neonatal chest x ray reading

DR MUHAMMAD SHAHZADCHILDREN COMPLEX

MULTAN

Neonatal chest x-ray reading

In spite of recent modalities like USG, CT

SCAN, MRI, conventional radiography

is cornerstone of imaging…

Chest should be straight so that both

hemi thorax can be visualized equally

Film should be technically satisfactory…

Mediastinum in neonate has much

variability and mainly consist of heart

and thymus…..

Thymus can fill the whole of upper

mediastinum or is prominent on right

side or left……..

Apart from viewing pulmonary, cardiac,

and pleural pathology, neonatal x-ray

is used to demonstrate the position of

various lines and tubes……

Endotracheal intubation

A. Preferred location is halfway between the thoracic inlet and

carina

B. If ett is too low, it will enter into right main bronchus

C. Chest film may show asymmetric aeration with both

hyperinflation and atelactasis

D. If tube extends below carina and does not match tracheal air

column, suspect esophageal intubation

E. Ett placed too high has tip above clavicle , x-ray film may

show diffuse atelactasis

Nasogastric tube

Tip should be in mid stomach

Umblical vein catheterization

At junction of inferior vena cava and right atrium

Degree and position of patient rotation affect how the UVC appears positioned on radiograph……..

Umbilical artery catheterization

Cochrane review states that high catheters should be used exclusively

Recent analysis showed a decreased risk of vascular complications and no increased risk of hypertension, necrotizing enterocolitis, IVH or hematuria….

Low catheters are associated with increased risk of vasospasms………..

Radiographic pearls

PULMONARY DISEASES

A. RDS a fine, diffuse reticulogranular pattern is seen secondary to microatelectasis of alveoli. The chest radiograghs reveals radiolucent areas known as air bronchograms, produced by air in major airways and contrasted with the opacified alveoli

B. MECONIUM ASPIRATION SYNDROME

Bilateral, patchy, coarse infiltrates and hyperinflation of lungs are present. there is also an increased incidence of pneumothorax…

C. PNEUMONIA

Diffuse alveolar or interstitial disease that is usually asymmetric and localized.

group b streptococcal pneumonia can appear similar to respiratory distress syndrome (rds).pneumatoceles ( air – filled lung cysts ) can occur with staphylococcal pneumonia.

Pleural effusions or empyema may occur with any bacterial pneumonia…

Extensive bilateral (right greater than left) streaky interstitial pulmonary opacities with airspace opacification at the right base. Features are non-specific.

48 hours later, there has been an improvement in appearances with reduction in the degree of basal opacification.

D. TRANSIENT TACHYPNEA OF NEWBORN

Hyper aeration with symmetric peri hilar interstitial infiltrates are typical.

Pleural fluid may occur as well, appear as widening of pleural space or as prominence of the minor fissure

Bilateral extensive interstitial and alveolar opacities that are predominantly perihilar.

Nasal oxygen is being delivered. The patient is rotated. Interstitial copacity in all areas both lungs with thickening of horizontal fissure. Note sternal ossification centres projected over right lung. No effusions or pneumothorax.

E. BRONCHOPULMONARY DYSPLASIA

Now more commonly referred to as chronic lung disease….

Radiographic appearance is highly variable, from a fine, hazy appearance of the lungs to mildly coarsened lung markings to a coarse, cystic lung pattern..

Typically occurring in ventilated premature neonates.

Cld minimally requires a 7-10 days to develop

Bronchopulmonary Dysplasia. The lungs are usually overaerated, in this case the left more than the right. There are diffuse rope-like densities separated in some areas by zones of hyperlucency. The densities are coalescent in many areas. The heart borders are completely obliterated

F. AIR LEAKY SYNDROMES

1. Pneumopericardiumair surrounds the heart, including the inferior border..cardiac tamponade may result..

2. Pneumomediastinuma. AP viewhyperlucent rim of air is present lateral to the cardiac border and beneath the thymus, displacing the thymus superiorly away from the cardiac silhouette (“angel wing sign” )b. lateral viewan air collection is seen either substernally (anterior pneumomediastinum ) or in the retrocardiac area ( posterior pneumomediastinum)

3. Pneumothoraxlung is typically displaced away from the lateral chest wall by a radiolucent zone of air…Adjacent lung may be collapsed with larger pneumothoracessmall pneumothorax may be very difficult to identify with only a subtle zone of air peripherally, a diffusely hyperlucent hemithorax, unusually sharply defined cardiothymic margins or a combination of these…

4. Tension pneumothorax

diaphragm on affected side is depressedmediastinum is shifted to contralateral hemithorax.collapse of ipsilateral lobes is evident…

5. Pulmonary interstitial emphysema

single or multiple circular radiolucencies

with well-demarcated walls are seen in a

localized or diffuse pattern..the volume of

the involved portion of the lung is usually

increased.

PIE usually occurs in ventilated preemies

with RDS within initial few days of life…..

G. ATELECTASIS

A decrease in lung volume or collapse of part or all of a lung is apparent, appearing as areas of increased opacity. the mediastinum may be shifted toward the side of collapse. Compensatory hyperinflation of the opposite lung may be present.1. MICROATELECTASIS

non obstructed atelectasis associated with rds..

2. GENERALIZED ATELECTASISdiffuse increase in opacity

(“whiteout”) of lungs is visible on the chest film. It may be seen in severe rds, airway obstruction, if the endotracheal tube is not in the trachea, and hypoventilation…

3. LOBAR ATELECTASIS Atelectasis of one lobe Most common site is right upper

lobe Right minor fissure is usually

elevated Often occur after extubation

H . Pulmonary hypoplasia

small lung volumes and a bell shaped thorax are seen . The lungs usually appear radiolucent

I . Pulmonary oedema

lungs appear diffusely hazy with an area of greatest density around the hilum of each lung. Heart size is usually increased…

Cardiac diseases

Cardiothoracic ratio, which normally should be less than 0.6 is the width of the base of the heart divided by the width of the lower thorax

An index more than 0.6 indicate cardiomegaly

Pulmonary vascularity is increased if the diameter of descending branch of right pulmonary artery exceeds that of trachea…

A . Cardiac dextroversion.

• Cardiac apex is on right side..• Aortic arch and stomach bubble

areOn left side..

• Incidence of congenital heart disease is very high, more than 90 %.

B . CONGESTIVE HEART FAILURE

cardiomegaly, pulmonary venous congestion ( engorgement and increased diameter of the pulmonary veins ), diffuse opacification of perihilar region and pleural effusion are seen..

C . Patent ductus arteriosus

Cardiomegaly,, pulmonary edema, ductal haze ( pulmonary edema with a patent ductus arteriosus ), and increased pulmonary vascular markings are evident …

D . Ventricular septal defect

Cardiomegaly, an increase in pulmonary vascular density, enlargement of the left ventricle and left atrium, and enlargement of the main pulmonary artery

E . Coarctation of aorta

1. preductal coarctation generalized Cardiomegaly with

normal pulmonary vascularity is seen.

2. postductal coarctationenlarged left ventricle and left

atrium and a dilating ascending aorta are present

F . Tetrology of fallot

heart is boot shapednormal left atrium and left ventricle is associated with an enlarged, hypertrophied right ventricle and a small or absent main pulmonary artery. There is decreased pulmonary vascularity. A right aortic arch occur in approx 25% of patients

G . TRANSP0SITION OF GREAT ARTERIES

Cardiomegaly, enlarged right atrium and right ventricle, narrow mediastinum and increase pulmonary vascular markings

But in most cases, chest film appears normal.

H . TOTAL ANOMALOUS PULMONARY VENOUS RETURN

Pulmonary venous marking are increased…

Cardiomegaly is minimal or absent..Congestive heart failure and pulmonary

edema may be present…esp with type 3 TAPVR ( subdiaphragmatic )

I . Hypoplastic left heart syndrome

chest film may be normal at firstmay show cardiomegaly and pulmonary congestion and enlargement of right atrium and ventricle…

J . Tricuspid atresia

Heart size is usually normal or small, the main pulmonary artery is concave and pulmonary vascularity is decreased

Truncus arteriosus

cardiomegaly, increased pulmonary vascularity , and enlargement of left atrium.a right aortic arch occur in 30% of patients….

I . ATRIAL SEPTAL DEFECT

• varying degrees of enlargement of right atrium and ventricle is

seen• aorta and left ventricle is small• pulmonary artery is large• increased pulmonary vascularity is

evident

M . Ebstein anomaly

Gross cardiomegaly and decreased pulmonary vascularity are apparent

Right heart border is prominent as a result of right atrial enlargement

N . Valvular pulmonic stenosis

Heart size and pulmonary blood flow is usually normal unless the stenosis is severe.

Dilatation of main pulmonary artery is main chest film finding

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