ser 2016 30 mts k sodhi

Dr. Kushaljit Singh Sodhi MD,PhDAdditional Professor

Department of Radiodiagnosis & ImagingPGIMER, Chandigarh

Approach to Pediatric Chest Imaging in ER

SER 2016

Radiological Modalities: Pediatric Chest

Chest X-rayFluoroscopyUltrasoundContrast Studies CT scanMRI

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Radiological Modalities: Pediatric Chest

Chest X-ray

Ultrasound

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Approach to Pediatric Chest in ER

Age of the child Clinical profile

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ALARA

Non-traumatic Chest

Appropriateness Criteria American College of Radiology(ACR)

-Appropriateness criteria and referral guidelines for the appropriate use of imaging examinations

Evidence based guidelines Developed by panel of experts and

criteria covers over 180 topics with nearly 850 variants

www.acr.org/ac

Thoracic Emergencies in children of different ages

Neonatal respiratory distress

Infant Pre-school :1-5 yrs School age: 5-12 yrs

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Thoracic Emergencies in children of different ages

Pathology Infant (<1 yr)

Preschool(1-5 yrs)

School child(5-12 yrs)

Congenital anomalies

+

Infections + + +

Foreign bodies + +

Airleaks + +

Tumours + +

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Neonatal Respiratory Distress : Incidence

Neonatal respiratory distress occurs in 11-14 % of all live births

Incidence depends on gestational age

Babies< 30 wks: 60% Babies >34 wks: 6%

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Am Fam Physician 2007; 76:987-94Pediatrics:1999; 104:1229-46

Respiratory Distress in Neonate: Algorithm

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Medical Disease Surgical Disease



Preterm Full Term At Birth Postnatal Period

Hyaline Membrane

Disease

Transient Tachypnoea

Meconium Aspiration

Neonatal Pneumonia

CDHCPAM CLE

VascularRing/ Sling.

Medical Disease

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Approach to Medical Disease

Hyaline Membrane Disease (HMD)

AKA neonatal respiratory distress syndrome or surfactant deficiency syndrome

In premature infant– Insufficiency of surfactant

production – MC cause of resp distress in 60%

of babies <29 wks

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Develops typically before neonate is 4 hours old& persists>24 hrs of age

Hyaline Membrane Disease (HMD)CXR Findings: • Seen as reticulogranular

(ground-glass) appearance • Hypovolemic lungs

Key points: • Hyperinflation excludes HMD• Pleural effusions seldom seen

Ped Radiol:1997:27:26-31

Hyaline Membrane Disease

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Hyaline Membrane Disease: Post Surfactant

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1st Chest x-ray After 18 hours

Rapid response

Hyaline Membrane Disease:

Is there any role of Ultrasound?

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Sonography in HMD: Diagnostic Performance

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S.No Authors Reference Sensitivity Specificity

1. Bober, et al Med Sci Monit. 2006 ;12 : 440-6100% 92%

2. Copetti, et al Neonatology. 2008; 94: 52-9 100% 100%

3. Ahuja, et al (PGI study)

IJRI 2012:22;4: 279-283 84.2% 88%

Hyaline Membrane Disease: Role of Ultrasound

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Retrodiaphragmatic hyperechogenicity

Ultrasound in HMD

Increased retrodiaphragmtic hyperechogenicity

High sensitivity and specificity for HMD

Also used for follow up of HMD and prediction of BPD

Neonatology2008:94:52-9

Key points:

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IJRI 2012:22: 279-283Ahuja CK,Saxena A, SodhiKS, Kumar P,Khandelwal N

29 wks: 6 hour old

Day 14

Transient Tachypnea of Newborn Respiratory distress shortly after delivery (Term

babies)

Wet lung

Due to retained lung fluid – Caesarian section – No vaginal squeeze – Decreased function of pulmonary capillaries

and lymphatics

CXR Findings

Hyperinflation Small effusion Increased perihilar vascular markings Typically resolves within 24 – 48 hours

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Ultrasound inTransient Tachypnea of Newborn

Double lung point 100% sensitivity & specificity Diff. in lung echogenicity b/w

upper & lower lung fields

Neonatology:2007:91:203-9

Meconium Aspiration Syndrome (MAS)

Affects term and postmature neonates Occurs when infants take meconium

into their lungs during or before delivery

Three main complications – Blocking the airways– Decreasing oxygen exchange – Resulting in chemical

pneumonitis

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Meconium Aspiration Syndrome

CXR findings – Coarse opacities – Hyperinflation– No pleural effusion – Spontaneous

pneumothorax (20%)

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Acute complications: Air leakAir leak

– Pulmonary interstitial emphysema

– Pneumomediastinum– Pnuemopericardium– Pneumothorax

Pneumothorax in neonates Spontaneous or sec to

infection, mec asp, ventilation barotruama

Supine: Air in anteromedial and subpulmonic recesses

Spontaneous more in premature:

6% in premature 1-2% in term babies

Neonatal Pneumonia

Important cause Various Organisms Pulmonary

opacities/consolidation Non specific

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Approach to Surgical Disease

CXR: Detect LesionCT: Diagnosis + Characterization +Pre-op evaluationUSG: No definite role

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Sodhi KS: Acta Paediatr. 2014:103:807-11

Congenital Anomalies Lung

– Lobe: – Segment– Focal

Diaphragm

Mediastinum– Vessels

Agenesis/ Aplasia/ Hypoplasia

CCAM, CLE, Sequestration

• Vascular Ring/ Sling

• Diaphragmatic Hernia

30Sodhi KS,etal :Pediatr Emerg Care. 2005 :21:854-6.

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Pulmonary Agenesis / aplasia/ hypoplasia

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Agenesis Aplasia Hypoplasia

LungAgenesis

LungAplasia

LungHypoplasia

X LungX bronchus +++ Shift

X LungRudimentary bronchus +++ Shift

Rudimentary Lung √ bronchus, ↓+ Shift

X arteryX artery

√ artery, ↓

Sodhi KSIJRI 2001:145-46

Congenital Pulmonary Airway Malformation (CPAM)

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Congenital pulmonary airway malformation(CPAM)

Most common congenital /fetal lung lesion Failure of broncho-alveolar development Histologically- cysts lined by cuboidal or columnar

epithelium

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Thacker et al, current concepts and imaging findings, pg-171

Congenital Cystic Adenomatoid Malformation: CCAM

Congenital Pulmonary Airway Malformation, CPAMClassification (Stocker)

– Type I: (50%) Large cyst(s) (> 2 cm)– Type II: (40%) Multiple cysts (< 2 cm)– Type III: (10%) Solid

Stocker JT, Madewell JE, Drake RM. CCAM of the lung. Hum Pathol 1997; 8: 155 - 171

Type I Type II Type III

Classification(Stocker)

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Stocker JT. Histopathology 2002; 41(Suppl 2):424–30 Lee et al Radiology: Volume 247: Number 3—June 2008

1 Most common-70% 95% of cases involve only one lobe

2 20-25 % of CPAMs

3 8-10% of CPAMs

4 2-5 % of CPAMs

CPAM

Presentation: – Respiratory distress after birth

– Recurrent infection

– Incidental finding post natal cxr / prenatal US

CPAM

Radiological findings: Cystic mass (90%) Single lobe and unilateral

(>95%) Rare in RML If large, contralateral shift of

mediastinum

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CCAM Classification

Lee EY et al. Pediatr Radiol 2007

Type1 Type2 Type 3

CT Findings

40Type 4

Results from progressive over-distension of a pulmonary lobe

Associated with either intrinsic or extrinsic obstruction

Usually presents before 6 months of age (> 80%)

Not necessarily “lobar”

Congenital Lobar Emphysema

Congenital Lobar Hyperinflation

CLH : Clinical Presentation

Severity of symptoms depends on the amount of hyperinflation of the affected lobes (ball valve mechanism)

Resp distress: In newborn : 50 % < 6 months : 80% of cases.

MC site-LUL

42Biyyam DR,etal. Radiographics: 2010 Oct;30(6):1721-38

Congenital Lobar Hyperinflation

CXR Findings Hyperinflated lobe : hyperlucent Pulmonary vessels appear attenuated Surrounding pulmonary vessels displaced Adjacent lung is compressed & mediastinum

may be shifted to C/L side

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CLO

Congenital Diaphragmatic Hernia

Abnormal development of the diaphragm

Types – Bochdalek hernia – Morgagni’s hernia – Central tendon defects

Two major causes of death – Pulmonary hypoplasia – Pulmonary hypertension

Sodhi KS,etal: Afr J Paediatr Surg. 2011 :8:259-60.

Diaphragmatic Hernia Key Points: Early film:

– Radio-opaque hemithorax fluid-filled or collapse bowel

Later film: – Gas-containing bowel

Cystic appearance can change with time/ position

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At Birth After 24 hours

Congenital Diaphragmatic Hernia

CXR Findings – Bowel in chest – Mediastinal shift – Non-visualized diaphragm – Lack of bowel in abdomen – Position of NG tube

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Congenital Vascular Malformation and Tracheobronchial Obstruction

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Radiological investigation : CTA / MRA

1 month old girl c/o cyanotic attacks and noisy breathing since birth

Vascular RING : Trachea and esophagus completely surrounded

Double Aortic Arch: CT angiogram

Volume Rendering

Tracheal compression

MinIP VR: Air Structure

Pulmonary Sling: Incomplete surround

Trachea

Pulmonary sling

Type 2 sling

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Neonate with stridor

Aberrant rt. subclavian artery, forming a sling posterior to the trachea causing mild compression

Approach to Neonatal Respiratory Distress

CXR: Medical Disease

CXR + MDCT: Surgical Disease

MRI : Congenital Vascular lesions

Foreign Bodies in Children

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Foreign Body Aspiration

More common with food than toys

Highest risk between 1 and 3 years old(immature dentition – no molars, poor food control)

Common foods = peanuts, grapes, hard candies

Some foods swell with prolonged aspiration(may even sprout)

Sodhi KS etal ;Acta Paediatr. 2010:99(7):1011-5We used low doses of 80-100 kVp and 50-80 mA

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Clinical Manifestations

Typically …Acute respiratory distress (now resolved or ongoing)

Witnessed choking period

Uncommonly …Cyanosis and resp arrest

Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

Investigations

Xrays Lateral neck Chest – inspiratory, expiratory, decubitus views

Expiratory views

Overinflation (partial obstruction with inspiratory flow)

Volume loss with mediastinal shift towards obstructed side (partial obstruction with expiratory flow)

Atelectasis (complete obstruction)

Decubitus views

Normal Smaller volumes and elevated diaphragmon side down

Abnormal Hyperinflation or “normal” volumes indecub position

If suspected …Need a bronchoscope to rule out or

remove Foreign Body

Next?

Expiratory CXR

Decubitus views

Approach to suspected foreign body

Equivocal cases: do an expiratory viewToddlers cannot !

Bilateral decubitus lateral films allows assessment of air-trapping caused by an inhaled foreign body.

Pediatric Chest Infections

Approach

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ROLE OF IMAGING

Detect the presence

Determine its location and extent

Determination of specific etiological agent

Exclude other thoracic causes of respiratory symptoms

Show complications

Donnelly LF. Imaging in immunocompetent children who have pneumonia. RCNA 2005

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PEDIATRIC CHEST RADIOGRAPHY

Most frequently performed radiographic examination in children

Projection - depending on the age SUPINE AP ERECT PA Lateral view - left lateral -abnormality in mediastinum/ lung base -localise lesion identified on frontal radiograph

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PEDIATRIC CHEST ULTRASOUND

Widely used and valuable in pediatric patients No need for sedation No radiation exposure Real time examination Portable

Brian D. Coley, MD. Chest Sonography in Children: Current Indications, Techniques, and Imaging Findings. RCNA 2011

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ATELECTASIS AND CONSOLIDATION

Atelectatic/consolidated lung transmits sound

Difficult to differentiate between the two

sonographic air bronchogram

sonographic fluid bronchogram

Occasionally homogenously echogenic with few visible bronchi - hepatization

ROLE OF USG

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PLEURAL EFFUSIONS

Sensitivity of USG > supine/decubitus radiographs for small pleural effusion

SIMPLE (serous/chylous) Anechoic fluid collectionCOMPLEX

(purulent/hemorrhagic) Multiple internal echoes Septations &loculations

Brian D. Coley, MD. Chest Sonography in Children: Current Indications, Techniques, and Imaging Findings. RCNA 2011

ROLE OF USG

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ROLE OF CT IN PEDIATRIC LRTI Complications of bacterial pneumonia To exclude underlying abnormality in recurrent

infection To evaluate immunocompromised children - normal

CXR but clinical suspicion To guide FNAC/biopsy DISADVANTAGES

• radiation exposure• requires sedation

Copley SJ. Application of computed tomography in childhood respiratory infections. British Medical Bulletin 2002

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PEDIATRIC CHEST CT

CT technique should be modified to reduce dose & acquisition time by:

-80 to 120 kVp -increasing pitch -decreasing gantry rotation time -reducing mAs according to weight

-smallest FOV ‘Justification & optimization’

Sodhi KS : Acta Paediiatr.2014:103:807-11

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EMPYEMA

Lenticular shape Uniform enhanching

wall (<5 mm) Compression of

adjacent lung Obtuse angle with

chest wall Separation of pleural

layers

ABSCESS

Round shape Thick irregular wall Pulmonary vessels

directly extends towards the lesion

Acute angle with chest wall

Locules of gas within the wall

“split pleura sign” and pulmonary compression are more specific for empyema as they are never seen in lung abscess

ROLE OF CT

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ADENOPATHY

Mediastinal or hilarNon specific finding in

the setting of pneumonia

Low attenuation necrotic centre on CECT - primary TB

ROLE OF CT

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MR IMAGING OF LUNG INFECTIONS

Characterise lung parenchymal, pleural, and lymph node inflammatory abnormalities

To evaluate suspected, acute complications of pneumonia

Absence of ionising radiation –Benefit children with chronic lung conditions and recurrent infection

Sodhi KS et al : J MRI 2016:43:1196-1206Sodhi KS et al : Leuk Lymph 2016:57:70-5

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Sodhi KS et al : J MRI 2016:43:1196-1206Sodhi KS et al : Leuk Lymph 2016:57:70-5

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COMMON BACTERIAL PNEUMONIAS IN CHILDREN

COMMON BACTERIA RADIOGRAPHIC PATTERN

Streptococcus pneumoniae Partial lobar consolidation, round pneumonia

Group A streptococci Segmental bronchopneumonia

Staphylococcus aureus Lobular bronchopneumonia, pneumatocoele, pleural effusion, empyema

Bordetella pertussis Bronchopneumonia, “shaggy heart” appearance

Chlamydia trachomatis Young infant. B/L patchy consolidation and hyperaeration

Mycoplasma pneumoniae School age. Segmental interstitial/airspace opacities

ADLER B, EFFMANN EL. PNEUMONIA AND PULMONARY INFECTION. IN, CAFFEY’S PEDIATRIC DIAGNOSTIC IMAGING, 11TH EDITION

Types of Pulmonary TB

Post primary Primary

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Primary TB Seen in patients not previously exposed to M

tuberculosis Infants and children< 5 years Usually self-limiting 4 main entities:

1.Parenchymal2.Nodal3.Pleural effusion4.Milliary

Ghon focus : primary parenchymal focus Ghon complex: combination of Ghon focus andenlarged draining LNs

Eur J Radiol 2004;51:139 –149.

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Lymphadenopathy Radiological hallmark of primary TB

Prevalence decreases with age

Seen in upto 96% of children and 43% of adults

MC sites – Rt. paratracheal and hilar nodes(UL)

Bilateral in about 1/3rd of the cases

Can be the sole radiographic feature

(more common in infants)

Int J Tuberc Lung Dis 2004:8:392–40286

Lymphadenopathy CT scan more sensitive than CXR

Features:

1.Nodes > 1cm in diameter

2.Central low attenuation with peripheral rim

enhancement

3. Airway compression by enlarged mediastinal lymph

nodes common in children< 5 years of age.

Eur J Radiol 2005;55:158 –172, Pediatr Pulmonol2008;43:505-10

Int J Tuberc Lung Dis 2004;8:392-402

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No contrast injections on MRI

Role of MRI in TB: Lymph node evaluation

MRI: Sensitivity and specificity of 100% for enlarged L nodes (short axis>1cm) Sodhi KS etal: J MRI,2016

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Parenchymal disease in Primary TB

Segmental/lobar distribution

Lower & middle lobe predominance

Indistinguishable from bacterial

pneumonia

Resolution without scarring – 2/3rd of the

cases.

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MILIARY TB

Miliary TB” (Latin word “miliarius,” -millet seed)

~2-6% of the patients with TB

Can occur in both primary and post-primary disease, more

frequent in latter.

Within 6 months of initial exposure

Elderly, infants, immunocompromised

Lymphohematogenous spread.

RadioGraphics 2007;27:1255–1273

WHO. Global Tuberculosis Control: Surveillance, Planning, Financing. Geneva: WHO; 2008.

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MILIARY TB

CXR: may be normal at onset

– diffuse 2-3 mm nodules with slight

lower lobe predominance (85%)

CT

– more sensitive, early detection

– small random nodules(MC)

– ground glass opacities91

Post Primary TB

Occurs in patients previously sensitized to M tuberculosis.

Refers to both reinfection and reactivation of TB. Adolescence & adulthood

Progressive, with cavitation as its hallmark.

Manifest as parenchymal disease, airway involvement, and pleural extension

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Post Primary TB

Distinguishing features of post-primary tuberculosis:

1.Predilection for the upper lobes2. Absence of lymphadenopathy3.Cavitation

AJR2008; 191:834–844.

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VIRAL PNEUMONIASRNA VIRUSES RADIOGRAPHIC PATTERN

RSV HA, BWT, AT, +/- BPParainfluenza HA, BWT, ATInfluenza BPMeasles BP, adenopathyHIV Opportunistic infections,

LIP/PLH

DNA VIRUSES RADIOGRAPHIC PATTERN

Adenovirus BP, BWT, AT, HA. Bronchiectasis and bronchiolitis obliterans

Cytomegalovirus Interstitial pneumonitis, alveolar opacities

Varicella BP, calcificationEpstein-barr virus Adenopathy, LIP/PLHPapillomavirus Nodules +/- cavitation

HA: HYPERAERATIONBWT: BRONCHIOLAR WALL THICKENINGAT: ATELECTASISBP: BRONCHOPNEUMONIA


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FUNGAL PNEUMONIASINFECTION RADIOGRAPHIC

APPEARANCEActinomycosis Lung, nodal, pleual

disease, chest wallNocardia Cavitating nodules,

irregular consolidationBlastomycosis, Cryptococcosis

Consolidation, cavitation, nodules

Candidiasis Bronchopneumonia, nodules

Aspergillosis, invasive Bronchocentric/angiocentric lesion, “halo sign”, “air crescent sign”

Coccidioidomycosis Simulates TB. Thin walled cavities

Histoplasmosis Simulates TB


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PARASITIC INFECTIONS

PARASITIC AGENT RADIOGRAPHIC PATTERN

Pneumocystis jirovecii Progressive bilateral perihilar edema and consolidation

Paragonimus westermani/lung fluke

Patchy/homogenous lung opacity, may calcify, pleual effusions common

Echinococcus Single/multiple round mass lesions, rupture and abscess formation

Toxocara cati and canis Granulomatous lung opacities


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ROUND PNEUMONIA

Children < 8 years Solitary Well-defined borders Often in the perihilar region

or posteriorly in the lungs. Radiologic follow-up after 2-3

weeks to document interval resolution

SUPPURATIVEPARENCHYMALCOMPLICATIONS

COMPLICATIONS OF PNEUMONIAACUTE

CAVITARY NECROSIS, ABSCESS,

PNEUMATOCELE

PULMONARY GANGRENE

BRONCHOPLEURAL FISTULA

PLEURAL EFFUSIONS, EMPYEMA

PNEUMOTHORAX

CHRONIC

BRONCHIECTASIS

BRONCHIOLITIS OBLITERANS

FIBROTHORAX

TRAPPED LUNG

FIBROSING MEDIASTINITIS

Eslamy HK, Newman B. Pneumonia in Normal and Immunocompromised Children: An Overview and Update. Radiol Clin N Am 49 (2011) 895–920

Approach to child with acute respiratory infection

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Always compare with previous imaging to R/O congenital malformations

Wait as LONG AS POSSIBLE for follow up radiographs (2-4 weeks to clear). Recommended in CF/sickle cell anemia/round pneumonia

Our main role is to EXCLUDE bacterial pneumonia, not CONFIRM it, hence EXCLUDE children NOT requiring antibiotics

O2 saturation <94%, RR>60/min, nasal flaring, reduced breath sounds have statistically significant correlation with radiographic diagnosis of pneumonia

Also consider in atypical presentation: Malaise, irritability, headache, chest/abdominal painFEVER, COUGH,

WHEEZING, TACHYPNEA, CHEST

RETRACTIONS

CHEST RADIOGRAPH SHOWS PNEUMONIA

BACTERIAL/VIRAL

FAILURE OF PNEUMONIA TO CLEAR?

PLEUTAL/PARENCHYMAL

COMPLICATIONS

PNEUMONIA MIMICS?? CAUSE OF

PNEUMONIA??

CHEST RADIOGRAPH NORMAL

CT IN IMMUNOCOMPROMISED

CHILDREN

Imaging in Immunocompetent Children Who Have Pneumonia. Radiol Clin N Am 43 (2005) 253 – 265

Chest XRAY recommended for

diagnosis & management

decisions

CECT/USG depending on the clinical scenario

Other causes of acute respiratory distress in children

S.No Cause Recommended Investigation of choice

1 Pulmonary Embolism CTA /MRA

2 Trauma CXR -----Spiral CT

3 Masses / Tumours CXR----MDCT/ MRI

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10 years old boy, with a known diagnosis of Acute myeloid leukemia(AML).Chest radiograph reveals mediastinal mass, with moderate left pleural effusion.

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Imaging in Pulmonary Embolism

CT -PA 3D GRE True FISP

Conclusion

Approach to Pediatric Chest in ER Age of the child Clinical profileChest X-rayUltrasound: Pleural effusionCT & MRI: Congenital & TumoursALARA

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There are no seven wonders of the world in the eyes of a child. There are seven million. ~Walt Streightiff

THANK YOU!

ser 2016 30 mts k sodhi

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