PEDIATRICS Section 5: CHEST Flashcards
When assessing the chest, what are the things you need to look for?
- Hyper-inflated or not?
Flattening of the diaphragms
Horizontal-appearing ribs (6 anterior, 8 posterior)
Increased lucency under the heart - Know what “Granular, Streaky or Roby” looks like
Describe
A. Granular
B. Streaky
C. Ropy
A. Granular
evenly distributed, fine granular opacification and pulmonary hypoventilation.
Classic appearance of “Hyaline Membrane Disease” or Surfactant-defincient Disease
Describe
A. Granular
B. Streaky
C. Ropy
B. Streaky
Interstitial opacitification in all areas of both lungs with thickening of interstitium
Seen in Transient Tachypnea of the newbord
Describe
A. Granular
B. Streaky
C. Ropy
C. Ropy
Bilateral alveolar opacities. Hyperinflated lungs with flattened hemidiaphragm.
Seen in Meconium aspiration
When you see HIGH volumes + Perihilar streaky, think of these.
- Meconium
- Aspiration
- Non GB (Group B) neonatal
When you see Not High volumes (Low or normal) + Granular
- SDD or Hyaline membrane Disease
- Group B
Describe Meconium Aspiration
This typically occurs secondary to stress (hypoxia),
POST-TERM babies
The pathophysiology is all secondary to chemical aspiration.
Ropy appearance + Hyperinflation + pneumothorax in 20-40% of cases
Meconium aspiration
Why are the lungs in Meconium aspiration hyperinflated?
The poop in the lungs act like miniature ball-valves (“floaters” I call them), causing air trapping - hence the increased lung volumes
Describe Transient Tachypnea of the Newborn (TTN)
Classic histories: C-Section, Maternal Sedation, Maternal Diabetes
Onset: Peaks at day 1, Resolved by Day 3
Lung Volumes - Normal to Increased
Other names for Surfactant-Deficient Disease
Hyaline Membrane Disease or RDS
Describe SDD
Classic Histories: PRE-MATURE (born without surfactant)
LOW lung VOlumes + Bilatera GRANULAR opacities (just like B-hemolytic Pneumonia
NORMAL plaine film at 6 hours excludes SDD
Most common cause of death in premature newborns
Surfactant-deficient disease
Surfactant Replacement Therapy has increased risk of these conditions
Pulmonary Hemorrhage and PDA
Thisisthemostcommontypeofpneumoniainnewborns.
Neonatal Pneumonia (Beta-Hemolytic Strep - or “GBS”)
How is Neonatal Pneumonia (GBS) acquired?
duringexitofthedirtybirth canal.
Describe Neonatal Pneumonia (GBS)
Low lung volume (NON-GB - high)
Granular opacities (for this and SDD)
Pleural effusion
Less likely to have pleural effusion than (25% vs 75% in nonGB)
Describe Neonatal Pneumonia (Non GBS)
Patchy asymmetric perihilar densiries
+ effusions
+ Hyperinflation
When high pressures persist in the lungs
Persistent Pulmonary HTN
Diagnosis?
Pulmonary Interstitial EMphysema
- Consequenceofventilation
- Usually occurs in the first week of life
- Warning Sign for Impending Pneumothorax
- Treatment is to put the bad side down
- Buzzword = Linear Lucencies
Pulmonary Interstitial Emphysema
Prolonged ventilation in a premature (<32wk) tiny (<1000g) kid
Bronchopulmonary dysplasia
DIagnosis?
Describe the classic look
Bronchopulmonary dysplasia
Alternating regions of:
Fibrosis (coarse reticular opacities) + Hyperaeration
“Band like opacities”
Bronchopulmonary dysplasia
“Linear lucences”
Pulmonary Interstitial Emphysema
Both PIE and Chronic Lung Disease (CLD, Bronchopulmonary Dysplaisa) have this similar feature. What is the difference?
Both have cystic lucencies. The difference (classic peds) is TIME.
“Post Term Baby”
Meconium Aspiration
“C-Section”
Transient Tachypnea of the newborn
“Maternal Sedation”
Transient Tachypnea of the newborn
“Premature”
RDS, Hyaline membrane disease or Surfactant defficiency disease.
Identify
Umbilical Venous Catheter (UVC)
Things to know about UVCs:
* The ideal spot is at the IVC - Right Atrium junction.
* Clot forming in a portal vein branch can cause lobar atrophv
* Development of a “Cystic Liver Mass” (Hematoma) can suggest UVC
erosion into the liver.
Umbillical Artery Catheter
Things to know about UACs:
* It goes down first
* It should be placed either high (T8-T10) or low (L3-L5) * Should stay left of midline on AXR (aorta on the left)
* Omphalocele is a contraindication
Extracorporeal Memdrane Oxygenation is used for what conditions?
as a last resort in neonatal sepsis, severe SSD, and meconium aspiration.
When I say “Peribronchial Edema”
Think of viral Infection
Diagnosis?
<8 years old + cough
What is the culprit?
Younger than 8 you are thinking round pneumonia, round pneumonia, round pneumonia - with S. Pneumonia being the culprit.
Round pneumonia occurs because of this reeason
You don’t have good collateral ventilation pathways
Next step if you find round pneumonia
NO CT, just follow up x ray
Descirbe Neonatal atypical peripheral atelectasis (NAPA)
It is best to think about this as a cousin or uncle of Round Pneumonia (they are in the same family).
essentially the same thing except it is peripheral.
Classic look of Neonatal atypical peripheral atelectassi
Pleural based mass int he apex
history is a parent giving their newborn a teaspoonful of olive oil daily to cultivate “a spirit o f bravado and manliness.
Lipoid Pneumonia
Result of chronic fat aspiration
Lipoid pneumonia
classic finding of Lipoid pneumonia
CXR is nonspecific - it is just airspace opacities.
CT is much more likely to be the modality used on the exam.
The classic finding is low attenuation (-30 to -100 HU) within the consolidated areas reflecting fat content.
Key concept of bronchial foreign body
The key concept is that it causes air trapping.
How to assess Bronchial foreign body
You put the affected side down and it will remain lucent (from air trapping).
under fluoro the mediastinum will shift AWAY from the affected side on EXPIRATION
What do you do to elicit air trapping?
Expiratory films
This is the classic unilateral lucent lung.
Swyer James Syndrome
Diagnosis? What’s the cause?
The size of the affected lobe is smaller than a normal lobe (it’s not hyper-expanded).
occurs after a viral lung infection in childhood resulting in
POST INFECTIOUS OBLITERATIVE BRONCHILITIS.
soft tissue masses within the airway and lungs.
Papillomatosis
Culprit of papillomatosis?
Neonatal HPV
Adult who smoke
Diagnosis? Describe
give differential
Papillomatosis
Multiple lung nodules which demonstrate cavitation
Diff: LCH
Papillomatosis has a risk of this disease
Squamous cell CA (2%)
Kids with sickle cell can get what disease?
“Acute chest”
Leading cause of death in sickle cell patients
Acute test
Pathology of Acute chest in Sickle cell disease?
you infarct a rib -> that hurts a lot, so you don’t breathe deep -> atelectasis and infection.
Diagnosis?
Sickle cell disease
- Kid with Big Heart
- Kid with bone infarcts (look at the humeral heads)
- Kid with H shaped vertebra (look on lateral)
- Cholecysectomy Clips (look at right upper abdomen)
Pathophysiology of Cystic Fibrosis
sodium pump doesn’t work and they end up with thick secretions and poor pulmonary clearance leading to recurrent infections
Diagnosis? Describe
Cystic Fibrosis
Things to know in cystic fibrosis?
Things to know
* Bronchiectasis (begins cylindrical and progresses to varicoid)
* It has an apical predominance (lower lobes are less involved)
* Hyperinflation
* They get Pulmonary Arterial Hypertension
* Mucus plugging (finger in glove sign)
* Men are infertile (vas deferens is missing)
Give the Cystic fibrosis related diseases
Fatty Replaced Pancreas on CT
Abdominal Films with Constipation
Biliary Cirrhosis (from blockage of intrahepatic bile ducts), and resulting portal HTN
The motile part of the cilia doesn’t work. They can’t clear their lungs and get recurrent infections. These guys have lots o f bronchiectasis just like CF.
Primary Ciliary Dyskinesia
MAin difference of Cystic fibrosis and Primary Ciliary Dyskenesia?
Things to know in Primary Ciliary Dyskenesia?
Bronchiectasis (lower lobe)
50% have kartageners (situs inversus), so 50% will not
Men are infertile (sperm tails don’t work)
Women are subfertile (Cilia needed to push eggs around)
