link to powerpoint presentation on interpretation of the chest x-ray
TRANSCRIPT
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Interpretation of the Chest X-ray in Children
Robert Gie Desmond Tutu Tuberculosis Centre
Department Paediatrics and Child Health Stellenbosch University
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Sensitivity = 67% Specificity = 59%
Pediatricians> general physicians
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Inter-observer agreement = 0.33
Intra-observer agreement = 0.55
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DISEASE SPECTRUM AND YIELD
Disease manifestation Total (%)
N = 439
Bacteriologic yield
Not TB
Intra-thoracic TB
Uncomplicated LN
Complicated LN
Other
Extra-thoracic TB
Cervical lymphadenitis
TBM
Other
Intra+Extra
85 (19.4)
307 (69.9)
147 (47.9)
106 (34.5)
54 (17.5)
72 (16.4)
35 (48.6)
14 (19.4)
23 (31.9)
25 (5.7)
120/195 (61.5)
22/64 (34.4)
59/80 (73.5)
39/51 (76.5)
31/46 (67.4)
27/27 (100)
1/10 (10.0)
5/9 (55.6)
12/13 (92.3)
Marais, Hesseling et al. Clin Infect Dis 2007
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Diagnosing Childhood Tuberculosis - What do we have?
History Tuberculin- Skin Test (1890)
Chest X-ray
(1896)
Bacteriology (1882)
Low Specificity
Low Sensitivity
History Chest X-ray
(1896)
Low Specificity
Negative predictive value 99,8% Ozuah (2001) JAMA
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Value of the chest radiograph
Is the CXR normal ?
Is there pathology?
Is this TB?
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Quality of the CXR
• Essential for a good opinion
– Rotation
– Penetration
– Inspiration
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Rotation
• In children use the anterior rib ends
• Clavicle ends are difficult to locate
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Penetration
• Correct penetration is ensured by being able to just distinguish the intervertebral spaces through the heart shadow.
• Under penetration
– White x-ray
• Over penetration
– Black x-ray
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Inspiration
• Adequate inspiration is when the 8-9th posterior rib is visible or 6th anterior rib
• Use only posterior ribs in younger children
• Hyperinflation
– > 9 posterior ribs
• Poor inspiration
– < 8 posterior ribs
• Unilateral hyperinflation (Ball-valve effect)
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Systematic approach
• Identification • Name
• Date
• Supine or erect
• Quality • Rotation
• Penetration
• Inspiration
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Systematic approach
• White • Soft tissue
• Bones
• Heart – Size
– Shape
– Position
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Systematic approach
• Black structures • Trachea and bronchi
• Lungs – Size
– Compare 3 lung fields
– Hilum and vascular structure
» Size
» Shape
» Density
• Stomach bell
• Other structures
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Systematic approach
• Other structures
– Diaphragm
– Costrophrenic angles and pleura
– Mediastinal structures
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The great pretender
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Look in the hidden spaces
• Behind the heart
• Below the diaphragm
• Behind the stenum
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Classification of intrathoracic pulmonary Tb in childhood
• Parenchymal involvement – Progressive primary TB – “Adult” type TB
• Lymph-node disease
– Uncomplicated – Bronchial involvement (Lymphobronchial disease)
• Obstruction • “Check valve” obstruction • Collapse • Ulceration into the bronchus
–Bronchopneumonic spread – Lobar involvement
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Classification of intrathoracic TB in childhood
• Lymph node involvement • With infiltration
– Oesophagus – Phrenic nerve – Ductus thoracicus
• Pleural disease – With effusion – With empyema – With or without pneumothorax
• Pericardial disease • Long-term consequences
• Fibrosis • Calcifications • Bronchiectasis
• Unusual • Unknown
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Adult-type disease
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Adult type disease
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Uncomplicated lymph-node disease
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Subcarinal lymphnodes
1. Fullness below carina
2. Narrowing of both left and right main bronchus
3. Shift of the esophageal adhesion line
1
2 2
3
Subcarinal lymphnodes
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Case 3
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Complicated lymph-node disease Airway compression
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Complicated lymph-node disease Expansile pneumonia
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Complicated lymphnode disease with collapse
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Complicated Ghon focus (Poorly contained disease)
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Ghon focus with breakdown and bronchopneumonia
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Uncomplicated pleural effusion
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Pleural effusion Complicated
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Disseminated disease
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Unusual CXR
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Spinal TB
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Unusual cases
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Consequences of TB Bronchiectasis
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Bronchiectasis and active TB
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HIV related lung disease
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Lymphocytic interstitial pneumonia (pneumonitis)
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HIV/TB : the problem
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Mediastinal T cell lymphoma
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Paratracheal glands
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IRIS
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Resolution: Do not prognosticate too soon
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Conclusion:
• Brief example of how to approach the CXR in a child suspected of TB
• There will always remain large variability between readers
• New technology: transmit images.