The Lateral Decubitus View: An Aid in Evaluating Poorly Defined

Pulmonary Densities in Children

ALLAN S. KAUFMAN’ AND LAWRENCE R. KUHNS2

The upper lung on a lateral decubitus chest radiograph Is Results

uniformly better expanded than on a frontal upright chest
In all 20 cases the upper hung on the lateral decubitus
radiograph. The lateral decubitus view is useful in distinguish-
ing pulmonary vascular structures mimicking pneumonia from radiograph demonstrated a much better degree of infla-
actual pulmonary infiltrates in infants and young children in tion compared to the initial upright frontal radiograph
whom deep inspiratory chest films are difficult to obtain. This (figs. 1 and 2). On the basis of this decubitus view, six
study included 20 children whose initial radiographs could not children were interpreted as having a definite infiltrate
be obtained in deep inspiration and demonstrated equivocal and 14 as normal.
areas of pulmonary infiltrate. Clinical follow-up was possible The 16 patients whose clinical courses were reviewed
in 16 of the 20 patients. We reviewed the routine chest radio- included the six interpreted as having an infiltrate and 10
graphs and lateral decubitus views independently and retro- of the 14 patients interpreted as normal. Although there
spectively. The decubitus films showed more appropriate cor-
was a clinical suspicion of pneumonia in all the children,
relation with the subsequent clinical course and consistently
the treatment they received was largely based on the film
allowed more confident interpretation of the radiographs.
interpretation. Only the six patients with infiltrates were
placed on antibiotics. All of these patients demonstrated
One of the most common pediatric examinations is the
American Journal of Roentgenology 1977.129:885-888.

interval clinical improvement. None of the 10 patients

routine chest radiograph to “rule out pneumonia.” Ide-
with normal radiographs subsequently developed further
ally, these chest films should be obtained in deep mnspi-
clinical evidence of pneumonia.
ration. Although uncooperative infants and young chil-
Table 1 summarizes our retrospective review. In 12 of
dren may be stimulated to take a deep breath [1], it is
the 20 cases, interpretation of the lateral decubitus film
often difficult to obtain satisfactory radiographs during
differed from the upright frontal film. Of these cases, the
peak inspiration. Even slight degrees of expiration can
routine films were negative in three cases and equivocal
result in poorly defined pulmonary densities mimicking
in eight cases. Only one positive routine film differed in
pneumonia, especially next to the lower heart bonders on
interpretation.
frontal nadiographs [1-5]. We have sometimes noeated a
The six positive lateral decubitus films correspond with
study two or three times without obtaining adequate
the six patients initially interpreted as having infiltrates
inspiration. This paper evaluates the lateral decubitus
and subsequently treated for pneumonia. Although we
view as an aid in distinguishing pulmonary densities
have no proof as to the actual presence or absence of
mimicking pneumonia from actual pulmonary infiltrates.
pneumonia, the lateral decubitus film seems to show a
Materials and Methods more appropriate correlation with the clinical course of
each patient.
The patient material consisted of children referred from the
pediatric clinic because of a clinical suspicion of pneumonia. Discussion
Patients with unequivocally normal or abnormal nadiognaphs
were excluded. In 20 children initial nadiographs could not be To immobilize the child for upright films, we use a
obtained in deep inspiration and equivocal areas of pulmonary chest chair which holds the arms beside the head [1]. in
infiltrates were present, frequently adjacent to the night lower this position, the frontal chest radiograph sometimes
heart border or in the suprahilar regions. Lateral decubitus appears as though the child were purposely positioned
views were obtained with the side in question up and the contra- for an apical hordotic view [2]. Consequently, obtaining a
lateral side down, with attempts to obtain exposure in deep true apical lordotic view in addition to these standard
inspiration. Four patients required both right and left lateral
upright films may not provide any additional information.
decubitus views because of bilateral suspicious densities on the
The lateral decubitus view is an alternative to both the
initial films. Follow-up was obtained on 16 of the 20 patients to
apical lordotic view and to a repeat frontal upright radio-
compare the clinical course with our film interpretation. Follow-
up was not possible in four. Finally, we both reviewed the graph.
routine chest radiographs and the lateral decubitus views inde- Lateral decubitus views are also useful in detecting
pendently and retrospectively to determine which films had a small amounts of free pleural fluid [1 4-6], ,in demon-
more appropriate correlation with the presence or absence of strating a change in position of an air-fluid level within a
pneumonia. cavity [4, 5], in evaluating a possible pneumothorax [1,

Received April 26, 1977; accepted after revision June 22, 1977.
I Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109.
2 Division of Pediatric Radiology, C. S. Mott Children’s Hospital, University of Michigan Medical Center, Ann Arbor, Michigan 48109. Address reprint
requests to L. A. Kuhns.

Am J Roentg.nol 129 :885-888, November 1977 885

 886 KAUFMAN AND KUHNS

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American Journal of Roentgenology 1977.129:885-888.

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4], in distinguishing an anterior pneumothonax from a in evaluating possible infiltrates is essentially analogous
pneumomediastinum in a neonate [3], and in evaluating to its use in evaluating air trapping [7], except that the
air trapping [7]. area in question is not the dependent side. When the
The basis for using the lateral decubitus view as an aid child is positioned for the lateral decubitus view, the
 LATERAL DECUBITUS CHEST FILMS 887
American Journal of Roentgenology 1977.129:885-888.

dependent thorax is effectively splinted. The motion of TABLE 1

that hemithorax is limited, the dependent lung tends to Retrospective Review of 20 Cases
be underaerated [7], and the dependent hemidiaphragm
L ateral Decubitus Vsew
will be elevated [4]. Since the hemithorax on the nonde- Frontal Upright
View
pendent side is not restricted, the lung on this side is Positive Negative Equivocal

relatively hypenexpanded [7]. The paramediastinal lung Positive 1 1 C

on the upper side is well visualized, since gravity results Negative 3 7 0
Equivocal 2 6 0
in a downward shift of the mediastinum [6]. In the well
expanded upper lung, the pulmonary vessels spread
apart. In addition, these vessels are less prominent be- quined bilateral studies. It was never necessary to repeat
cause of decreased perfusion of the upper lung [8]. a lateral decubitus view in our series. Second, since
All of these factors will enhance inflation of the upper many pneumonias are associated with pleural effusions
lung. As a result, the poorly defined pulmonary densities [5], the use of both lateral decubitus views to evaluate
seen on the initial radiograph (fig. 1A) can be interpreted bilateral suspicious densities may reveal an associated
as normal vascular structures (figs. lB and 1C). Con- but unsuspected subpulmonic pleural effusion. Finally,
versely, when an infiltrate is actually present, we have the lateral decubitus view consistently allows more confi-
observed that the infiltrate stands out against the less dent interpretation of the radiographs.
prominent vasculanity and the air bronchogram appears The lateral decubitus view seems most valuable when
more prominent (fig. 2). Cane must be taken when ob- initial routine radiognaphs are equivocal. When routine
taming the lateral decubitus films, since infants and chest films are normal, the lateral decubitus view may
young children often will lean toward a prone or supine occasionally confirm the clinical suspicion of pneu-
position, resulting in a notated view. The standard lateral monia.
chest nadiognaphs wore not helpful in our series, pro-
sumably because middle lobe, lingular, and perihilan in- ACKNOWLEDGMENTS
filtrates are obscured by the heart and thymus in this We thank Drs. Andrew K. Poznanski, Ramiro Hernandez,
projection. George Wislo, and Nathan Wei for help in performing this study.
The use of the lateral decubitus view offers three ad-
vantages. First, the repeat examinations frequently re-
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 888 KAUFMAN AND KUHNS

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effervescent granules enhance cardiac imaging. European Journal of Radiology 52:3, 271-275. [Crossref]
2. Gary L. Hedlund, Donald R. Kirks. 1990. Emergency radiology of the pediatric chest. Current Problems in Diagnostic Radiology
19:4, 137-164. [Crossref]
3. Jeremy J Hollerman, Stuart M Simms. 1986. The contralateral decubitus chest film. Annals of Emergency Medicine 15:2, 198-201.
[Crossref]
American Journal of Roentgenology 1977.129:885-888.