The paediatric lateral chest view may be performed as an adjunct to a frontal chest radiograph in cases where there is diagnostic uncertainty.
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Indications
The lateral chest view examines the lungs, bony thoracic cavity, mediastinum, and great vessels. Lateral radiographs can be particularly useful in assessing the retrosternal and retrocardiac airspaces.
There is a body of research that suggests the lateral projection it is not required for the detection of pneumonia in the paediatric patient 1,2. The appropriateness of a lateral chest x-ray in the paediatric patient will differ from institution to institution.
The lateral view of the paediatric patients shares many of the same points regarding positioning, however, the aspect of immobilisation and exposure factors differ greatly.
For patients under the age of 6 months see: Paediatric chest (horizontal beam lateral view).
Patient position
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the patient will often be placed on a chair or standing, depending on co-operation and age
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chair
arms above head, either held by a carer or held by velcro straps
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standing
patient is holding a vertical pole/handle to ensure stability. It is not advisable to ask the patient to keep his/her arms above their head, they will find this difficult to do while keeping still
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left side of the thorax adjacent to the image receptor
chin raised out of the image field
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midsagittal plane must be perpendicular to the divergent beam, therefore:
right side rotated 5-10° anterior
Technical factors
lateral projection
suspended inspiration
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centring point
the midcoronal plane of the level of the 7th thoracic vertebra, approximately the inferior angle of the scapulae
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collimation
superiorly 5 cm above the shoulder joint to allow proper visualisation of the upper airways
inferior to the inferior border of the 12th rib
anteroposterior to the level of the acromioclavicular joints
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orientation
portrait
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detector size
fit to childs chest
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exposure
80-90 kVp
1-3 mAs
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SID
180 cm
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grid
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 visualised above the diaphragm
the ribs and thoracic cage are seen only faintly over the heart
clear vascular markings of the lungs should be visible
Lead shielding
Contact lead shielding is no longer recommended for any paediatric examination, multiple radiological societies have released statements supporting the cessation of this practice 4-7 the most comprehensive guidance statement on this matter (86 pages) is a joint report found at this citation 8.
Please see your local department protocols for further clarification as they may differ from these recommendations.
Practical Points
In order to streamline workflow, preparing the room beforehand (set up the detector and prepare lead gowns) will be extremely useful in paediatric chest imaging.
Ensuring appropriate inspiration and no motion may also require specialised communication techniques to gain co-operation 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!”
“freeze!”
Immobilisation
Some children will maintain their position for the examination, others will not. Research regarding the most effective method of immobilisation is lacking. Immobilisation methods will range from radiographers/parents holding the child to the utilisation of multiple Velcro straps, some departments may consider the latter 'restraint' it is important to clarify with local guidelines 3.
Family members may assist in distracting or holding the child. It is important to give the parents a focussed task; particularly when they are feeling anxious for their children.
Specialised equipment
Specialised paediatric departments will have 'chairs' appropriate to hold children during the examination 3, these chairs often contain multiple Velcro strap points, are counter weighted 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.