Unintentional Exposure and Incidental Findings during Conventional Chest Radiography in the Pediatric Intensive Care Unit

Abstract Background: Anatomical overexposure is common in CXRs of pediatric patients. However, overexposure may reveal incidental findings that can help to guide patient management or warrant quality improvement. Objective: To assess the prevalence of overexposure in chest X-ray (CXRs) in pediatric intensive care unit (PICU); and identify the incidental findings within overexposed areas. Materials and methods: Retrospective cohort study of children admitted to PICU. Two independent evaluators reviewed patient’s charts and digital CXRs according to the American College of Radiology standards; to evaluate overexposure of the anatomical parameters and incidental findings. Results: A total of 400 CXRs of 85 patients were reviewed. The mean number of CXRs per patient was 4.7. Almost all (99.75%) CXRs met the criteria for overexposure, with the most common being upper abdomen (99.2%), upper limbs (97%) and neck (95.7%). In addition, 43% of these X-rays were cropped by the radiology technician to appear within the requested perimeter. There was a significant association between field cropping and overexposure (t-test: t=9.8, p<.001). Incidental findings were seen in 41.5% of the radiographs; with the most common being gaseous abdominal distension (73.1%), low-positioned nasogastric tube (24.6%), and constipation (10.3%). Conclusions: Anatomical overexposure in routine CXRs remains high and raises a concern in PICU practice. Appropriate collimation of the X-ray beam, rather than electronically cropping the image, is highly recommended to minimize hiding incidental findings in the cropped-out areas. Redefining the anatomic boundaries of CXR in critically ill infants and children may need further studies and consideration. Quality improvement initiatives to minimize radiation overexposure in PICU are recommended.