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

2. 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

3. 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

4. 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.

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

6. 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

7. RDS

8. RDS

9. RUL Atelectasis

10. TTN

11. MAS

12. Diaphragmatic Hernia

13. Pulmonary Interstitial Emphysema

14. BPD

15. 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.