newborn chest reid

Fellow Radiology Lecture Series 2012

Janet R Reid MD, FRCPC

Children’s Hospital of Philadelphia

Janet R Reid MD, FRCPC

Children’s Hospital of Philadelphia

Newborn ChestNewborn ChestNewborn ChestNewborn Chest


Part IPart I

Common Patterns


Ground GlassGround Glass

RDS vs Group B Strep infection

Clinical Clue:Clinical Clue:

Gestational age: RDS always in premature

Xray Clue: Xray Clue:

Pleural effusion rare in RDS






Fine ReticularFine Reticular

Transient tachypnea vs edema

Clinical Clue:Clinical Clue:History of C-Section in TTN

Xray Clue:Xray Clue: Cardiomegaly more pronounced in Heart Disease

Clinical Clue:Clinical Clue:History of C-Section in TTN

Xray Clue:Xray Clue: Cardiomegaly more pronounced in Heart Disease


Coarse ReticularCoarse Reticular

Meconium aspiration vs pneumonia

Clinical Clue:Clinical Clue:Thick meconium at birth; fetal distress

Xray Clue:Xray Clue: Effusion more common in pneumonia

Clinical Clue:Clinical Clue:Thick meconium at birth; fetal distress

Xray Clue:Xray Clue: Effusion more common in pneumonia


MassMass

Sequestration vs bronchogenic cyst


Presence and appearance on prenatal US


Doppler showing systemic vessel


Presence and appearance on prenatal US


Doppler showing systemic vessel


Multiple LucenciesMultiple Lucencies

Diaphragmatic hernia vs cystic adenomatoid malformation (vs pulmonary interstitial

emphysema)


Growth pattern on prenatal US; RDS

Xray Clue:Xray Clue:

Location of stomach bubble


Growth pattern on prenatal US; RDS

Xray Clue:Xray Clue:

Location of stomach bubble


Increased Blood FlowIncreased Blood Flow

Intracardiac Shunt vs Edema


Murmur


Distinctness of vessels


Murmur


Distinctness of vessels


Case: Newborn child (3 hours old) with grunting Case: Newborn child (3 hours old) with grunting and nasal flaringand nasal flaring


Ground GlassGround Glass

RDS vs Group B Strep infection










A B

Cases: 2 premature newborns with respiratory Cases: 2 premature newborns with respiratory distress/same patterndistress/same pattern


Cases: 2 premature newborns with respiratory Cases: 2 premature newborns with respiratory distress/same patterndistress/same pattern

RDS Pneumonia


RDSRDS

• Alveolar collapse

• Interstitial thickening

• Epithelial injury

• Bronchiolar distension

• Alveolar collapse

• Interstitial thickening

• Epithelial injury

• Bronchiolar distension


RDSRDS

• Symmetric ground glass

• Air bronchograms

• Low lung volumes

• NO PLEURAL EFFUSION

• Symmetric ground glass

• Air bronchograms

• Low lung volumes

• NO PLEURAL EFFUSION


Case: Full term newborn admitted to NICU with Case: Full term newborn admitted to NICU with labored breathinglabored breathing


Coarse Reticular: Coarse Reticular: Differential DiagnosisDifferential Diagnosis

• Meconium Aspiration

• Pneumonia• Partially treated

RDS• Transient

Tachypnea

No pleural effusion

Full Term

Rarely


Meconium AspirationMeconium Aspiration

• Full term, fetal distress

• Bile acids

• Small airway inflammation

• Thick exudate

• Obstruction

• Full term, fetal distress

• Bile acids

• Small airway inflammation

• Thick exudate

• Obstruction


Meconium AspirationMeconium Aspiration

• Subsegmental collapse

• Compensatory overinflation

• Coarse lines

• PTX (25%)

• Subsegmental collapse

• Compensatory overinflation

• Coarse lines

• PTX (25%)


Neonatal PneumoniaNeonatal Pneumonia

• Airspace filling

• E Coli; Streptococcus; Staphylococcus

• No clinical markers

• Prolonged rupture of membranes

• Airspace filling

• E Coli; Streptococcus; Staphylococcus

• No clinical markers

• Prolonged rupture of membranes


•Patchy asymmetric densities

•Hyperinflation

•Pleural effusion

•Patchy asymmetric densities

•Hyperinflation

•Pleural effusion

Neonatal PneumoniaNeonatal Pneumonia


Case: Term child born by C SectionCase: Term child born by C Section


Fine Reticular: Fine Reticular: Differential DiagnosisDifferential Diagnosis

• Transient

tachypnea of the

newborn (retained

fetal lung liquid)

• Pulmonary edema

• Pneumonia

Heart usually bigger

No clinical or radiographic improvement


Transient TachypneaTransient Tachypnea

•Caesarian section

•Lack of squeezing of chest during delivery

•Fluid in interstitium and airspaces

•Caesarian section

•Lack of squeezing of chest during delivery

•Fluid in interstitium and airspaces


Transient TachypneaTransient Tachypnea

• Interstitial edema

• Possible cardiomegaly

• Pleural effusion

• Rapid improvement in 24 hours

• Interstitial edema

• Possible cardiomegaly

• Pleural effusion

• Rapid improvement in 24 hours


Cases: 2 preterm children with respiratory distressCases: 2 preterm children with respiratory distress


Multiple Lucencies: Multiple Lucencies: Differential DiagnosisDifferential Diagnosis

• Congenital Diaphragmatic Hernia

• Congenital Cystic Adenomatoid Malformation

• Pulmonary Interstitial Emphysema

Mass effect; stomach down

Prematurity; day 3 ventilation

Mass effect; stomach up


Cases: 2 preterm children with respiratory distressCases: 2 preterm children with respiratory distress

CDH PIE


CDHCDH

•Foramen of Bochdalek

•Failure of mesenchymal induction

•Mass effect

•Foramen of Bochdalek

•Failure of mesenchymal induction

•Mass effect


CDHCDH

• More commonly left-sided

• Stomach, intestine, liver, spleen

•>35% associated heart disease

• Pulmonary hypoplasia

• Contralateral lung: prognosis

• More commonly left-sided

• Stomach, intestine, liver, spleen

•>35% associated heart disease

• Pulmonary hypoplasia

• Contralateral lung: prognosis


PIEPIE

• RDS, pressure ventilation

• “Air block”

• Interstitium and lymphatics

• RDS, pressure ventilation

• “Air block”

• Interstitium and lymphatics


PIEPIE

• Multiple dark distinct rounded lucencies

• Ventilator settings “going up”

• Can progress to PTX, pneumomediastinum, pneumoperitoneum, pneumopericardium, parenchyma

• Multiple dark distinct rounded lucencies

• Ventilator settings “going up”

• Can progress to PTX, pneumomediastinum, pneumoperitoneum, pneumopericardium, parenchyma


Case: Asymptomatic newbornCase: Asymptomatic newborn

• Chest mass


Mass: Mass: Differential DiagnosisDifferential Diagnosis

• Congenital Diaphragmatic Hernia

• Diaphragm Eventration

• Cystic Adenomatoid Malformation

• Bronchogenic Cyst• Sequestration

Possible

Location

Where is the stomach?

Not cystic

Possible


SequestrationSequestration

• Present prenatally• Diagnosis: Doppler or MRI

• Systemic arterial supply

• Systemic (ELS) or pulmonary (ILS) venous drainage

• Present prenatally• Diagnosis: Doppler or MRI

• Systemic arterial supply

• Systemic (ELS) or pulmonary (ILS) venous drainage


CCAM/CPAMCCAM/CPAM


Bronchogenic CystBronchogenic Cyst


Mass: Mass: Differentiating FeaturesDifferentiating Features

• Congenital Diaphragmatic Hernia:• Prenatal diagnosis (fetal MRI)• Respiratory distress• High position of the stomach

• Diaphragm Eventration:• Cannot differentiate from CDH with imaging

• Cystic Adenomatoid Malformation:• Prenatal diagnosis; US; CT

• Bronchogenic Cyst:• Usually mediastinal or right-sided parenchymal


Cases: Two full term newborns with tachypnea Cases: Two full term newborns with tachypnea

A B


Cases: Two full term newborns with tachypnea Cases: Two full term newborns with tachypnea

Edema Shunt

• In edema the vessels are indistinct

• With shunt vascularity, they are big and distinct

• In both there is usually cardiomegaly

• In edema the vessels are indistinct

• With shunt vascularity, they are big and distinct

• In both there is usually cardiomegaly


Part IIPart II

Additional Patterns


Focal Lucency Focal Lucency

PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

• Uplifted thymus

• Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchyma

PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

• Uplifted thymus

• Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchyma


Focal Lucency Focal Lucency

PNEUMOTHORAXPNEUMOTHORAX

• Spontaneous or related to ventilation

• ALWAYS UNDER TENSION

PNEUMOTHORAXPNEUMOTHORAX

• Spontaneous or related to ventilation

• ALWAYS UNDER TENSION


Small ThoraxSmall Thorax

PULMONARY HYPOPLASIAPULMONARY HYPOPLASIA

• Dysplastic, obstructed or absent kidneys

• Oligohydramnios leads to pulmonary hypoplasia

PULMONARY HYPOPLASIAPULMONARY HYPOPLASIA

• Dysplastic, obstructed or absent kidneys

• Oligohydramnios leads to pulmonary hypoplasia


Asymmetric VentilationAsymmetric Ventilation

CHRONIC LUNG DISEASE OF CHRONIC LUNG DISEASE OF PREMATURITYPREMATURITY

• Air trapping• Atelectasis• Cysts

CHRONIC LUNG DISEASE OF CHRONIC LUNG DISEASE OF PREMATURITYPREMATURITY

• Air trapping• Atelectasis• Cysts


Opaque HemithoraxOpaque Hemithorax

A B


Opaque HemithoraxOpaque Hemithorax

Pulmonary Agenesis Atelectasis

ATELECTASISATELECTASIS• +/- Air bronchograms• ET tube

ATELECTASISATELECTASIS• +/- Air bronchograms• ET tube

PULMONARY AGENESISPULMONARY AGENESIS• Pleural rind• No lung markings

PULMONARY AGENESISPULMONARY AGENESIS• Pleural rind• No lung markings


SummarySummary

• There are several common patterns of disease on newborn chest radiographs

• One can differentiate between diseases based on clinical and radiographic clues

• Important to adopt a differential diagnosis to include 2 “top contenders” for each pattern

• Use ultrasound and prenatal MRI in pediatric chest disease


SummarySummary

• Gestational age: RDS always in premature

• Pleural effusion rare in RDS

• Gestational age: RDS always in premature

• Pleural effusion rare in RDS

RDS vs GBSRDS vs GBS InfectionInfection

GROUND GLASSGROUND GLASS

• History of C-Section in TTN

• Cardiomegaly more pronounced in Heart Disease

• History of C-Section in TTN

• Cardiomegaly more pronounced in Heart Disease

FINE RETICULARFINE RETICULAR

TTN vs EdemaTTN vs Edema

• Thick meconium at birth; fetal distress

• Effusion more common in pneumonia

• Thick meconium at birth; fetal distress

• Effusion more common in pneumonia

COARSE RETICULARCOARSE RETICULAR

Meconium vs Meconium vs PneumoniaPneumonia


SummarySummary

• Presence and appearance on prenatal US• Doppler showing systemic vessel

• Presence and appearance on prenatal US• Doppler showing systemic vessel

Sequestration vs bronchogenic cyst

MASSMASS

• Growth pattern on

prenatal US; RDS

• Location of stomach

bubble

• Growth pattern on

prenatal US; RDS

• Location of stomach

bubble

MULTIPLE LUCENCIESMULTIPLE LUCENCIES

CDH vs CCAM vs PIECDH vs CCAM vs PIE

• Murmur

• Distinctness of

vessels

• Murmur

• Distinctness of

vessels

INCREASED FLOWINCREASED FLOW

Edema vs L-->R Edema vs L-->R ShuntShunt

newborn chest reid

Education

prenatalusxray clue

murmurxray clue

prematurexray clue

massclinical clue

premature xray clue

ttn xray clue

ground glass clinical

coarse reticularclinical