Chest X-ray in Neonates and Children Swapan K Ray
INDEX
Page numbers followed by f refer to figure.
A
Abdomen 1
Adeno virus 32
Airspace pneumonia 28
right upper lobe 32f
Airway pneumonia 28, 30f
Asphyxiating thoracic dystrophy 16f
Aspiration pneumonitis 42
Axillary fold, anterior 11f
B
Barium meal 55f
Barotrauma, sign of 60
Bat wing appearance 24f
Bochdalek hernia 54
Bone 1, 12
within bone appearance 16
Bony thorax 13
Bony trabeculae 15
Brock's right middle lobe syndrome 32
Bronchogenic carcinoma 34
Bronchopneumonia 28
Bronchopulmonary dysplasia 59f
Bronchovascular markings 25
C
Caffey's disease 14
costal hyperostosis in 14f
Cardiac border
part of left 21
right 28f, 43f
Cardiac enlargement 16
Cardiac pathology 21
Cardiac shadow 54
Cardiac silhouette 18, 23
Cardiomegaly 21, 21f
Cardiomyopathy 21f
Cardiothoracic ratio 19, 19f
Central nervous system 45
Cervical rib on right side 13f
Chest 1
normal neonatal 46f
ultrasonography 45
Chest X-ray 2, 33f, 36f, 38f, 40f44f, 51f-52f, 53f, 57f
ABCS of interpreting 1
basics of pediatric 1
characteristics of newborn 45
in neonates 45
interpretation of 1
normal 8, 8f
prerequisites for proper 5
reading 2
Cleidocranial dysostosis 12
Community-acquired pneumonia, symptoms of 33
Cystic hygroma 11f
D
Dextrocardia with situs inversus 20, 20f
E
Emphysema, surgical 10f
Encysted pleural effusion, right sided 37f
Expiration 4f
F
Fallot's physiology 22
Fallot's tetralogy 22f
Fissure
left side 29f
major 29
minor 29
right sided 29f
Foreign bodies 3
Frontal film 5f
G
Granulomas 41
Great arteries, transposition of 23, 23f
H
Heart
chambers of 18f
disease, congenital 25
hypoplasia, left 55
Hemithorax, right 36f
Hemolytic anemia, chronic 15f
Hemosiderosis 41
Hernia 55
Hyaline membrane disease 50
stages of 50f
I
Inspiration 4f
Intrathoracic causes 46
J
Jeune syndrome 16f
K
Klebsiella pneumonia 32
L
Leukemia 41
Lobar emphysema, congenital 57
Lobar pneumonia 28
Lobe, right upper 30f
Lung
abscess 35f
cyst, congenital 58f
fields appear oligemic 23
hypoplastic right 51
immaturity 55
sequestrated 43
volume 46
decreased 46
increased 46
normal 46
variable 46
Lymphoma 43
M
Marble bone disease 15f
Meconium aspiration syndrome 48, 59f
Mediastinal lymphadenopathy, superior 26, 26f
Mediastinal neurogenic tumor, posterior 44
Mediastinal shadows 31
superior 25
Metastasis 41
Miliary mottling 40
Miliary shadows 40
Mitral stenosis 41
Morgagni hernia 55f
Mycobacterium tuberculosis 32
N
Neonatal pulmonary diseases 46
Neuroblastoma 44
Neuroenteric cyst 43
O
Osteopetrosis 15f
P
Paralysis, type of 44
Paratracheal lymph node 17f
Patcy radio-opacities 59f
Pericardial effusion 22, 22f
Pneumatocele 32f
causes of 32
Pneumonia 28, 44, 46
complication of 35
infiltrative 28
interstitial 28, 34f
right middle lobe 31f
round 33f, 34
Pneumonitis, hypersensitivity 42
Pneumothorax 3
right sided 11f
Prominent air bronchogram 50
Pulmonary airway malformation, congenital 56f
Pulmonary alveolar microlithiasis 41, 41f
Pulmonary artery
left 18
right 18
Pulmonary bay 20
Pulmonary conditions 28
Pulmonary edema 24, 24f
Pulmonary hypertension, persistent 55
Pulmonary hypoplasia 17, 55
Pulmonary intersitial emphysema 60, 60f
Pulmonary plethora 20f, 21, 23, 25
Pulmonary space occupying lesion 43
Pulmonary trunk 18
Pulmonary valve 18
R
Radiation injury 45
Radiopacity in chest 11
Respiratory distress, causes of 45
Respiratory tract infection, lower 28
S
Skeletal abnormalities 45
Skiagram, adequacy of 3
inspiration 3
overexposure 7
penetration 5
rotation 7
underexposure 6
Soft tissue 1
inflammation 39
shadows 10
on left side 38f
Staphylococcus aureus 32
Streptococcus pneumoniae 32, 33
T
Thoracic dystrophy 13f
Thoracic wall, left inner 53f
Thymic enlargement 27
Thyroid, medullary carcinoma of 41f
Trachea, narrowing of 17f
Tracheal anomaly 17
Transient tachypnea of newborn 47f
Tricuspid valve 18
U
Upper motor neuron 44
V
Vena cava
inferior 18
superior 18
×
Chapter Notes

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Basics of Pediatric Chest X-rayCHAPTER 1

Interpretation of X-ray chest is of immense importance in pediatric practice. Although, sophisticated gadgets are very much used in the day to day practice yet role of conventional radiographic examination cannot be ignored rather still remains the corner stone of basic investigation. Plain and fluoroscopy chest X-ray constitute 80–85% of pediatric study. Other investigations like ultrasonography (USG) (8–12%), computed tomography (CT) (3–5%), magnetic resonance imaging (2–4%), nuclear medicine (2–4%), and vascular and interventional procedure (0.5–1%) contribute the rest. Among plain X-rays, chest X-ray takes its share of 65–70%. So one must know how to read chest X-rays properly and methodically.
 
ABCS OF INTERPRETING CHEST X-RAY
  • A: Abdomen
  • B: Bones
  • C: Chest
  • S: Soft tissues.
Everybody must learn a methodical approach, so that it becomes a routine practice and thus missing findings may be minimized.2
 
Reading Chest X-ray
  • Have a structured method!
  • Be consistent with that method
  • Please don't take short cuts
  • Look at all your patient's X-rays yourself
  • Practice…Practice… Practice.
 
CHEST X-RAY
  • Views
    • Posterior-Anterior (PA),
    • Lateral
    • Anterior-Posterior (AP)
    • Lateral decubitus.
  • Steps of interpretation
    1. Soft tissue shadows
    2. Bones
    3. Domes of diaphragm
    4. Trachea
    5. Cardiac silhouette
    6. Superior mediastinal and hilar shadows
    7. Costophrenic sulci
    8. Lung fields.
This approach of reading chest X-ray will be very helpful as missing even subtle findings would be narrow.
Differences between PA and AP views is shown in table 1.3
TABLE 1   Differences between posterio-anterior and anterio-posterior views.
Anterio-posterior view
Posterio-anterior view
Heart appears larger
Not magnified
Heart details not well visualized
Heart well delineated
Clavicles higher in position
Clavicles are not high up
Ribs appear parallel
Anterior ends look downward
Scapulae more sharper and close to film
Scapulae are more likely to be drawn laterally
Disc spaces (cervical) more clearly seen
Disc spaces (cervical) not clearly seen
 
Adequacy of a Skiagram
One should be able to count 10 posterior and 6 anterior ribs in supine AP view.
Three main factors determine the technical quality of the radiograph:
  • Inspiration
  • Penetration
  • Rotation.
 
Inspiration
The chest radiograph should be obtained with the patient in full inspiration to help assess intrapulmonary abnormalities.
At full inspiration, the diaphragm should be observed at about the level of the 8th–10th rib posteriorly, or the 5th–6th rib anteriorly (Fig. 1).
Expiratory film is required to diagnose (Fig. 2):
  • Pneumothorax
  • Foreign bodies.4
zoom view
Fig. 1: Inspiration.
zoom view
Fig. 2: Expiration.
5
 
Penetration
In a properly exposed chest radiograph:
  • The lower thoracic vertebrae should be visible through the heart
  • The bronchovascular structures behind the heart (trachea, aortic arch, pulmonary arteries, etc.) should be seen.
 
Prerequisites for Proper Chest X-ray
zoom view
Fig. 3: Frontal film.
  • Frontal film: Both pedicles of spine and broncho-vascular markings should be visible through cardiac shadow (Fig. 3)
  • Lateral film: More caudal thoracic vertebral bodies should appear darker than the cranial ones (Fig. 4).6
zoom view
Fig. 4: Lateral film.
 
Underexposure
In an underexposed chest radiograph, the cardiac shadow is opaque, with little or no visibility of the thoracic vertebrae.
The lungs may appear much denser and whiter, much as they might appear with infiltrates present (Fig. 5).
zoom view
Fig. 5: Underexposure.
7
 
Overexposure
With greater exposure of the chest radiograph, the heart becomes more radiolucent and the lungs become proportionately darker. In an overexposed chest radiograph, the air-filled lung periphery becomes extremely radiolucent, and often gives the appearance of lacking lung tissue, as would be seen in a condition such as emphysema (Fig. 6).
zoom view
Fig. 6: Overexposure.
 
Rotation
Patient rotation can be assessed by observing the clavicular medial heads and determining whether they are equal distance from the spinous processes of the thoracic vertebral bodies (Fig. 7).8
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Fig. 7: Rotation.
 
NORMAL CHEST X-RAY
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Fig. 8: Normal chest X-ray.
Now you must learn how to read out a normal chest X-ray. It should be methodical and structured (Fig. 8).9
X-ray chest PA view shows normal soft tissues, visualized bones, and the diaphragm. Trachea is central in position. Cardiac silhouette appears normal. Superior mediastinal and hilar shadows appear normal. Costrophrenic angles are clear. Lung fields are clear. No other significant finding.
Impression: Normal appearance.