Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Postgraduate Column
Year : 2019 | Volume : 6 | Issue : 3 | Page : 70 - 75

OSCE: Learning chest X-ray.

Kundan Mittal1, Anupama Mittal2, H K Aggarwal3, Utkarsh Sharma4, Jayant Wagha5, R K Yadav6

1Senior Professor and Incharge PICU, Respiratory Medicine, 3Senior Professor Medicine and Nephrology, 6Senior Professor Radiology, Pt B D Sharma, PGIMS, Rohtak, 2Deputy Civil Surgeon, Rohtak, Hrayana India. 4Professor in Pediatrics, Dehradun, Uttarakhand, India, 5Professor in Pediatrics, JNMC, Wardha, Maharashtra, India.

Correspondence Address:

Dr. Kundan Mittal, Senior Professor Pediatrics
Pt B D Sharma, PGIMS, Rohtak, Haryana, India,
Phone : +919416514111, Email :
Received: 11-May-19/ Accepted: 25-May-19/Published Online:05-Jun-19

Source of Funding:None Conflict of Interest:None


X-ray is a form of ionizing radiation having more energy than UV waves passed through patient and onto a detector mechanism, which produces image. Chest radiography is most commonly done procedure in critically sick children. Thus, a basic knowledge of chest radiograph interpretation is essential for intensivist. If we follow the systematic approach for interpretation, we will not miss the diagnosis.

Variable size of mediastinum in same child may pose diffi culty in assessment. Thymus grows until puberty but radiologically visible up to three years of age. Three classical signs have been described while reading thymus structure. These are wave sign, sail sign and cardio-thymic incisure. During stress state in children thymus size may reduce in size and can grow ≥50% once stress is removed.
In children fi lm taken in supine position and AP view in expiratory phase show heart enlargement. One third of heart is present on right side from midline and twothird on left. Trachea proximal to subglottic area show bilateral convexities “described as shouldering of air column” and distally the diameters remains constant. During tracheal infl ammation this shouldering is lost. Due to less space in upper mediastinum, vessels may indent the trachea. Because of large size and fl exibility of trachea in small children below 5years angulation may be seen. Trachea may be physiologically deviated to right side. Tracheal narrowing beside above-mentioned reason is always abnormal. Left hilum is higher than right hilum. Arteries and veins branch vertically in upper and lower lobe and also upper lobe vessels have smaller diameter. Right dome of diaphragm is higher than left (1cm approximately). Age specifi c changes are appreciated by reading developmental anatomy.

Q. What are various imaging modalities of thorax in children?
Various modalities are;
• Conventional chest ray:
Conventionally PA and lateral view are preferred. The distance from source is usually kept by 6 feet and kilovoltage (140kVp) radiation.

• Portable chest x-ray:
During portable x-ray longer duration of exposure is required. Distance usually kept is 40 inches. This will change magnifi cation of structure (Heart by 15-20% and decreas

• Digital radiography:
Increased dose effi ciency and quality image but poor spatial resolution. Dual-energy subtraction and digital tomosynthesis are more advanced techniques.
• Ultrasound:Preferred for assessment of fl uid, air
• Computed Tomography and High-Resolution Computed Tomography
• Magnetic Resonance Imaging
• Positron Emission Tomography
• Ventilation/Perfusion Lung Scanning
• Diagnostic Pulmonary Angiography
• Thoracic Needle Biopsy
• Percutaneous Catheter Drainage

Q. What are the positions or view for x-ray chest?
Various position or views are:
Principle is to keep site in examination close to the film.
• Postero-anterior View (PA) or frontal view: Most commonly used with low radiation exposure
• Antero-posterior View (AP): If scapulae overlap the lung, picture is AP and also if clavicle projected over lung fi eld. Level of diaphragm is higher in AP view compare to PA view.

• Lateral View: Rarely used with higher dose of radiation, helpful in analysing posterior costophrenic and lower lobe area
• Obliques View
• Apical Lordotic View: X-ray beam is angled superiorly 15-20 degree
• Penetrated postero-anterior
• Inspiration / expiration postero-anterior: Expiratory fi lm to assess air trapping

Q. What is best position or view for x-ray chest?
Best view is PA taken in standing position keeping hands on posterior aspect of hip, elbow rolled forward, shoulder touching the x-ray fi lm to keep scapula away from lung fi elds. Also, fi lm size should be adequate to cover lateral lung fi eld, dome of diaphragm during inspiration, and 5-8cm above patient shoulder. The size of heart and pulmonary vessels is related to distance from fi lm. Pulmonary vessels are not equally perfused in standing position. Supine position causes accentuation of apical and upper zone vessels. Apical zones seem smaller from clavicle in supine position. Depth of respiration and phase of respiration also contributes to size of heart and pulmonary vessels perfusion. In children below 5years AP is common. Thus, PA view is superior over AP view. During AP view smaller fi lm-focus distance also contributes to magnifi cation. Also, during supine position higher position of diaphragm contributes to cardiac enlargement. But in intensive care settings AP view taken commonly. Lateral radiograph if needed is taken from right to left beam projection. The rays should be projected at the level of fourth thoracic vertebra in midline in PA view and sternal notch in AP view at right angle during inspiration at a distance of 180-200cm approximately.

Q. What are various pattern of chest diseases?
• Congenital
• Infl ammatory: Bacterial, viral, fungal, parasitic
• Traumatic
• Neoplastic
• Vascular
• Idiopathic
• Iatrogenic

Q. Describe radiographic appearance of thoracic structures.
The differential absorption of radiation by different tissues or diseases is responsible for all radiographic shades of grey. Tissue which has good penetration will produce black picture while with poor penetration will have white picture. Attenuation depends tissue density, thickness, composition, phase of respiration, and distance from fi lm. Tissue of different density must strike tangentially by roentgen beam to produce well defi ned boundary line. Air, fat, soft tissue (muscle, fl uid), and metal (bone) absorb progressively more radiation. The thicker the tissue, the more it absorbs.

Q. What are principle division of lungs?
Various practical division of lung on PA view are;
• Apical zone: Area above the clavicle
• Upper zone: Inferior border of clavicle to superior border of pulmonary hilum or apex to upper boarder of second costal cartilage anteriorly
• Middle zone: Superior border to inferior border of hilum or between second and fourth costal cartilage anteriorly
• Lower zone: Inferior border to diaphragm or below fourth cartilage anteriorly
• Central lung
• Peripheral lung

Anatomical division based on fi ssure
Right lung is divided by oblique or major (run from anteriorly from diaphragm to posteriorly fourth thoracic vertebra dividing upper and lower lobe) and horizontal or minor fi ssure (run from right hilum to sixth rib in axillary line dividing lung into upper and middle zone)
Left lung is two lobes by oblique fi ssure

Q. Discuss steps of interpretation of Chest radiograph
• Pattern approach should be:
- Systematic
- Begin with the less important areas
- Focus on the region of interest.
- Completed a systematic review
• Review periphery of chest. Start at neck and include shoulders, ribs, clavicles, and diaphragms
• Evaluate heart size and mediastinal contours, edges, and shape
• Follow trachea to carina and main bronchi
• Evaluate peripheries of lungs for air and fl uid
• Study lungs up and down and side to side. Include lung volumes and symmetry of markings
• Check for gastric bubble, free air, and abnormal air collections
• Check for devices

Points to be appreciated during reading chest x-ray are;
• Identifi cation number, name, age or date of birth, and date of exposure
• Type of view or projection: PA/AP/Lateral. If the scapulae lie over lung fi eld, fi lm is AP view.
• Orientation: Left or right marking
• Rotation: Spinous process between the clavicle and at equidistance and clavicles lie on fi rst rib. During rotation medial end of clavicle moves closure to spinous process of that side. This is most commonly used in adults and less reliable in children. Abnormal rotation may show hyperlucent lung. Also, distance between anterior costal arches and spine is equal in non-rotated fi lm and more reliable in children.

• Adequate penetration:
Superior thoracic vertebral bodies behind heart are visible. Clearly visible vertebral behind indicate over exposure. Both the lungs fi eld should have equal translucency. Horizontal fi ssure should run from hilum to 6th rib in axillary line.

• Position of the patient:
Ideal is standing and in full inspiration.

• Depth of inspiration:
9th posterior rib visible above dome of diaphragm, well defi ned costophrenic angles, heart and diaphragm. Also, the anterior end 6th rib is seen above the diaphragm. In inadequately ventilated fi lm vessels at lung base look like consolidation or collapse.

• Type and quality of radiograph:
Misalignment results in unilateral hyperlucency. Poorly inspired fi lm child results in increase lung density, poor defi nition of vessels, and widening of mediastinum.

• ABCDFEFG’sSequence:
Airway (trachea, bronchi, alveoli)& Aorta, Breathing & Bone cage, Circulation (blood vessels)& Cardiac (cardiothoracic ratio, borders, chambers, position), Diaphragm (level, shape, tenting, costo-phrenic and cardio-phrenic angles)) & Deformity (shape of thorax, ribs, borders, intercostal space, pleura level), Soft tissues (emphysema, tumour), Extrathoracic structures, Fissures, Gastric air bubble, Hilum (ABCDEFGH).

• Pleura: Both costophrenic angles are visible
• Mediastinum: Trachea in midline, left hilum is slightly up to right hilum and concave in shape

• Look for four silhouettes: Loss of right heart
border indicates of air in middle lobe and loss of left heart border points towards loss of air in lingula. Similarly, loss of both the hemidiaphragm indicates loss of air in lower lobe or something between diaphragm and lower lobe.
• Lung parenchyma: Apices are visible 2.5- 5cm above the clavicle in adults.
• Foreign materials: ET tube, Feeding tube, central line, pace maker, artifi cial valve, PIG tail catheter, ICD tube etc.
• Diagnosis includes identifying and localizing abnormalities, defi ning appearance, categorizing grades or pattern, and differential diagnosis.
Different tissue absorbs difference in amount of x-ray beam leading to different attenuation of tissues.

Q. What are review areas in x-ray chest?
Various areas are; Behind heart, Cardiophrenic angles, Costophrenicangles, Apices, Peripheries, Bones, Soft tissues, Below diaphragm.

Q. What are pseudo-abnormalities in normal fi lm?
Magnifi cation of cardiac size on AP fi lm. Azygous vein, accessory fi ssure, unexpanded chest resulting crowding of lung tissue, during expiration some area of lung may appear collapsed and pulmonary vessels seem to congested.

Q. What are the hazards of x-ray radiation?
It depends on radiation dose, dose rate, volume of tissue irradiated and type of radiation (alpha particles, x-rays, neutrons, etc).

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