Chest Flashcards
Cardiothoracic ratio decreases as the child grows older and should be less than 50%, with the heart appearing similar to an adult by what decade
Second decade
A guide for normal heart is that a line drawn along the posterior tracheal wall on the lateral CXR should pass _______ to the heart
Posterior
True cardiomegaly in children is seen usually in what view of chest xray
Lateral
Thymus is proportionately largest at _____
Birth
It is the primary finding in asthma
Hyperinflation
Hyperinflation in asthma is much more common in viral or bacterial pneumonia?
Viral
What is the rib that should be the first to cross the diaphragm to know if the chest is adequately aerated
6th anterior rib
If expiratory CXR for evaluating air trapping cannot be obtained due to an uncooperative child, what technique should be done
Bilateral decubitus radiographs
Syndrome that presents one lung to be hyperlucent
Obliterative bronchiolitis, also called Swyer-James-Macleod syndrome
A decrease in the AP size of the trachea otherwise suggests a
Tracheomalacia or extrinsic compression
On frontal expiratory CXR, the trachea often buckles, at times dramatically. The trachea always buckles in what direction
Opposite to the location of the aortic arch
Normal trachea lies slightly to the ____ of the midline, due to the position of the aortic arch
Slightly to the right of the midline
True or false: a true midline trachea is abnormal, and it is a sign of ____
True.
Sign of double aortic arch
A focal right-sided impression on the trachea is almost always due to a
Right arch
True or false: lung volume can be increased, normal or decreased in Swyer-james syndrome
True
True or false: air trapping due to a foreign body will usually have increased lung volume, and should not have decreased lung volume in the absence of atelectasis
True
Normal tracheal buckling has _____ angles compared with the more ______ displacement seen with masses
Normal: sharp angles
With mass: rounded displacement
with surfactant deficiency disease, there should be no finding suggesting______ or ______
Pleural fluid or asymmetry of opacities
Bilaterally symmetrical coarse linear and branching opacities suggest
Meconium aspiration
Aspirated meconium-stained fluid causes mechanical and chemical airway trauma due to its ______
Particulate nature and the presence of irritants including bile
Meconium aspiration pneumonia appears as
Areas of atelectasis and inflammation alternating with areas of hyperinflation
Features of SDD that distinguishes it from other causes of diffuse opacity
Low lung volumes with granular diffusely increased attenuation that is evenly distributed, without pleural effusion
Linear opacities, central greater than peripheral particularly when radiating from the hila, suggest
Retained lung fluid, aka transient tachypnea of the newborn
Retained lung fluid resolves both clinically and radiographically by ____ hours and should not be suggested in older infants
72 hours
A pneumonia that simulate SDD which presents as diffuse ground glass opacities is mainly caused by what organism
group B streptococcus
In the immediate neonatal period, GBS usually cause ____
Pneumonia
Later in early infancy, GBS is more likely to cause _____
Meningitis
Most common cause of lung abnormalities in older infants in the neonatal ICU
Bronchopulmonary dysplasia or chronic lung disease
Suggested pathophysiology of BPD
Diffuse capillary leak
More common area of pneumothorax in neonates
Basal pneumothoraces, particularly medially located
These area of pneumothorax are seen as lucency adjacent to the cardiomediastinal silhouette with a sharply defined cardiac or diaphragmatic margin much more often than with a pleural line
Basal pneumothoraces
True or false: lungs are usually very stiff in infants with neonatal lung disease
True
What is the highest point in a supine patient
Lung base
Best sign of pneumonediastinum in a neonate
Elevation of thymus from rest of mediastinum
In a neonate with pneumodiastinum, its extension is more common in the
Peritoneum, rather than in the neck as subcutaneous emphysema
True or false, isolated pneumomediastinum almost never require drainage
True
Pneumopericardium is best distinguished from pneumomediastinum by air surrounding the entire cardiac silhouette, particularly where
Superiorly
When in doubt if a supine baby has pneumothorax, what radiograph should be added
Decubitus view
Radiograph that would make the distinction of pneumopericardium over pneumomediastinum
Lateral radiograph
A complication of barotrauma that occurs when alveolar tears allow air to enter the pulmonary interstitium and lymphatics
Pulmonary interstitial emphysema
Development of pneumomediastinum or pneumothorax in patients with PIE is often due to
The extra-alveolar air that stiffens the lung
CXR appearance of PIE
Small round and rod-like lucencies superimposed on a background of higher attenuation lung
True or false: PIE usually resolves quickly, but there us an entity of persistent PIE than can persist fo months
True
Tip positioning of ET tube in neonates and infants can be considered satisfactory in all neonates and infants
Tip positioning midway between thoracic inlet and carina
Type of umbilical catheter that extends cephalad from the umbilicus with a straight or gently curve course
Venous
Type of umbilical catheter that first extends caudad and then turns and extends cephalad. The turning point forms an acute angle that usually lies close to the bottom of the sacroiliac joint
Arterial
Type of umbilical catheter that remains anterior
Venous
Type of umbilical catheter that passes posteriorly to the posteriorly located aorta and overlies the spine
Arterial
Incorrectly positioned UACs are almost always within the ______, with the catheter tip either too high or too low
Aorta
Two accepted placements of umbilical arterial catheter
High placement- between T6 and T9 and low placement- with the catheter tip ideally at the bottom of L3
True or false, course of UVC is more complex, and there are multiple opportunities for malposition
True
Course of the umbilical vein
Umbilical vein—> left portal vein —> ductus venosus —> IVC just below the hepatic veins
Course of the umbilical artery
Umbilical artery —> internal iliac artery —> aorta
Risk of important complications if the UV catheter tip is
Within the liver, “slightly low” position
Single catheter extracorporeal membrane oxygenation (venous) usually ends in the
Low Right atrium
What type of ECMO allows full bypass of the heart
2 catheter
Position tip of UVC
Diaphragm
Arterial ECMO catheter proper placement site
Above aortic arch
Upper extremity PICC position
Carina to 2 vertebral bodies (including interspaces) below carina
Lower extremity PICC position
Diaphragm
Most common type of CPAM (congenital pulmonary airway malformation) that contain one or more cysts greater than 2cm and make up about half of CPAMs
Type 1
Single most important feature to identify on imaging of congenital lung malformations is the presence or absence of
A feeding vessel. A feeding vessel identifies the lesion as a sequestration
Most common congenital lung malformation, making up about 1/4 to 1/2 of lung lesions diagnosed prenatally
Congenital pulmonary airway malformation
Type of CPAM with multiple smaller cysts
Type 2
Type of CPAM wherein the cysts are <5mm, larger than type 2, affecting the entire lobe. It is associated with hydrops and a poor prognosis
Type 3
It is a mass of nonfunctioning lung tissue that does not connect to the rest of the tracheobronchial tree
Pulmonary sequestration
Type of sequestration within the visceral pleura and aerate from the collateral ventilation
Intralobar sequestration
Type of sequestration that have their own pleura and cannot become aerated
Extralobar sequestration
Type of sequestration that can be solid or cystic, and usually contain both components
Intralobar
Arterial and venous drainage in pulmonary sequestration is variable, but is most commonly from the
Aorta and to a pulmonary vein
Both types of pulmonary sequestration can be seen at what part of the lung
Lower lobes, left more common than right
Foregut duplication cysts include
Bronchogenic cysts, esophageal duplication cysts and neuroenteric cysts
They are round, well- defined masses that can occur in mediastinum or in the lung, usually centrally
Bronchogenic cysts
Aberrant budding of the bronchopulmonary foregut is thought to result from
Cyst lined with respiratory epithelium and filled with fluid or mucus
What feature of bronchogenic cyst distinguishes it from an infection
BCs do not communicate with the tracheobronchial tree
Foregut duplication cyst that occur adjacent to the esophagus and appear similar to mediastinal bronchogenic cyst
Esophageal duplication cysts
Neuroenteric cysts appear where
Posterior mediastinum, and can be associated with vertebral body anomalies
A developmental abnormality that results in overinflation of a lobe. An airway abnormality, particularly abnormal cartilage and airway malacia resulting in a check-valve mechanism
Congenital lobar overinflation
Congenital lobar overinflation occurs most commonly in the
Left upper, right upper and middle lobes
Abnormality affecting the entire lung lobe with no bronchus present
Pulmonary agenesis
Lung malformation affecting the entire love where a short, blind-ending bronchus is present
Pulmonary atresia
Lung malformation affecting an entire lobe wherein the size of the lung and/or the number of bronchopulmonary segments are decreased
Pulmonary hypoplasia
There is abnormal drainage of a lung lobe. The configuration of the abnormal vein has been linked to a scimitar sword. The affected lobe is small.
Pulmonary venolobar or scimitar syndrome
The abnormal drainage of a lobe in scimitar syndrome is usually connected to
IVC, hepatic vein or left atrium. The abnormal arterial supply is from the aorta
Occurs when there is focal interruption of a bronchus during lung development. The cause is unknown, but there is normal development of the bronchial distal to the interruption suggesting a prenatal traumatic event
Bronchial atresia
A soft tissue nodule associated with focal air trapping will almost always be due to a
Bronchial atresia
In bronchial atresia, there would always be these things present
Mucocele or mucus collection distal to the occlusion, and air trapping
Best way to defined pulmonary situs
Defining the relationship of the main bronchi (right and left) to the pulmonary arteries
Eparterial
Right upper lobe bronchus
Type of tracheal stenosis from airway trauma such ad from repeated suctioning, or prolonged intubation
Focal tracheal stensosis
Type of tracheal stenosis that is congenital
Diffuse stenosis
Tracheal stenosis associated with congenital heart disease is often due to
Complete tracheal rings
Most common infectious disease of children
Infection of lower respiratory tract
Most common response to lower respiratory tract infection of any etiology is
Inflammation of the airways and increased mucus production
Best predictor for a bacterial lung infection
Pleural effusion
Most common causes of pneumonia in the first month of life
GBS and gram-negative enteric bacteria
Viral appearance of pneumonia in 6-12 week old infant is usually caused by
Chlamydia trachomatis
Most common etiology of pneumonia in 1-3 months infant
Streptococcus pneumoniae
From a few months of age to a few years, what is the most common etiology of pneumonia
Viral
Older children pneumonia
Bacterial
Most common etiology of pulmonary infection in infants and young children
Respiratory syncytial virus
Most common cause of bronchiolitis in infants and young children
Respiratory Syncytial virus
Clinically defined as a disease of wheezing and respiratory distress in children less than 2 years old
Bronchiolitis
“Wandering” or “shifting” atelectasis
Bronchiolitis
Most common cause of pneumonia in children, responsible for 40% or more of pediatric pneumonia. Affects children from school age through adolescence
Mycoplasma pneumonia
Bacterial pneumonia that appears as a “viral” pattern with hilar adenopathy and small pleural effusions seen in some cases
Mycoplasma pneumonia
Mycoplasma can occur in a mixed infection, particularly with
Pneumococcus
Common cause of pneumonia in premature infants
Listeria
Most common cause of bacterial pneumonia in children after neonatal period
S. Pneumoniae
It is a manifestation of streptococc al pneumonia with a strikingly mass-like appearance.
Round pneumonia
Round pneumonia is usually seen in
Lower lobe of children less than 8 y.o
Most often pulmonary primary disease until the age of puberty, after which adult type reactivation disease becomes more common
Childhood TB
The primary focus and lymphadenopathy from the primary TB is calles
Ghon complex
Most common finding in primary TB is
Adenopathy
Parenchymal disease appearance of TB
Nonspecific infilrate associated with hilar or mediastinal lymphadenopathy
Infiltrates of TB can occur in any location, but is most often where
Peripheral and in the mid or lower lung
Most common lung mass in child
Pseudomass, most commonly a round pneumonia
Most common neoplasms in pediatric chest
Metastases
Most common true lung mass in children
Inflammatory myofibroblastic tumor/ plasma cell granuloma ans xanthogranuloma
Most common primary benign neoplasm of pediatric chest
Pulmonary hamartoma
Pulmonary hamartoma usually presents as
Solitary, noncalcified lobular mass
Most common primary malignant lesion in pediatric chest
Endobronchial carcinoid and pleuropulmonary blastoma
Pleuropulmonary blastoma usually occurs in children of what age
Younger than 6 years old
CPAM can be distinguished from PPB in a neonate with
Pneumothorax, multiple lesions and a family history (DICER 1)
Very rare in children, but can be a cause of thin-walled cysts
Lymphangioleiomyomatosis
Appears as irregurly shaped cysts
Langerhans cell histiocytosis
When lung nodules are associated with cysts, pulmonary involvement by _____ and _____ should be considered
Papillomatosis and langerhans cell histiocytosis
Largest normal structure in the anterior mediastinum
Thymus
Thymic contour in infants are in what shape
Rounded or rectangular
By school age, the shape of the thymus becomes
Triangular
Appearance of thymus in ultrasound that can be used to confirm the presence of normal thymus and so exclude other causes of an anterior mediastinal process
“Dot-dash” appearance
Most common anterior mediastinal mass in children
Lymphoma
True mass such as lymphoma can be distinguished from thymus with these features
Irregular contour, heterogeneous attenuation, mass effect
Most common neurogenic tumor in children
Neuroblastomas
Relatively common form of ILD that has a classic imaging appearance of ground-glass opacities most marked in the right middle lobe and lingula and otherwise distributed predominantly in a perimediastinal location
Neuroendocrine hyperplasia
Crazy paving pattern of ILD in children
Surfactant protein mutations
Common form of ILD in infants from a prenatal or perinatal lung insult. Seen in infants with BPD, pulmonary hypoplasia due to oligohydramnios and in association with cardiac and chromosomal abnormalities such as trisomy 21
Alveolar growth abnormality
ILD that appears as ground glass opacity, cysts and distorted secondary pulmonary lobular architecture with the secondary lobules varying in size and attenuation
Alveolar growth abnormality
Bacterial infections are more common in humoral or cellular immunodeficiency?
Humoral
Viral and opportunistic infection more common in humoral or cellular immunodeficiency?
Cellular
Features of several primary immunodeficiencies
Small or absent thymus, adenoids or tonsils
Caused by a defect in a cell membrane chloride channel called the cystic fibrosis transmembrane regulator
Cystic fibrosis
Most common chest finding in children with sickle cell disease
Mild cardiomegaly
Most common pulmonary manifestation of sickle cell disease
Acute chest syndrome
Suggested common etiology un sickle cell disease
Rib infarcts and associated pain
Common pulmonary manifestation of rheumatoid/collagen vascular disease
Diffuse lung disease, with band-like or focal peripheral areas of “reticular ground-glass”
Commonly found in patients with spontaneous pneumothorax
Apical blebs
Spontaneous pneumothorax occurs primarily in what gender
Teenage boys
Common etiology of spontaneous pneumothorax
Abnormal collagen
Type of spontaneous pneumothorax without associated respiratory disease
Primary
Type of spontaneous pneumothorax in which respiratory disease such as asthma is present
Secondary
Usually, pneumomediastinum in children has unknown etiology, but may be seen mostly in patients with
Asthma
A sign that may distinguish contusion from atelectasis is the presence of
Subpleural sparing
Viral infection that affects the upper and lower airways, particularly the subglottic trachea
Croup or laryngotracheobronchitis
Most common infectious disease of the upper airway
Croup
Most common pathogen of croup
Parainfluenza
Croup commonly affects what age group
6 months to 3 years of age
Appears on imaging as symmetrical narrowing of the subglottic airway with a configuration that is describes as a pencil point or church steeple. The epiglottis and aryepoglottic folds are normal
Croup
Most common pathogens of bacterial tracheitis aka bacterial croup or membranous croup
Moraxella catarrhalis and Staphylococcus aureus
Identification of an intraluminal defect, representing a sloughed membrane is a specific but not sensitive sign on airway radiographs of what disease
Bacterial tracheitis
Swelling involves the aryepiglottic fold as well as epiglottis caused by haemophilus influenza
Epiglotittis or supraglottitis
Most common single organism of retropharyngeal abscess
Group A strep
Congenital softening of the soft tissues of the pharynx that leads to airway collapse with inspiration. Most common cause of noisy breathing in infants and is the most common congenital abnormality of the larynx
Laryngomalacia
