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Newborn Chest
    Janet R Reid MD, FRCPC
Children’s Hospital of Philadelphia



     Fellow Radiology Lecture Series 2012
Part I


  Common Patterns



Fellow Radiology Lecture Series 2012
Ground Glass

                 Clinical Clue:
                 Gestational age: RDS
                 always in premature

                 Xray Clue:
                 Pleural effusion rare in RDS



RDS vs Group B Strep infection


Fellow Radiology Lecture Series 2012
Fine Reticular

                 Clinical Clue:
                 History of C-Section in
                 TTN
                 Xray Clue:
                 Cardiomegaly more
                 pronounced in Heart
                 Disease


Transient tachypnea vs edema


Fellow Radiology Lecture Series 2012
Coarse Reticular

                    Clinical Clue:
                    Thick meconium at birth;
                    fetal distress
                    Xray Clue:
                    Effusion more common in
                    pneumonia



Meconium aspiration vs pneumonia


  Fellow Radiology Lecture Series 2012
Mass

                        Clinical Clue:
                        Presence and
                        appearance on prenatal
                        US
                        Xray Clue:
                        Doppler showing
                        systemic vessel


Sequestration vs bronchogenic cyst


    Fellow Radiology Lecture Series 2012
Multiple Lucencies

                         Clinical Clue:
                         Growth pattern on
                         prenatal US; RDS
                         Xray Clue:
                         Location of stomach
                         bubble

Diaphragmatic hernia vs cystic adenomatoid
   malformation (vs pulmonary interstitial
              emphysema)

        Fellow Radiology Lecture Series 2012
Increased Blood Flow

                      Clinical Clue:
                      Murmur

                      Xray Clue:
                      Distinctness of vessels



  Intracardiac Shunt vs Edema


  Fellow Radiology Lecture Series 2012
Case: Newborn child (3 hours old) with grunting
             and nasal flaring




           Fellow Radiology Lecture Series 2012
Ground Glass

                  Clinical Clue:
                  Gestational age:
                  RDS always in premature

                  Xray Clue:
                  Pleural effusion rare in RDS



RDS vs Group B Strep infection

 Fellow Radiology Lecture Series 2012
Cases: 2 premature newborns with respiratory
            distress/same pattern




       A                                          B
           Fellow Radiology Lecture Series 2012
Cases: 2 premature newborns with respiratory
            distress/same pattern




      RDS                          Pneumonia
          Fellow Radiology Lecture Series 2012
RDS




                               • Alveolar collapse
                               • Interstitial thickening
                               • Epithelial injury
                               • Bronchiolar distension


Fellow Radiology Lecture Series 2012
RDS



                        • Symmetric ground glass
                        • Air bronchograms
                        • Low lung volumes
                        • NO PLEURAL EFFUSION




Fellow Radiology Lecture Series 2012
Case: Full term newborn admitted to NICU with
               labored breathing




           Fellow Radiology Lecture Series 2012
Coarse Reticular:
              Differential Diagnosis
• Meconium
  Aspiration
• Pneumonia                            No pleural effusion
• Partially treated
  RDS                                  Full Term
• Transient
  Tachypnea                            Rarely




              Fellow Radiology Lecture Series 2012
Meconium Aspiration




                          •   Full term, fetal distress
                          •   Bile acids
                          •   Small airway inflammation
                          •   Thick exudate
                          •   Obstruction


 Fellow Radiology Lecture Series 2012
Meconium Aspiration



                          •   Subsegmental collapse
                          •   Compensatory overinflation
                          •   Coarse lines
                          •   PTX (25%)




 Fellow Radiology Lecture Series 2012
Neonatal Pneumonia




                • Airspace filling
                • E Coli; Streptococcus; Staphylococcus
                • No clinical markers
                • Prolonged rupture of membranes


 Fellow Radiology Lecture Series 2012
Neonatal Pneumonia



                                 •Patchy asymmetric
                                 densities
                                 •Hyperinflation
                                 •Pleural effusion




 Fellow Radiology Lecture Series 2012
Case: Term child born by C Section




     Fellow Radiology Lecture Series 2012
Fine Reticular:
             Differential Diagnosis
• Transient
  tachypnea of the
  newborn (retained
  fetal lung liquid)
• Pulmonary edema                      Heart usually bigger
• Pneumonia                            No clinical or
                                       radiographic
                                       improvement


             Fellow Radiology Lecture Series 2012
Transient Tachypnea




                          •Caesarian section
                          •Lack of squeezing of chest
                          during delivery
                          •Fluid in interstitium and
                          airspaces


 Fellow Radiology Lecture Series 2012
Transient Tachypnea




                   • Interstitial edema
                   • Possible cardiomegaly
                   • Pleural effusion
                   • Rapid improvement in 24 hours


 Fellow Radiology Lecture Series 2012
Cases: 2 preterm children with respiratory distress




             Fellow Radiology Lecture Series 2012
Multiple Lucencies:
            Differential Diagnosis
• Congenital
  Diaphragmatic                        Mass effect;
                                       stomach up
  Hernia

                                       Mass effect;
                                       stomach down
• Congenital Cystic
  Adenomatoid
  Malformation                         Prematurity;
                                                day 3
• Pulmonary                            ventilation
  Interstitial
  Emphysema
             Fellow Radiology Lecture Series 2012
Cases: 2 preterm children with respiratory distress




         CDH                                  PIE
             Fellow Radiology Lecture Series 2012
CDH




                           •Foramen of Bochdalek
                           •Failure of mesenchymal
                           induction
                           •Mass effect


Fellow Radiology Lecture Series 2012
CDH




                     • More commonly left-sided
                     • Stomach, intestine, liver, spleen
                     •>35% associated heart disease
                     • Pulmonary hypoplasia
                     • Contralateral lung: prognosis


Fellow Radiology Lecture Series 2012
PIE




                           • RDS, pressure ventilation
                           • “Air block”
                           • Interstitium and lymphatics


Fellow Radiology Lecture Series 2012
PIE




          • Multiple dark distinct rounded lucencies
          • Ventilator settings “going up”
          • Can progress to PTX, pneumomediastinum,
          pneumoperitoneum, pneumopericardium,
          parenchyma


Fellow Radiology Lecture Series 2012
Case: Asymptomatic newborn

• Chest mass




          Fellow Radiology Lecture Series 2012
Mass:
           Differential Diagnosis
• Congenital
  Diaphragmatic                       Where is the
  Hernia                              stomach?
• Diaphragm
                                      Possible
  Eventration
• Cystic
  Adenomatoid                         Not cystic
  Malformation
• Bronchogenic Cyst                   Location
• Sequestration                       Possible

            Fellow Radiology Lecture Series 2012
Sequestration




                        • Present prenatally
                        • Diagnosis: Doppler or MRI
                        • Systemic arterial supply
                        • Systemic (ELS) or
                        pulmonary (ILS) venous
                        drainage


Fellow Radiology Lecture Series 2012
CCAM/CPAM




Fellow Radiology Lecture Series 2012
Bronchogenic Cyst




Fellow Radiology Lecture Series 2012
Mass:
              Differentiating 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




          A                                  B
          Fellow Radiology Lecture Series 2012
Cases: Two full term newborns with tachypnea




       • In edema the vessels are indistinct
       • With shunt vascularity, they are big and distinct
       • In both there is usually cardiomegaly


      Edema                                      Shunt
             Fellow Radiology Lecture Series 2012
Part II


 Additional Patterns



Fellow Radiology Lecture Series 2012
Focal Lucency



                             PNEUMOMEDIASTINUM
                             • Uplifted thymus
                             • Can progress to PTX,
                             pneumoperitoneum,
                             pneumopericardium,
                             parenchyma




Fellow Radiology Lecture Series 2012
Focal Lucency



                                PNEUMOTHORAX
                                PNEUMOTHORAX
                                • Spontaneous or
                                related to ventilation
                                • ALWAYS UNDER
                                TENSION




Fellow Radiology Lecture Series 2012
Small Thorax



                         PULMONARY HYPOPLASIA
                        • Dysplastic, obstructed or
                        absent kidneys
                        • Oligohydramnios leads to
                        pulmonary hypoplasia




Fellow Radiology Lecture Series 2012
Asymmetric Ventilation




CHRONIC LUNG DISEASE OF
 CHRONIC LUNG DISEASE OF
         PREMATURITY
         PREMATURITY
• Air trapping
• Atelectasis
• Cysts


    Fellow Radiology Lecture Series 2012
Opaque Hemithorax




A                                   B
 Fellow Radiology Lecture Series 2012
Opaque Hemithorax




 PULMONARY AGENESIS
 PULMONARY AGENESIS                      ATELECTASIS
                                         ATELECTASIS
 • Pleural rind                    • +/- Air bronchograms
 • No lung markings                • ET tube


Pulmonary Agenesis                      Atelectasis

          Fellow Radiology Lecture Series 2012
Summary
• 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
Summary
   GROUND GLASS              FINE RETICULAR         COARSE RETICULAR




• Gestational age: RDS    • History of C-Section   • Thick meconium at
always in premature
                          in TTN                   birth; fetal distress
                          • Cardiomegaly more      • Effusion more
• Pleural effusion rare   pronounced in Heart      common in
in RDS                    Disease                  pneumonia

   RDS vs GBS                TTN vs Edema             Meconium vs
    Infection                                          Pneumonia


                    Fellow Radiology Lecture Series 2012
Summary
        MASS              MULTIPLE LUCENCIES         INCREASED FLOW




• Presence and           • Growth pattern on       • Murmur
appearance on
                         prenatal US; RDS
prenatal US
• Doppler showing        • Location of stomach     • Distinctness of
systemic vessel          bubble                    vessels

 Sequestration vs        CDH vs CCAM vs PIE           Edema vs L-->R
bronchogenic cyst                                        Shunt


                    Fellow Radiology Lecture Series 2012

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Newborn chest reid

  • 1. Newborn Chest Janet R Reid MD, FRCPC Children’s Hospital of Philadelphia Fellow Radiology Lecture Series 2012
  • 2. Part I Common Patterns Fellow Radiology Lecture Series 2012
  • 3. Ground Glass Clinical Clue: Gestational age: RDS always in premature Xray Clue: Pleural effusion rare in RDS RDS vs Group B Strep infection Fellow Radiology Lecture Series 2012
  • 4. Fine Reticular Clinical Clue: History of C-Section in TTN Xray Clue: Cardiomegaly more pronounced in Heart Disease Transient tachypnea vs edema Fellow Radiology Lecture Series 2012
  • 5. Coarse Reticular Clinical Clue: Thick meconium at birth; fetal distress Xray Clue: Effusion more common in pneumonia Meconium aspiration vs pneumonia Fellow Radiology Lecture Series 2012
  • 6. Mass Clinical Clue: Presence and appearance on prenatal US Xray Clue: Doppler showing systemic vessel Sequestration vs bronchogenic cyst Fellow Radiology Lecture Series 2012
  • 7. Multiple Lucencies Clinical Clue: Growth pattern on prenatal US; RDS Xray Clue: Location of stomach bubble Diaphragmatic hernia vs cystic adenomatoid malformation (vs pulmonary interstitial emphysema) Fellow Radiology Lecture Series 2012
  • 8. Increased Blood Flow Clinical Clue: Murmur Xray Clue: Distinctness of vessels Intracardiac Shunt vs Edema Fellow Radiology Lecture Series 2012
  • 9. Case: Newborn child (3 hours old) with grunting and nasal flaring Fellow Radiology Lecture Series 2012
  • 10. Ground Glass Clinical Clue: Gestational age: RDS always in premature Xray Clue: Pleural effusion rare in RDS RDS vs Group B Strep infection Fellow Radiology Lecture Series 2012
  • 11. Cases: 2 premature newborns with respiratory distress/same pattern A B Fellow Radiology Lecture Series 2012
  • 12. Cases: 2 premature newborns with respiratory distress/same pattern RDS Pneumonia Fellow Radiology Lecture Series 2012
  • 13. RDS • Alveolar collapse • Interstitial thickening • Epithelial injury • Bronchiolar distension Fellow Radiology Lecture Series 2012
  • 14. RDS • Symmetric ground glass • Air bronchograms • Low lung volumes • NO PLEURAL EFFUSION Fellow Radiology Lecture Series 2012
  • 15. Case: Full term newborn admitted to NICU with labored breathing Fellow Radiology Lecture Series 2012
  • 16. Coarse Reticular: Differential Diagnosis • Meconium Aspiration • Pneumonia No pleural effusion • Partially treated RDS Full Term • Transient Tachypnea Rarely Fellow Radiology Lecture Series 2012
  • 17. Meconium Aspiration • Full term, fetal distress • Bile acids • Small airway inflammation • Thick exudate • Obstruction Fellow Radiology Lecture Series 2012
  • 18. Meconium Aspiration • Subsegmental collapse • Compensatory overinflation • Coarse lines • PTX (25%) Fellow Radiology Lecture Series 2012
  • 19. Neonatal Pneumonia • Airspace filling • E Coli; Streptococcus; Staphylococcus • No clinical markers • Prolonged rupture of membranes Fellow Radiology Lecture Series 2012
  • 20. Neonatal Pneumonia •Patchy asymmetric densities •Hyperinflation •Pleural effusion Fellow Radiology Lecture Series 2012
  • 21. Case: Term child born by C Section Fellow Radiology Lecture Series 2012
  • 22. Fine Reticular: Differential Diagnosis • Transient tachypnea of the newborn (retained fetal lung liquid) • Pulmonary edema Heart usually bigger • Pneumonia No clinical or radiographic improvement Fellow Radiology Lecture Series 2012
  • 23. Transient Tachypnea •Caesarian section •Lack of squeezing of chest during delivery •Fluid in interstitium and airspaces Fellow Radiology Lecture Series 2012
  • 24. Transient Tachypnea • Interstitial edema • Possible cardiomegaly • Pleural effusion • Rapid improvement in 24 hours Fellow Radiology Lecture Series 2012
  • 25. Cases: 2 preterm children with respiratory distress Fellow Radiology Lecture Series 2012
  • 26. Multiple Lucencies: Differential Diagnosis • Congenital Diaphragmatic Mass effect; stomach up Hernia Mass effect; stomach down • Congenital Cystic Adenomatoid Malformation Prematurity; day 3 • Pulmonary ventilation Interstitial Emphysema Fellow Radiology Lecture Series 2012
  • 27. Cases: 2 preterm children with respiratory distress CDH PIE Fellow Radiology Lecture Series 2012
  • 28. CDH •Foramen of Bochdalek •Failure of mesenchymal induction •Mass effect Fellow Radiology Lecture Series 2012
  • 29. CDH • More commonly left-sided • Stomach, intestine, liver, spleen •>35% associated heart disease • Pulmonary hypoplasia • Contralateral lung: prognosis Fellow Radiology Lecture Series 2012
  • 30. PIE • RDS, pressure ventilation • “Air block” • Interstitium and lymphatics Fellow Radiology Lecture Series 2012
  • 31. PIE • Multiple dark distinct rounded lucencies • Ventilator settings “going up” • Can progress to PTX, pneumomediastinum, pneumoperitoneum, pneumopericardium, parenchyma Fellow Radiology Lecture Series 2012
  • 32. Case: Asymptomatic newborn • Chest mass Fellow Radiology Lecture Series 2012
  • 33. Mass: Differential Diagnosis • Congenital Diaphragmatic Where is the Hernia stomach? • Diaphragm Possible Eventration • Cystic Adenomatoid Not cystic Malformation • Bronchogenic Cyst Location • Sequestration Possible Fellow Radiology Lecture Series 2012
  • 34. Sequestration • Present prenatally • Diagnosis: Doppler or MRI • Systemic arterial supply • Systemic (ELS) or pulmonary (ILS) venous drainage Fellow Radiology Lecture Series 2012
  • 36. Bronchogenic Cyst Fellow Radiology Lecture Series 2012
  • 37. Mass: Differentiating 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
  • 38. Cases: Two full term newborns with tachypnea A B Fellow Radiology Lecture Series 2012
  • 39. Cases: Two full term newborns with tachypnea • In edema the vessels are indistinct • With shunt vascularity, they are big and distinct • In both there is usually cardiomegaly Edema Shunt Fellow Radiology Lecture Series 2012
  • 40. Part II Additional Patterns Fellow Radiology Lecture Series 2012
  • 41. Focal Lucency PNEUMOMEDIASTINUM • Uplifted thymus • Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchyma Fellow Radiology Lecture Series 2012
  • 42. Focal Lucency PNEUMOTHORAX PNEUMOTHORAX • Spontaneous or related to ventilation • ALWAYS UNDER TENSION Fellow Radiology Lecture Series 2012
  • 43. Small Thorax PULMONARY HYPOPLASIA • Dysplastic, obstructed or absent kidneys • Oligohydramnios leads to pulmonary hypoplasia Fellow Radiology Lecture Series 2012
  • 44. Asymmetric Ventilation CHRONIC LUNG DISEASE OF CHRONIC LUNG DISEASE OF PREMATURITY PREMATURITY • Air trapping • Atelectasis • Cysts Fellow Radiology Lecture Series 2012
  • 45. Opaque Hemithorax A B Fellow Radiology Lecture Series 2012
  • 46. Opaque Hemithorax PULMONARY AGENESIS PULMONARY AGENESIS ATELECTASIS ATELECTASIS • Pleural rind • +/- Air bronchograms • No lung markings • ET tube Pulmonary Agenesis Atelectasis Fellow Radiology Lecture Series 2012
  • 47. Summary • 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
  • 48. Summary GROUND GLASS FINE RETICULAR COARSE RETICULAR • Gestational age: RDS • History of C-Section • Thick meconium at always in premature in TTN birth; fetal distress • Cardiomegaly more • Effusion more • Pleural effusion rare pronounced in Heart common in in RDS Disease pneumonia RDS vs GBS TTN vs Edema Meconium vs Infection Pneumonia Fellow Radiology Lecture Series 2012
  • 49. Summary MASS MULTIPLE LUCENCIES INCREASED FLOW • Presence and • Growth pattern on • Murmur appearance on prenatal US; RDS prenatal US • Doppler showing • Location of stomach • Distinctness of systemic vessel bubble vessels Sequestration vs CDH vs CCAM vs PIE Edema vs L-->R bronchogenic cyst Shunt Fellow Radiology Lecture Series 2012

Notas do Editor

  1. Ask one question- what is the gestational age What is this pattern What is the most helpful associated finding for this diagnosis.
  2. Ground glass
  3. What is the pattern: Course reticular
  4. Pattern- fine reticular
  5. Pattern: multiple radiolucencies
  6. Pattern: mass
  7. Pattern: Increased blood flow
  8. Which is pulm agenesis and which is atelectasis