Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including: • Esophageal foreign body • Mucus plugging • Pneumonia • Atelectasis • Bronchiolitis • E-cigarette vaping associated lung injury (EVALI)

1. Pediatric Chest X-Rays Of The Month
Nikki Richardson MD & Jennifer Potter MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
December 2019

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and now… Tanzania and Brazil.
 Cases submitted this week will be distributed monthly.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Normal CXR
For Your Reference

5. 6-month-old male with no
significant medical history
presented to the emergency
department with 2 months of
worsening wheezing. Patient was
recently by his pediatricians and
started on nizatidine for reflux as
his symptoms worsened with
feeding. Family presents to ED due
to worsening of symptoms.
Physical Exam: Coarse wheezing
heard from across the room.
Scattered wheezes heard on lung
auscultation with transmitted
upper airway sounds. Coarse
breath sounds over the trachea.

6. 6-month-old male with no
significant medical history
presented to the emergency
department with 2 months of
worsening wheezing.
Earing seen in upper thoracic
esophagus.

7. 6-month-old male with no
significant medical history
presented to the emergency
department with 2 months of
worsening wheezing.
Dx: Esophageal foreign body
leading to soft tissue swelling.
Soft tissue thickening noted
between the airway and
esophagus.

8. Not All That Wheezes Is Asthma!
• This phrase was first coined by Dr. Chevalier Jackson in 1986, and it
remains as true today as it did while he was in practice.
• In fact, Dr. Liston notes that:
“A foreign body impacted in the subglottic area can present as croup,
reactive airway disease, or upper airway obstruction, and that…it is still
necessary to proceed with endoscopy examination of the airway in
young children who present with stridor and wheezing and do not
respond as expected to the usual methods of clinical management.”
Am J Dis Child. 1986;140(8):742.

9. Not All That Wheezes Is Asthma!
The type of stridor heard can be diagnostic of the location of the
obstruction:
Am J Dis Child. 1986;140(8):742.
Inspiratory Stridor Extra-Thoracic Lesions
Expiratory Stridor Intra-Thoracic Lesions
Biphasic Stridor Fixed Lesions

10. Not All That Wheezes Is Asthma!
Am J Dis Child. 1986;140(8):742.

11. 8-year-old previously
healthy boy presents to the
Emergency Department
with 2 days of fever, cough,
nose bleeds and scant
hemoptysis.
CXR with concern for airway
foreign body on lateral view.

12. 8-year-old previously healthy boy presents to the Emergency Department with 2
days of fever, cough, nose bleeds and scant hemoptysis.
Patient taken to the operating room by Pediatric Surgery where rigid bronchoscopy
showed a mucus plug in the left bronchial tree WITHOUT evidence of foreign body!
Dx: Viral illness with mucus
plugging!

13. 7-year-old female who presented
to the ED with 2 days of fever,
cough, shortness of breath.
History of prematurity (born at
33wks) requiring intubation and
NICU stay for respiratory distress.
Vital Signs: Temp 98.1F, HR 129,
BP 109/79, SpO2 97% on room air.

14. 7-year-old female who presented
to the ED with 2 days of fever,
cough, shortness of breath.
History of prematurity (born at
33wks) requiring intubation and
NICU stay for respiratory distress.
Vital Signs: Temp 98.1F, HR 129,
BP 109/79, SpO2 97% on room air.
Right middle and right lower
lobe consolidation.

15. Right middle and right lower
lobe consolidation.
Dx: Right middle and lower lobe
pneumonia. Lateral View
7 year old female who presented
to the ED with 2 days of fever,
cough, shortness of breath.
History of prematurity (born at
33wks) requiring intubation and
NICU stay for respiratory distress.
Vital Signs: Temp 98.1F, HR 129,
BP 109/79, SpO2 97% on room air.

16. 14-year-old female with history of
trisomy 21, asthma, and congenital
heart disease status post repair,
presented to the emergency
department for evaluation of hypoxia.

17. 14-year-old female with history of
trisomy 21, asthma, and congenital
heart disease status post repair,
presented to the emergency
department for evaluation of hypoxia.
She was referred to us by her
pediatrician where she was being seen
in follow-up and noted to have
ambulatory oxygen saturation of 83%.
Per family, she has had 10 days of
intermittent fever, cough, and increasing
fatigue.

18. 14-year-old female with history of
trisomy 21, asthma, and congenital
heart disease status post repair,
presented to the emergency
department for evaluation of hypoxia.
Initial CXR shows large right pleural
effusion with extensive right middle
and lower lobe consolidation.
She was referred to us by her
pediatrician where she was being seen
in follow-up and noted to have
ambulatory oxygen saturation of 83%.
Per family, she has had 10 days of
intermittent fever, cough, and increasing
fatigue.

19. Thoracic ultrasound
revealed extensive,
loculated right pleural
effusion.

20. Patient taken to the
operating room for a right
sided VATS with chest tube
placement for evacuation of
the pleural effusion and
takedown of the adhesions.

21. Chest tube removed
on post operative
day #6. Patient
discharged in stable
condition on post
operative day #10.
CXR on post
operative day #8
shows right lung
patchy airspace
opacity with right
lower lobe
consolidation and
moderate loculated
right pleural
effusion.

22. 4-year-old healthy female
presented to the emergency
department with fever, cough
and increased respiratory effort.
Dx: Right Middle Lobe
pneumonia in the setting of
viral illness.
Right middle lobe infiltration.
Bilateral peribronchial cuffing.

23. Lateral View
4-year-old healthy female
presented to the emergency
department with fever, cough
and increased respiratory effort.
Dx: Right Middle Lobe
pneumonia in the setting of
viral illness.
Right middle lobe infiltration.

24. 10-month-old ex-36-week preemie who
presents with wheezing and increased
work of breathing in the setting of
cough, congestion and fever which
began the day prior.
Vital Signs: HR 125, RR 40, SpO2 100%.
Dx: Viral Bronchiolitis
Extensive peribronchial cuffing

25. 16-year-old female who presented to
an outside hospital with altered mental
status in the setting of drug overdose.
While undergoing evaluation the
patient had multiple tonic-clonic
seizures. She was stabilized AND
transferred to our pediatric ICU.
Dx: Left Lung Atelectasis with
right basilar atelectasis.
Left lung and right base
atelectasis.
Upon presentation to our hospital, the
patient was noted to have increasing
confusion and hypoxia. Bedside CXR
obtained shown.

26. 16-year-old female who presented to
an outside hospital with altered mental
status in the setting of drug overdose.
While undergoing evaluation the
patient had multiple tonic-clonic
seizures. She was stabilized AND
transferred to our pediatric ICU.
Post intubation CXR shows improving
aeration with positive pressure!

27. Atelectasis
• Defined: reduced lung inflation
• CXR features (that distinguish
atelectasis from consolidation):
• Elevation of the hemidiaphragm
• Displaced fissure
• Crowded vasculature
• Mediastinal shift toward the
collapse
• Subsegmental, with a linear or
band-like appearance
• Types/Causes:
• Post obstructive
• Mucous plug
• Foreign body aspiration
• Mass
• Compressive
• Mass
• Round/Cicatricle
• Chronic TB or sarcoid
• Adhesive
• ARDS
• Passive
• Pneumothorax
• Pleural effusion
https://litfl.com/cxr-essentials-types-of-atelectasis/
From Last Month…

28. Atelectasis: Patterns Based On Location
• Right Upper Lobe
• Triangular opacity
• Elevation of right hilum
• Rightward mediastinal shift
• Right Middle Lobe
• Loss of right heart border
• BEST seen on lateral film as a wedge pointing toward the hilum
• Right Lower Lobe
• Triangular opacity near the spine
• Silhouetting of right hemidiaphragm
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/
From Last Month…

29. Atelectasis: Patterns Based On Location
• Left Upper Lobe
• Loss of left upper heart border
• Elevated left hilum
• Luftsichel Sign: crescent of air creating
sharp border along the aorta
• Left Lower Lobe
• Triangular opacity creating an oddly
linear left heart border
• Silhouetting of the left
hemidiaphragm
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/
. https://4.bp.blogspot.com/_fBQVVpFhTQs/SjlDlLXAlrI/AAAAAAAAAvU/7By_wSFvB4k/s1600-h/left-upper-lobe-collapse-1.jpg
From Last Month…

30. Patient is a 17-year-old
female with a history of
asthma and tobacco/vape
pen presented as a transfer
from Iredell Memorial
Hospital ED by air transport
for acute respiratory
distress and severe acute
hypoxemic respiratory
failure.
CXR obtained at the outside
hospital shows extensive
bilateral patchy infiltrates.

31. Patient is a 17-year-old
female with a history of
asthma and tobacco/vape
pen presented as a transfer
with acute respiratory
distress and severe acute
hypoxemic respiratory
failure.
Chest CT obtained at outside
hospital shows extensive
bilateral patchy infiltrates

32. Patient is a 17-year-old female
with a history of asthma and
tobacco/vape pen presented as
a transfer with acute respiratory
distress and severe acute
hypoxemic respiratory failure.
Upon presentation, vital signs
included RR 44, HR 163, end-
tidal CO2 15, SPO2 high 70s.
Decision was made to proceed
with intubation. Upon
intubation, patient noted to
have copious volume straw
colored fluid in the posterior
oropharynx.
Post intubation CXR

33. Patient is a 17-year-old female
with a history of asthma and
tobacco/vape pen presented as
a transfer with acute respiratory
distress and severe acute
hypoxemic respiratory failure.
Due to worsening respiratory
distress and refractory shock,
decision was made to proceed
with extracorporeal membrane
oxygenation cannulation
Unfortunately, after cannulation
patient went into PEA arrest and
was unable to be resuscitated
despite heroic efforts.
During resuscitation, copious
amounts of straw color fluid
(>2L) was suctioned from the
patients ETTDx: E-cigarette vaping
associated lung injury (EVALI)

34. Patient is a 17-year-old
previously healthy female
who presented to an
outside hospital in
respiratory distress. She
endorses cigarette and
vape pen use, with use of
both tobacco and black
market marijuana pods.
Initial CXR shows patchy
infiltrates bilaterally
Dx: E-cigarette vaping
associated lung injury (EVALI)

35. Patient is a 15-year-old
previously healthy female who
presented to an outside
hospital in respiratory distress.
CXR prior to discharge
She was treated with high flow
nasal cannula, high dose
steroids, and discharged home
in stable condition on hospital
day 7 with prolonged taper of
her high dose steroids.
Dx: E-cigarette vaping
associated lung injury (EVALI)

36. Patient is a 15- year old
previously healthy female who
presented to an outside
hospital in respiratory distress.
Follow-up CXR
Follow-up CXR shows significant
improvement in lung aeration.
Unfortunately, patient was re-
admitted 2 weeks after discharge due
to steroid induced psychosis.
Remember, our treatments are not
without consequences. Patient/family
education is imperative to ensure
prompt recognition of adverse effects!

37. If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact
CDC-INFO or call 1-800-232-4636.
Latest Outbreak Information
This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands,
substances, and e-cigarette, or vaping, products.
The EVALI cases and EVALI deaths reported as of December 3, 2019, include data from a two-weekThe EVALI cases and EVALI deaths reported as of December 3, 2019, include data from a two-week
period, November 17 through November 30.period, November 17 through November 30.
As of December 3, 2019,As of December 3, 2019, CDC will only report hospitalized EVALI cases and EVALI deaths regardless of
hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts.
Due to only reporting hospitalized EVALI cases as of December 3, 2019, CDC removed 175Due to only reporting hospitalized EVALI cases as of December 3, 2019, CDC removed 175
nonhospitalized cases from previously reported national case.nonhospitalized cases from previously reported national case. SeeSee Public Health ReportingPublic Health Reporting forfor
more information.more information.
As of December 3, 2019As of December 3, 2019, a total of 2,291 cases of hospitalized e-cigarette, or vaping, product use associated
lung injury (EVALI) have been reported to CDC from 50 states, the District of Columbia, and two U.S. territories
(Puerto Rico and U.S. Virgin Islands).

38. Latest Outbreak Information
Updated every Thursday
This complex investigation spans almost all states, involves over a thousand patients, and a wide variety of
brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new cases are
being reported, which makes it more difficult to determine the cause or causes of this outbreak.
As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have
been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida,
Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri,
Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia.
More deaths are under investigation.
The median age of deceased patients was 49 years and ranged from 17 to 75 years.
Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019):
70% of patients are male.
The median age of patients is 23 years and ages range from 13 to 75 years.
79% of patients are under 35 years old.
By age group category:
Latest Outbreak Information
This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands,
substances, and e-cigarette, or vaping, products.
The EVALI cases and EVALI deaths reported as of December 3, 2019, include data from a two-weekThe EVALI cases and EVALI deaths reported as of December 3, 2019, include data from a two-week
period, November 17 through November 30.period, November 17 through November 30.
As of December 3, 2019,As of December 3, 2019, CDCwill only report hospitalized EVALI cases and EVALI deaths regardless of
hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts.
Due to only reporting hospitalized EVALI cases as of December 3, 2019, CDC removed 175Due to only reporting hospitalized EVALI cases as of December 3, 2019, CDC removed 175
nonhospitalized cases from previously reported national case.nonhospitalized cases from previously reported national case. SeeSee Public Health ReportingPublic Health Reporting forfor
more information.more information.
As of December 3, 2019As of December 3, 2019, a total of 2,291 cases of hospitalized e-cigarette, or vaping, product use associated
lung injury (EVALI) have been reported to CDCfrom 50 states, the District of Columbia, and two U.S. territories
(Puerto Rico and U.S. Virgin Islands).
Forty-eight deaths have been confirmed in 25 states and the District of Columbia (as of December 3, 2019)(as of December 3, 2019):
Alabama, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas,
Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New
York, Oregon, Pennsylvania, Tennessee, Texas, Utah, and Virginia

41. Summary of This Month’s Diagnoses
• Esophageal foreign body
• Mucus plugging
• Pneumonia
• Atelectasis
• Bronchiolitis
• E-cigarette vaping associated lung injury
(EVALI)