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Viewing the pediatric chest and lungs, whether by radiographic or bronchoscopic means, is often central in the evaluation of these patients. Although the chest x-ray has a venerable place in history, radiologic technologies now available include computerized tomography (CT), chest ultrasound, magnetic resonance imaging (MRI), and nuclear medicine. These novel methods allow better evaluation of the respiratory tract both anatomically and physiologically. The rigid bronchoscope has been available since the early part of the twentieth century, but advances in fiberoptics now allow for safer bronchoscopic studies in pediatric patients. These newer technologies improve the evaluation of the infant or child with pulmonary complaints. This section will deal with the various radiographic and nuclear medicine imaging techniques as well as with rigid and flexible bronchoscopic evaluation of the airways. Other diagnostic techniques such as pulmonary function testing are described in Chapter 503.

Imaging has long been important in the evaluation, diagnosis, management and follow-up of pediatric chest diseases; and it contributes greatly to our understanding of the pathophysiology of many entities. The chest is no exception to the increased sophistication and complexity of imaging techniques, with a myriad of available options involving a bewildering array of modalities and choices. This section will provide an overview of these options and their advantages, disadvantages, and most appropriate use in the pediatric population.

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 3D 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.1-12

Chest Radiographs and Chest Fluoroscopy

Plain radiographs of 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. 1. Patient history and specific reason for the current radiograph

    2. Quality of the study: patient 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, ...

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