Ekwulugwo OP, et al.

J Nucl Med Radiol Radiat Ther 2023, 7: 031

DOI: 10.24966/NMRR-7419/100031

HSOA Journal of
Nuclear Medicine Radiology & Radiation Therapy
Research Article

Assessment of Patients and their 75th percentile value was obtained as the DRL for anatom-
ical region studied. DRLs proposed for chest CT examinations for
Rivers state were: 10.6 mGy and 414.70 mGy.cm for CTDIv and DLP
Radiation Doses during respectively. These values are lower than the European Commission
DRLs and comparable to other international studies. Wide variation
Computed Tomography Chest in mean doses are noted across the region. Therefore, the chest CT
examination practice within the region is optimized.
Imaging Examination: Propose Keywords: Computed Tomography; Dose Length Product; Diag-
nostic Reference Level; Optimization; Medical Imaging; Volumetric
Diagnostic Reference Level Computed Tomography Dose Index

Ojike Peter Ekwulugwo1*, Orji Chikwendu Emenike2, Okeoma Introduction

Kelechukwu Bierechi 2, Madu Chinyere Ada2, Rilwan Usman3
Department of Radiology, Federal University Owerri Teaching Hospital, Imo
1 Computed Tomography (CT) is a valuable medical imaging ex-
State, Nigeria amination for the diagnosis of wide range of chest diseases such as
breast cancer, interstitial lung diseases, lung abscess [1,2] Sequel to
Department of Physics, Federal University of Technology Owerri, Imo State,
2

Nigeria development of Multi-Dictator Computed Tomography (MDCT) ma-

chines, new clinical applications are continuously evolving in medi-
3
Department of Physics, Nigerian Army University, Biu, Borno state, Nigeria cal procedures. It is estimated that in UK, computerized tomography
examinations are the leading cause of 40% of annual collective dose
Abstract resulting from medical exposure in 1999 compared to 20% in 1990
[3,4]. This increase in population radiation dose burden is of utmost
In medical imaging, Computed Tomography (CT) scan examina-
concern to mankind due to the possibility of radiation induced malig-
tion is a major source of ionizing radiation. All medical radiological
nant diseases like cancer [5,6] Therefore, sensible use of this imaging
exposures should be justified and optimized to meet up with the
needed clinical outcome. Therefore, to avoid unnecessary radia- modality requires strict adherence to the principles of radiation pro-
tion doses to patients, Diagnostic Reference Levels (DRLs) for CT tection: Justification, optimization and dose limitation, ensuring that
examinations should be adhered to. The DRLs are used to identify the risk to patients does not outweigh the benefit gained from the pro-
radiation dose outliers during CT scan examinations, which does not cedure [7,8]. Doses are routinely estimated by using standard 16cm
contribute to good clinical diagnosis. DRLs have been successfully
or 32 cm diameter Polymethylmethacrylate (PMMA) cylinder phan-
implemented in the UK, Australia, Japan, Canada and United States
of America; and a few underdeveloped countries. The present study tom representing “average” patients [9,10]. Although, the CT dose
aimed at assessment of patients’ radiation dose during chest CT in chest imaging is high, tissue reactions are not expected because a
scan examination with a view to establishing local diagnostic levels specific threshold is required for it to occur, about 2000 mGy [11,12].
in Rivers State, South-South, Nigeria. Sixty (60) adult patients com- In CT chest imaging, the dose to skin is ranged between 20 mGy-40
prising of 20 patients from center A, 20 patients from center B, and
mGy [13,14]. The International Commission on Radiological Protec-
20 patients from centre C were purposively sampled. The patients
aged between 16-100 years and weighed 70±10 kg. The prospec- tion (ICRP) recommended that Diagnostic Reference Levels (DRLs)
tive data collection spans four months, and CTDIv and DLP were should be used by regional, national and local authorized bodies like
retrieved after each CT scan examination. SPSS version 25.0 was Nigeria Nuclear Regulatory Authority (NNRA), so as to minimized
used to analyze data. Mean CTDIv and DLP values were calculated the patient doses from unnecessary exposure by keeping all patient
exposures to as low as reasonably achievable (ALARA Concept)
*Corresponding author: Ojike Peter Ekwulugwo, Department of Radiology, [15,16]. In CT examinations, the volume Computed Tomography
Federal University Owerri Teaching Hospital, Imo State, Nigeria. Email: saintpe-
terlivy@gmail.com Dose Index (CTDIv) and Dose Length Product (DLP) are the param-
eters used to estimate the dose to the standard phantom representing
Citation: Ekwulugwo OP, Emenike OC, Bierechi OK, Ada MC, Usman R (2023) average patients [17,18]. The CTDIv represents the average dose to
Assessment of Patients Radiation Doses during Computed Tomography Chest
Imaging Examination: Propose Diagnostic Reference Level. J Nucl Med Radiol a cross section of a phantom (measured in mGy) [6,7]. Dose length
Radiat Ther. 7: 031. Product (DLP) is the product of the CTDIv and the scan Length (L)
for a group of scans along x-axis (measured in mGy.cm) [19,20]. Cur-
Received: October 03, 2023; Accepted: October 20, 2023; Published: October
30, 2023 rently, these two dosimetric variables are displayed on CT dose re-
ports page after each scan series. The aim of this study was to estimate
Copyright: © 2023 Ekwulugwo OP et al. This is an open-access article distribut- the radiation dose to adult patient during chest computed tomography
ed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the orig- imaging examination in Rivers state, Nigeria, and to establish local
inal author and source are credited. diagnostic reference levels.
Citation: Ekwulugwo OP, Emenike OC, Bierechi OK, Ada MC, Usman R (2023) Assessment of Patients Radiation Doses during Computed Tomography Chest
Imaging Examination: Propose Diagnostic Reference Level. J Nucl Med Radiol Radiat Ther. 7: 031.

• Page 2 of 5 •

Materials and Methods Volumetric computed tomography dose index (CTDIv) is ex-
pressed as the average dose delivered to the scan volume for specific
Materials
examination. It is derived from the CTDI. For a single slice scanner,
The materials required for the conduct of this research were Com- CTDIv is defined by Equation 3 as:
puted Tomography Scanner Machines which is domiciled at the study
centre, IAEA recommended data collection sheet, SPSS version 25
software for data analysis and Ethical clearance obtained from the
participating centers. Where N is the number of scans, T is the nominal scan width (mm)
and L is the distance between scans (mm) [23].
Study Area: The study area was located in Port Harcourt Rivers State.
The three study centres were all located in the Port Harcourt City. For MSCT system, NXT is the total nominal scan width, and I cor-
Methods respond to the patient table movement during one gantry rotation. Ac-
cording to the work of [24] the Multiple Scan Average Dose (MSAD)
This study adopted a prospective and quantitative research design for spiral scans can be expressed in Equation 4 as:
to estimate the absorbed radiation dose to patient undergoing CT scan
of the chest. A quantitative design was appropriate because the study
involved the use of numerical data.

Study Population: The study involved all adult patients that attended Comparing Equation 3 and 4, we have Equation 5;
for chest CT scan examinations in the studied centers.

Ethical Consideration: In line with Helsinki declaration 1964 on re-

search involving human subjects, ethical approval and consent was
granted by studied centers and patients’ confidentiality was main- Results
tained by obtaining an informed consent before participating in the
research. To compute the result for the chest CT dose examination for adult
patient in Rivers State radio-diagnostic centers in Nigeria, CT scanner
Data Collection: The data was collected with the assistance of a CT
type, model, number of slices, year of manufacture and year of instal-
radiographer who was trained on how to collect the data.
lation were obtained, recorded and presented in (Table 1). Also, the
Sample Size: A sample size of sixty (60) qualified patients were re- patients’ average age (years) and weight (kg) were measured and the
cruited for chest CT in the study. This was obtained through selection patients’ gender characteristics were all shown in (Table 2). Lastly,
of twenty (20) participants from centre A, (20) from B, and (20) from the CT scan parameters (anthropo-technical features) like kV, mA,
C respectively. Scan length, pitch, FOV, CTDIv and DLP were calculated and pre-
Inclusion Criteria sented in (Table 3).

• Only ambulant adult patients weighing 70±10 kg was included in Cen- Manufac- Model Configura- Manufac- Installed
tre turer Detector tion tured Year Year
the study [21,22].
A Siemens Somatom 16-Slice 2019 2019
• Only adult patients that presented for chest CT scan examinations General
were considered. B Electric Brivo 8-Slice 2015 2015
(GE)
• Data was acquired on a CT scanner routinely calibrated by the Ni-
General
geria Nuclear Regulatory Authority (NNRA). C Electric
Bright
4-Slice 2006 2015
Speed
(GE)
Exclusion Criteria: Generally, all the patients that do not fall within
the inclusion criteria were excluded from the study. Table 1: Details of Facility CT Scan Machines.

Data Analysis
Cen- Examina- Age ± SD Sex Mean Weight ±
Total
CT dose index (CTDI (mGy)), which is the measure of the dose tre tion Type (years) M F SD (kg)
from single-slice irradiation is defined as the integral along a line par- A Chest 60.17±16.59 12 8 20 74.09±8.44
allel to the axis of rotation (z) of the dose profile, D(z), divided by the
B Chest 59.40±13.66 9 11 20 74.95±5.56
nominal slice thickness, T as shown in Equation 1 [23].
C Chest 54.71±6.82 9 11 20 71.55±7.22

Table 2: Demographic distribution and patient’s Chest characteristics of

the study population.
The weighted CT air kerma index, CTDIw (mGy), used to com-
bine values of CTDI measured at the centre (c) and periphery (p) of a Result Analysis
standard CT dosimetry phantom as shown in Equation 2 [23].
In order to analyze the obtained results, bar charts were plotted
and comparison was made with international recommendations, and
some Nigeria authors’ local and regional values.
J Nucl Med Radiol Radiat Ther ISSN: 2572-7419, Open Access Journal Volume 7 • Issue 1 • 100031
DOI: 10.24966/NMRR-7419/100031
Citation: Ekwulugwo OP, Emenike OC, Bierechi OK, Ada MC, Usman R (2023) Assessment of Patients Radiation Doses during Computed Tomography Chest
Imaging Examination: Propose Diagnostic Reference Level. J Nucl Med Radiol Radiat Ther. 7: 031.

• Page 3 of 5 •

Cen- Exam-
kV mA Scan Length Pitch FOV
tre ination

A Chest 110 125.22 5.12 1.09 30.17

B Chest 110 57.950 30.60 0.83 30.00

C Chest 120 185.30 37.35 0.98 36.20

Table 3: Scan parameters for all the studied centers.

Discussion
In this study we investigated the patient’s radiation dose during
chest CT scan examination and based on that propose diagnostic ref-
erence level for that anatomical body region for South-South, Nige-
ria. Both male and female patients were involved in the study with
the percentage of males = 30 (50%), and females = 30 (50%) for the
population. The radiological centers studied were selected because
they met the inclusion criteria for the study having a functional and
accredited CT scan machine.

(Table 1) shows details of different CT scan machines available in

the three studied centers, manufacturers, model, detector configura-
tions, year of manufacture and installation.

Demographic distribution and patient chest dose characteristics of

the studied population was detailed in (Table 2). The centers A, B and Figure 1: Bar Charts Showing Comparison of Scan Parameters of the
Study Centres.
C patients’ mean age (in years), with their standard deviation were,
respectively 60.17±16.59, 59.40±13.66 and 54.71±6.82.

Sixty (60) males and females’ patients with twenty (20) in center
A, twenty (20) in B and twenty (20) in C were recruited. The patient’s
respective mean weights were (in kg), 74.09 ± 5.49, 74.95±5.01 and
71.55±7.22 for centres A, B and C respectively. The scan parameters
of the studied centers were shown in (Table 3) and (Figure 1). The
Centre Mean Dose in terms of CTDIv (mGy) and DLP (mGy.cm)
and standard deviation for CT of chest in the studied region were
shown on (Table 4) and (Figure 2). The mean CTDIv were 9.72±1.73
mGy, 5.60±1.75 mGy and 11.15±4.02 mGy for centres A, B and C Figure 2: Comparison of Center Mean CTDIv (mGy) and DLP (mGy.cm)
respectively. While, the mean DLP were 322.03 ± 33.87 mGy.cm, with their respective values.
241.95±53.78 mGy.cm and 485.10±51.36 mGy.cm for centers A, B
and C respectively. Observable CT dose patient variation exist among
the studied centers. This is due to different CT scan parameters kVp,
scan range, time, pitch, time and mAs among the centers.

Centre Body Region CTDIv (mGy) DLP (mGy.cm)

A Chest 9.72±1.73 322.03±33.87

B Chest 5.60±1.75 241.95±53.78

C Chest 11.15±4.02 485.10±51.36

Table 4: Centre Mean Dose in Terms of CTDIv (mGy) and DLP (mGy.
cm).

(Table 5) and (Figure 2) shows the combined mean of CTDIv as

8.82±2.54 mGy and DLP as 349.70±65.82 mGy.cm. The proposed lo- Figure 3: Comparison of Combined CTDIv (mGy) and DLP (mGy.cm)
cal diagnostic reference level for chest CT examination of the region with their Derived State DRL.
was 10.63 mGy and 414.70 mGy.cm with respect to CTDIv and DLP.
Comparison of our DRL with that of international DRLs values was
(Table 7) and (Figure 4), shows the table and comparison of our
shown in (Table 6) and (Figure 3) respectively. European Commis-
DRL in terms of DLP. (414.7 mGy.cm) being lower than the European
sion [14] (10mGy) and Australia [15] had same values with our study
in terms of CTDIvol (mGy). Our DRL value of 10.6 mGy in terms Commission [14] (600 mGy.cm), and Japan [17] (510 mGy.cm), but
CTDIvol was comparable with the works of UK [16] (8.5mGy) and comparable with Australia [15] (390 mGy.cm), and higher than UK
Japan [17] (13 mGy). [16] (290 mGy.cm). These lower doses obtained in our study is likely

J Nucl Med Radiol Radiat Ther ISSN: 2572-7419, Open Access Journal Volume 7 • Issue 1 • 100031
DOI: 10.24966/NMRR-7419/100031
Citation: Ekwulugwo OP, Emenike OC, Bierechi OK, Ada MC, Usman R (2023) Assessment of Patients Radiation Doses during Computed Tomography Chest
Imaging Examination: Propose Diagnostic Reference Level. J Nucl Med Radiol Radiat Ther. 7: 031.

• Page 4 of 5 •

DRL Body Region Mean 75th Percentile

CTDIv (mGy) Chest 8.82±2.54 10.63

DLP (mGy.cm) Chest 349.70±65.82 414.7

Table 5: Combined Mean of CTDIv (mGy) and DLP (mGy.cm) with De-
rived State DRLs.

Body Region Authors Year CTDIv (mGy)

Chest Present Study 2023 10.6

Chest European Commission 2014 10

Chest Australia 2020 10

Chest Japan 2020 13

Chest UK 2019 8.5

Figure 5: Comparison of our DRL in terms of DLP with International
Table 6: Comparison of Established DRLs in Terms of CTDIv (mGy) with Values.
International Values.

due to adherence to patient radiation protection principle of optimiza- in North west, Southwest, and Northeast respectively (Figure 6). The
tion in all the three diagnostic centers (Figure 5). third quartile value is chosen as an appropriate investigation level, on
the grounds that if 75% of the CT centers can operate satisfactorily
Body Region Authors Year CTDIv (mGy) below this dose value, then the remaining 25% should be made aware
Chest Present Study 2023 414.7 of their considerably higher dose values and optimization should be
Chest European Commission 2014 600
initiated.
Chest Australia 2020 390 Body CTDIv
Authors Year Location
Chest Japan 2020 510 Region (mGy)

Chest UK 2019 290 Chest Ogbole & Obed 2014 South-West, Nigeria 22.7

Chest Joseph et al. 2018 North-East, Nigeria 18

Table 7: Comparison of Established DRLs in Terms of DLP (mGy.cm)
with International Values. Chest Buhari & Buhari 2021 North-West, Nigeria 17.25

Chest Rilwan et al. 2020 North-Central, Nigeria 10.9

Chest Present Study 2023 South-South, Nigeria 10.6

Table 8: Comparison of Established DRLs in terms of CTDIv (mGy) with

Other Part of Nigeria Values.

Body Re- DLP (mGy.

Authors Year Location
gion cm)

Chest Ogbole & Obed 2014 South-West, Nigeria 1189

Chest Buhari & Buhari 2021 North-West, Nigeria 735

Chest Joseph et al. 2018 North-East, Nigeria 659

Chest Rilwan et al. 2020 North-Central, Nigeria 432.8

Chest Present Study 2023 South-South, Nigeria 414.7

Figure 4: Comparison of our DRL in Terms of CTDIv with International Table 9: Comparison of Established DRLs in terms of DLP (mGy.cm)
Values. with Other Part of Nigeria values.

In Nigeria, some authors have established DRLs both locally as per

state, and regionally as per geographical zones (Tables 8,9 and Figures Conclusion
6,7). The results of our study were compared with the works of Buhari Local DRLs for chest CT examinations was proposed for Rivers
[18] from Northwest with CTDIv and DLP (17.25mGy/735mGy.cm) State, South-South, Nigeria. The proposed LDRL were analogous or
and percentage variation with our work as 21.7% and 21.4% respec- below other international works and Europeans Commission reports.
tively. In a similar study, in Northcentral, Rilwan et al., [19] obtained Therefore, there is good patient dose optimization for chest CT exam-
10.9 mGy/432.8mGy.cm for CTDIv and DLP and variation with our inations in the region studied.
work shows 13.7% and 12.6% respectively. In the same vein, Og-
bole and Obed [20] in Southwest obtained 22.7 mGy/1189 mGy.cm Although the CTDIv obtained in this study is relatively similar
with percentage variation of 28.6% and 34.7%. Also, Joseph et al., to the internationally, locally and regionally reported data in the lit-
[21] carried out a similar study in Northeast with CTDIv and DLP erature, and the DLP values is comparably lower than the European
values as 18 mGy/659 mGy.cm, and variation of 22.7% and 19.2% Commission reported value, but higher than data reported by some
existed. Therefore, our established DRLs for chest examination in countries. Our result is intended for Preliminary Regional Diagnostic
South-South region of Nigeria, was comparable with the work in Reference Levels (PDRLs) for State studied. Also, variation between
North-Central Nigeria (Figure 6), but lower than the values obtained CT scan centers was observed. It is therefore recommended that the
J Nucl Med Radiol Radiat Ther ISSN: 2572-7419, Open Access Journal Volume 7 • Issue 1 • 100031
DOI: 10.24966/NMRR-7419/100031
Citation: Ekwulugwo OP, Emenike OC, Bierechi OK, Ada MC, Usman R (2023) Assessment of Patients Radiation Doses during Computed Tomography Chest
Imaging Examination: Propose Diagnostic Reference Level. J Nucl Med Radiol Radiat Ther. 7: 031.

• Page 5 of 5 •

7. Huda W (2007) Radiation Doses and Risks in Chest Computed Tomogra-

phy Examination. Proceedings of the American Thoracic Society 4: 316-
320.

8. ICRP (1991) Publication 60: 1990 Recommendations of the International

Commission on Radiological Protection. Ann ICRP 21: 1-201.

9. European Commission (2019) Guidelines on Quality Criteria for Diagnos-

tic Radiographic Images European Commission EUR 16261 EN. Europe-
an Commission, Europe.

10. Goldman LW (2007) Principles of CT Radiation Dose and Image Quality.

J Nucl Med Technol 35: 213-225.

11. Karthikeyan D, Chegu D (2005) Step by Step CT Scan (A Practical Guide

for Residents and Technologist). Jaypee Brothers Medical Publisher, New
Delhi, India.
Figure 6: Comparison of our DRL in Terms of CTDIv (mGy) with Other
Part Nigeria values. 12. Morin RL, Gerber TE, McCollough CH (2003) Radiation Dose in Com-
puted Tomography of the Heart. Circulation 33: 917-922.

13. European Commission (2014) Diagnostic Reference Levels (DRLS) in

Thirty-Six European Countries. Radiation protection, European Commis-
sion, Europe.

14. Lee KC, Beveridge T, Sanagou M, Thomas P (2020) Updated Australian

diagnostic reference level for adult CT. J Med Radiat Sci 67: 5-15.

15. UK Health Security Agency-RCE (2019) Doses from Computed Tomogra-

phy (CT) Exams in the UK Review, UKHSA, England.

16. Japan Medical Imaging and Radiological Systems Industries Association

(2020) National Institutes for Quatum and Radiological Science and Tech-
nology. National Diagnostic Reference Levels in Japan 1-22.

17. Buhari M, Buhari S (2021) Review of Diagnostic Reference Levels for

Adult Patients Undergoing Chest and Abdomen Computed Tomography
Figure 7: Comparison of our DRL in Terms of DLP with Other Part of Scan in Northern Nigeria. African Journal of Environment and Natural
Nigeria values. Research 4: 83-90.

18. Rilwan U, Sabiu LK, Umar I, Yusuf SD, Ugwu EI (2021) Assessment of
tube current and tube current time product be investigated and re- Radiation Dose in Computed Tomography Examination of Adult Patient
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revised LDRL that will be equal to or lower than the internationally ria. West African Journal of Radiology 21: 1-6.
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DOI: 10.24966/NMRR-7419/100031
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