Pediatric emergency medicine trisk 1661 1661
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do not support the utility of obtaining a chest radiograph for all patients with their
first episode of wheezing. The diagnosis of asthma can be supported by symptom
reversal with bronchodilator treatment. However, in unclear or complex cases, a
chest radiograph can assist in identifying disease complications such as
pneumonia, atelectasis, pneumothorax, or pneumomediastinum. Routine chest
radiographs are not necessary for the confirmation of suspected pneumonia in
patients well enough to be treated in the outpatient setting. Posteroanterior and
lateral chest radiograph should be considered if there is hypoxemia or significant
respiratory distress, failure of initial antibiotic therapy for pneumonia, or need for
hospitalization for the management of pneumonia. A chest radiograph may also
help diagnose heart disease, mediastinal masses, and radiopaque foreign bodies of
the airway and esophagus. Varying degrees of hyperaeration, peribronchiolar
thickening, and subsegmental atelectasis are the most common radiographic
findings in patients with bronchiolitis or asthma.
An immediate and aggressive workup is always justified in patients suspected
of having an airway foreign body (see Chapter 32 Foreign Body: Ingestion and
Aspiration ) on the basis of acute and sudden symptomatology. In this setting,
chest radiographs are usually normal, although occasionally they can demonstrate
a radiopaque object, the faint outline of a radiolucent foreign body, segmental
atelectasis, or a focal area of hyperinflation. Patients with a subacute presentation
of lower airway foreign body are more likely to show focal collapse and
consolidation on standard chest radiographs. Bilateral decubitus views,
inspiratory and expiratory radiographs, or airway fluoroscopy may be used to
provide additional diagnostic information related to possible foreign-body
aspiration, however negative studies do not rule out disease. Chest computed
tomography with virtual bronchoscopy has shown promising results in diagnosing
suspected foreign-body aspiration, but conventional bronchoscopy remains the
procedure of choice both from a diagnostic and therapeutic perspective.
Patients suspected of having aspirated oropharyngeal or gastric contents should
have plain radiographs taken of the chest. Nonspecific findings consistent with
lower airway obstruction generally precede the appearance of infiltrates. Patients
believed to have recurring episodes of pulmonary aspiration should have further
testing at a subsequent time to identify swallowing dysfunction, GE reflux, or
actual tracheobronchial soiling. Such inpatient or outpatient tests might include a
swallow study, esophageal pH monitoring, esophageal endoscopy and biopsy, or
radionuclide scintigraphy. Flexible bronchoscopy may be required to diagnose
patients with a tracheoesophageal fistula.
