Clinical Radiology (1997) 52, 172-186
Review
Imaging the Neonatal Chest
A. T. GIBSON and G. M. STEINER*
Neonatal Intensive Care Unit, The Jessop Hospital for Women, Sheffield and *Department of Radiology,
Sheffield Children's Hospital, Sheffield, UK
Accurately performed and carefully interpreted skilled radi-
ological examination has a central role in the management
of both term and pre-term infants. It is important to appre-
ciate that such infants are not miniature adults with scaled-
down versions of adult diseases but a separate population of
individuals who may develop disorders that are unique in
their pathogenesis, radiological appearances and complica-
tions. Both immaturity and its treatment, and childbirth with
its complications, may produce a variety of conditions that
are unique in their presentation both to the radiologist and
neonatologist.
The role of the radiologist is to work very closely with the
paediatricians in the Special Care Baby Unit (SCBU) and
provide continuous ongoing expertise in all branches of
imaging. Although this is primarily radiography and ultra-
sound, CT and MRI are being used with increasing fre-
quency [1,2]. Close links are very important to achieve the
best results as interpretation of the images is so dependent
on the age of the patient, the treatment and the possible
complications. Images constantly change with the advances
and improvements in treatment.
Risk of Radiation
One of the roles of the radiologist is to guarantee as safe a
service as possible by ensuring that the radiation load on the
babies is as small as possible. Routine lateral views of the
chest are unnecessary. Modern fast film screen combina-
tions combined with high output machines and good colli-
mation ensure that the radiation dose is very low. In 1986 it
was calculated that an infant having seven chest X-rays had
a 1 in 40 000 or more chance of developing a cancer [3,4].
One of the main purposes of imaging is to check the position
of the various pieces of equipment that are used to ventilate,
hydrate, monitor and feed the infant receiving intensive care
(Fig. la,b).
Ventilation
Many babies receiving intensive care will require some
form of positive pressure artificial ventilation. This may be
in the form of a moderate elevation of airway pressure
applied continuously through nasal prongs or a face mask
(Continuous Positive Airway Pressure - CPAP) or by a
cyclical inflation of the lungs through an endotracheal (ET)
tube (Intermittent Positive Pressure Ventilation - IPPV).
Pressures in the range of 2 - 6 cm H20 are used during CPAP
and peak pressures between 12-26 cmH20 are commonly
used during IPPV. Pressure of 50cmH20 or more may
occasionally be required although this considerably
increases the chances of barotrauma (see below). Normally,
Correspondence to: G. M. Steiner, Sheffield Children's Hospital,
Western Bank, Sheffield S10 2TH, UK.
© 1997 The Royal College of Radiologists.
ventilation rates approximate the normal respiratory rates of
the infant (30-90 breaths per minute) but, on occasions,
oscillatory ventilation at rates of 600-900 cycles per minute
may be utilized. When conventional ventilation has failed,
extracorporeal membrane oxygenation (ECMO) provides a
temporary means of adequate gas exchange to tide the baby
over the respiratory crisis. The highest success rates for this
technique are reported for conditions such as meconium
inhalation and persistent fetal circulation in which the
pulmonary damage is potentially reversible [5,6].
One of the radiologist's most important roles is to check
that the tip of the endotracheal tube (ET tube) does not abut
the carina or enter one of the main bronchi. The preferred
position for the tip of the ET tube is about 1 cm above the
carina. The efficiency of high frequency oscillatory ventila-
tion is normally measured by radiological assessment of the
degree of lung filling. The fight diaphragm should be seen to
lie at a level between the posterior ends of the 8th and 9th
ribs (Fig. la) [7].
Hydration and Monitoring
Umbilical arterial and venous lines must be differentiated
from each other. They are frequently used to monitor
arterial Poe, Pco2 and blood pressure in the case of the
arterial line and to hydrate and nourish the infant and inject
drugs in the case of the venous line. Confirmation of correct
positioning of the arterial and venous lines is essential. The
umbilical artery catheter initially courses caudally into the
pelvis through the internal and common iliac arteries to
enter the aorta and the tip should ideally lie above the level
of the coeliac axis and superior mesenteric arteries or below
the level of the renal arteries. The umbilical vein catheter
courses directly cephalad to enter the left portal vein at
which point it may pass through the ductus venosus to enter
the inferior vena cava (Fig la). Radiographs should confirm
that the tip lies above the liver and has not passed into a
tributary vein.
Feeding Tubes
Feeding may be through a nasogastric tube or a naso-
jejeunal tube with the tip in the small bowel (Fig. 19a). The
radiologist should comment on the position of the tips of
these tubes as infusion of enteral feeds through an incor-
rectly positioned tube may have serious consequences.
Respiratory illness, associated cardiovascular problems,
complications of treatment and physiological instability of
the newborn infant are the most important causes of pre-
ventable mortality and morbidity in infancy and may be due
to faulty development or prematurity. In the latter case
neither the respiratory epithelium nor the biochemical sys-
tems that ensure normal lung function has developed suf-
ficiently to ensure adequate gas exchange. The circulation