Date	Location	Examination
01/03/10 – 05/03/10	RHSC	Supine Chest 4 O 5 A 1 U

 

 

 

 

 

 

 

 

 

 

Journal

This piece of writing is information on Paediatric Chest Projections taken from the Wiki Radiography website. Demonstrating the difficulties encountered with paediatric radiography.

I found paediatric radiography one of the most difficult disciplines within radiography.

Reflection

There is no difference in the diagnostic value of an antero-posterior (AP) projection compared to the postero-anterior (PA) projection of the chest in a child less than 4 years of age as the thoracic cage is essentially cylindrical in young children and magnification of mediastinal organs is insignificant (Blickman, J.G. (1994) Pediatric Radiology: The Requisites. Mosby, London). However, an AP projection is associated with a higher radiation dose to the developing breast, sternum and thyroid, and radiographers should take this into consideration when choosing the radiographic projection. In children under 4 years of age, the AP projection is often preferred due to ease of positioning and immobilisation. Young children like to see what is going on around them and positioning for an AP projection allows the child to watch the radiographer. A disadvantage of the AP projection is the likelihood of lordosis.
Antero-Posterior AP (Supine)
The patient is positioned supine with the median sagittal plane at 90° to the image receptor. A 15° foam pad is placed under the upper chest and shoulders to prevent lordosis. The chin is raised and the arms are flexed and held on either side of the head to prevent rotation. Sandbags and lead rubber are placed over the hips and legs to provide immobilisation of the legs or alternatively, the legs may be held at the knees by another radiographer or guardian. The primary beam should be centred to the area of interest thereby ensuring that effective collimation can be applied and dose reduced.
Antero-Posterior AP (Erect)
This projection can be performed with the patient standing or seated erect. For younger children, correct positioning and immobilisation are easier to maintain with the child seated. The patient is positioned initially with the posterior aspect of the chest in contact with a cassette. A 15° foam pad is then placed behind the upper chest and shoulders to prevent lordosis. The chin is raised and the arms are flexed and held on either side of the head by another radiographer or guardian to prevent rotation. The primary beam is centred to the middle of the area of interest and collimated to within the area of the cassette. Devices often used for this view are the “Fuller Chair” or “Pig O Stat”.
Postero-Anterior PA (Erect)
This projection can be performed with the patient standing or seated. The patient is positioned with the anterior aspect of the chest in contact with a cassette and their arms around it. Both shoulders should touch the cassette to ensure that there is no rotation. The cassette is positioned to include both apices and the patient’s chin is rested on the cassette top. It is often easier for a young child to maintain this position rather than the more traditional position of the hands being placed on the back of the hips. However, if you are satisfied that the child will maintain the adult position then this should be used as it is more likely to help clear the scapulae away from the chest. The primary beam is centred to the middle of the area of interest and collimated to within the area of the cassette.
Lateral
Lateral chest radiography is often easier to perform on young children if they are seated. The child sits or stands with the side under investigation closest to an appropriately sized cassette. The cassette is positioned to include the whole of the chest. The patient’s chin is raised and the arms are flexed at the elbow and held on either side of the head by a suitably protected radiographer or guardian to prevent rotation. The primary beam is centred to the middle of the area of interest and collimated to within the area of the cassette.

Radiographic Assessment of Paediatric Chest

Area of interest to be included on the radiograph
The radiograph should include the whole of the chest including the first rib to the costophrenic angles inferiorly and the outer margins of the ribs laterally. When assessing the image the PACEMAN image evaluation technique should be used.
Rotation
The chest of a young child is more cylindrical than that of an adult and therefore a small amount of rotation will lead to the appearance of significant asymmetry. Due to difficulties visualising the medial ends of the clavicles in young children, rotation is better judged using the anterior ribs, which should be of equal length and symmetrically positioned with respect to the vertebral column. Minimising patient rotation is essential as many pathological conditions may be simulated as a result of rotation (enlarged cardiac outline).

Lordosis
Lordosis is a common technical fault when performing AP chest radiographs and may be corrected by placing a 15° pad behind the patient’s shoulders and by ensuring that the arms are not hyperextended. Radiographically, lordosis can be identified when the anterior ribs appear horizontal or are angled cranially to lie above the posterior ribs. The altered position of the clavicles is not an accurate indication of lordosis in children as clavicular position changes with shoulder movement.

Artefacts
Care should be taken to avoid artefacts on children’s clothing (e.g. decals on T-shirts, or metal press studs on jumpsuits).

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