pediatric cxr moritz haager nov 20, 2003. not just small adults what’s different about the...

Pediatric CXRPediatric CXR

Moritz HaagerMoritz Haager

Nov 20, 2003Nov 20, 2003

Not just small adultsNot just small adults

What’s different about the pediatric CXR?What’s different about the pediatric CXR?– Thymus Thymus – Occult FB aspirationOccult FB aspiration– Congenital anomaliesCongenital anomalies– Smaller airways; more subtle disease findingsSmaller airways; more subtle disease findings– Infectious etiologies & presentationsInfectious etiologies & presentations

Normal newborn chest

prominent right thymic lobe because of rotation.

wavy thymic sign on the left

ThymusThymus

Anterior upper mediastinal structureAnterior upper mediastinal structureLow density – should be able to see Low density – should be able to see pulmonary vasculature behind itpulmonary vasculature behind itDoes not displace trachea posteriorlyDoes not displace trachea posteriorlyCan increase in size after acute illnessCan increase in size after acute illnessDoes not decrease in size w/ aging – Does not decrease in size w/ aging – rather stays roughly same size (~3x3 cm) rather stays roughly same size (~3x3 cm) and so becomes smaller in proportion to and so becomes smaller in proportion to chestchest

2-month old male with fever, noisy 2-month old male with fever, noisy breathing, and tachypnea breathing, and tachypnea

congestive heart failure due to congenital heart disease

CHF FindingsCHF Findings

Cardiothoracic RatioCardiothoracic Ratio– Infants (less than 1 yo)Infants (less than 1 yo)

May be up to 0.6May be up to 0.6

– Toddlers and olderToddlers and olderMaximum is 0.5Maximum is 0.5

CHF findingsCHF findings– Plethora, fluid in fissures, peribronchial cuffingPlethora, fluid in fissures, peribronchial cuffing– Don’t see pleural effusions and upper lobe Don’t see pleural effusions and upper lobe

redistribution as much as in adultsredistribution as much as in adults

2 mo w/ VSD now presents with 2 mo w/ VSD now presents with resp distress and “seizure”resp distress and “seizure”

Cardiomegaly and absence of the thymic shadow most consistent with DiGeorge Syndrome (thymic and hypoparathyroid aplasia or hypoplasia).

11-month old female presents with 11-month old female presents with fever and coughing.fever and coughing.

viral pneumonia

Viral PneumoniaViral Pneumonia

Far more common than bacterial Far more common than bacterial pneumonia in kidspneumonia in kids

Non-specific X-ray findings:Non-specific X-ray findings:– OverexpansionOverexpansion– Peribronchial thickeningPeribronchial thickening– Interstitial infiltratesInterstitial infiltrates– Perihilar flaringPerihilar flaring

6-week old female with fever and cold symptoms. 6-week old female with fever and cold symptoms.

VS T39.1, P125, R45, BP 75/35, O2 sat 98% RAVS T39.1, P125, R45, BP 75/35, O2 sat 98% RA

consolidation or atelectasis in the posterior segment of the right upper lobe

15-month old male with fever and coughing.15-month old male with fever and coughing.

right upper lobe consolidation.

15-month old male with fever, coughing, and tachypnea15-month old male with fever, coughing, and tachypnea. .

Right middle and left lower lobe infiltrates

9 year old male with a history of fever, 9 year old male with a history of fever, headache, nausea, and coughingheadache, nausea, and coughing

round pneumonia

Round PneumoniaRound Pneumonia

Often present w/ pleuritic chest painOften present w/ pleuritic chest pain

See spherical opacity with See spherical opacity with poorly defined poorly defined marginsmargins (compared to tumors which have (compared to tumors which have clear margins)clear margins)

Usually located posteriorly adjacent to Usually located posteriorly adjacent to pleurapleura

Uncommon to see air bronchogramsUncommon to see air bronchograms

10 year old male with a history of coughing and fever. 10 year old male with a history of coughing and fever.

Left-sided pneumonia and foreign body in the left mainstem bronchus

4-month old with respiratory distress and 4-month old with respiratory distress and

diminished breath sounds on the rightdiminished breath sounds on the right

Congenital RML lobar emphysema

Foreign Body AspirationForeign Body Aspiration

Many FB’s are radiolucentMany FB’s are radiolucentCXR less than perfect in detecting FB’sCXR less than perfect in detecting FB’sDifficult histories often but if clear history Difficult histories often but if clear history of object in mouth + choking then need of object in mouth + choking then need bronchoscopy regardless of radiographic bronchoscopy regardless of radiographic results (especially with nuts)results (especially with nuts)If unclear and child asymptomatic then If unclear and child asymptomatic then reasonable to d/c after informing parents reasonable to d/c after informing parents of signs + Sx to be vigilant forof signs + Sx to be vigilant for

7 mo native child w/ cough & fever7 mo native child w/ cough & fever

Miliary TB

11-month old female w/ near-11-month old female w/ near-drowning episodedrowning episode

Pulmonary edema

13 month old male with wheezing, coughing, 13 month old male with wheezing, coughing, and rhinorrhea for the past month. T 37.5, P and rhinorrhea for the past month. T 37.5, P

138, RR 52, BP 95/40, O2 95% RA138, RR 52, BP 95/40, O2 95% RA

Pulmonary sequestration

Pulmonary SequestrationPulmonary Sequestration

Congenital non-functional (not connected to Congenital non-functional (not connected to tracheobronchial tree) accessory lung tissue w/ tracheobronchial tree) accessory lung tissue w/ anomalous arterial supply anomalous arterial supply – IntralobarIntralobar

More common, shares pleural lining w/ lungMore common, shares pleural lining w/ lungPresent w/ recurrent pneumoniaPresent w/ recurrent pneumonia

– ExtralobarExtralobarContained in its own pleural sacContained in its own pleural sacPresent w/ resp distress or feeding difficulty in infancyPresent w/ resp distress or feeding difficulty in infancy

Angiography is gold standard for DxAngiography is gold standard for DxMultiple variantsMultiple variants– Scimitar syndrome, horseshoe lung, cystic Scimitar syndrome, horseshoe lung, cystic

adenomatoid malformation, pulmonary AVMadenomatoid malformation, pulmonary AVM

10 month old male with wheezing and 10 month old male with wheezing and coughingcoughing

cystic mass posterior to the trachea and the mainstem bronchi

6-month old male with difficulty 6-month old male with difficulty breathing breathing

Vascular RingVascular Ring

Aortic arch malformation causing trachea Aortic arch malformation causing trachea & esophagus to be encircled by major & esophagus to be encircled by major blood vessels or branches thereofblood vessels or branches thereofSee a right-sided aortic arch in nearly all See a right-sided aortic arch in nearly all cases cases – passes over the R mainstem bronchus rather passes over the R mainstem bronchus rather

than the Lthan the L– Pushes carina to L rather than the usal RPushes carina to L rather than the usal R– May see only compression in double archMay see only compression in double arch

Vascular RingVascular Ring

5 year old, male w/ fever x 10 d, coughing, sore 5 year old, male w/ fever x 10 d, coughing, sore

throat and mild back painthroat and mild back pain

Lung abscess

Two week old male infant w/ a history of noisy breathing and worsening Two week old male infant w/ a history of noisy breathing and worsening respiratory distress. VS T36.7, P160, R60, O2 sat 86% RArespiratory distress. VS T36.7, P160, R60, O2 sat 86% RA

Congenital lobar emphysema.

ReferencesReferences

Cases courtesy of:Cases courtesy of:Loren G. Yamamoto, MD, MPHLoren G. Yamamoto, MD, MPHAlson S. Inaba, MDAlson S. Inaba, MDRobert M. DiMauro, MDRobert M. DiMauro, MDKapiolani Medical Center For Women And Kapiolani Medical Center For Women And ChildrenChildrenDept. Pediatrics, University of Hawaii John A. Dept. Pediatrics, University of Hawaii John A. Burns School of MedicineBurns School of Medicine1319 Punahou Street, Honolulu, HI 968261319 Punahou Street, Honolulu, HI 96826http://www.hawaii.edu/medicine/pediatrics/pemxrhttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.htmlay/pemxray.html