Reading a Neonatal Chest X-ray Fred Hill, MA, RRT

Steps of Chest X-ray Review Confirm correct patient and date/time View X-ray in correct orientation Review technical aspects of X-ray Inspect anatomic structures

Technical Aspects of X-ray Exposure or penetration Appropriate positioning Inspiratory vs expiratory film Exposure or penetration: Spaces between the vertebrae should be visible and distinct, but not excessively dark Positioning: Spine and clavicles should form a “T” Inspiratory film: ~9th rib Expiratory film: 6th to 7th ribs

Anatomic Structures Diaphragm Abdomen Cardiac silhouette Hilum Trachea ETT position Mainstem bronchi Lung fields & ribs Pleural surface Diaphragms should be domed and right higher by about one rib than left. Abdomen: air in stomach and bowel, lower margin of liver not more than 1.5 cm below rib cage. UAC tip at T7-T8 (high) or L3-L4 (low). UVC with tip above the liver. Cardiac silhouette: Includes thymus, highly variable in newborn, but usually cardiac shadow should occupy <60% of thoracic diameter. Hilum: note vascularity, escessive vascularity = CHF, ↓ vascularity = R →L anatomic shunt Trachea: for midline position vs shift R or L ETT: midway between clavicles and carina Mainstem bronchi: usual shape and orientation Lung fields: uniform appearance L & R, good aeration, no air bronchograms Pleural surface: presence of air or liquid or chest tube. Other: placement of electrodes, G tubes, etc.

Internet Tutorial Google Search: Radiologia Brasileira newborn chest X-ray

Pathologic Manifestations RDS Atelectasis TTN Pneumonia MAS Diaphragmatic hernia Congenital lobar emphysema Pneumothorax Pneumopericardium Pulmonary interstitial emphysema Bronchopulmonary dysplasia RDS: fine reticulogranular pattern (ground glass) with air bronchograms Atelectasis: increased localized opacity, often with shifting of mediastinal structures, trachea, and/or elevation of diaphragms Pneumonia: diffuse opacities or localized in segments or lobes or entire lung, silhouette sign, may mimic RDS Meconium aspiration syndrome: Many manifestations, may appear normal, often patchy, irregular, fluffy infiltrates Diaphragmatic hernia: loops of bowel and/or stomach in thorax, usually left-sided Congenital lobar emphysema: single emphysematous lobe, usually an upper lobe or RML. Pneumothorax: lung displaced from chest wall by a lucent band of air, usual line of demarcation with absence of lung markings toward chest wall Pneumomediastinum: air surrounding the heart, but does not include the apex of the heart Pneumopericardium: air in pericardial sac surrounding the heart including the apex. Pulmonary interstitial emphysema: diffuse cystic areas associated with interstitium BPD: varies

RDS

RDS

RUL Atelectasis

TTN

MAS

Diaphragmatic Hernia

Pulmonary Interstitial Emphysema

BPD

Conclusions To become proficient at reading chest X-rays, you must practice, practice, practice. The more you look at X-rays, the more you will be able to see. Lean on more experienced people to help you develop this skill.