What is the Value of the Lateral Chest Projection?

Introduction

Some institutions (or even countries/continents) perform lateral chest radiography as a routine view whilst others almost never do. Is the lateral chest X-ray useful and, if so, is it useful enough to warrant its inclusion as a routine view? Has the cost/benefit equation changed with the introduction of digital imaging? Some radiologists have argued that the lateral chest view is never required- all pathology can be seen on the AP/PA.... but these radiologists are usually not around at 0300hrs in the Emergency Department when the image interpretation/treatment decision could be taking place.

You could argue that the lateral chest projection is required on the basis of selected case studies where it can be shown to reveal or clarify significant chest pathology. But wouldn't this be an argument for performing chest radiography as a screening tool on asymptomatic patients? (if you randomly perform chest radiography on the asymptomatic population you will find significant pathology)

Would the health care resources spent on lateral chest radiography provide a better yield if spent elsewhere?

If you are only performing AP/PA chest radiography, could an argument be made for more bedside chest radiography in the wards?

The Cases

If you are one of those people that advocate a "PA only" approach to chest radiography, consider the cases below. Each case has had AP/PA and lateral views of the chest. Can you confidently identify the pathology without the aid of the lateral projection?

Some cases are quite easy in terms of image interpretation and some are difficult

Case 1

Answer

Case 2

Answer

Case 3

Answer

Case 4

Answer

Case 5

Answer 5

Case 6

answer

Case 7

answer

Case 8

Answer

Case 9

Answer

Case 10

Answer

Case 11

Answer

Case 12

Answer

Case 13

Answer

Case 14

Answer

Case 15

Answer

Case 16

Case 17

Case 18

The Exceptions

Not every patient who is referred for chest radiography should be subject to a lateral view. B Golberg refers with great wit to the "fish and Chips" lateral...

I have written mainly... about what I classify as the
"fish and chips" lateral view-a request made purely from habit
or conditioned reflex. In the same week as I received the annotated
form mentioned in the first paragraph a casualty officer,
on his first day at the hospital, requested

posteroanterior and
lateral views " ? pneumothorax."

An experienced radiographer did the correct examination-namely, views in inspiration and expiration, only to receive patient and form back immediately
with the insistence that a lateral view be done. Such a view is certain to be useless if he really was looking for a pneumothorax. If there was something else on his mind it was certainly not on the request form.

B Golberg, BRITISH MEDICAL JOURNAL 29 MARCH 1980, p 909

Links

http://education.thoracicrad.org/2007/BTB/735/player.html

Discussion

I am hoping that there will be some attempt(s) to interpret these images without the lateral view. You can post your comments using the "post a new thread" link at the bottom of this page. Once a few brave souls have had a go, I will post the lateral chest images.

I have very little doubt that an expert in chest image interpretation will correctly identify the pathologies on this page without the benefit of the lateral chest image. This is arguably not the point- the person who views the image and acts upon the findings needs to be furnished with images that allow him/her to arrive at the correct diagnosis. It is often the case that pathologies that are sited behind the heart shadow or below the diaphragm are easier to appreciate with the aid of a lateral image. Are you left wondering how many chest pathologies you have missed over the years?

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M.J.Fuller	Latest page update: made by M.J.Fuller , Mar 8 2010, 3:13 AM EST (about this update About This Update Edited by M.J.Fuller 1 word added view changes - complete history)
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Englander66

ROUTINE LATERAL CHEST RADIOGRAPH

Oct 26 2012, 11:22 PM EDT by metal-fan-666

Thread started: Feb 18 2012, 7:08 PM EST Watch

Whilst you may argue that some cases may be missed with a single PA/AP view , it should be argued that a vast number of patients will receive an unnecessary radiation dose if a diagnosis can be made or normality established. I am, at present, against a routine lateral view.In how many cases has significant pathology been seen on the lateral view that is either missed or not seen on the PA? I hypothesise that the "pick up" rate would be so low as to stop routine lateral views.This must be part of the discussion regarding "lateral or no lateral."

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RE: ROUTINE LATERAL CHEST RADIOGRAPH
By: metal-fan-666, Oct 26 2012, 11:22 PM EDT

I would have to agree to what tnxrayman is saying. Essentially, to have a discussion on this topic we must first consider what do we mean by routine? I think very few people would argue that a lateral chest should not be include for a routine chest series for ? pleural effusion. However there seems little point in routinely performing a lateral for a pulmonary embolism. The question speaks more largely to justification and optimisation, in other words, indiciations or clinical objectives. It may vary from country to country but from my limited research there seems to be similar general structures in different countries, that is that as part of a program to ensure that imaging is provided safely, certain people have certain responsibilities for certain things, imaging needs to be justified as if it is not indicated then there is no cost:benefit balance, rather cost:cost scenario. As such there is need to justify a study, either on a patient by patient basis (does this person have pneumonia) or generally (people in a certain demographic should have a preop CXR before anaesthetics). The study should then be performed such that the radiation delivered to the patient is adequate to demonstrate clinical objective and not more than is required to demonstrate the clinical objective. In this context routine is going to pertain to indications, in that a series of projections should routinely be performed in these specific scenarios so that conclusions drawn from the imaging are as accurate as possible.

It sounds to me that there is a lack of quality assurance of justification and optimisation processes.

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Englander66

LATERAL CXR AS ROUTINE

Feb 19 2012, 3:55 AM EST by Englander66

Thread started: Feb 18 2012, 7:02 PM EST Watch

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	I have written mainly... about what I classify as the "fish and chips" lateral view-a request made purely from habit or conditioned reflex. In the same week as I received the annotated form mentioned in the first paragraph a casualty officer, on his first day at the hospital, requested posteroanterior and lateral views " ? pneumothorax." An experienced radiographer did the correct examination-namely, views in inspiration and expiration, only to receive patient and form back immediately with the insistence that a lateral view be done. Such a view is certain to be useless if he really was looking for a pneumothorax. If there was something else on his mind it was certainly not on the request form.
	B Golberg, BRITISH MEDICAL JOURNAL 29 MARCH 1980, p 909