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INTRODUCTION

Viewing the pediatric chest and lungs, whether by radiographic or bronchoscopic means, is often central in the clinical evaluation of children. Although the chest x-ray has a venerable place in history, radiologic technologies now available include computed tomography (CT), chest ultrasound, magnetic resonance imaging (MRI), and nuclear medicine. These technologies allow for better evaluation of the respiratory tract both anatomically and physiologically. The rigid bronchoscope has been available since the early part of the 20th century, but advances in fiberoptics now allow for safer bronchoscopic studies in pediatric patients. This section will deal with the various imaging techniques as well as with bronchoscopic evaluation of the airways.

RADIOLOGIC IMAGING

Children are often unwilling or unable to cooperate with the maneuvers required to produce high-quality imaging. Optimal studies are most often the product of experienced personnel who work with children in friendly surroundings with appropriate distraction, immobilization, analgesic, and sedation techniques.

Although plain film radiography remains the mainstay for chest imaging, cross-sectional techniques provide remarkably detailed images with versatile multiplanar and 3-dimensional reconstruction capabilities, sophisticated angiographic and Doppler techniques, and functional imaging even at the molecular level. It has become increasingly important to tailor the imaging studies to the specific clinical questions and concerns or limitations of individual patients. Imaging is no longer “one size fits all,” and close collaboration between radiology and clinical colleagues is not just desirable but essential in making the most appropriate choices and providing the best patient care.

CHEST RADIOGRAPHS AND CHEST FLUOROSCOPY

Plain radiographs with frontal and lateral views of the chest remain the mainstay of screening imaging of a child with a suspected chest abnormality. Digital imaging systems are now widely available. These radiographs usually include portions of the upper airway, larynx, trachea, and central bronchi as well as the mediastinal structures, heart, lungs, and bony and soft tissue chest wall. Evaluation of a chest radiograph should include an overview of the following:

  1. Patient history and specific reason for the current radiograph

  2. Quality of the study: patient name and positioning, inspiratory effort, motion, or presence of artifacts (eg, jewelry)

  3. Overall pulmonary aeration and symmetry, position, and patency of the airway

  4. Presence and location of any tubes, lines, catheters, and foreign bodies

  5. Mediastinum: contour and position; location of the aortic arch; presence of any mass, displacement, or compression of the mediastinum and/or airways

  6. Heart size and configuration

  7. Central and peripheral pulmonary vessels and symmetry

  8. Lung parenchyma: symmetry, vascularity, lucency, density, mass, volume loss, or air trapping

  9. Pleura, diaphragm, and bony and soft tissues of the chest wall

  10. Comparison with prior related imaging studies

When appropriate, 2 views of the chest increase diagnostic confidence, determining the location of a lesion more precisely and assessing its impact on adjacent structures such as the diaphragm or airway. Some lesions may look quite different on the frontal and ...

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