Pediatric chest (horizontal beam lateral view)
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The horizontal beam (cross-table) pediatric lateral chest view is a modified lateral projection often utilized in populations under the age of 6 months old due to the inability of that patient to independently hold up their head.
A lateral radiograph helps confirm the presence of an anterior pneumothorax that is suspected but not definite based on a frontal radiograph 4. A lateral decubitus view would be an alterative for this indication.
There is a body of research that suggest the lateral projection is not required for the detection of pneumonia in the paediatic patient 1,2. The appropriateness of a lateral chest x-ray in the paediatic patient will differ from institution to institution.
- the patient is supine, placed on a radiolucent sponge to ensure the entirety of the chest is imaged
- arms are held above the patients by either a carer, nurse or external velcro straps. Legs are kept still by either a carer, nurse or external velcro strap
- left side of the thorax adjacent to the image receptor
- chin raised out of the image field
- midsagittal plane must be perpendicular to the divergent beam
- patient is placed close to the image receptor to ensure little to no magnification and ultimately a safe examination
- lateral projection
- suspended inspiration (on observation)
- the midcoronal plane of the level of the 7th thoracic vertebra, approximately the inferior angle of the scapulae
- superiorly 5 cm above the shoulder joint to allow proper visualization of the upper airways
- inferior to the inferior border of the 12th rib
- anteroposterior to the level of the acromioclavicular joints
- fit to childs chest
- 70 kVp
- 1.6 mAs
- 180 cm
- grid is often not used
Image technical evaluation
The entire lung fields should be visible superior from the apices inferior to the posterior costophrenic angle
- the chin should not be superimposing any structures
- there is superimposition of the anterior ribs
- the sternum is seen in profile
- superimposition of the posterior costophrenic recess
- a minimum of ten posterior ribs are visualized above the diaphragm
- the ribs and thoracic cage are seen only faintly over the heart
- clear vascular markings of the lungs should be visible
Contact lead shielding is no longer recommended for any pediatric examination, multiple radiological societies have released statements supporting the cessation of this practice 5-8 the most comprehensive guidance statement on this matter (86 pages) is a joint report found at this citation 9.
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.
Children under the age of 6 months will seldom maintain a position, and to leave them on an examination table unattended is irresponsible. Departments will either have specialized equipment or utilize the carer/parent, radiographer, or nurse to maintain the child's position.
Specialized pediatric departments will often have immobilization devices that possess multiple velcro attachment points to ensure the patient is not moving during the examination. The appropriateness in using these devices will vary greatly from region to region.
Personnel immobilizing the patient
When specialized equipment is not available, yet a lateral cross table projection is required, the radiographer may nominate themselves, a carer/parent or the nurse to maintain a correct patient position. The patient should be placed on a radiolucent sponge to ensure no artifact from the table/bed is present, arms will be placed above head (placing them behind the head restricts movement and is most effective) and the legs kept still to avoid movement.
- 1. Lynch T, Gouin S, Larson C, Patenaude Y. Does the lateral chest radiograph help pediatric emergency physicians diagnose pneumonia? A randomized clinical trial. (2004) Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 11 (6): 625-9. Pubmed
- 2. Audette LD. BET 1: Lateral chest radiography and the diagnosis of pneumonia in children. (2017) Emergency medicine journal : EMJ. 34 (1): 57-58. doi:10.1136/emermed-2016-206487.1 - Pubmed
- 3. Knight SP. A paediatric X-ray exposure chart. (2014) Journal of medical radiation sciences. 61 (3): 191-201. doi:10.1002/jmrs.56 - Pubmed
- 4. Dillman JR, Sanchez R, Ladino-Torres MF, Yarram SG, Strouse PJ, Lucaya J. Expanding upon the unilateral hyperlucent hemithorax in children. (2011) Radiographics : a review publication of the Radiological Society of North America, Inc. 31 (3): 723-41. doi:10.1148/rg.313105132 - Pubmed
- 5. Statement No. 13 – NCRP Recommendations For Ending Routine Gonadal Shielding During Abdominal And Pelvic Radiography (2021)". Ncrponline.org, 2021. [Link].
- 6. ASMIRT Position Statement Gonad Shielding". Asmirt.org, 2021. [Link].
- 7. ASRT Statement on Fetal and Gonadal Shielding. Asrt.org, 2021. [Link].
- 8. 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.
- 9. Guidance on using shielding on patients for diagnostic radiology applications Joint report. Bir.org.uk, 2021. [Link].