1. Gold Standard/ Optimal Unacceptable / Suboptimal
PRE GESTATIONAL & PAEDIATRIC MOBILE CHEST IMAGING
Kirsty Livesley & Jenna Knowles (2016)
ABSTRACT Throughout the UK, most of the neonatal chest x- rays are performed in non-specialist hospitals. Within our district general hospital we have performed on average around 227 portable neonatal chest x-rays each year on the Neonatal Unit (NNU). The quality of these x-rays has been an international issue for over 20 years. Most are performed AP Supine with a small percentage
being performed decubitus or prone. There is very little guidance aimed at radiographers who undertake these examinations.
An audit was undertaken within our Trust that investigated pre-gestational chest imaging. This looked at the previous 12 months chest images performed and the quality of these x-rays. Image quality was assessed through positioning,
artefacts, use of lead protection, collimation, radiation dose and exposure. As a result, this poster aims to assist the radiographers when undertaking these examinations and ways to improve their technique which in turn will improve image quality.
PRE-TERM NEONATAL CHEST IMAGING (AUDIT) BACKGROUND – The potential harmful effects of chest imaging in neonates is becoming more of a risk than a diagnostic value. There is up to a 25% increase in the dose received to a neonates organs in comparison to an adult. (1) This can be harmful as a neonates cells are rapidly changing and mutating after birth so during mitosis the cells are extremely radiosensitive therefore leading to erythema and germ cell mutation. (2) It appears that some trusts are using a multi-modality approach when it comes to chest imaging in neonates and primary imaging being used in conjunction with US. (3) RDS, Pneumonia and plural effusion in the first weeks/months of life are diagnosed by mobile chest imaging. However US would be more specific and sensitive in some cases when making a diagnosis in particular the diagnosis of fluid within the lungs. Due to the number of x-rays and imaging that a neonate will go through during their first few months of
life it is important that technique is gold standard to reduce dose and scatter during the exposure.
AIM – To improve the quality of neonatal chest x-rays performed by radiographers in our hospital.
METHOD – An audit was undertaken looking at 50 chest images performed on the NNU at Warrington & Halton Hospitals and analysing whether they are gold standard, acceptable or unacceptable/ suboptimal. Areas evaluated included: exposure, positional rotation, collimation and use of lead protection. Also included were the number of neonatal chest images are repeated and how many times more than one x-ray is performed on a neonate. Common types of artefacts to the image were also noted.
RESULTS – There results showed that no repeats was performed on any of the 50 chest x-rays as well as highlighting that 62% of the babies have more than one x-ray during their stay in NNU. Common artefacts included
bedding, lines, holders fingers, ECG leads, breathing equipment and clothing. The table below shows the results from the audit showing areas where improvement can be made within our Trust, such as collimation and protection of the thyroid .
RESULTS TABLE
Gold Standard/ Optimal
Acceptable
Unacceptable / Suboptimal
Collimation
34%
30%
36%
Protection to the:
Eyes
78%
14% 8%
Thyroid
40%
16%
44%
Gonads
54% 4%
Exposure
84% -
Positioning
76%
24%
NEONATAL CXR AND THE RADIOGRAPHER THINGS TO CONSIDER – Technique; line and tube artefact; Airways; Appearance of the thymus; Radiation Protection; Congenital abnormalities; Artefacts on the incubator; Exposure factors depending on the patient’s weight as per departmental protocol. ISRRT (International society of radiographers & radiological technologists) RESEARCH (4) – This research aimed to improve practice for radiographers undertaking neonatal chest x-rays. Their method included taking 100 random neonatal CXR from 2 hospitals and evaluating the images for image acquisition, dose, technical quality criteria and the learning needs of radiographers. We took this research and applied it to the key areas highlighted by the audit to suggest improvements to develop high quality x-rays within our hospital.
1. ARTEFACTS: 
As per the audit performed at WHH, we found multiple areas that caused the most artefacts on neonatal chest x-rays. To reduce repeats these need to be removed or out of the primary beam where possible before exposure. ECG Leads, lines and breathing equipment cannot always be removed but the excess wires/tubes can be moved away from the chest.
2. LINES & TUBES: Awareness of lines and tubes is key in neonatal imaging. Being aware their position and appearance on x-ray helps to improve the quality of x-rays and highlights that positioning plays a big part in ensuring lines are correctly placed. The following lines are particularly important – Endotracheal Tube; Nasogastric Tube; Long Lines; Umbilical Venous Catheter line; Umbilical Artery Line; Peripherally Inserted Central Catheter Line.
3. HOW TO ASSESS FOR ROTATION:
4th Rib - Suggests shoulder rotation
8th Rib - Suggests pelvis rotation
4. COLLIMATION: The EC Guidelines state (5) – ▪ Laterally: 1cm beyond the widest rib. ▪ Superiorly: Level of C ▪ Inferiorly: Lower border of L1.   In the audit, it was highlighted that only 34% of the x-rays followed the suggested EC guidelines leaving a wide margin to improve quality of x-rays.
5. POSITION OF THE PATIENT: ▪ Head straight to reduce rotation. This reduced rotation by 30%. (4)
▪ Arms either adducted laterally or held caudal by patient’s side. This reduced rotation from %. (4)
6. IMAGE APPEARANCE: ▪ Image appearance depends on the centering point of the exposed area. (4) ▪ Individual hospitals post-processing algorithms will interpret images differently. ▪ Ensure the x-ray is post-processed under a paediatric chest algorithm as per local protocols.
SUGGESTIONS TO IMPROVE TECHNIQUE – Remove artefacts where possible; Straight tube; Head positioned straight(4); Centre to midline at the level of intermamillary line(4); Arms symmetrical(4); Collimate well (to EC Guidelines(5)); Ensure post-processed as paediatric chest algorithm.
REFERENCES – 1. Akshaya V, Neeta A. Vachharajani, Tasnim Najaf. NeoReviews. Neonatal Radiation Exposure Apr 2013, 14 (4), Taghi, M et al. (2012). Radiation dose to newborns in neonatal intensive care units. Radiology. 9 (3), Acta P. (2016) Lung ultrasound decreased radiation exposure in preterm infants in a neonatal intensive care unit. 105(5), Bev Snaith & Maryann Hardy; ISRRT Research; Improving nenonatal chest radiography; an evaluation of image acquisition techniques, dose and technical quality, European Commisson; European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatric, EUR report (Luxembourg, EC), 1996.