Application of the ILO International Classification of Radiographs of Pneumoconioses to Digital Chest Radiographic Images


July 2008
DHHS (NIOSH) Publication Number 2008-139

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A NIOSH Scientific Workshop

The following content has been adapted from a presentation given at the NIOSH Scientific Workshop: Application of the ILO International Classification of Radiographs of Pneumoconioses to Digital Chest Radiographic Images.

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American College of Radiology Perspective

Daniel A. Henry, M.D., F.A.C.R
ACR Pneumoconiosis Committee

Objectives, organizational perspective

  • To implement digital acquisition and display for local x-ray facilities
  • To implement digital classification for readers who classify images

Stakeholder actions / challenges

  • Facilitate the development of technical guidelines for the acquisition and display of digital chest images suitable for ILO classification
  • Based on the above, transition established teaching methods of classification from an analog to digital format and environment

The Beginning

  • Collaboration with National Institute of Occupational Safety and Health & ILO
  • An Integrated Mission
    • Education
    • Technical development and support

ACR The Beginning

  • 1969 – Federal Coal Mine Health & Safety Act
    • Active miners: CXR within 18 mos, 3yr, 5yr
    • Retired miners
    • Disability / compensation benefits
    • Length of exposure / radiographic findings
    • International Union Against Cancer/Cincinnati system (based on 1958 ILO system)
  • NIOSH / US Public Health Service requests assistance
  • 1970 – ACR Pneumoconiosis Task Force

ACR Education

  • Meeting the Instructional Challenge
  • A crash program was developed
  • Weekend Symposia for attendee convenience
  • 6 courses in the first year
  • > 30 meetings since 1970
  • 4,000-5,000 physician attendees
  • Viewbox teaching method
  • Test-Teach-Test sequence of instruction*
  • Compels active participation in the learning process
  • Incorporated into other ACR subspecialty teaching seminars
  • Remains the backbone of the current ACR Symposia on the Pneumoconioses

*Felson B, Jacobson G, Pendergrass E, Bristol L, Linton O, Harrington R. Viewbox seminar: A new method for teaching roentgenology. Radiology 1975; 116:75-78.

  • Symposia restricted to physicians
  • 6 Technical Symposia for radiographers on chest radiographic technique
  • Special seminars for administrative judges & lawyers interpreting the law for state and federal programs
  • Development of Home Study Syllabi
    • Classification for Physicians / B-reader candidates
    • Chest technique for radiographers
  • Exhibits detailing proper radiographic technique and the ILO classification system
  • Cinematic production explaining the law and the obligation of physicians
  • Support for and validation of the “B reader” examination
  • Implementation of the step wedge for improving radiographic technique*
  • Development of a teaching module on asbestos related diseases


  • ACR Pneumoconiosis Task Force consulted with various federal agencies conducting related programs:
    • Food and Drug Administration
    • Department of Labor
    • Social Security Administration
    • National Cancer Institute
  • Development of Technical Guidelines prepared for NIOSH
  • Home Study Syllabus on Technique for Chest Radiography
  • Technique for Chest Radiography for Pneumoconiosis


  • Members of the Task Force have been or are members of ILO committees
  • Participated in the development/revisions of ILO Guidelines 1971, 1980, & 2000
  • ACR sponsored conferences in Washington, D.C. which subsequently led to the 1980 & 2000 Guidelines
  • ACR instrumental in the production of the 1980 ILO Standard Radiographs & the subsequent quadrant standards
  • Participated as consultants to NIOSH for the review of teaching materials including the transition to digital
  • 1982-84: ACR-NEMA collaboration
  • ACR members requested non-proprietary format for image production from digital sources (CT, NM, US)
  • National Electrical Manufacturers Association
  • ACR-NEMA Digital Communication Standard
  • Digital Imaging and Communication in Medicine standard – DICOM

Technique for Chest Radiography for Pneumoconiosis

  • Overview
  • Equipment
  • Technique guides
  • Scatter control
  • Quantum mottle
  • Screen/film combinations
  • Sensitometric monitoring
  • Radiation protection
  • ACR practice guidelines
    • Performance of Adult Chest Radiography (10/06)
    • Digital Radiography* (10/07)
  • ACR Technical Standard for Electronic Practice of Medical Imaging (10/07)

*Developed collaboratively by American College of Radiology
American Association of Physicists in Medicine
Society for Imaging Informatics in Medicine


  • To promote communication of digital image information, regardless of manufacturer
  • To facilitate the development and expansion of PACS that can interface with other systems of hospital information
  • To allow the creation of information databases that can be accessed by a wide variety of devices distributed geographically
  • Used by other specialties utilizing digital imaging such as cardiology, GI endoscopy, pathology, dentistry, & dermatology
  • Consists of 13 layers or sections
  • Ongoing evolution
  • Critical to digital imaging and this transition

American College of Radiology “Dust to Digital”

  • Collaboration with National Institute of Occupational Safety and Health
  • An Integrated Mission
    • Education
    • Technical development and support

ACR: Dust to Digital

  • Transition to digital “viewbox” seminars
  • Maintain the individual or registrant oriented approach for instruction
  • Test – Teach – Test, interactive model
  • What type of digital display devices will be necessary?
  • Emulate the test and practice environment
  • The challenge for teaching
  • Transition away from the viewbox
  • Classroom of the future
  • New logistical paradigm using digital media but maintaining the benefits of the viewbox seminar
  • Converting analogue material
  • New facility
  • Site of future teaching seminars?
  • Site of future b-reader testing?
  • Image processing driving display market
  • Industry has moved to color LCD monitors
  • More versatile for cross sectional imaging and CR/DR
  • Color monitors generally load images faster
  • Cheaper
  • Can we use color monitors for B-reading?
  • Will we require a B/W monitor?
  • Established models for image acquisition
  • Reestablish the primacy of high quality standard procedures in acquiring images regardless of modality
  • Integrate digital acquisition and display guidelines with basic elements of chest radiography
  • Reinvent the 1984 monograph as “Technique for Digital Chest Radiography for Pneumoconiosis”
  • Use past experience as template
  • Transition the current ACR Pneumoconiosis Committee to a Task Force, once again
  • Draw from ACR Digital Guidelines authors & collaborators and members of this workshop
  • Expand the Task Force’s role and composition from primarily education to a more integrated and supportive posture with NIOSH & ILO to assist in the “dust to digital” technical and educational transition
  • Explore accreditation/ QA function
Page last reviewed: June 6, 2014