Approach to Pediatric Chest

Radiography

Imaging investigation of most thoracic symptoms (whether suggestive of pulmonary, cardiovascular, gastrointestinal, or chest wall origin) almost always begins with chest radiographs. In patients who are clinically stable & capable of following directions, the preferred technique is upright frontal (PA) & lateral views of the chest with full inspiration. However, supine (AP) views will typically be employed in patients who are unstable or are otherwise not able to support themselves upright. It is important to note how the image was obtained as this can cause problems with interpretation. One pitfall is that the lungs will typically be hypoinflated in supine patients, which can accentuate lung opacity (thereby mimicking disease such as edema or pneumonia) & create the appearance of an enlarged heart. Additionally, gas collections (such as pneumothorax & free peritoneal air) will accumulate anteriorly in the supine patient (rather than superiorly on an upright view). This change in the position of gas can help determine the position of the patient on the study at hand (though this is often indicated on the image by an arrow or note by the technologist): Gas in the stomach will outline the gastric fundus on an upright view but will outline the anterior body or antrum on a supine cross-table lateral view.

Additional views are rarely needed but do arise in specific circumstances. Oblique views of the ribs are sometimes requested to look for bone pathology. Such views have shown to increase rib fracture detection in the infant with suspected nonaccidental trauma. However, their utility in the older child with accidental trauma or chest wall pain is questionable (as the routinely obtained 2 views will typically suffice for clinical significance).

If a bronchial foreign body is suspected, bilateral decubitus views or inspiratory/expiratory views may be requested to look for unilateral air-trapping that suggests airway obstruction with a 1-way valve mechanism. However, the sensitivity & specificity of these techniques are limited, & these studies may be bypassed for CT or bronchoscopy depending on the level of clinical suspicion.