Pediatric chest (AP erect view)
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The anteroposterior erect chest view is ideal in younger cooperative pediatric patients (approximately 3-7 years old; this age range is only a guide). This chest view examines the lungs, bony thoracic cavity, mediastinum and great vessels.
The AP erect view is often chosen over the PA erect view for younger children as this view allows for observing the child’s breathing and decreased patient stress (due to the child being able to observe what is happening in the room). However, the AP view will result in an increased radiation dose to radiosensitive organs and magnify the heart and mediastinum 1. The choice to perform a PA erect or AP erect chest view will depend on the radiographer’s judgment of the patient’s cooperative and understanding ability.
- patient is sitting or standing erect
- if patient is seated, ensure that the lower limbs are not on the same level as the buttocks (i.e. full extension) as this creates lordosis. Ideally, have the child sit on a box or sponge so the legs are below the buttocks 1
- head is straight and chin raised out of the field of view
- have the patient's arms raised above their head
- anteroposterior projection
- observe breathing by watching the patient’s stomach
- the level of the 7th thoracic vertebra; on or above the level of the nipple
- superior to the 3rd cervical vertebrae
- inferior to the thoracolumbar junction
- lateral to the skin margins
- it is advised not to collimate too tightly at the apices as breathing may cause the apices to move superiorly
- 24 cm x 30 cm or 35 cm x 43 cm depending on the patient’s size
- 60-80 kVp
- 1-2 mAs
- 110 cm
Image technical evaluation
- entire lung fields should be visible; post-processing collimation is not advisable in pediatric imaging (if it is exposed it should be examined). This is particularly important if the clinical indications query a foreign body as demonstrating the abdomen will also be useful in diagnosis
- full inspiratory effort 4
- ensure 8 visible posterior ribs in children aged 0-3 years old
- ensure 9 posterior ribs in children aged 3-7 years old
- ensure 10 posterior ribs in children aged 7 years old and above
- lung fields are symmetrical in size,
- the clavicles lie on the same horizontal plane and anterior ribs are of equal length 1
- due to ossification centers in children, the medial ends of clavicles are difficult to visualize; therefore measuring the medial ends of the clavicle to the spinous process is not advised
- the head of clavicles to lie at the level between T2 and T4 4
Contact lead shielding is no longer recommended for any pediatric examination, multiple radiological societies have released statements supporting the cessation of this practice 6-9 the most comprehensive guidance statement on this matter (86 pages) is a joint report found at this citation 10.
Please see your local department protocols for further clarification as they may differ from these recommendations.
In order to streamline workflow, preparing the room beforehand (set up the detector and prepare lead gowns) will be extremely useful in pediatric chest imaging.
Ensuring appropriate inspiration and no motion may also require specialized communication techniques to gain cooperation from the child. Examples include:
- “you have to breathe in like you are about to blow out a birthday candle!”
- “take a big sniff now”
- “lets play dead fish!”
The AP erect chest view is often associated with using the parent or a staff member to hold the child’s arms above their head. However, research regarding the most effective method of immobilization is lacking. It is suggested to try explanations and distraction before automatically assuming the patient requires physical holding 5.
Specialized pediatric departments will have 'chairs' appropriate to hold children during examination 5, these chairs often contain multiple Velcro strap points, are counterweighted for stability and have a radiolucent backing such as perspex. It is important when using this equipment that the children is safely fastened with no risk of falling. In extreme cases, the parent may stand in front of the patient ensuring they feel safe.
- 1. Maryann Hardy, Stephen Boynes. Paediatric Radiography. (2003) ISBN: 9780632056316
- 2. European guidelines on quality criteria for diagnostic radiographic images. Luxembourg: Directorate-General for Research and Innovation (European Commission), 2000.
- 3. A paediatric X‐ray exposure chart. (2014) Journal of Medical Radiation Sciences. 61 (3): 191. doi:10.1002/jmrs.56 - Pubmed
- 4. Sebastian Tschauner, Robert Marterer, Michael Gübitz, Peter I. Kalmar, Emina Talakic, Sabine Weissensteiner, Erich Sorantin. European Guidelines for AP/PA chest X-rays: routinely satisfiable in a paediatric radiology division?. (2016) European Radiology. 26 (2): 495. doi:10.1007/s00330-015-3836-7 - Pubmed
- 5. Ng JHS, Doyle E. Keeping Children Still in Medical Imaging Examinations- Immobilisation or Restraint: A Literature Review. (2019) Journal of medical imaging and radiation sciences. 50 (1): 179-187. doi:10.1016/j.jmir.2018.09.008 - Pubmed
- 6. Statement No. 13 – NCRP Recommendations For Ending Routine Gonadal Shielding During Abdominal And Pelvic Radiography (2021)". Ncrponline.org, 2021. [Link].
- 7. ASMIRT Position Statement Gonad Shielding". Asmirt.org, 2021. [Link].
- 8. ASRT Statement on Fetal and Gonadal Shielding. Asrt.org, 2021. [Link].
- 9. Yogesh Thakur, Stephanie C. Schofield, Thorarin A. Bjarnason, Michael N. Patlas. Discontinuing Gonadal and Fetal Shielding in X-Ray:. (2021) Canadian Association of Radiologists Journal. doi:10.1177/0846537121993092 doi:10.1177/0846537121993092.
- 10. Guidance on using shielding on patients for diagnostic radiology applications Joint report. Bir.org.uk, 2021. [Link].