physical factors and challenges to radiation management Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

6. Radiation Protection in Cardiology Lecture 5: Patient dose management6 X-ray intensity decreases rapidly with distance from source; conversely, intensity increases rapidly with closer distances to source. 1 unit of intensity 4 units of intensity 16 units of intensity 64 units of intensity Physical factors and challenges to radiation management 70 cm35 cm17.5 cm 8.8 cm Reproduced with permission from Wagner LK, Houston, TX 2004.

7. Radiation Protection in Cardiology Lecture 5: Patient dose management7 Lesson: Understanding how to take advantage of the rapid changes in dose rate with distance from source is essential to good radiation management. Practical applications are demonstrated in following slides. Physical factors and challenges to radiation management

8. Radiation Protection in Cardiology Lecture 5: Patient dose management8 All other conditions unchanged, moving patient toward or away from the x-ray tube can significantly affect dose rate to the skin Lesson: Keep the x-ray tube at the practicable maximum distance from the patient. Physical factors and challenges to radiation management 2 units of intensity 4 units of intensity 16 units of intensity 64 units of intensity Reproduced with permission from Wagner LK, Houston, TX 2004.

9. Radiation Protection in Cardiology Lecture 5: Patient dose management9 Physical factors and challenges to radiation management All other conditions unchanged, moving image receptor toward patient lowers radiation output rate and lowers skin dose rate. 4 units of intensity Image Receptor 2 units of intensity Image Receptor Image Receptor Physical factors and challenges to radiation management Reproduced with permission from Wagner LK, Houston, TX 2004.

10. Radiation Protection in Cardiology Lecture 5: Patient dose management10 Physical factors and challenges to radiation management 4 units of intensity Image Receptor 2 units of intensity Image Receptor Image Receptor Physical factors and challenges to radiation management Lesson: Keep the image intensifier as close to the patient as is practicable for the procedure. Reproduced with permission from Wagner LK, Houston, TX 2004.

11. Radiation Protection in Cardiology Lecture 5: Patient dose management11 Positioning anatomy of concern at the isocenter permits easy reorientation of the C-arm but usually fixes distance of the skin from the source, negating any ability to change source-to-skin distance. Physical factors and challenges to radiation management

12. Radiation Protection in Cardiology Lecture 5: Patient dose management12 When isocenter technique is employed, move the image intensifier as close to the patient as practicable to limit dose rate to the entrance skin surface. Physical factors and challenges to radiation management

13. Radiation Protection in Cardiology Lecture 5: Patient dose management13 Small percentages of dose reduction can result in large savings in skin dose for prolonged procedures. The advantages of a 20% dose savings are shown in this Table. Normal dose (Gy) Dose saved (Gy)New dose (Gy) 10.20.8 20.41.6 40.83.2 81.66.4 163.212.8 Physical factors and challenges to radiation management

14. Radiation Protection in Cardiology Lecture 5: Patient dose management14 Lesson: Actions that produce small changes in skin dose accumulation result in important and considerable dose savings, sometimes resulting in the difference between severe and mild skin dose effects or no effect. Physical factors and challenges to radiation management

15. Radiation Protection in Cardiology Lecture 5: Patient dose management15 Large percentages of dose reduction result in enormous savings in skin dose when procedures are prolonged. The advantages of a factor of 2 dose savings are shown in this Table. Normal dose (Gy) Dose saved (Gy)New dose (Gy) 10.5 211 422 844 1688 Physical factors and challenges to radiation management

16. Radiation Protection in Cardiology Lecture 5: Patient dose management16 Thicker tissue masses absorb more radiation, thus much more radiation must be used to penetrate the large patient. Risk to skin is greater in larger patients! [ESD = Entrance Skin Dose] 15 cm 20 cm 25 cm30 cm ESD = 1 unitESD = 2-3 unitsESD = 4-6 unitsESD = 8-12 units Example: 2 GyExample: 4-6 GyExample: 8-12 GyExample: 16-24 Gy Physical factors and challenges to radiation management Reproduced with permission from Wagner LK, Houston, TX 2004.

17. Radiation Protection in Cardiology Lecture 5: Patient dose management17 Thicker tissue masses absorb more radiation, thus much more radiation must be used when steep beam angles are employed. Risk to skin is greater with steeper beam angles! Physical factors and challenges to radiation management Quiz: what happens when cranial tilt is employed? Reproduced with permission from Wagner LK, Houston, TX 2004.

18. International Atomic Energy Agency 100 cm 80 cm Dose rate: 20 – 40 mGy t /min Thick Oblique vs Thin PA geometry 100 cm 50 cm Dose rate: ~250 mGy t /min 40 cm

19. Radiation Protection in Cardiology Lecture 5: Patient dose management19 A word about collimation What does collimation do? Collimation confines the x-ray beam to an area of the users choice. Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

20. Radiation Protection in Cardiology Lecture 5: Patient dose management20 A word about collimation Why is narrowing the field-of-view beneficial? 1.Reduces stochastic risk to patient by reducing volume of tissue at risk 2.Reduces scatter radiation at image receptor to improve image contrast 3.Reduces ambient radiation exposure to in- room personnel 4.Reduces potential overlap of fields when beam is reoriented

21. Radiation Protection in Cardiology Lecture 5: Patient dose management21 A word about collimation What collimation does not do – It does NOT reduce dose to the exposed portion of patient’s skin In fact, dose at the skin entrance site increases, sometimes by a factor of 50% or so, depending on conditions.

22. Radiation Protection in Cardiology Lecture 5: Patient dose management22 Physical factors and challenges to radiation management Lesson: Reorienting the beam distributes dose to other skin sites and reduces risk to single skin site. Physical factors and challenges to radiation management Reproduced with permission from Wagner LK, Houston, TX 2004.

23. Radiation Protection in Cardiology Lecture 5: Patient dose management23 Lesson: Reorienting the beam in small increments may leave area of overlap in beam projections, resulting in large accumulations for overlap area (red area). Good collimation can reduce this effect. Physical factors and challenges to radiation management Reproduced with permission from Wagner LK, Houston, TX 2004.

24. Radiation Protection in Cardiology Lecture 5: Patient dose management24 Physical factors and challenges to radiation management Conclusion: Orientation of beam is usually determined and fixed by clinical need. When practical, reorientation of the beam to a new skin site can lessen risk to skin. Overlapping areas remaining after reorientation are still at high risk. Good collimation reduces the overlap area. Physical factors and challenges to radiation management

25. Radiation Protection in Cardiology Lecture 5: Patient dose management25 Dose rate dependence on image receptor field-of-view or magnification mode.

26. Radiation Protection in Cardiology Lecture 5: Patient dose management26 INTENSIFIER Field-of-view (FOV) RELATIVE PATIENT ENTRANCE DOSE RATE FOR SOME UNITS 12" (32 cm) 100 9" (22 cm) 200 6" (16 cm) 300 4.5" (11 cm) 400

27. Radiation Protection in Cardiology Lecture 5: Patient dose management27 How input dose rate changes with different FOVs depends on machine design and must be verified by a medical physicist to properly incorporate use into procedures. A typical rule is to use the least magnification necessary for the procedure, but this does not apply to all machines.

28. Radiation Protection in Cardiology Lecture 5: Patient dose management28

29. Radiation Protection in Cardiology Lecture 5: Patient dose management29 Unnecessary body mass in beam Reproduced from Wagner – Archer, Minimizing Risks from Fluoroscopic X Rays, 3 rd ed, Houston, TX, R. M. Partnership, 2000 Reproduced with permission from Vañó et al, Brit J Radiol 1998, 71, 510-516 Unnecessary body parts in direct radiation field

30. Radiation Protection in Cardiology Lecture 5: Patient dose management30 Wagner and Archer. Minimizing Risks from Fluoroscopic X Rays. At 3 wksAt 6.5 mos Surgical flap Following ablation procedure with arm in beam near port and separator cone removed. About 20 minutes of fluoroscopy. Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

31. Radiation Protection in Cardiology Lecture 5: Patient dose management31 Big problem! Lessons: 1.Output increases because arm is in beam. 2.Arm receives intense rate because it is so close to source. Arm positioning – important and not easy! Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

32. Radiation Protection in Cardiology Lecture 5: Patient dose management32 Reproduced with permission from MacKenzie, Brit J Ca 1965; 19, 1 - 8 Reproduced with permission from Vañó, Br J Radiol 1998; 71, 510 - 516. Reproduced with permission from Granel et al, Ann Dermatol Venereol 1998; 125; 405 - 407 Examples of Injury when Female Breast is Exposed to Direct Beam

33. Radiation Protection in Cardiology Lecture 5: Patient dose management33 Lesson Learned: Keep unnecessary body parts, especially arms and female breasts, out of the direct beam.

34. Radiation Protection in Cardiology Lecture 5: Patient dose management34

35. Radiation Protection in Cardiology Lecture 5: Patient dose management35 Beam energy: X rays used in fluoroscopy systems have a spectrum of energies that can be controlled to manipulate image quality. How a system manipulates the spectrum depends on how the system is designed. Some systems permit the operator to select filtration schemes Design of fluoroscopic equipment for proper radiation control

36. Radiation Protection in Cardiology Lecture 5: Patient dose management36 Beam energy: In general, every x-ray system produces a range of energies as depicted in the diagram below: Low energy x rays: high image contrast but high skin dose Middle energy x rays: high contrast for iodine and moderate skin dose High energy x rays: poor contrast and low dose Reproduced with permission from Wagner LK, Houston, TX 2004.

37. Radiation Protection in Cardiology Lecture 5: Patient dose management37 Beam energy: The goal is to shape the beam energy spectrum for the best contrast at the lowest dose. An improved spectrum with 0.2 mm Copper filtration is depicted by the dashes: Middle energy x rays are retained for best compromise on image quality and dose Low-contrast high energy x rays are reduced by lower kVp Filtration reduces poorly penetrating low energy x rays Reproduced with permission from Wagner LK, Houston, TX 2004.

38. Radiation Protection in Cardiology Lecture 5: Patient dose management38 Beam energy: kVp controls the high-energy end of the spectrum and is usually adjusted by the system according to patient size and imaging needs: kVp Reproduced with permission from Wagner LK, Houston, TX 2004.

39. Radiation Protection in Cardiology Lecture 5: Patient dose management39 Beam energy: Filtration controls the low-energy end of the spectrum. Some systems have a fixed filter that is not adjustable; others have a set of filters that are used under differing imaging schemes. Physical factors and challenges to radiation management Design of fluoroscopic equipment for proper radiation control Reproduced with permission from Wagner LK, Houston, TX 2004.

40. Radiation Protection in Cardiology Lecture 5: Patient dose management40 Physical factors and challenges to radiation management Filters:The advantages of filters are that they can reduce skin dose by enormous factors. (Factors of about 2 or more.) The disadvantages are that they reduce overall beam intensity and require heavy-duty x-ray tubes to produce sufficient radiation outputs that can adequately penetrate the filters. Beam energy spectrum before and after adding 0.2 mm of Cu filtration. Note the reduced intensity and change in energies. To regain intensity tube current must increase, requiring special x-ray tube. Design of fluoroscopic equipment for proper radiation control Reproduced with permission from Wagner LK, Houston, TX 2004.

41. Radiation Protection in Cardiology Lecture 5: Patient dose management41 Physical factors and challenges to radiation management If filters reduce intensity excessively, image quality is compromised, usually in the form of increased motion blurring or excessive quantum mottle. Lesson: To use filters optimally, systems must be designed to produce appropriate beam intensities with variable filter options that depend on patient size and the imaging task. Design of fluoroscopic equipment for proper radiation control

42. Radiation Protection in Cardiology Lecture 5: Patient dose management42 Physical factors and challenges to radiation management Modern fluoroscopy systems employ special filtration to reduce skin dose and, for detail cardiologic work, employ a set of filters with varying properties that are switched by the system according to imaging needs. Some schemes are selectable by the user. Conclusion: Users must establish protocols for use of manufacturer supplied filter options that provide the best compromise in patient dose and image quality for each machine employed. Design of fluoroscopic equipment for proper radiation control

43. Radiation Protection in Cardiology Lecture 5: Patient dose management43 Physical factors and challenges to radiation management Fluoroscopic kVp: Fluoroscopic kVp in modern systems is controlled by the system. The user might be able to influence the way the system works: 1.By selecting various dose rate selection options 1.By selecting a kVp floor Design of fluoroscopic equipment for proper radiation control

44. Radiation Protection in Cardiology Lecture 5: Patient dose management44 Physical factors and challenges to radiation management Lessons regarding kVp floor: 1.Available on a few machines 2.Sets kVp below which system does not operate 3.Unit usually operates at floor kVp unless regulatory dose rates are challenged due to poor beam penetration. 4.If set too low, dose rates are always excessive because system always operates at maximum rates Design of fluoroscopic equipment for proper radiation control

45. Radiation Protection in Cardiology Lecture 5: Patient dose management45 Physical factors and challenges to radiation management The kVp floor: Lesson: Be sure kVp floor, if available, is set at appropriately high value to assure system operates at moderate to low dose rates. Design of fluoroscopic equipment for proper radiation control

46. Radiation Protection in Cardiology Lecture 5: Patient dose management46

47. Radiation Protection in Cardiology Lecture 5: Patient dose management47 Design of fluoroscopic equipment for proper radiation control Understanding Variable Pulsed Fluoroscopy Background: dynamic imaging captures many still images every second and displays these still-frame images in real-time succession to produce the perception of motion. How these images are captured and displayed can be manipulated to manage both dose rate to the patient and dynamic image quality. Standard imaging captures and displays 25 - 30 images per second. Design of fluoroscopic equipment for proper radiation control

48. Radiation Protection in Cardiology Lecture 5: Patient dose management48 30 images in 1 second Continuous fluoroscopy X rays In conventional continuous-beam fluoroscopy there is an inherent blurred appearance of motion because the exposure time of each image lasts the full 1/30 th of a second at 30 frames per second. Continuous stream of x rays produces blurred images in each frame Images Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

49. Radiation Protection in Cardiology Lecture 5: Patient dose management49 Each x-ray pulse shown above has greater intensity than continuous mode, but lasts for only 1/100 th of a second; no x rays are emitted between pulses; dose to patient is same as that with continuous Pulsed fluoroscopy, no dose reduction Images Pulsed fluoroscopy produces sharp appearance of motion because each of 30 images per second is captured in a pulse or snapshot (e.g., 1/100 th of a second). X rays 30 images in 1 second Reproduced with permission fromWagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

50. Radiation Protection in Cardiology Lecture 5: Patient dose management50 Physical factors and challenges to radiation management Pulsed imaging controls: Displaying 25 – 30 picture frames per second is usually adequate for the transition from frame to frame to appear smooth. This is important for entertainment purposes, but not necessarily required for medical procedures. Manipulation of frame rate can be used to produce enormous savings in dose accumulation. Design of fluoroscopic equipment for proper radiation control

51. Radiation Protection in Cardiology Lecture 5: Patient dose management51 Pulsed fluoroscopy, dose reduction at 15 pulses per second Sharp appearance of motion captured at 15 images per second in pulsed mode. Dose per pulse is same, but only half as many pulses are used, thus dose is reduced by 50%. The tradeoff is a slightly choppy appearance in motion since only half as many images are shown per second Images X rays 15 images in 1 second Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

52. Radiation Protection in Cardiology Lecture 5: Patient dose management52 Pulsed fluoroscopy at 7.5 images per second with only 25% the dose Pulsed fluoroscopy, dose reduction at 7.5 pulses per second Images X rays Average 7.5 images in 1 second Reproduced with permission from Wagner LK and Archer BR. Minimizing Risks from Fluoroscopic Radiation, R. M. Partnership, Houston, TX 2004.

53. Radiation Protection in Cardiology Lecture 5: Patient dose management53 Pulsed fluoroscopy, dose enhancement at 15 pulses per second Dose per pulse is enhanced because pulse intensity and duration is increased. Overall dose is enhanced. Images X rays 15 images in 1 second Reproduced with permission from Wagner LK, Houston, TX 2004.

54. Radiation Protection in Cardiology Lecture 5: Patient dose management54 Design of fluoroscopic equipment for proper radiation control Lesson: Variable pulsed fluoroscopy is an important tool to manage radiation dose to patients but the actual effect on dose can be to enhance, decrease or maintain dose levels. The actual effect must be measured by a qualified physicist so that variable pulsed fluoroscopy can be properly employed. Design of fluoroscopic equipment for proper radiation control

55. Radiation Protection in Cardiology Lecture 5: Patient dose management55 Quantum Noise Control

56. Radiation Protection in Cardiology Lecture 5: Patient dose management56 Physical factors and challenges to radiation management Quantum noise controls: Quantum noise controls control the clarity of the image by changing the dose rate to the image receptor. This requires that dose rate to the patient be manipulated. They come in two forms – conventional dose level controls and high level controls. Conventional level controls permit the adjustment of dose rates only within the low-dose rate regulatory limits. High level controls permit the adjustment of dose rates beyond these limits. Design of fluoroscopic equipment for proper radiation control

57. Radiation Protection in Cardiology Lecture 5: Patient dose management57 Physical factors and challenges to radiation management Quantum noise controls: Lessons : Adjust quantum noise options so that image quality is adequate and not excessive for the task at hand. Limit the use of high-level control to very brief episodes when fine detail is required. Overuse of high-level controls as a surrogate for conventional fluoroscopy can be dangerous and can result in very high dose accumulations and possible severe injury in a matter of minutes! Design of fluoroscopic equipment for proper radiation control

58. Radiation Protection in Cardiology Lecture 5: Patient dose management58 32 Why does the five-minute timer exist? No dose monitoring devices

59. Radiation Protection in Cardiology Lecture 5: Patient dose management59 Deterministic Risks to Skin AJR 2001; 173: 3-20