COMMENTARY

MILITARY MEDICINE, 00, 0/0:1, 2022

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Dual-Energy, Dual-Exposure PA and Lateral Chest Radiograph:
Not Your Father’s Chest X-Ray
Gilbert E Boswell, MD; Capt Sione T Wolfgramm, MD, USAF; CAPT Raynard K Fong, USN (Ret);
CAPT Daniel B Hawley, MD, USN Specialty Leader, Radiology, US Navy

ABSTRACT In the last two decades, our military and federal health care facilities have transitioned from traditional
X-rays exposing film screen systems, developed much like photographic film, to an entirely digital detection system
that affords computer processing of images and digital image and report distribution. While health care providers are
well aware of the practicality of these advancements, they may not be aware of the improved diagnostic capabilities
afforded by these new methods. In this report, we outline how application of physical principles of X-rays, with digital
detectors and computer data manipulation, can present images demonstrating chest and heart diseases that were pre-
viously not readily visible by traditional film screen systems. More recently, dual-energy, dual-exposure systems have
been implemented. This commentary is to educate the medical community so that they may better understand not only
the written report but the information on the images being provided, along with potential pitfalls to avoid. Specifically,
we demonstrate improved detection of pulmonary nodules and coronary atherosclerosis with the dual-energy technique.

INTRODUCTION due to poor image quality. Digital detectors also introduced

In the mid 2000s, most military medical facilities began tran-
sitioning X-ray equipment to direct digital capture units. This
allowed for digital archiving of images and networked dis-
tribution of images and reports, allowing rapid access to
interpreting physicians and referring providers. Costly film
processing, use of hazardous chemicals, and film archiving
have been eliminated, reducing operational and storage costs.
This has allowed for ready comparison with older examina-
tions in an organized fashion, allowing for better evaluation
of disease progression or stability. Digital datasets introduced
the capability for mathematical processing, pixel by pixel,
to optimize the images presented. It allowed a wider lati-
tude in processing. By simply changing a level or window
setting, visualization of lung parenchyma, mediastinum, and
bones improved. Fewer radiographs needed to be repeated
Department of Radiology, Naval Medical Center San Diego, San Diego,
CA 92134-5000, USA
The views expressed herein are those of the authors and do not necessarily
reflect the official policy or position of the Department of the Navy, DoD, or
the U.S. Government.
We are military service members or employees of the U.S. Government.
This work was prepared as part of my official duties. Title 17, U.S.C. 105
provides that copyright protection under this title is not available for any work
of the U.S. Government. Title 17 U.S.C.101 defines a U.S. Government work
as a work prepared by a military service member or employee of the U.S.
Government as part of that person’s official duties.
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2022. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
the usefulness of acquiring posterior to anterior (PA) views
with two exposures of different energies allowing improved
visualization of lungs and bones. This will be detailed further
below.1
This article is presented to help any provider, whether
in operational medicine or specialty practice, learn how
the images are created and thereby appreciate how nor-
mal anatomy or disease processes are presented, depending
on tissue density and elements in the body. It shows how
advancements in computer processing lead to better use of
physical principles separating tissue types. A unique aspect
for military medicine is the application of these techniques
in detecting unsuspected coronary calcium among our mil-
itary members. As military providers our task is to be the
best in preventive care and early detection in the care of our
patients, so that they may perform the military mission. Chest
radiographs are routine in our medical screening for many
military operational roles. This article explains improvements
and added capabilities of this test.
SIMPLE PHYSICS IN MODERN CHEST
RADIOGRAPHY
To better understand the concept of dual-energy techniques, a
short primer on X-ray physics is helpful. In projection radio-
graphy, as X-ray photons are transmitted through the patient,
some of the photons are attenuated (absorbed) by the tissues
before reaching the image detector. The probability of X-ray
photon absorption is proportional to the atomic number (Z) of

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FIGURE 1. Dual-energy, dual-exposure lateral CXR, 60-year-old male with right upper chest pain. (A) Standard view obtained at 120 kVp. (B) Calculated
“lung” subtraction image emphasizing lower atomic numbers demonstrate a 3 cm mass (arrow), obscured by ribs and spine on standard view. (C) Calculated
“bone” subtraction image emphasizing higher atomic numbers. (D) CT image (inset) confirming lung mass posterior to the liver and obscured on the frontal
projection. Biopsy confirmed adenocarcinoma.

the target material and inversely proportional to the energy of
the X-ray photon beam. Tissue composition with low atomic
numbers (i.e., soft tissue), composed of hydrogen (Z = 1),
oxygen (Z = 8), (water) and carbon (Z = 6) (protein, fat), will
attenuate fewer photons than tissues with higher atomic num-
bers, such as calcium (Z = 20) (bone, calcified atherosclerotic
plaque). Likewise, X-ray photons with a lower beam energy
spectrum will have a higher attenuation differential in bone as
compared to soft tissue. These principles allow for the cre-
ation of two image datasets obtained from different X-ray
beam energy exposures, enabling the decomposition of tis-
sue characteristics by mathematically computing and creating
images that emphasize either soft tissue (low Z) or bone
(high Z).
This technique also allows chemical element separation
to “emphasize,” or “subtract” metal (nickel Z = 28, copper
Z = 29, titanium Z = 22, iron Z = 26), implanted in, or over-
lying the chest, and characterize prostheses that may have
silicon (Z = 14) or lithium (Z = 7) components. This allows
for better identification of vascular access lines or a patient’s
indwelling tubes or devices (coronary stents and left atrial
appendage closure devices) and also demonstrates tissues oth-
erwise hidden by them. This may allow the observer to “see”
behind a pacemaker or jewelry on clothing or on the chest
wall.
CURRENTLY, THERE ARE TWO CLINICAL IMAGING
SYSTEMS AVAILABLE FOR DUAL-ENERGY
RADIOGRAPHY
One system allows processing two images simultaneously
from a single exposure by employing two imaging plates on
the X-ray detector that are geometrically aligned and sepa-
rated by a copper filter, which preferentially absorbs lower
X-ray energies. A low-energy image and a high-energy image
are acquired with a single X-ray beam. The advantage of this
system eliminates any patient motion artifacts. The disadvan-
tage is that the energy differential between the two images
is small, resulting in a relatively less separation of the tissue
characteristics. There is a low signal-to-noise ratio for the soft
tissue and bone images at typical patient exposures.
The other system uses a detector with fast read-out capa-
bility, allowing the use of two closely timed separate X-rays
of different energies. The large differences in the effective
energy of the X-ray beams result in a higher signal-to-noise
ratio and better separation of tissue types. The first acquisition
occurs with the high-energy beam (120 kVp), followed imme-
diately by a low-energy beam (60 kVp). In the most current
systems, the two exposures are 160 milliseconds apart. This
system is more demanding on the technologist, to make sure
the patient is not moving, and has suspended breathing before
the chest radiography exposures.
The image data are captured on high-resolution direct
photon to digital electronic signals and then processed by
computer algorithms that allow the creation of images, which
prioritize low-atomic-number tissues (water, carbohydrates,
fat, protein, and air) and higher atomic number tissues and
elements (calcium, silicon, and metals) (Fig. 1).
The technology to generate dual-energy exams has been
present since the early 2000s. However, the advent of faster
digital detectors, faster computer processing, and advanced
mathematical algorithms has recently allowed these applica-
tions to be applied in the lateral X-ray projection.2

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FIGURE 2. Asymptomatic male mid 60s preparing for a marathon. (A) Standard view at 120 kVp does not demonstrate coronary calcium. (B) Calculated
“lung” subtraction image emphasizing lower atomic numbers. Better visualization of lungs and hila. (C) Calculated “bone” subtraction image emphasizing
higher atomic numbers. Heavy coronary calcium, unexpected finding. Much greater than expected for patient age. Right, left anterior descending, and left
circumflex coronary arteries are demonstrated. (D) and (E) CT images (inset) from the subsequent calcium score inset to demonstrate anatomic correlation.

Dual-Energy, Dual-Exposure PA and Lateral
Radiographs in Current Practice
Dual-energy soft tissue–reconstructed images, often referred
to as “lung” images, have been demonstrated to improve
the detection of pulmonary nodules, consolidation, and lung
disease.3 “Bone” images were initially designed to identify
calcium in pulmonary nodules, thereby obviating the need for
CT, as these could generally be classified as benign calcified
pulmonary granulomas. This technique has been particularly
beneficial in detecting noncalcified nodules that would oth-
erwise be obscured by the clavicles or ribs. In the mid 2000s,
Gilkeson published a series of reports on dual-energy imaging
to evaluate coronary calcifications in the frontal projection.4,5
More recently, this technique has been modified to allow
imaging in the lateral projection in addition to the frontal
projection.
There are advantages of employing this technique on the
lateral chest X-ray. The lateral projection presents a better
view of the spine, central lungs and airways, and medi-
astinum. On the frontal projection, the overlapping shadows
of the sternum, vertebrae, and calcified cartilage of the rib
ends obscure the heart and coronary arteries and much of the
aorta, central airways, and pulmonary arteries. The lateral pro-
jection has been a favorite point of instruction by academic
chest radiologists since the publication of classic manuscripts
on the lateral chest radiograph by Proto, a chest radiolo-
gist with the U.S. Air Force in the late 1970s.6,7 With some
training, a reader can identify the anatomic structures of the
mediastinum and central lungs well on the lateral projection.
Dual-energy subtraction imaging with “lung” images remove
the overlying ribs and spine, thereby allowing the reader to
more readily detect regions of pulmonary consolidation or
obscured pulmonary nodules. This allows better definition of
the central airways and hila, aorta, and pulmonary arteries.
Similarly, “bone” images can be created that better demon-
strate the spine, calcified heart valves, and atherosclerotic
calcifications of the coronary arteries, thoracic aorta, and great
arteries of the aortic arch (Fig. 2).
Military Relevance and Current Use
Military treatment facilities provide care to service
members—individuals who are selected to be fit and healthy
for worldwide deployment. They are often deployed away
from specialty medical care in stressful and often hazardous
environments and often for prolonged period of time. Given
these considerations, military medicine has a low thresh-
old for imaging, whether this is a screening exam for an
accession physical, a recruit with suspected pneumonia, a
routine 5-year aviation or dive physical, or an occupational
health physical. We also care for many retired members
who are eligible beneficiaries and who may continue to
work as government employees or contractors at military
facilities.
Additional importance for sensitive chest radiography in
the military population is due to the legacy of high smok-
ing rates in the military, which directly leads to higher rates
of atherosclerosis, heart disease, osteoporosis, and lung can-
cer among other well-known diseases.8,9 Importantly, chest
radiography is not an established or recognized means of
screening for coronary disease or lung cancer. However, when
chest X-rays are obtained for other indications, dual-energy
techniques allow for the opportunistic detection of coronary
atherosclerotic calcifications or suspicious pulmonary nod-
ules that otherwise may not be detected.10–12

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 Dual-Energy, Dual-Exposure PA and Lateral Chest Radiograph
THE SIGNIFICANCE OF CORONARY CALCIUM BY
AGE
It is not inevitable that everyone will develop coronary
atherosclerotic calcification with age.13 In fact, 10%-15% of
patients in their eighth and ninth decade will not have any
coronary calcium. As a general rule, the median age for males
to develop their first scorable coronary calcium by CT is 50.
For women, it is 60. Therefore, if we detect coronary cal-
cium by dual-energy CXR in individuals at younger ages,
these patients are identified as outliers and at increased risk for
coronary event. In our experience, we have detected unsus-
pected coronary atherosclerotic calcifications in active duty
members in their 30s and 40s. Furthermore, the greater the
calcium burden identified by age, the greater the risk of a car-
diac event. Chiles et al. demonstrated that a trained reader
can semiquantify the burden of calcium by CT and assign risk
categories.14
When coronary calcium is detected, it is important for the
referring provider to recognize the significance of this, put it in
context with the patient’s age and other risk factors, and use
this information to add guidance in lipid management if the
patient does not have symptoms referable to coronary disease.
If the patient does have symptoms, then appropriate referral
for further evaluation should be initiated. Similarly, it should
be emphasized that CXR is not a screening tool for coronary
atherosclerosis, but can be useful when detected on an exam-
ination ordered for other indications. Not detecting coronary
calcium on a CXR does not exclude coronary disease.
PITFALLS TO RECOGNIZE WHEN VIEWING THESE
EXAMINATIONS
Dual-energy, dual-exposure chest radiographs are obtained
by performing two examinations in rapid succession. These
data are then used to create “subtraction” images, which then
best demonstrate lung and soft tissues and calcified or bony
tissues. Because this requires two exposures, there will be
some cardiac motion artifact. If the patient is actively breath-
ing during the exposures, imaging artifacts will also occur.
Heart motion will result in artifacts adjacent to the heart and
mediastinal borders. On the subtraction images, this should
not be mistaken for pneumomediastinum. Similarly, if there
is chest wall or diaphragm motion, there could be confusing
artifacts, which one may mistake as pneumothorax. If these
entities are suspected, one should refer to the standard view
images (120 kVp) to avoid this pitfall.
SUMMARY
With this introduction of the dual-energy radiography tech-
nique and brief discussion of the advantages for the detection
4 MILITARY MEDICINE, Vol. 00, Month/Month 2022
of important pathology in our military population, it is our
hope that the reader will better understand how to interpret
these images and understand the value added as these digital
subtraction images become commonplace in military treat-
ment facilities. Reference 2 will present the reader with more
examples, illustrating the applicability of the techniques and
more details about physical principles behind dual-energy
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chest radiography.
FUNDING
None declared.
CONFLICT OF INTEREST STATEMENT
None declared.
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