paediatric chest conditions

8/7/2019 Paediatric Chest Conditions

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PAEDIATRIC CHEST CONDITIONS

Reuben GRECH29 th April 2009


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Anatomy


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Thoracic Wall

1. Chest Wall

Ribs 12 pairs (1 st , 11 th and 12 th ribs atypical)Costal cartilagesIntercostals 3 pairs (external, internal, innermost)

Vertebrae Th1 Th12Sternum 3 parts (manubrium, body, xiphoid)

2. Diaphragm (Fibromuscular Structure)

Central TendonMuscular Fibres Peripherally

3. Thoracic Inlet


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Thoracic Cavity

LungsRt lung (3 lobes 10 bronchopulmonary segments)Lt lung (2 lobes 10 bronchopulmonary segments)

PleuraParietalVisceral

MediastinumSuperior (Great Vessels, Trachea, Nerves)Anterior (Thymus)

Middle (Pericardium, Heart )Posterior (Descending Aorta, Oesophagus, Thoracic Duct, Azygos, Thoracic Sympathetic Trunk)


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Thoracic Cavity


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Lungs


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Heart and Large Vessels


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Normal CXR


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Abnormal findings

PleuraEffusionPlaque

LungsConsolidation

Reticuloar ShadowingNodular ShadowingCystic LesionCollapsePneumothoraxAtelactasis

HeartCardiomegaly

Pericardial Effusion

Mediastinum

Extra Thoracic

Bones


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Imaging in Paediatrics

Difficulties in acquiring Images

Uncooperative patientMovementPhase of respiration

Difficulties in Interpretation

Anatomical VariationThymus


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Ca n be very prominent on r ad iogr a phy up to5 ye a rs of a ge

Begins to become sm a ller rel a tive to thechestby the en d of the 1 st d ec ad e

Sha pe c a n be very v a ria ble

Ultra sonogr a phy d emonstr a tes echogenicsept a e, which c a n be helpful in i d entifyingectopic thymus

Differenti a l d ia gnosis(i.e. other c a uses of a nterior me d ia stin a l ma sses)

1. Lymphom a (commonest)2. Ter a tom a3 . Thymic Cyst4. LCH

Thymus


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Congenit

al Respir

atory Disor

ders

Pulmon a ry Agenesis / H ypopl a siaBronchi a l Atresi aCongenit a l Dia phr a gm a tic H erni a sCC AMCongenit a l Loba r Emphysem aTEF / OESequestr a tionBronchogenic Cyst


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Congenit a l Dia phr a gm a tic H erni a s

Incidence = 1:3000M : F = 1:1L : R = 5-9:1Presents with severe respiratory distress in neonates, scaphoid

abdomen, less severe cases may present later in life or incidentally on

radiographyAssociated with other anomalies in 20%Types: Bochdalek, Morgagni, Septum Transversum defect, Hiatal

hernia, EventrationUsually a posterior defect in the diaphragm (Bochdalek)Complicaions: Bilateral pulmonary hypoplasia, Persistent fetal

circulationRadiography : Appearance depends on hernia contents

Bowel loops in the chestContralateral shift of mediastinumCompressed LugDecreased bowel gas in abdomenAbnormal position of NGT


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Congenit a l Cystic Ad enom a toi d Ma lform a tio n

Cause: arrest of normal bronchoalveolar differentiation withovergrowth of terminal bronchioles

Incidence: 25% of congenital lung disordersM:F = 1:1Presents with respiratory distress and sever cyanosis, recurrent

infectionsEqual frequency in all lobes

Imaging appearance depends on type:Type 1: 1 or more large (2-10cm) cystsType 2: numerous small cysts of uniform sizeType 3: appears solid on gross inspection and imaging but

has microcystsMost CCAMs confined to one lobe

Cysts typically contain air communicate with bronchi at birthCan appear as a solid mass: CCAM type 3, Fluid not yet cleared from

cysts


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Congenit a l Loba r Emphysem a

Idiopathic, congenital, progressive over-distension of one/multiple

pulmonary lobes

Classic imaging appearance: hyperlucent, hyperexpanded lobe

Lobar prediliction: Left upper lobe in 43%Presents with respiratory distress and progressive cyanosis

M:F = 3:1

Initially after birth lobe may appear radiodense

causes contrlateral mediastinal shiftPulmonary vessels may appear attenuated

Can be multilobar


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Tra cheo Eosoph a ge a l Fistul a / Eosop a hge a l Atresi a

Disorder in the formation and separation of the primitive foregut intotrachea and oesophagus

5 types- EA without Fistula (type A)- EA with Fistula (types B, C, D)- TOF without atresia (type E - H-shaped fistula)

Radiograph:1. Air filled distended pharangeal pouch2. Food impaction

3. Unsuccessfully passed NGT coiled NGT4. With TEF gas in stomach and bowel5. Without fistula no distal bowel gas6. Signs of other congenital anomalies (VACTERL)


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Sequestr a tion

Congenital malformation consisting of:1. Non functioning lung segment2. No communication with tracheobronchial tree3. Systemic arterial supply

2 types:1. Intralobar (75%) eclosed by visceral pleura of affected

pulmonary lobe2. Extralobar - accessory lobe with its own pleural sheath, which

prevents collateral air drift resulting in an airless round mass

On imaging :round well defined solid homogenous mass near the diaphragmwith mass effectContrast enhancement of sequestration at the same time asthoracic aorta


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Bronchogenic Cyst

Developmental lesion (a foregut duplication cyst)BestDo not communicate with bronchial treeDo not contain air unless infectedPresent with recurrent infections, stridor(from airway compression)May be an incidental finding

Best imaging clue: well defined, soft tissue density mass in middlemediastinum or central lungMay be mediastinal or lung parencymalAlmost always solitaryDo not communicate with the airway


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Acquire d :Respir a tory Distress Syn d romeMeconium Aspir a tion Syn d romeBronchi a l FBPneumothor axPneumome d ia stinumPulmon a ry Interstiti a l Emphysem aCroupEpiglottitisExuda tive tr a che a tisRetroph a rynge a l AbcessEnla rge d TonsilsGlossoptosis

Vira l Disea seBa cteri a l Pneumoni aRoun d Pneumoni aCa vita tory Pneumoni a


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Respir a tory Distress Syn d rome (RDS)

= Surfactant deficiency disorder (SDD) immature type 2 pneumocytesM > FMost common cause of death in newbornsAffects mostly PREMATURE infantsOnset


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Meconium Aspiration Syndrome

= respiratory distress that occurs secondary to intrapartum or intrauterine aspiration of meconium

Most commonly occurs in full term or postmature infantsMost common cause of neonatal respiratory distress in full term

infants

Aspirated meconium causes obstruction of small airways secondary toits tenacious nature

Leads to asymmetric areas of hyperinflation and consolidationPresents with respiratory distress, rarely cyanosisRadiographs:

1. Areas of asymmetric, patchy consolidation, atelactasis

2. Hyperinflation with areas of emphesema3. NO AIR BRONCHOGRAMS4. Rope like perihilar densities5. Pleural effusion6. Rapid clearing usually within 48hrs


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Bronchi a l FB

= aspiration of a FB that lodges in the bronchus leading to bronchialobstruction

May have ball valve effect leading to hyperinflation or completeobstruction leading to collapsePresentation: typically in infants/toddelrs, wheezing, cough,

sometimes fever Best imaging clue: static lung volume at different phases of the

respiratory cycleRadiograph:

1. Volume of affected lung may be normal, increased or decreased2. Hyperinflation

3. Oligaemia4. Atelactasis5. Lung consolidationRarely (3%) aspirated FB is radio-opaque


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Pneumothor ax

Presence of air within the pleural space

Spontaneous pneumothorax1. Primary (occurring in persons without clinically or radiologically

apparent lung disease)

2. Secondary(in which lung disease is present and apparent)Traumatic pneumothorax

1. Resulting from direct (blunt) chest trauma2. Resulting from penetrating chest trauma

Iatrogenic pneumothorax1. Resulting from biopsy procedure

2. Resulting from therapeutic procedures

CX: pneumomediastinum and pneumopericardium , bronchopleuralfistula , tension pneumothorax, re-expansion pulmonary edema


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Pulmon a ry Interstiti a l Emphysem a

Abnormal location of pulmonary air within the interstitium andlymphatics secondary to barotrauma

Best imaging clue: bubble-like and linear lucencies alongbronchovascular structures (often radiate from hilum)

typically presents on routine radiographs prior to symptoms

Serves as a warning sign for other pending air blockcomplications : pneumothorax/pneumomediastinum

Occurs during the first days of lifeusually transientmay be focal (one lobe) or diffuse and bilateralinvolved lung usually non compliant


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Vira l Infection of the Lower Respir a tory Tr a ct

Evaluation of potential LRTI is one of the commonestindications for imaging in children

Etiology of LRTI: Viruses (commonest cause),Mycoplasma Pneumoniae, Strep. PneumoniaePresents with cough, fever, often symptoms of URTI

Radiograph: major goal is to differentiate from bacterialpneumonia

Best imaging clues:1. Lack of focal lung consolidation (hallmark for bacterial

infection)2. Increased peribronchial markings

3. Hyperinflation4. Subsegmental Atelactasis5. Hilar lymphadenopathy

RX: supportive (no need for antibiotics)


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Roun d Pneumoni a

Bacterial pneumonia with a very round, well defined appearance onchest radiography, simulating a mass

Only seen up to approximately 8 years of ageTypically caused by Stept. PneumoniaeClassic imaging appearance: round lung opacity with well defined

borders (+ air bronchograms)Presents with cough and fever May progress to lobar pneumonia


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Ca vita tory Pneumoni a

Dominant area of necrosis of consolidated lobe associated with avariable number of thin walled cysts

Classic appearance on CT: lack of normal lung architecture,decreased lung enhancement, thin walled cysts

Most commonly seen with Strep. Pneumoniae (nowadays)

Children exhibit persistent or progressive symptoms despiteantibiotics

Radiograph: cystic lesions develop within an area of lungconsolidated with pneumonia

RX: needs intensive support


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Ca rd ia c Con d itionsTetr a logy of F a llotEbstein s Anom a lyTruncus ArteriosusTAPVRTra nsposition

Lt to Rt ShuntsScimit a r Syn d romeH ypopl a stic Lt H ea rt Syn d romeCoa rct a tionPulmon a ry Atresi aKa wa sak i Disea se

Ca rd iomyop a thiesRha bd omyom aDouble Aortic ArchPulmon a ry Sling


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Manifestations of CHD

1. Cyanosis

2. Cardiomegaly

3. Pulmonary vasculature

4. Thymic atrophy


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Cardiomegaly

Cardio-Thoratic RatioOnly on the PA viewAP projection leads to magnifcation of heart and mediastinum

Paediatric Conditions leading to Cardiomegaly:

1. Ebstein Anomaly2. Truncus Arteriosus3. TAPVR (types 1 & 2)4. transposition of the great arteries5. Lt to Rt shunts6. Hypoplastic left heart syndrome

7. Vein of Galen8. Pulmonary Atresia9. Cardiomyopathies10....others...


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Pulmonary Vasculature1. Increased (ex: Truncus Arteriosus)

2. Decreased (ex: Fallots, Ebstein)

3. Pulmonary oedema (ex: type 3 TAPVR)

4. Irregular (ex: MAPCAs in Pulmonary Atresia)


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Tetralogy of Fallot

most common cyanotic heart lesionPresents with clubbing, dyspnoea on exertion, episodic spells,

cyanosis by 3-4months of age

TETRAD

1. Rt ventricular outflow tract obstruction2. Large VSD3. Over riding aorta4. Rt ventricle hypertrophy

Radiograph

1. Normal heart size2. Rt sided aortic arch in 25%3. Boot-shaped Heart4. Decreased Pulmonary vasculature


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Ebstein Anomaly

Dysplastic inferiorly displaced tricuspid valve with ventricular division into:a) A large superior atrialized portion with thin ventricular wallb) A small inferior functional chamber

Associated with ASD, PFO, VSD, PDA

Presentation: cyanosis, CHF, systolic murmur, hydropsM = F

Radiograph1. severe Rt sided cardiomegaly box shaped heart2. Small vascular pedicle

3. Calcification of tricuspid valve may occur


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Truncus Arteriosus

= single outlet of the heart (failure of separation of the conotruncus)One great artery arises from the heart, large VSDAssociated with Rt sided aortic arch, forked ribs, and DiGeorge

syndromePresents with moderate cyanosis, severe CHF, systolic murmur

Radiograph:1. Cardiomegaly2. Wide mediastinum3. Concave pulmonary segment4. Increased pulmonary blood flow

5. Waterfall / hilar comma sign


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Coarctation of the Aorta

LOCALISED Form (post-, juxta- ductal, Adult form)-Short narrowing close to ligamentum arteriosum(most common type)-Coexisting cardiac anomalies uncommon-Ductus usually closed

TUBULAR Form (preductal, Infantile form, diffuse type)-Hypoplasia of a long segment of aortic arch

- patent ductus arteriosus-CHF in 50%-Coexistent cardiac anomalies

M:F = 4:1Collateral circulation: via subclavian artery and its branches

Radiograph:Rib notching (above age 5 years)Post stenotic dilatation of proximal descending aorta figure 3 signLV hypertrophy: rounded apex


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Total Anomalous Pulmonary Venous Return

entire pulmonary venous return directed to RAAssociated with asplenia, ASD, PFO, CCAM, sequestration

A. Supradiaphragmatic TAPVR (82%)-Type 1: Supracardiac drainage into Lt brachiocephalic vein, SVC, azygos vein

- Type 2: Cardiac drainage into coronary sinus, RAB. Infradiaphragmatic TAPVR (12%)- Type 3: drainage into portal vein, IVC, L gastric vein. >90%obstructed

Presentation:


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Lt to Rt shunts

Low pressure shunts - ASDHigh pressure shunts VSD, AVSD, PDA

Most common congenital cardiac lesionPresents with CHF without cyanosis

Most small muscular VSDs close spontaneouslyUntreated large shunts may lead to Eisenmangers syndrome

Radiograph1. Cardiomegaly2. Convex pulmonary artery segment

3. Interstitial fluid with CHF4. Hyperinflation due to bronchial compression by dilated pulmonaryarteries


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N on Acci d ent a l Injuries ( Child Abuse)Rib fra ctures

Classic imaging appearance: posterior rib fractures in the region of the costovertebral joints,

rib fractures of different ages

Unfortunately common

30% of fractures in infants are due to abuse

Secondary to thorax being squeezed by abuser

Most children are less than 1 year at presentation

May be subtle prior to callous formation

OTHER CHEST FINDINGS

Scapular fractures

Spinous process fractures

Sternal fractures

Lung contusions on CT

paediatric chest conditions

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