Lung- and airway emergencies

Charlotte de Lange,MD,PhD

Pediatric Radiology unit,

Oslo University Hospital, Norway

5th Nordic course - Emergency Radiology

Oslo 18-21.5.2015 clange@ous-hf.no

How come pediatric lung/airway

emergencies are so important

and demand rapid treatment?

www.consultant360.com

More acute emergencies than adults!

Physiology, anatomy and pathology

specific for children

Smaller, flexible airways

collateral ventilation

Large tongue

Increased metabolic rate

Rapid hemodynamic/ respiratory decompensation!

75%

44%

Airway emergencies

Upper

Lower

Traumatic

Non-traumatic

Non-traumatic

lung and lower airway emergencies

Lung and airway emergencies in different age groups

Age/

pathology

Neonate(0-1 mth)

Infant(1-23 mths)

Preschool

child (2-5 y)

Child(6-12y)

Adoles.(13-18y)

Infection Viral

bronchiolitis

Virus

Bacterial

pneumonia

Bacterial

pneumonia

Bacterial

pneumonia

Foreign

body

X

6mths-3y

X

6mths-3y

Tumor Teratoma

Neuro-

blastoma

Lymphoma

Leukemia

Histiocytosis

Lymphoma

Leukemia

Histiocytosis

Lymphoma

Leukemia

Congen .

anomalies

Heart/

lung/vasc./

tracheobron.

anomalies

Diaphr.hernia

Heart/

lung/vasc. /

tracheobron.

anomalies

Diaphr.hernia

Airleaks x x x spont.

de Lange C, Insights Imaging 2011

Clinical presentation

Stridor, cough

Wheezing

Swallowing difficulty

Respiratory distress

Tachypnea

Nasal flaring

Intercostal retractions

Hemoptysis

Failure to thrive

Fever, pain, sepsis

or

Asymptomatic!!

Chest x-ray

Ultrasonography

Computed tomography(CT)

CT/HRCT, MDCT, CTA

Magnetic resonance imaging (MRI), MRA

(PET-CT, Scintigraphy)

ALARA principle (As Low As Reasonably Acheiveable)

Imaging

en.wikipedia.org

cough

at night / with exercise

wheezing

~10-20% chest pain

Chest x-ray if complications are suspected

(air leaks/ infection)

Asthma

Pulmonary infection and

complications

Virus > Bacteriae

(airways) (alveoli)

NB! Overlapping imaging findings

Girl 3 y Boy 4 y

Viral infection Bacterial lobar pneumonia

30% of viral infections – normal x-ray findings (Durand et al 2005)

Complications to infection:

Parapneumonic effusion/ Empyema

Boy 6 y - pneumonia left lower lobe

and pleural effusion

Chest x-ray

US

CT, iv C

2-12 % parapneumonic effusion -few need drainage (Bradley 2011, Elllis 2002)

(Up to date guidelines, 2013)

Boy 13 y - ALL treatment with Asparginase,

central venous line - slight chest pain

CE CTUS w doppler

Pulmonary thrombo embolismBabyn P , Pediatr Radiol 2005 - PTE in children

Uderzo C Jclin Oncol 1995 - 2.9% of ALL pat develpped PTE

Goldenberg NA,NEJM 2005 - Predictors for outcome of ped. PTE

Victoria T Pediatr Radiol 2009- Evaluation for PTE in children with clinical suspicon

Air leaks

Pneumothorax-

neonates and ...

Adolescents

Pneumothorax/ pneumomediastinum/

subcutaneous emphysema

Chest x-ray, US

(expiratory AP views)

CT only in selected cases!

Masses

Vascular malformations

Fibromatosis

Lymphoma/leukemia

Neuroblastoma

Teratoma

Vascular malformations Boy 8 months - rapidly growing tumor in the axilla

Lymphatic

malformation

CT

Cor

MRI Ax -STIR

Boy 8 y – Previous asthma - chest pain

with increasing respiratory distress

Chest CT = acute imaging of airways

T cell lymphoma/ leukemia

Acute fatal outcome!

Congenital anomalies

Heart

Lung

Vascular

Tracheobronchial

Vascular ringschest x-ray

upper GI series

CTA/ MRA

Boy 6 months - stridor

Double aortic arch

“Always look at the airways”

Boy 1 y - Viral inf. with severe breathing problems

Tracheal deviation? Tracheo-bronchomalacia?

Bronchography/

CT – VR 3DTracheal bronchus with

stenosis and malacia

Foreign body aspiration airway/oesophagus etc

Foreign body aspirationGirl 2 y -

cough/ wheezing last 2 weeks

Chest x-ray + fluoroscopy

Medistinal shift

Airtrapping of the ipsilateral side

Diaphragmatic restricted motion

Bronchoscopy - diagnosis/treatm.

Girl 3 y. Cough for 9 mths

before first x-ray

Corpus alienum

Summary

Lung and airway emergencies in children

-respiratory and swallowing difficulties

Radiology is important for a rapid diagnosis

Radiography - still first choice

(US, CT, MRI)

”Always look at the airways”

clange@ous-hf.no