Interpretation of Pediatric Chest X rays

1. Approach to Interpret
Paediatric Chest X ray
DR ABHINAV GUPTA MD (RADIODIAGNOSIS)
Institute of Medical Sciences & SUM Hosp
Bhubaneswar, Odisha

2. PA Vs AP CXR ?

3. Perfect PA View Vs Rotated Film?

4. Inspiratory Vs Expiratory CXR Film?

5. Which is Wrong in these Films?

6. Any Difference between following X ray Films.
Which one is Technically Correct?

7. Any Difference between following Lateral X ray Films

8. Identify
Abnormality?
Orientation ?

9. Systematic Approach to Interpret
A Chest X ray Film
Termed: RIPE

10. Check Rotation
➢RIPE
➢Rotation
➢Inspiration
➢Picture
➢Exposure Identify the medial ends
of the clavicles – the
vertebral spinous
processes should be
equidistant between
them.

11. ▪ Size and shape of the
mediastinal structures will be
affected.
▪ If the patient is rotated with the
left shoulder towards the x-ray
beam: -
- Heart appear larger (more left
ventricle will be seen)
- A normal thymus may look like
an upper lobe infiltrate.
Effect of Rotation

12. Normal Thymus -Thymus
Sail Sign ( Neonates &
Infants)
Rotated infant- pseudo
atelectasis RUL Thymic
shadow

13. Check if Film is Inspiratory
➢RIPE
➢Rotation
➢Inspiration
➢Picture
➢Exposure
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
Posterior
ribs Anterior
ribs
Normal CXR, should see 7 anterior ribs and
9 posterior. Do not need to count both.

14. At Full Inspiration
Diaphragm at level of 8-10 ribs posteriorly or
5-6th ribs anteriorly

15. Picture-Ensure important body parts
included in image
➢RIPE
➢Rotation
➢Inspiration
➢Picture
➢Exposure
Adequate CXR Suboptimal CXR

16. Criteria for Good Lateral Film

17. RIPE : Check Exposure
(Vertebra & Broncho vascular structures* should be faintly visible through Heart)
Cardiac shadow- Radiolucent
vertebral bodies too much visible
Lungs - Dark
Under exposed
‘too bright’
Over exposed
‘too dark’
Cardiac shadow - Opaque
Vertebral bodies – not visible
Lungs -whiter

18. & Soft Tissues
H
Hidden Areas

21. Coarctation of the Aorta
Chest radiograph shows rib
notching (ribs 4-8 bilaterally).
The figure 3 sign
▪ Prestenotic dilatation of
the aortic arch and left
subclavian artery,
▪ Indentation at the
coarctation site (also
known as the "tuck"), and
▪ Post-stenotic dilatation of
the descending aorta.

22. Examine all the Areas where the Lung Borders
the Diaphragm, the Heart and other Mediastinal structures.
Lung Soft Tissue Interface Results in:
•Line or stripe – e.g Right Para Tracheal stripe.
•Silhouette – e.g. Normal Silhouette of the Aortic knob or Left ventricle
These lines and silhouettes can be displaced or obscured with loss of the normal
silhouette. This is called the silhouette sign,
Displacement of Paraspinal line - Paravertebral abscess, hemorrhage due to a # or
metastases
Widening of the paratracheal line (> 2-3mm) -Lymphadenopathy, pleural
thickening, hemorrhage or fluid overload and heart failure.
Displacement of the para-aortic line - Elongation of the aorta, aneurysm, dissection
and rupture.

23. Lung Soft
Tissue Interface

24. Abnormal soft tissue
mass at right apex.
Abnormal bony lesion
on left rib.

25. Cardiac
Silhouette
PA View
Right Heart Border
▪ SVC
▪ Right atrium
▪ IVC
Left Heart Border
▪ Aortic knob
▪ Pulmonary trunk
▪ Left Atrial
Appendage
▪ Left Ventricle

27. Cardiac
Silhouette
Lateral View

28. Cardiac – Size & Positioning
Cardiothoracic Ratio, Abnormal Silhoutee
• Ratio of Greatest
transverse dimension
of the heart/Greatest
transverse dimension
of chest cavity
measured to the inner
surface of the ribs on
the PA radiograph.
• Normal CT Ratio < 0.5
• Infants: <0.6

29. Left Atrial Enlargement
PA Film-
▪ Extra right heart
border,
▪ Enlarged left atrial
appendage,
▪ splaying of carina >
90 degree

30. Left Atrial Enlargement
PA film -Outpouching of the
upper heart contour on the
right ( black arrow)
Lateral film –Pressure on
esophagus ( blue arrow)

31. PA Film-
▪ Cardiomegaly
▪ Uplifting of apex
of heart
Right Ventricular
Enlargement

32. Right Ventricular
Enlargement ( lateral
Fim)

33. Left Ventricular Enlargement
•Left heart border is displaced
leftward, inferiorly, or
posteriorly
•Rounding of the cardiac apex

34. Pulmonary Plethora Versus Pulmonary
Edema
Pulmonary plethora in a patient with a VSD.
Note the increased number and size of
discrete vessels without haziness.
Pulmonary oedema in a supine patient with cor triatriatum- A
(membranous obstruction to LA outflow). Note cardiomegaly,
perihilar alveolar haziness/consolidation and peribronchial
cuffing

35. Right Atrial Enlargement
Difficult to diagnose in CXR
Non-Specific signs:
•Enlarged globular heart
•Narrow vascular pedicle
•Increased convexity of lower
right heart border
•Rt Atrial margin > 5.5 cm from
midline

36. Pericardial Effusion
▪ Cardiomegaly
• Globular heart with
narrow pedicle.
• Widening of the
carinal angle in
posterior extension of
effusion

37. Tetralogy of Fallot
• Boot Shaped Heart with an
upturned cardiac apex due
to right ventricular
hypertrophy and
▪ Concave pulmonary arterial
segment
▪ Pulmonary oligemia
▪ A right-sided aortic arch is
seen in 25%.

38. Total anomalous
pulmonary venous
connection
Cardiomegaly, increased
pulmonary arterial
markings., dilation of both
the left and right innominate
veins and right SVC
producing classical
"snowman" or "figure of 8"
appearance.

39. Transposition of Great
Vessels
Cardiomegaly, Narrow
Pedicle producing classical
“Egg on Side Appearance
Superior mediastinum
appears narrow due to AP
position of great vessels &
radiological absence of
thymus

40. Normal
Right hemi diaphragm is
normally higher than left,
approx. one rib space.
Clear costophrenic angles.
Right sided effusion.
Rt Hemidiaphragm
merged with effusion,
blunted costophrenic
angle.
ABCDEFG :Diaphragm

42. Umbilical arterial
line • High:
Between T6 and
T9 thoracic
vertebrae • Low:
Between L3 and
L4 vertebrae

43. Umbilical venous
line: 0.5 cm to 1
cm above the
diaphragm

49. Endotracheal
tube tip: T1 or
T2; at least 2
cm above
carina

52. Pathology in following areas can easily
be overlooked.
These areas are also known as the
hidden areas:
•Apical zones
•Hilar zones
•Retrocardial zone
•Zone below the dome of diaphragm
Hidden areas

53. Zones of Lungs
▪ Lungs may be assessed as
Upper, Middle and Lower
Zones instead of Lobes
• Lower Zones reach below
the diaphragm – the
lungs passes behind the
dome of the diaphgram
(*)

54. Large lesion in the right lower lobe in
hidden area behind right dome of
diaphragm

55. Well demarcated RUL area of
infilterate with air bronchogram
compatible with consolidation
Downward displacement of
horizontal fissure by this infilterate
(In atelectasis the fissure would be
pulled up)
Consolidation

56. RUL, LUL atelectasis
The horizontal fissure is
displaced upwards.
The trachea is pulled to
the right side
Atelectasis

57. Atelectasis
Atelectasis of left lung –
Heart is displaced into
the left hemithorax and
the diaphragm is
obscured.
There are air
bronchograms present
suggesting some
consolidation as well.

58. Pleural Effusion
Rt Sided Pleural
Effusion
Right CPA Obliterated
Fluid is layering out
along right side and
back

59. Pleural Effusion
Rt Sided Pleural
Effusion
Right CPA Obliterated
Meniscus Shape of
effusion- slightly higher
laterally and medially
than at center

60. Small
Pneumothorax
Left Side

61. Large Pneumothorax
Right Side Pneumothorax
Heart and ETT pushed to
left side
Diaphragm pushed
downward
Tension Pneumothorax

62. Hydropneumothorax
Air-fluid level in the right
hemithorax erect PA CXR
No lung markings above
fluid level ( Air)
Because of air above fluid
no meniscus but flat fluid
level

63. Acute Pulmonary Edema
• Cardiomegaly
• Upper lobe pulmonary
venous diversion (Stag
Antler’s sign)
• Pulmomary Interstitial
edema (peribronchial
fluffing, kerley B lines)
• Bat wing Alveolar
Edema

64. Silhouette sign

65. Consolidation in right
upper lobe
with bulging horizontal
fissure sign
Positive silhouette sign
- Right Tracheal line
not visible

66. Consolidation in right
middle lobe
Positive silhouette sign -
Right heart border not
visible

67. Right Middle Lobe Consolidation

68. Consolidation in Rt
lower lobe
Negative silhouette
sign - Right heart
border clearly visible

69. Consolidation in
Lingular lobe
Positive
silhouette sign-
Left heart border
not visible

70. PA View
Positive silhouette
sign of the left heart
border. Consolidation
in Anterior Segment
Confirmed in lateral
view
Silhouette sign

71. Consolidation in
Left Lower lobe
Negative
silhouette sign -
left heart border
visible
Confirmed in
posterior segment
LLL lateral view

73. Pulmonary vessels
The left main pulmonary
artery (in purple) passes over
the left main bronchus and is
higher than the right
pulmonary artery (in blue)
which passes in front of the
right main bronchus.

74. Left to Right Shunt
Posteroanterior (PA)
chest radiograph
demonstrates
▪ Increase in
pulmonary arterial
markings with a
normal sized heart.
• Small Aortic knuckle
• Prominent
Pulmonary Artery

75. Prominent Convex
Dilated Pulmonary
Artery
Decreased Pulmonary
arteries markings
Eisenmenger
Syndrome/PAH

76. Coarctation of the Aorta
Chest radiograph shows rib
notching (ribs 4-8 bilaterally).
The figure 3 sign
▪ Prestenotic dilatation of
the aortic arch and left
subclavian artery,
▪ Indentation at the
coarctation site (also
known as the "tuck"), and
▪ Post-stenotic dilatation of
the descending aorta.

77. Findings in this PA Film ?
• A
• B
• C
• D
• E
• F
• G

78. Neonatal Chest X ray
Rotated

79. Skin fold artifact.
Curvilinear density is
seen in the left
costophrenic angle area
(arrowheads), which
should not be interpreted
as presence of
pneumothorax.

80. Neonatal RDS.
Granular lungs
with air
bronchograms in
the central
regions.
The volume of
the lung is
relatively small.

81. TTNB
Overaerated lungs
Radiating streaky
densities from the
hilum to the peripheral
lungs bilaterally.
Right minor fissure is
accentuated ( minor
fluid)

82. MAS
B/L Coarse irregular
opacities
Lungs overinflated left
costophrenic sulcus
shows an
emphysematous area
Right minor fissure is
accentuated ( minor
fluid)

83. Air leak ( Pneumo)
Right Lung is
partially collapsed
(arrows), which is
delineated by
pneumothorax.

84. BPD in Neonate
with RDS after 2
months
Irregular scar-like
densities with
emphysema, cystic
areas, and
atelectasis .
ETT still needed

85. Congenital
Diaphgrammatic Hernia
Air-filled bowel loops
occupy the left hemithorax,
compressing the heart to
the opposite side. The
trachea is also displaced to
the right side and the small
partially aerated left lung is
seen in left upper
hemithorax

86. Bibliography
• Liszewski et al Neonatal Lung Disorders, AJR, 2018; 210:964–975
• Chan M. Approach to interpreting Pediatric Chest X rays. Peds cases.
• Ruth Abelt. Chest X ray Interpretation: The ABC’s. Texas Children Hospital
• Ray SK. Paediatric Radiology Review. Indian J Pedaitrics, 2018: 7.1: 61-64
• Jain SN, Modi T, Varma RU. Decoding the neonatal chest radiograph: An insight into neonatal respiratory
distress. Indian J Radiol Imaging 2020;30:482-92
• Hye-Kyung Yoonn. Interpretation of Neonatal Chest Radiography. J Korean Soc Radiol 2016;74(5):279-290
• Kumar P. Neonatal Chest X-Ray interpretation. Neonatal unit, Department of Pediatrics, PGIMER, Chandigarh
• Menashe et al. Pediatric Chest Radiographs: Common and Less Common Errors. AJR 2016; 207:903–91
• Liam du Preez. Pediatric Chest X-rays. University of Vermont UVM ScholarWorks. 2020
• Rebeca Slagle. The NICU’s 50 Shades of Gray: X-ray interpretation. Texas Children Hospital
• William F Hook. X ray Film Reading Made easy. University of North Dakota School Of Medicine and Health
Sciences.
Author is thankful to authors of above publications/ web resources from which
presentation has been made for purpose of educating medical students and
postgraduates