Part 2.0 Standardised Interpretation of Paediatric CXR Done in collaboration with: Authors: The Northern School of Radiology, UK Dr. Alasdair Mackie MD Dr. Nadia Mcallister MD County Durham and Darlington NHS Foundation Trust Dr. Abdelrahman Omer MD Dr. Ramdas Senasi MD Special Thanks: Professor Bernard Laya

Aim Demonstrate a systematic approach to paediatric Chest X-rays using an ABCDE method.

Systematic approach Technique A - Airways and lungs B - Bones and soft tissues C - Cardiac D - Diaphragm E - Extra body equipment + - ABC Double check: Important review areas to minimise missing abnormalities.

RIPE Technique Rotation Inspiration Picture Exposure Centred film. Equal distance between medial ends of clavicles

RIPE Technique Rotation Inspiration Picture Exposure Rotated film. Note the gap between medial end of right clavicle.

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

RIPE Technique Rotation Inspiration Picture Exposure Overinflated Underinflated

RIPE Technique Rotation Inspiration Picture Exposure Ensure important body parts included in image RIPE Rotation Inspiration Picture Exposure Adequate CXR Suboptimal CXR

RIPE Technique Rotation Inspiration Picture Exposure Vertebral bodies should be faintly visible throughout. RIPE Rotation Inspiration Picture Exposure Underexposed ‘too bright’ Overexposed ‘too dark’

Normal Structures seen on a CXR

Systematic approach Technique Airways and lungs: B C D + - ABC Double check. Start at top and compare right with left. Trachea should always be central. Can deviate to right on expiration in younger patients.

Lobar anatomy – right lung – 3 lobes upper, middle and lower lobes Note the overlap of the lobes on the frontal view. Minor (Horizontal) fissure separates the upper an middle lobes

Lobar anatomy – left lung, 2 lobes upper and lower lobes Note the overlap of the lobes on the frontal view

Systematic approach Technique A Bone and soft tissues: C D E + - ABC Double check. Bony or soft tissue lesions can be easily missed if not looked for.

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

Systematic approach Technique A B Cardiac and mediastinum: D E + - ABC Double check. Important to review size, borders and for mediastinal masses.

Mediastinum; thymus regularly seen in children. Normal Normal thymus Normal thymus Size; generally no more than 50% (exception is neonates, can be bigger) Mediastinum; thymus regularly seen in children. Not to be confused with mediastinal lymphadenopathy. Abnormal mediastinal adenopathy seen in lymphoma Enlarged

Systematic approach Technique A B C Diaphragms: E + - ABC Double check. Should be clear and crisp, if blurred/obscured this should raise suspicion.

Right hemi diaphragm is normally higher than the left, approximately one rib space. Clear costophrenic angles. Normal Right sided effusion. Can not see entire hemi diaphragm and have lost costophrenic angle.

Systematic approach Technique A B C D Extras: + - ABC Double check. Check for lines and tubing

Umbilical artery catheter Endotracheal tube Temperature probe Nasogastric tube Endotracheal tube Central line Umbilical artery catheter Umbilical vein catheter Nasogastric tube

Systematic approach Technique A B C D E + - ABC Double check Apex, Behind heart, costophrenic and cardio phrenic angles.

These lesions can be easily missed. Review areas are important.

Summary Demonstrated a systematic approach to paediatric CXR using ABCDE. Reinforced importance of review areas to ensure subtle things not missed.

Thank you for your attention. Any questions?

References Images obtained from following resources; Eurorad.org Radiopaedia.org Wikiradiography.net Lifeinthefastlane.com Slideshare.net