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
Fellow Radiology Lecture Series 2012
Part IPart I
Common Patterns
Fellow Radiology Lecture Series 2012
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
Clinical Clue:Clinical Clue:
Gestational age: RDS always in premature
Xray Clue: Xray Clue:
Pleural effusion rare in RDS
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
MassMass
Sequestration vs bronchogenic cyst
Clinical Clue:Clinical Clue:
Presence and appearance on prenatal US
Xray Clue: Xray Clue:
Doppler showing systemic vessel
Clinical Clue:Clinical Clue:
Presence and appearance on prenatal US
Xray Clue: Xray Clue:
Doppler showing systemic vessel
Fellow Radiology Lecture Series 2012
Multiple LucenciesMultiple Lucencies
Diaphragmatic hernia vs cystic adenomatoid malformation (vs pulmonary interstitial
emphysema)
Clinical Clue:Clinical Clue:
Growth pattern on prenatal US; RDS
Xray Clue:Xray Clue:
Location of stomach bubble
Clinical Clue:Clinical Clue:
Growth pattern on prenatal US; RDS
Xray Clue:Xray Clue:
Location of stomach bubble
Fellow Radiology Lecture Series 2012
Increased Blood FlowIncreased Blood Flow
Intracardiac Shunt vs Edema
Clinical Clue:Clinical Clue:
Murmur
Xray Clue: Xray Clue:
Distinctness of vessels
Clinical Clue:Clinical Clue:
Murmur
Xray Clue: Xray Clue:
Distinctness of vessels
Fellow Radiology Lecture Series 2012
Case: Newborn child (3 hours old) with grunting Case: Newborn child (3 hours old) with grunting and nasal flaringand nasal flaring
Fellow Radiology Lecture Series 2012
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
Clinical Clue:Clinical Clue:
Gestational age: RDS always in premature
Xray Clue: Xray Clue:
Pleural effusion rare in RDS
Fellow Radiology Lecture Series 2012
A B
Cases: 2 premature newborns with respiratory Cases: 2 premature newborns with respiratory distress/same patterndistress/same pattern
Fellow Radiology Lecture Series 2012
Cases: 2 premature newborns with respiratory Cases: 2 premature newborns with respiratory distress/same patterndistress/same pattern
RDS Pneumonia
Fellow Radiology Lecture Series 2012
RDSRDS
• Alveolar collapse
• Interstitial thickening
• Epithelial injury
• Bronchiolar distension
• Alveolar collapse
• Interstitial thickening
• Epithelial injury
• Bronchiolar distension
Fellow Radiology Lecture Series 2012
RDSRDS
• Symmetric ground glass
• Air bronchograms
• Low lung volumes
• NO PLEURAL EFFUSION
• Symmetric ground glass
• Air bronchograms
• Low lung volumes
• NO PLEURAL EFFUSION
Fellow Radiology Lecture Series 2012
Case: Full term newborn admitted to NICU with Case: Full term newborn admitted to NICU with labored breathinglabored breathing
Fellow Radiology Lecture Series 2012
Coarse Reticular: Coarse Reticular: Differential DiagnosisDifferential Diagnosis
• Meconium Aspiration
• Pneumonia• Partially treated
RDS• Transient
Tachypnea
No pleural effusion
Full Term
Rarely
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Meconium AspirationMeconium Aspiration
• Subsegmental collapse
• Compensatory overinflation
• Coarse lines
• PTX (25%)
• Subsegmental collapse
• Compensatory overinflation
• Coarse lines
• PTX (25%)
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
•Patchy asymmetric densities
•Hyperinflation
•Pleural effusion
•Patchy asymmetric densities
•Hyperinflation
•Pleural effusion
Neonatal PneumoniaNeonatal Pneumonia
Fellow Radiology Lecture Series 2012
Case: Term child born by C SectionCase: Term child born by C Section
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Cases: 2 preterm children with respiratory distressCases: 2 preterm children with respiratory distress
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Cases: 2 preterm children with respiratory distressCases: 2 preterm children with respiratory distress
CDH PIE
Fellow Radiology Lecture Series 2012
CDHCDH
•Foramen of Bochdalek
•Failure of mesenchymal induction
•Mass effect
•Foramen of Bochdalek
•Failure of mesenchymal induction
•Mass effect
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
PIEPIE
• RDS, pressure ventilation
• “Air block”
• Interstitium and lymphatics
• RDS, pressure ventilation
• “Air block”
• Interstitium and lymphatics
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Case: Asymptomatic newbornCase: Asymptomatic newborn
• Chest mass
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
CCAM/CPAMCCAM/CPAM
Fellow Radiology Lecture Series 2012
Bronchogenic CystBronchogenic Cyst
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Cases: Two full term newborns with tachypnea Cases: Two full term newborns with tachypnea
A B
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Part IIPart II
Additional Patterns
Fellow Radiology Lecture Series 2012
Focal Lucency Focal Lucency
PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM
• Uplifted thymus
• Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchyma
PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM
• Uplifted thymus
• Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchyma
Fellow Radiology Lecture Series 2012
Focal Lucency Focal Lucency
PNEUMOTHORAXPNEUMOTHORAX
• Spontaneous or related to ventilation
• ALWAYS UNDER TENSION
PNEUMOTHORAXPNEUMOTHORAX
• Spontaneous or related to ventilation
• ALWAYS UNDER TENSION
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
Opaque HemithoraxOpaque Hemithorax
A B
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
Fellow Radiology Lecture Series 2012
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
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