paediatric chest radiology

THE PAEDIATRIC CHESTTHE PAEDIATRIC CHEST

BY Dr. SUNIL GOELBY Dr. SUNIL GOEL

SPECIFIC FEATURES OF THE SPECIFIC FEATURES OF THE CHEST RADIOGRAPH IN CHEST RADIOGRAPH IN CHILDRENCHILDREN• CT ratio is 65%CT ratio is 65%

• Kink of trachea to the rightKink of trachea to the right

• The soft tissuesThe soft tissues

• Pleural effusionsPleural effusions

• Diphragm lies normally at the level of Diphragm lies normally at the level of 6th to 86th to 8thth ant. Rib. ant. Rib.

• ThymusThymus

THYMUSTHYMUS

• Normal thymus mimic widening of Normal thymus mimic widening of mediastinum and should not be confused mediastinum and should not be confused with a mediastinal or pulmonary mass. with a mediastinal or pulmonary mass.

• Thymic wave sign-undulating lat marginsThymic wave sign-undulating lat margins

• Sail signSail sign

• May involute in time of stress and steroids May involute in time of stress and steroids tt.tt.

• Normal thymus does not compress or Normal thymus does not compress or displace other structures.displace other structures.

Tubes and LinesTubes and Lines

• The ideal position of the The ideal position of the endotracheal tube is in the mid endotracheal tube is in the mid trachea, 2.0 cm above the carina.trachea, 2.0 cm above the carina.

• Chest tubes are ideally positioned Chest tubes are ideally positioned anterior and apical for treatment of anterior and apical for treatment of pneumothorax.pneumothorax.

• The chest tube should be positioned The chest tube should be positioned posterior and inferior for drainage of posterior and inferior for drainage of pleural fluid.pleural fluid.

Pneumothorax Pneumothorax

• Most exams in the neonate will be performed Most exams in the neonate will be performed in the supine position, so the air will rise to in the supine position, so the air will rise to the least dependent portion of the body. the least dependent portion of the body.

• The least dependent portion of the chest is The least dependent portion of the chest is the anterior, lower chest. the anterior, lower chest.

• an unusually sharp heart border or an unusually sharp heart border or

• an unusually sharp and hyperlucent an unusually sharp and hyperlucent costophrenic angle on a supine CXR (deep costophrenic angle on a supine CXR (deep sulcus sign)sulcus sign)

Right anterior pneumothorax demonstrating a sharp right heart border.

The following illustrates one case of a pneumothorax shown on supine CXR and confirmed by decubitis CXR, and one case of pneumoperitoneum confirmed on left side down decubitis view.

pneumoperitoniumpneumoperitonium

Supine CXR demonstrating hyperlucency over the anterior abdomen.

Left side down decubitis CXR confirms the free intraperitoneal air.

Bilateral pneumothoraces with hyperlucency of the anterior chest

Respiratory Neonatal Respiratory Neonatal DistressDistress

• Excluding congenital heart disease, Excluding congenital heart disease, neonatal respiratory distress can be neonatal respiratory distress can be broken down into two broad broken down into two broad categories:categories:

• medical and surgical. medical and surgical.

• Medical causes are managed by the Medical causes are managed by the neonatologist.neonatologist.

Respiratory Neonatal Respiratory Neonatal DistressDistress

• Surgical causes need the immediate care of Surgical causes need the immediate care of a pediatric surgeon because of mass effect on a pediatric surgeon because of mass effect on the developing lungs and possible acute the developing lungs and possible acute airway compromise. airway compromise.

• Congenital heart disease is suspected when Congenital heart disease is suspected when external oxygenation does not raise the external oxygenation does not raise the oxygen saturation. oxygen saturation.

• The oxygen saturation will respond to The oxygen saturation will respond to external oxygenation if lung disease is the external oxygenation if lung disease is the cause. cause.

Medical Causes of Neonatal Medical Causes of Neonatal Respiratory DistressRespiratory Distress

• Transient Tachypnea of the NewbornTransient Tachypnea of the Newborn

• Meconium AspirationMeconium Aspiration

• Neonatal PneumoniaNeonatal Pneumonia

• Respiratory Distress Syndrome Respiratory Distress Syndrome (Surfactant Deficiency)(Surfactant Deficiency)

Surgical Causes of Neonatal Surgical Causes of Neonatal Respiratory DistressRespiratory Distress

• Congenital Diaphragmatic HerniaCongenital Diaphragmatic Hernia

• Congenital Cystic Adenomatoid Congenital Cystic Adenomatoid MalformationMalformation

• Congenital Lobar EmphysemaCongenital Lobar Emphysema

• SequestrationSequestration

Transient Tachypnea of the Transient Tachypnea of the Newborn (TTN)Newborn (TTN)

• Transient tachypnea of the newborn is Transient tachypnea of the newborn is delayed clearance of intrauterine delayed clearance of intrauterine pulmonary fluid.pulmonary fluid.

• The thoracic squeeze of a normal The thoracic squeeze of a normal vaginal delivery will clear 30% of the vaginal delivery will clear 30% of the pulmonary fluid. pulmonary fluid.


• Therefore, either C-section or a precipitous Therefore, either C-section or a precipitous vaginal delivery may lead to TTN. vaginal delivery may lead to TTN.

• The infant has normal respiration during The infant has normal respiration during the first hours of life but then gradually the first hours of life but then gradually develops mild respiratory distress which develops mild respiratory distress which begins around 4-6 hours and peaks at 24 begins around 4-6 hours and peaks at 24 hours with rapid recovery by 48 ö 72 hours. hours with rapid recovery by 48 ö 72 hours.

• Since the respiratory distress is mild, Since the respiratory distress is mild, intubation is usually not required.intubation is usually not required.


• The chest radiograph will follow the clinical The chest radiograph will follow the clinical course with the abnormalities peaking course with the abnormalities peaking during the first day of life then rapidly during the first day of life then rapidly clearing. clearing.

• The CXR will demonstrate the findings of The CXR will demonstrate the findings of fluid overload with vascular congestion fluid overload with vascular congestion and small pleural effusions. and small pleural effusions.

• The CXR is nearly always normal by 48-72 The CXR is nearly always normal by 48-72 hours. hours.

TTN on day one of life with mild vascular congestion and small pleural effusions

On day two of life the fluid overload has resolved and the CXR is normal

Neonatal PneumoniaNeonatal Pneumonia

• Neonatal pneumonia can be a difficult Neonatal pneumonia can be a difficult clinical and radiographic diagnosis. clinical and radiographic diagnosis.

• Frequently, the child will be covered Frequently, the child will be covered with antibiotics without positive with antibiotics without positive confirmation of pneumonia. confirmation of pneumonia.

• However, pneumonia can be confirmed However, pneumonia can be confirmed with positive blood cultures.with positive blood cultures.


• Many different organisms can cause Many different organisms can cause neonatal pneumonia but group B neonatal pneumonia but group B streptococcus is one of the most streptococcus is one of the most common infecting agents as 25% of common infecting agents as 25% of women are colonizedwomen are colonized

• The radiographic presentation of The radiographic presentation of neonatal pneumonia is frequently neonatal pneumonia is frequently nonspecific. nonspecific.


• Neonatal pneumonia can present with either Neonatal pneumonia can present with either diffuse diffuse reticulonodular densitiesreticulonodular densities similar to similar to respiratory distress syndrome or with respiratory distress syndrome or with patchy, asymmetric infiltrates with patchy, asymmetric infiltrates with hyperaerationhyperaeration similar to meconium similar to meconium aspiration.aspiration.

• The presence of a The presence of a small pleural effusionsmall pleural effusion is a is a useful distinguishing feature as it is a useful distinguishing feature as it is a common finding in neonatal pneumonia (up common finding in neonatal pneumonia (up to 2/3 thirds) and is uncommon in to 2/3 thirds) and is uncommon in respiratory distress syndrome. respiratory distress syndrome.

patchy, asymmetric opacities with a small right pleural effusion.

Meconium Aspiration Meconium Aspiration SyndromeSyndrome

• Meconium staining of the amniotic Meconium staining of the amniotic fluid is relative common, affecting fluid is relative common, affecting approximately 10% of live births, but approximately 10% of live births, but only 1% will have meconium only 1% will have meconium aspiration syndrome. aspiration syndrome.

• The diagnosis is confirmed with The diagnosis is confirmed with visualization of meconium below the visualization of meconium below the vocal cords. vocal cords.


• Because of the thick tenacious properties Because of the thick tenacious properties of meconium, aspiration into the of meconium, aspiration into the tracheobronchial tree will result in tracheobronchial tree will result in significant respiratory compromise and significant respiratory compromise and can be complicated by persistent can be complicated by persistent pulmonary hypertension.pulmonary hypertension.

• The child will usually be intubated and not The child will usually be intubated and not infrequently extracorporeal membrane infrequently extracorporeal membrane oxygenation is necessary. oxygenation is necessary.


• The mortality can approach 25% despite The mortality can approach 25% despite these supportive measures.these supportive measures.

• The radiology of meconium aspiration The radiology of meconium aspiration reflects the underlying pathophysiology. reflects the underlying pathophysiology.

• The aspirated meconium results in The aspirated meconium results in complete obstruction of the bronchi, complete obstruction of the bronchi, resulting in atelectasis and compensatory resulting in atelectasis and compensatory hyperinflation of the remaining patent hyperinflation of the remaining patent airways. airways.

• Overall the lungs appear hyperinflated. Overall the lungs appear hyperinflated. Barotrauma is a frequent complication. Barotrauma is a frequent complication.

CXR shows hyperinflation and patchy asymmetric airspace disease that is typical of meconium aspiration

Respiratory Distress Respiratory Distress Syndrome (RDS)Syndrome (RDS)

• Respiratory distress syndrome is the Respiratory distress syndrome is the term used to describe the clinical term used to describe the clinical manifestations of surfactant manifestations of surfactant deficiency, and deficiency, and

• It is synonymous with hyaline It is synonymous with hyaline membrane disease (HMD).membrane disease (HMD).


• RDS is seen in children less than 36 weeks old RDS is seen in children less than 36 weeks old and is obviously more prevalent and more and is obviously more prevalent and more severe the younger the premature infant. severe the younger the premature infant.

• Surfactant production from type 2 Surfactant production from type 2 pneumatocytes begins at 24 weeks. pneumatocytes begins at 24 weeks.

• Surfactant lowers the surface tension of the Surfactant lowers the surface tension of the alveoli, and without it, the alveoli lose their alveoli, and without it, the alveoli lose their compliance, collapse and have difficulty compliance, collapse and have difficulty ventilating. ventilating.


• RDS presents immediately at birth RDS presents immediately at birth with respiratory compromise. with respiratory compromise.

• Synthetic surfactant is now Synthetic surfactant is now administered in the delivery room to administered in the delivery room to high-risk infants and has greatly high-risk infants and has greatly improved the survival of premature improved the survival of premature infants. infants.


• The classic radiographic findings of RDS The classic radiographic findings of RDS include include diffuse symmetric reticulogranular diffuse symmetric reticulogranular densitiesdensities, , prominent central air bronchogramsprominent central air bronchograms and and generalized hypoventilationgeneralized hypoventilation. .

• Neonatal pneumonia can have a similar Neonatal pneumonia can have a similar appearance. appearance.

• The classic findings may not be present The classic findings may not be present because of the early intervention with because of the early intervention with surfactant and ventilatory support with surfactant and ventilatory support with intubation. intubation.

CXR in a premature infant prior to intubation with severe hypoventilation, marked air bronchograms and diffuse symmetric reticulogranular opacities.

Complications of Complications of Respiratory DistressRespiratory Distress

• The neonatologist must maintain a The neonatologist must maintain a balance between the ventilatory balance between the ventilatory needs of the infant and the needs of the infant and the complications that can result from complications that can result from positive pressure ventilation. positive pressure ventilation.

• The lung volumes on the daily The lung volumes on the daily neonatal CXR are used as a guide to neonatal CXR are used as a guide to determine the ventilator settings. determine the ventilator settings.


• If the compliance of the lungs is too low, or the If the compliance of the lungs is too low, or the mean airway pressure is too high, barotrauma mean airway pressure is too high, barotrauma will result. will result.

• The signs of barotrauma should be identified The signs of barotrauma should be identified on the neonatal CXR. Pneumothorax has on the neonatal CXR. Pneumothorax has already been discussed.already been discussed.

• Pulmonary interstitial emphysema (PIE) results Pulmonary interstitial emphysema (PIE) results from rupture of the alveoli with air from rupture of the alveoli with air accumulating in the peribronchial and accumulating in the peribronchial and perivascular spaces.perivascular spaces.


• PIE is recognized by linear lucencies PIE is recognized by linear lucencies radiating from the hilum. radiating from the hilum.

• However, PIE can also be cystic in However, PIE can also be cystic in appearance, which can be difficult to appearance, which can be difficult to distinguish from chronic lung distinguish from chronic lung disease. disease.


• Correlation with the clinical course is Correlation with the clinical course is helpful as PIE occurs early and is helpful as PIE occurs early and is associated with high ventilatory associated with high ventilatory settings, and chronic lung disease settings, and chronic lung disease occurs later in the hospital course occurs later in the hospital course with lower ventilatory settings.with lower ventilatory settings.


• PIE is an ominous sign because it PIE is an ominous sign because it indicates the poor compliance of the lungs indicates the poor compliance of the lungs and is frequently followed by a and is frequently followed by a pneumothorax. pneumothorax.

• In addition to adjusting the ventilatory In addition to adjusting the ventilatory settings as much as tolerated, it is helpful settings as much as tolerated, it is helpful to put the most affected side down. to put the most affected side down.

Example of unilateral PIE with a pneumothorax

• Close up of left lung demonstrating the stre aky lucencies of the air in the interstitium (red arrows)

• complicated by a pneumothorax (yellow arrow).

• This patient was treated with a chest tube and by placing the left side down. The PIE resolved after 2 days.

Patent Ductus Arteriosus Patent Ductus Arteriosus (PDA)(PDA)

• The ductus is normally open in utero The ductus is normally open in utero but will close in 1-2 days after birth but will close in 1-2 days after birth in response to the decreased in response to the decreased pulmonary resistance.pulmonary resistance.

• If the pulmonary resistance remains If the pulmonary resistance remains high then the ductus may remain high then the ductus may remain open with a right to left shunt. open with a right to left shunt.


• During the first week of life, as the During the first week of life, as the ventilatory therapy decreases the ventilatory therapy decreases the pulmonary resistance, the ductus may pulmonary resistance, the ductus may switch to a left to right shunt resulting switch to a left to right shunt resulting in increased pulmonary blood flow.in increased pulmonary blood flow.

• This is demonstrated on CXR by This is demonstrated on CXR by increased heart size and increased increased heart size and increased pulmonary vascularity. pulmonary vascularity.


• An echo will confirm the PDA.An echo will confirm the PDA.

• PDA is treated with indomethacin, PDA is treated with indomethacin, which inhibits prostaglandins. which inhibits prostaglandins.

• If indomethacin does not work, then If indomethacin does not work, then surgical ligation is necessary. surgical ligation is necessary.

CXR shows an enlarged heart and significant vascular congestion with a pulmonary edema pattern resulting from a PDA

Chronic Lung Disease (CLD)Chronic Lung Disease (CLD)Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia (BPD)(BPD)

• long-term sequelae of respiratory distress long-term sequelae of respiratory distress syndrome.syndrome.

• Oxygen toxicity and positive pressure Oxygen toxicity and positive pressure ventilation are thought to result in pulmonary ventilation are thought to result in pulmonary inflammation with subsequent fibrosis.inflammation with subsequent fibrosis.

• Clinically, CLD is defined as continued oxygen Clinically, CLD is defined as continued oxygen needs and CXR abnormalities beyond 28 days needs and CXR abnormalities beyond 28 days of life or 36 weeks gestational age.of life or 36 weeks gestational age.

Chronic Lung Disease (CLD)Chronic Lung Disease (CLD)Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia (BPD)(BPD)

• The radiographic manifestations of CLD The radiographic manifestations of CLD are diffuse interstitial thickening with are diffuse interstitial thickening with hyperinflation. hyperinflation.

• The most severe form manifests in cystic The most severe form manifests in cystic changes in the lungs.changes in the lungs.

• Steroid therapy may result in Steroid therapy may result in improvement and prevention of CLD. improvement and prevention of CLD.

Cystic interstitial pulmonary changes

Surgical Respiratory Surgical Respiratory Neonatal DistressNeonatal Distress

• Previously, mass lesions in the chest Previously, mass lesions in the chest presented postnatally and were presented postnatally and were diagnosed with the help of the diagnosed with the help of the postnatal CXR. postnatal CXR.

• Currently, with the widespread use of Currently, with the widespread use of prenatal OB US, many chest mass prenatal OB US, many chest mass lesions are discovered prior to birth. lesions are discovered prior to birth.


• Prenatal MRI can be helpful in Prenatal MRI can be helpful in working up the chest mass.working up the chest mass.

• Regardless of the prenatal imaging, Regardless of the prenatal imaging, chest masses will be evident on the chest masses will be evident on the postnatal CXR.postnatal CXR.


• Chest masses can result in mass Chest masses can result in mass effect and shift of the mediastinum. effect and shift of the mediastinum.

• This will result in airway compromise This will result in airway compromise and pulmonary hypoplasia.and pulmonary hypoplasia.


• Additionally, mass effect on the Additionally, mass effect on the esophagus can result in decreased esophagus can result in decreased swallowing and polyhydramnios. swallowing and polyhydramnios.

• The mass effect may be severe The mass effect may be severe enough to limit venous return to the enough to limit venous return to the heart and significantly decrease heart and significantly decrease cardiac output. cardiac output.

Etiologies of Surgical Etiologies of Surgical Neonatal Respiratory Neonatal Respiratory DistressDistress • Congenital Diaphragmatic Congenital Diaphragmatic

HerniaCongenital HerniaCongenital

• Cystic Adenomatoid MalformationCystic Adenomatoid Malformation

• Congenital Lobar EmphysemaCongenital Lobar Emphysema

• SequestrationSequestration

Congenital Diaphragmatic Congenital Diaphragmatic Hernia (CDH)Hernia (CDH)

• A defect in the diaphragm will result A defect in the diaphragm will result in herniation of abdominal contents in herniation of abdominal contents into the thoracic cavity. into the thoracic cavity.

• The mass effect from the abdominal The mass effect from the abdominal contents in the chest will lead to contents in the chest will lead to severe respiratory distress from severe respiratory distress from pulmonary hypoplasia in both the pulmonary hypoplasia in both the ipsilateral and contralateral lung. ipsilateral and contralateral lung.


• The most common defect is in the The most common defect is in the posterior and lateral diaphragm.posterior and lateral diaphragm.

• This is a Bochdalek hernia, which is This is a Bochdalek hernia, which is more common on the left (75%). more common on the left (75%).


• A Morgagni hernia is less common and is A Morgagni hernia is less common and is anterior and medial.anterior and medial.

• Morgagni hernias present later in life and Morgagni hernias present later in life and are more common on the right because are more common on the right because the heart and pericardium will protect the the heart and pericardium will protect the left side.left side.

• Congenital diaphragmatic hernia is Congenital diaphragmatic hernia is frequently diagnosed on prenatal US.frequently diagnosed on prenatal US.

• The postnatal CXR is confirmatory. The postnatal CXR is confirmatory.

• Postnatal CXR Postnatal CXR demonstrates a mass in demonstrates a mass in the lower left chest with the lower left chest with shift of the mediastinum.shift of the mediastinum.

• The presence of bowel gas The presence of bowel gas (red arrow) indicates the (red arrow) indicates the mass is due to a mass is due to a diaphragmatic hernia. diaphragmatic hernia.

• In this case, the stomach In this case, the stomach remains in the abdominal remains in the abdominal cavity as indicated by the cavity as indicated by the position of the nasogastric position of the nasogastric tube (yellow arrow).tube (yellow arrow).

• CXR demonstrates a CXR demonstrates a mass in the left mass in the left chest with shift of chest with shift of the mediastinum.the mediastinum.

• Although no bowel Although no bowel gas is identifiedgas is identified

• the position of the the position of the nasogastric tube nasogastric tube (red arrow) indicates (red arrow) indicates the stomach is the stomach is located in the located in the thoracic cavity.thoracic cavity.

Congenital Cystic Adenomatoid Malformation Congenital Cystic Adenomatoid Malformation (CCAM)(CCAM)

• Congenital cystic adenomatoid Congenital cystic adenomatoid malformation is a hamartoma of the malformation is a hamartoma of the lung.lung.

• If there is significant mass effect in the If there is significant mass effect in the chest, CCAM is surgically resected.chest, CCAM is surgically resected.

• Occasionally CCAM can regress. Occasionally CCAM can regress. • CCAM that is discovered on prenatal US CCAM that is discovered on prenatal US

may not be recognized on the postnatal may not be recognized on the postnatal CXR. CXR.

Congenital Cystic Adenomatoid Malformation Congenital Cystic Adenomatoid Malformation (CCAM)(CCAM)

• Chest CT may be necessary to demonstrate Chest CT may be necessary to demonstrate the CCAM.the CCAM.

• The presentation can vary from a large The presentation can vary from a large cystic lesion to a grossly solid appearing cystic lesion to a grossly solid appearing lesion that is composed of microscopic cysts. lesion that is composed of microscopic cysts.

• CCAM has a normal pulmonary arterial CCAM has a normal pulmonary arterial supply as opposed to pulmonary supply as opposed to pulmonary sequestration. sequestration.

• Three types of CCAM are recognized Three types of CCAM are recognized depending on gross appearance: depending on gross appearance:

• Type I CCAM - Most frequent (2/3 of cases), Type I CCAM - Most frequent (2/3 of cases), contains a dominant cyst > 2 cm surrounded by contains a dominant cyst > 2 cm surrounded by multiple, smaller cysts.multiple, smaller cysts.

• Type II CCAM ö (15-33%) uniform smaller cysts up Type II CCAM ö (15-33%) uniform smaller cysts up to 2 cm. Other congenital malformations are to 2 cm. Other congenital malformations are associated with Type II CCAM in 50% of cases.associated with Type II CCAM in 50% of cases.

• Type III CCAM ö Least common (< 10%), contains Type III CCAM ö Least common (< 10%), contains microscopic cysts that are not grossly visible. microscopic cysts that are not grossly visible. Grossly and on imaging the lesion appears solid. Grossly and on imaging the lesion appears solid.

Example of a Type 1 CCAM on CXR with a large dominant cyst containing an air fluid level

Chest CT on the same patient confirms a Type I CCAM with a large dominant cyst surrounded by multiple smaller cysts

Congenital Lobar Congenital Lobar Emphysema (CLE)Emphysema (CLE)

• characterized by overexpansion of characterized by overexpansion of one or more lobes. one or more lobes.

• Emphysema is a misnomer as there Emphysema is a misnomer as there is no destruction of alveoli. is no destruction of alveoli.

• The etiology of CLE is not entirely The etiology of CLE is not entirely clear, but it is thought to result from clear, but it is thought to result from an airway obstruction, which can an airway obstruction, which can arise from a myriad of causes. arise from a myriad of causes.


• However, even at surgical resection and However, even at surgical resection and pathologic examination, the cause is pathologic examination, the cause is not usually identified. not usually identified.

• Prior to resection CT and bronchoscopy Prior to resection CT and bronchoscopy are helpful to rule out a treatable cause are helpful to rule out a treatable cause such as a pulmonary sling.such as a pulmonary sling.

• CLE has a distinct anatomic CLE has a distinct anatomic distribution: 43% in the left upper lobe, distribution: 43% in the left upper lobe,


• 32% in the right middle lobe, and 32% in the right middle lobe, and 20% in the right upper lobe. 20% in the right upper lobe.

• Initially, CLE will appear as a solid Initially, CLE will appear as a solid mass on both prenatal US and mass on both prenatal US and postnatal CXR because of the postnatal CXR because of the delayed clearance of pulmonary delayed clearance of pulmonary fluid. fluid.


• Over several days the fluid will slowly Over several days the fluid will slowly resorb, and resorb, and

• the classic findings of a hyperlucent lobe the classic findings of a hyperlucent lobe will be present. will be present.

• The initial appearance of a CLE as a solid The initial appearance of a CLE as a solid chest mass may mimic CCAM, chest mass may mimic CCAM, sequestration or even a tumor. sequestration or even a tumor.

• The appearance of a CLE as a hyperlucent The appearance of a CLE as a hyperlucent lobe can be confused with a lobe can be confused with a pneumothorax. pneumothorax.

• Initial postnatal CXR Initial postnatal CXR demonstrates a solid demonstrates a solid appearing mass in the appearing mass in the left upper chest (red left upper chest (red arrows) with mass arrows) with mass effect and shift of the effect and shift of the mediastinum (yellow mediastinum (yellow arrow). arrow).

• At this point, the CLE is At this point, the CLE is filled with fluid and thus filled with fluid and thus mimics a solid mass. mimics a solid mass.

• Chest CT on day 2 Chest CT on day 2 of life. of life.

• The fluid has been The fluid has been absorbed and the absorbed and the left upper lobe is left upper lobe is shown to be shown to be hyperinflated hyperinflated resulting in mass resulting in mass effect and shift of effect and shift of the mediastinum. the mediastinum.

•This is a more difficult case because it does not look like typical, hyperlucent CLE.•Remember that CLE is more opaque in the initial period due to the retention of fetal pulmonary fluid.

The gross specimen confirms the hyperexpansion of the left upper lobe.

Pulmonary sequestrationPulmonary sequestration

• Defined as a congenital mass of Defined as a congenital mass of aberrant pulmonary tissue that has aberrant pulmonary tissue that has no normal connection with the no normal connection with the bronchial tree or pulmonary arteries bronchial tree or pulmonary arteries

• And usually supplied by anomalous And usually supplied by anomalous artery arising from the aortaartery arising from the aorta

Two types Two types Intralobar sequestration(ILS)Intralobar sequestration(ILS)

• It is contained within the lung with no It is contained within the lung with no separate pleural covering and separate pleural covering and connected to adjacent lungconnected to adjacent lung

• It is confined to lower lobeIt is confined to lower lobe

• Venous drainage is via pulmonary Venous drainage is via pulmonary veinsveins

Extralobar sequstration(ELS)Extralobar sequstration(ELS)

• It is located between lower lobe and It is located between lower lobe and diaphragm and has its own pleural diaphragm and has its own pleural coveringcovering

• Commonly seen on left sideCommonly seen on left side

• Venous drainage via azygous systemVenous drainage via azygous system

ImagingImaging

1.1. USG- Modality of choice Antenatal USG- Modality of choice Antenatal usg shows fetal chest mass and strongly usg shows fetal chest mass and strongly suggests ds of ELSsuggests ds of ELS

2.2. Doppler- shows vascular connections to the Doppler- shows vascular connections to the sequestration sequestration

3.3. C.T- ILS- Localises and shows the extent of C.T- ILS- Localises and shows the extent of the abnormality, showing multicystic mass the abnormality, showing multicystic mass at lung base at lung base ELS- solid soft tissue mass with contrast ELS- solid soft tissue mass with contrast enhancement adjacent to diaphragmenhancement adjacent to diaphragm

ImagingImaging

1.1. MRI- useful for identifying the MRI- useful for identifying the pulmonary abnormality and pulmonary abnormality and vascular connections in a vascular connections in a multiplanar fashionmultiplanar fashion

TEA BREAK FOR 5minTEA BREAK FOR 5min

Pediatric AirwayPediatric Airway

•LaryngomalaciaLaryngomalacia • Evaluation of a child with an Evaluation of a child with an

inspiratory stridor is a frequent inspiratory stridor is a frequent request. request.

• Most commonly, inspiratory stridor is Most commonly, inspiratory stridor is caused by laryngomalacia. caused by laryngomalacia.


• Laryngomalacia is caused by a Laryngomalacia is caused by a characteristic infolding of the characteristic infolding of the aryepiglottic folds, which obstruct aryepiglottic folds, which obstruct the airway. the airway.

• This is self-limiting and improves by This is self-limiting and improves by 1-2 years of age. 1-2 years of age.

• If laryngomalacia is excluded, If laryngomalacia is excluded, tracheomalacia is considered. tracheomalacia is considered.


• The diagnosis can be made by The diagnosis can be made by bronchoscopy, but the radiologist may bronchoscopy, but the radiologist may be asked to image the child to identify be asked to image the child to identify the tracheomalacia and to look for a the tracheomalacia and to look for a cause such as a vascular anomaly.cause such as a vascular anomaly.

• Lateral fluoroscopy can identify the Lateral fluoroscopy can identify the collapse of the trachea with expiration collapse of the trachea with expiration confirming tracheomalacia. confirming tracheomalacia.

CroupCroup

• Croup, or acute Croup, or acute laryngotracheobronchitis, remains a laryngotracheobronchitis, remains a common cause of upper airway common cause of upper airway obstruction. obstruction.

• Croup is viral, most commonly Croup is viral, most commonly parainfluenza, and is seen mostly in parainfluenza, and is seen mostly in the fall and winter when the fall and winter when parainfluenza is more common. parainfluenza is more common.

CroupCroup

• Croup is seen in a younger Croup is seen in a younger population than epiglottitis (usually 6 population than epiglottitis (usually 6 months ö3 years). months ö3 years).

• Croup presents with a distinctive Croup presents with a distinctive barking cough and is self limited, barking cough and is self limited, lasting about a week.lasting about a week.

CroupCroup

• A lateral soft tissue radiograph will show A lateral soft tissue radiograph will show the AP narrowing of the subglottic the AP narrowing of the subglottic trachea, which normally should maintain trachea, which normally should maintain the same AP diameter to the thoracic the same AP diameter to the thoracic inlet. inlet.

• An AP soft tissue neck film will also show An AP soft tissue neck film will also show subglottic narrowing, but this can be subglottic narrowing, but this can be confused with normal respiration confused with normal respiration changes. changes.

CroupCroup

• CXR will usually show signs of the CXR will usually show signs of the viral bronchitis.viral bronchitis.

• Most importantly, the radiographic Most importantly, the radiographic examination will also determine if examination will also determine if there is a retropharyngeal abscess or there is a retropharyngeal abscess or an airway foreign body. an airway foreign body.

AP and lateral soft tissue exam of the neck demonstrates the subglottic edema.

Retropharyngeal AbscessRetropharyngeal Abscess

• Retropharyngeal abscess results Retropharyngeal abscess results from infection with group B from infection with group B streptococcus or staphylococcus streptococcus or staphylococcus infections of the orophaynx. infections of the orophaynx.

• Clinical presentation is with fever, Clinical presentation is with fever, stiff neck, dysphagia and cervical stiff neck, dysphagia and cervical adenopathy. adenopathy.

Retropharyngeal AbscessRetropharyngeal Abscess

• Soft tissue neck radiographs will Soft tissue neck radiographs will demonstrate retropharyngeal soft demonstrate retropharyngeal soft tissue swelling and soft tissue gas. tissue swelling and soft tissue gas.

• Neck CT is helpful to demonstrate Neck CT is helpful to demonstrate the extent of the disease and to the extent of the disease and to determine if there are drainable fluid determine if there are drainable fluid collections. collections.

Pulmonary Inflammatory Pulmonary Inflammatory DiseaseDisease

•Viral Pulmonary InfectionsViral Pulmonary Infections• Community acquired pediatric Community acquired pediatric

pulmonary infections are caused by a pulmonary infections are caused by a wide variety of organisms. wide variety of organisms.


• They are most commonly viral in etiology They are most commonly viral in etiology and present in children less than 5 years and present in children less than 5 years old. old.

• Bacteria and mycoplasma become more Bacteria and mycoplasma become more common with increasing age.common with increasing age.

• Respiratory syncytial virus (RSV) is the Respiratory syncytial virus (RSV) is the most frequently encountered viral agent in most frequently encountered viral agent in the infant and toddler population, usually the infant and toddler population, usually presenting in the winter months. presenting in the winter months.


• Parainfluenza, influenza, and Parainfluenza, influenza, and adenovirus are also common viral adenovirus are also common viral pathogens. pathogens.

• Viral infections tend to most severely Viral infections tend to most severely affect the tracheobronchial tree, affect the tracheobronchial tree, resulting in bronchiolitis and resulting in bronchiolitis and bronchitis, with relative sparing of bronchitis, with relative sparing of the lung parenchyma.the lung parenchyma.

Pulmonary Inflammatory Pulmonary Inflammatory DiseaseDisease • The role of the radiologist in interpreting a The role of the radiologist in interpreting a

CXR in a patient with a respiratory infection CXR in a patient with a respiratory infection is to determine if it is viral or bacterial. is to determine if it is viral or bacterial. These differences will be elaborated in the These differences will be elaborated in the following sections.following sections.

• In summary, viral respiratory infections In summary, viral respiratory infections result in bronchitis, which manifests as result in bronchitis, which manifests as peribonchial cuffing, dirty hilum and peribonchial cuffing, dirty hilum and hyperinflation. hyperinflation.

• Bacterial pneumonia will manifest as focal Bacterial pneumonia will manifest as focal lobar consolidation with pleural effusion lobar consolidation with pleural effusion being common. being common.

Viral Pulmonary InfectionViral Pulmonary Infection

• Bronchitis will manifest on the CXR Bronchitis will manifest on the CXR as peribronchial thickening or as peribronchial thickening or peribronchial cuffing.peribronchial cuffing.

• A bronchus seen on end will show A bronchus seen on end will show the bronchial wall thickening, and the bronchial wall thickening, and

• the hilum will demonstrate a dirty the hilum will demonstrate a dirty appearance, which is well appearance, which is well demonstrated on the lateral demonstrated on the lateral projection.projection.


• The bronchial inflammation results in The bronchial inflammation results in areas of mucus plugging and atelectasis areas of mucus plugging and atelectasis whereas other areas of the lung will whereas other areas of the lung will demonstrate hyperinflation from air demonstrate hyperinflation from air trapping. trapping.

• The overall lung volumes will be The overall lung volumes will be hyperinflated with an increase in the hyperinflated with an increase in the anterior retrosternal space and flattening anterior retrosternal space and flattening of the diaphragms.of the diaphragms.


• Viral infections do not have pleural Viral infections do not have pleural effusions, however, these are relatively effusions, however, these are relatively common in bacterial infections. common in bacterial infections.

• The CXR findings for viral infection are The CXR findings for viral infection are the same as that for , reactive airways the same as that for , reactive airways disease in the preschool population. disease in the preschool population.

PA CXR demonstrates atelectasis. LAT CXR demonstrates flattening

of the diaphragms.

Bacterial Pulmonary Bacterial Pulmonary InfectionInfection

• Neonatal pneumonia is frequently Neonatal pneumonia is frequently caused by group b streptococcus and caused by group b streptococcus and Chlamydia. Chlamydia.

• Chlamydia tends to present slightly Chlamydia tends to present slightly later, around 4 weeks, and later, around 4 weeks, and

• the chlamydial conjunctivitis is the chlamydial conjunctivitis is helpful in making the diagnosis.helpful in making the diagnosis.


• Other common organisms include Other common organisms include staphylococcus aureus, haemophilus staphylococcus aureus, haemophilus influenzae type b, and influenzae type b, and pneumococcus.pneumococcus.

• The CXR findings are diagnostic of The CXR findings are diagnostic of pneumonia but not specific as to the pneumonia but not specific as to the infecting organism. infecting organism.


• The most typical presentation is a lobar The most typical presentation is a lobar bronchopneumonia, which manifests on bronchopneumonia, which manifests on CXR as focal lobar consolidation with air CXR as focal lobar consolidation with air bronchograms. bronchograms.

• The consolidation may have a round The consolidation may have a round appearance, called ãround pneumonia, appearance, called ãround pneumonia, and which can mimic a pulmonary mass. and which can mimic a pulmonary mass.

Example of a right middle lobe pneumonia. PA and LAT CXR demonstrate consolidation in the right middle lobe.

Example of a "round pneumonia." PA and LAT CXR shows a round opacity in the superior segment of the right lower lobe which has the appearance of a mass.

Bacterial Pulmonary InfectionBacterial Pulmonary Infection

• Pneumatoceles are frequent with Pneumatoceles are frequent with staphylococcal infections, and they staphylococcal infections, and they should not be confused with a should not be confused with a pulmonary abscess. pulmonary abscess.

• Pneumatoceles have thin, smooth Pneumatoceles have thin, smooth walls and are seen with an improving walls and are seen with an improving clinical picture, whereas clinical picture, whereas


• pulmonary abscesses have thick, irregular pulmonary abscesses have thick, irregular walls with an air fluid level and the child walls with an air fluid level and the child tends to be very ill.tends to be very ill.

• Pneumatoceles are thought to be a form of Pneumatoceles are thought to be a form of localized pulmonary interstitial emphysema localized pulmonary interstitial emphysema and are self limiting with only the rare case and are self limiting with only the rare case of a large, persisting pneumatocele needing of a large, persisting pneumatocele needing surgery. surgery.

Initial CXR shows a dense right upper lobe consolidation.

CXR a week later shows a round cyst with thin walls in the right upper lobe.


• Pleural effusions are common in Pleural effusions are common in bacterial pneumonias and should be bacterial pneumonias and should be easily recognized on the CXR. easily recognized on the CXR.

• Most pleural effusions are Most pleural effusions are transudative parapneumonic transudative parapneumonic effusions that will resolve with effusions that will resolve with antibiotic treatment of the antibiotic treatment of the pneumonia. pneumonia.


• An empyema will result from spread An empyema will result from spread of the infection into the pleural fluid. of the infection into the pleural fluid.

• Differentiating sterile transudative Differentiating sterile transudative parapneumonic pleural fluid from an parapneumonic pleural fluid from an empyema is difficult with imaging, empyema is difficult with imaging, and therefore a sample of the fluid is and therefore a sample of the fluid is usually necessary. usually necessary.


• Children with pneumonia and Children with pneumonia and empyema that are not responding to empyema that are not responding to antibiotics will require drainage. antibiotics will require drainage.

• A chest CT is helpful to plan and A chest CT is helpful to plan and monitor the drainage procedure. monitor the drainage procedure.

PA and LAT CXR demonstrates a left lower lobe consolidation, representing pneumonia. Also note the meniscus in the left costophrenic angle indicating a parapneumonic left pleural effusion.

Example of an empyema. CT through the lower thorax shows a fluid collection in the right lower pleural space with an air fluid level and a thick enhancing wall.

TuberculosisTuberculosis

• Tuberculosis remains a significant Tuberculosis remains a significant pulmonary infection.pulmonary infection.

• Primary TB in the pediatric Primary TB in the pediatric population differs from the population differs from the presentation of reactivation TB seen presentation of reactivation TB seen in adults. in adults.

TuberculosisTuberculosis

• Primary TB produces a focal lobar Primary TB produces a focal lobar consolidation in any pulmonary lobe. consolidation in any pulmonary lobe.

• Hilar adenopathy and pleural effusions are Hilar adenopathy and pleural effusions are common.common.

• If the lungs are secondarily infected If the lungs are secondarily infected hematogenously, military TB will result hematogenously, military TB will result and present as characteristic, uniform and present as characteristic, uniform small nodules diffusely through the lungs. small nodules diffusely through the lungs.

PA and LAT CXR with diffuse air space disease throughout the right upper lobe and significant right paratracheal adenopathy. The red arrow indicates adenopathy; the yellow arrow indicates TB pneumonia.

Pulmonary underdevelopmentPulmonary underdevelopment

• Lung agenesisLung agenesis

• Lobar underdevelopmentLobar underdevelopment

• Scimitar syndromeScimitar syndrome

Lung agenesisLung agenesis

• Complete agenesis is easily Complete agenesis is easily recognisable with a small opaque recognisable with a small opaque hemithroaxhemithroax

• Mediastinal structures are displaced to Mediastinal structures are displaced to same sidesame side

• Rt. Lung agenesis has a higher Rt. Lung agenesis has a higher mortality rate, due to cv abnormalitiesmortality rate, due to cv abnormalities

• Ds –bronchography and angiographyDs –bronchography and angiography• Ass. With VATER SYNDROMEAss. With VATER SYNDROME

Lung agenesis Lung agenesis

Scimitar syndromeScimitar syndrome• Anomalous vein has the appearance of Anomalous vein has the appearance of

Turkish Sword shape- Scimitar,hence the Turkish Sword shape- Scimitar,hence the namename

• Hypoplasia or aplasia of one or more lobes of Hypoplasia or aplasia of one or more lobes of lung lung

• Ass with abnormalities of pulmonary vessels Ass with abnormalities of pulmonary vessels and thoraxand thorax

• It includes partial anomalous pulmonary It includes partial anomalous pulmonary venous return from abnormal lungvenous return from abnormal lung

• The vein normally drain to IVC but may drain The vein normally drain to IVC but may drain to portal vein, hepatic vein or Rt atriumto portal vein, hepatic vein or Rt atrium

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