Anda di halaman 1dari 36

PAEDIATRIC CHEST IMAGING

THE YOUNG CHILD

PRESENTER: Dr. Kinoti FACILITATOR: Dr. Mwango

Outline

Radiation protection in children Basics of chest imaging in paediatrics Evaluation of lines and tubes Infections: bacteria, viral, TB Pneumothorax, pleural effusion Inhaled foreign body Asthma Acute Chest Syndrome

Radiation protection

Justification – avoid unneccesary examinations Optimization

All necessary exposures to radiation should be kept As Lo w As

Reasonable Achievable (ALARA principle)

Gonadal protection Collimation as appropriate

3

Chest Radiograph. Remain the basis for chest evaluation. Usually supine AP in <5yr, PA in >5yr; +/-Lateral view. Difficulties –poor inspiration, motion blur, difficulty in positioning, magnification of anterior structures(heart). Normal CTR 55-60%. Beware of normal thymic shadow.

Normal Chest Radiograph

good inspiration

Normal Chest Radiograph good inspiration • Less than 1/3 of the heart below the dome of

Less than 1/3 of the heart below the dome of the hemidiaphragms

At least 8 posterior ribs clearly seen

7 anterior ribs

Lungs show good translucency.

GOOD INSPIRATION

GOOD INSPIRATION EXPIRATION

EXPIRATION

GOOD INSPIRATION EXPIRATION

Rotated chest radiographs

Rotated film.

Note sternal ossification centers

Rotated film. Note sternal ossification centers

Paediatric chest

Almost cylindrical in shape

Air bronchograms commonly seen

Normal CTR as much as 65% (due to Thymus)

Ribs more horizontal – Diaphragm at 6 th – 8 th Ant rib

Paediatric chest • Almost cylindrical in shape • Air bronchograms commonly seen • Normal CTR as

EVALUATION OF TUBES AND LINES

NGT- tip at the stomach ETT-tip should be 2cm above carina or at T2/3 level Pleural tubes- tip ant&sup (pneumithorax) and post&inf (effusion) if pt supine.

Umbilical artery

–iliac artery- into abdominal aorta the tip ideally at T6- T10 (high) or acceptably

L3-L5(low)

Umbilical vein-PV- ductus venosus-IVC-Rt atrium (tip should be at IVC/RA junction at t8-t9)

• Umbilical artery –iliac artery- into abdominal aorta the tip ideally at T6- T10 (high) or

INFECTIONS IN THE YOUNG CHILD

Pathogens include bacteria, viruses(RSV),fungi and mycobacterium

Mycoplasma is common in school-aged children(seen in 30% of childhood pneumonia)

These infections present as radiographic patterns that may narrow the differentials of causative organisms

The role of imaging is to confirm presence, extent, anatomical location and evaluate progress or complications

BACTERIAL PNEUMONIA

BACTERIAL PNEUMONIA Focal alveolar consolidation -mainly by strep peumoniae,haemophilus and rarely mycoplasma Multiple patchy alveolar opacities

Focal alveolar consolidation

-mainly by strep peumoniae,haemophilus and rarely mycoplasma

Multiple patchy alveolar opacities

-usually by staph ,fungal and opportunistic infections

-Homogenous opacity Air bronchograms

CXR-AP&LAT

14-month old male with a history of coughing and fever.

14-month old male with a history of coughing and fever. Left upper lobe and lingula consolidation.
14-month old male with a history of coughing and fever. Left upper lobe and lingula consolidation.

Left upper lobe and lingula consolidation.

3-year old male with fever and coughing.

3-year old male with fever and coughing. Left posterobasal segment consolidation 15

Left posterobasal segment consolidation

Round pneumonia

Caused by streptococcal pneumoniae Usually children <8 yrs Well rounded opacitie simulating a mass May have air bronchograms Ddx-tumor, sequestrated lung, bronchogenic cyst Follow up CXR is adviced.

Round pneumonia • Caused by streptococcal pneumoniae • Usually children <8 yrs • Well rounded opacitie

ROUND PNEUMONIA

Lat. Chest Radiographs

A-round soft tissue mass in superior segment of left lower lobe.

8-wks later, complete resolution after antibiotic Rx.

ROUND PNEUMONIA • Lat. Chest Radiographs • A-round soft tissue mass in superior segment of left

VIRAL PNEUMONIA

IMAGING:-

CXR-increased peribronchial markings, hyperinflation (hyperlucency,flattening of diaphragms, increased AP chest diameter), subsegmental atelectasis (wedge shaped opacity most common in mid/lower lung).

CT-prominent ill-defined hila ,peribronchial markings radiating into the lung, ground- glass opacities & increased interstitial markings

VIRAL PNEUMONIA

CXR-A. mild increased peribronchial markings & symmetric hyperinflation.

CXR- B. severe increased peribronchi al markings, hyperinfla tion & atelectasis in rt middle lobe silhouett- ing rt heart border

VIRAL PNEUMONIA • CXR-A. mild increased peribronchial markings & symmetric hyperinflation. • CXR- B. severe increased

14 month-old with cough

14 month-old with cough Peribronchial cuffing, increased perihilar streakiness, airtrapping in viral pneumonia 20

Peribronchial cuffing, increased perihilar streakiness, airtrapping in viral pneumonia

20

The immune compromised child

Primary immune deficiency related to congenital abnormality of B/T cells

All are prone to infections by less common organisms e.g pneumocystis carinii

Clinical picture and imaging features are diverse; from expected patterns to bizzare & atypical

The immune compromised child

PCP-widespread alveolar

shadowing

Miliary TB-fine nodularity

Inhaled Foreign Body

Most FBs enter the more vertically oriented rt bronchus Complete airway obstruction lead to atelectasis; partial obstruction lead to obstructive emphysema. Films taken in inspiration & expiration show mediastinal shift away from the obstructive emphysema on expiration

Inhaled Foreign Body

Inhaled Foreign Body • Obstructive emphysema from FB in lt main bronchus

Obstructive emphysema from FB in lt main bronchus

A-INSPIRATORY FILM-RT SIDE HYPERLUCENT AND EXPANDED B-EXPIRATORY- RT SIDE AIR TRAPPING C-NORMAL EXPIRATORY FILM AFTER PEANUT
A-INSPIRATORY FILM-RT SIDE HYPERLUCENT AND EXPANDED B-EXPIRATORY- RT SIDE AIR TRAPPING C-NORMAL EXPIRATORY FILM AFTER PEANUT

A-INSPIRATORY FILM-RT SIDE HYPERLUCENT AND EXPANDED B-EXPIRATORY- RT SIDE AIR TRAPPING C-NORMAL EXPIRATORY FILM AFTER PEANUT REMOVAL.

TB

Under 5 vulnerable Poverty ,malutrition,overcrowding and HIV

Can be focal lesion &, hilar adenopathy(ghon focus) miliary, pleural effusion

Primary & miliary more common in young children

secondary-cavitatory

A differential in atypical pneumonia-in HIV

TB • Under 5 vulnerable • Poverty ,malutrition,overcrowding and HIV • Can be focal lesion &,

10 YR PARATRACHEAL LN LL PATCHY OPCITIES MILIARY PATTERN IN LUNGS

5 Year old with fever and SOB

Primary TB with unilateral hilar adenopathy and

secondary RML collapse.

TB Radiologic Findings

Normal Unilateral hilar adenopathy Ranke complex Paratracheal adenopathy Subcarinal adenopathy

TOXIC,METABOLIC

Hydrocarbon Aspiration

Hydrocarbons – furniture polish, gasoline,

Aspirated due to low viscosity and surface tension

Severe chemical pneumonitis with

destruction of surfactant Radiographic abnormalities develop within

24hrs

Pneumatoceles may develop

CXR-Multiple patchy opacities at the lower lobes

TOXIC,METABOLIC Hydrocarbon Aspiration •  Hydrocarbons – furniture polish, gasoline,  Aspirated due to low viscosity

18 Month old with respiratory distress

18 month old status post hydrocarbon aspiration,

Showing central lower lobe alveolar opacities.

18 Month old with respiratory 18 month old status post hydrocarbon aspiration, Showing central lower lobe

Aspiration pneumonia

Aspiration of gut material in GERD, TEF or NGT tube feeding for the sick

RNI milk scan,24 hr PH monitoring and upper GI studies used to diagnose GERD

Upper lobe-infant ,supine Lower lobe-older ,upright

CXR-Para hilar peribronchial opacities resulting in a shaggy cardiac border

Aspiration pneumonia • Aspiration of gut material in GERD, TEF or NGT tube feeding for the

Pleural effusion 5 yr old with nephrotic syndrome

Pleural effusion 5 yr old with nephrotic syndrome

Pneumothorax

Pneumothorax • Spontaneous e.g infants on ventilator therapy • Trauma • Decubitus CXR with the side

Spontaneous e.g infants on ventilator therapy

Trauma

Decubitus CXR with the side of interest upright is ideal

Asthma

Main role is to exclude:

Pneumonia pneumothorax

Imaging features

Normal chest; most common finding Features of hyperinflation Segmental or subsegmental atelectasis seen as patchy opacities Peribronchial cuffing

10 year old asthmatic

10 year old asthmatic 34

34

Acute Chest Syndrome in SCD

9 Year old with SOB

Acute chest syndrome with cardiomegaly, absence of splenic shadow, and gallbladder clips indicating underlying sickle cell anemia. The bibasilar consolidations and bilateral small pleural effusions suggest the diagnosis of acute chest syndrome.

Acute Chest Syndrome in SCD 9 Year old with SOB Acute chest syndrome with cardiomegaly, absence

References

 

Grainger & Allison Diagnostic Radiology 5 th Edition

 

David Sutton Textbook of Radiology and Imaging 7 th Edition

Paediatric Radiology By Jack O. Haller; Thomas L. Slovis and Aparna Joshi

Paediatric radiology 3 rd edition Imaging in paediatric pulmonology Robert cleveland