Lecture prepared by UKM radiology resident

1. PAEDIATRIC
CHEST
Presented by: Yeat CM
Supervised by : Dr Erica

2. OUTLINE
▪ Diffuse Pulmonary Disease in
Newborn
▪ Focal Pulmonary Lesion in Newborn
(Lucent vs Solid Lesion)
▪ Assessment of Lines and Tubes
▪ Chronic Lung Disease of Prematurity
▪ Infections of Infants & Older Children
▪ Mediastinal Masses

3. Neonatal
Respiratory
Distress
Pulmonary
Disease
Congenital
Heart Disease
Thoracic
Mass
Airway
Disorder
Skeletal
Abnormalities
Vascular
Abnormali>es

4. DIFFUSE PULMONARY DISEASE
OF THE NEWBORN

5. Source: Paediatric Imaging the Fundamentals

7. 1) TRANSIENT TACHYPNOEA OF THE NEWBORN
• Most common cause
• Prostaglandin imbalance/ lack of thoracic squeeze
reduced absorption by pulmonary lymphatics ‘wet lung’
• Risk factors: maternal asthma, diabetes, C-section
• Benign: develops by 6H peaks at 1 day resolved by 2 to 3 days

8. • Similar to pulmonary edema
• airspace opacification
• coarse interstitial markings
• fluid in the fissures
• pleural effusion
• cardiomegaly
• Lung volumes normal to
increased.
antibiotics are often given initially
no specific treatment necessary for TTN.

10. 2) RESPIRATORY DISTRESS SYNDROME
• a.k.a ‘surfactant deficient disease’ or
‘hyaline membrane disease’
• Surfactant – lipoprotein produced by
type II pneumocytes, mature by 35w
gestation
• If symptoms started >8H, likely not
due to RDS
surfactant
inadequate alveoli
expansion
alveolar injury
fibrin and cellular debris
accumulation
poor O2 exchange

11. • Low lung volume
• Diffuse symmetrical reticular granular
opacities (ground glass)
• Complete white out lungs
• Prominent air bronchograms
* depends on severity
* Normal CXR at 6H excludes RDS
* Treatment alters radiological findings

12. • Treatment
- Exogenous surfactant
- Supportive O2 therapy
• Evolution of CXR in RDS:
- Normalize
- Mechanical ventilation related
eg barotrauma, superimposed infection
- Chronic lung disease/ Bronchopulmonary dysplasia
• No radiographic response post surfactant poor prognosis

13. 24 HoL (Post Surfactant)
2 HoL

14. Ventilatory
support
increase
alveolar
pressure
alveoli
perforation
Air escape into
interstitium &
lymphatics
PIE
3) PULMONARY INTERSTITIAL EMPHYSEMA
• Typically transient
• 2-3% in NICU
• Increases to 20-30% in prem
• HFOV reduces severity

15. ✔bubblelike or linear lucencies
✔Focal or diffuse
✔Non compliant lung – static volume
• Pneumomediastinum/ pneumothorax
• Difficult to differentiate diffuse PIE
from BPD

16. AIR LEAK PHENOMENON
(BAROTRAUMA RELATED)
Angel wing appearance

17. 4) MECONIUM ASPIRATION SYNDROME
• significant morbidity and mortality
among full term & post term
neonates
• Often history suggest (*POST
DATE*)
• Causes chemical pneumonitis
• Meconium causes complete
obstruction of bronchi atelectasis
+ compensatory hyperinflation of
remaining patent airways

18. Clear lungs with hyperinflation
Coarse irregular interstitial opacities +
segmental atelectasis + hyperinflation
Pneumothorax (10-40%)

19. • Leading cause of mortality in
developing countries
• TORCHES, bacterial (eg. GBS)
• RF: PROM, prolonged labour, prem.
❖ Normal
❖ Patchy or diffuse alveolar densities
❖ Interstitial lung disease
❖ + Pleural effusion
❖ Hyperinflation
❖ ** Wide spectrum of imaging abN
** mimic RDS
5) NEONATAL PNEUMONIA
absent in RDS

20. CHARACTERISTIC PATTERN FOR SOME
PNEUMONIAS
Group B Strep Pleural effusion
E.Coli
Haemophilus Influenzae
Staph. Aureus (less common now)
Pneumatocoele formation
(uncommon in neonates)
Chlamydia Overinflation with marked
bilateral interstitial changes at
4-6weeks

22. Source: Core

23. CHRONIC LUNG DISEASE
OF PREMATURITY
a.k.a
BRONCHOPULMONARY
DYSPLASIA

24. • Diagnosis
Oxygen dependence for at least 28 postnatal days
• Grading :
- at 36 postmenstrual wk for infants born at <32 wk
- 56 days of life for infants born at ≥32 wk
- depending on FiO2, CPAP or mechanical ventilation requirement
• New vs Old BPD
- two different morphologic outcomes
- Acquired at different gestational ages and alveolar development stages

26. Prof Faizah’s lecture on ‘Neonatal CXR’, Radiology Survival Course 2020

28. OLD NEW

29. Increased
reticulations
PIE BPD
RDS

30. 🌟
In

31. FOCAL PULMONARY LESION
IN NEWBORN

32. • Often surgical causes
• Compress onto normal lung respiratory distress
• Lucent vs opaque
Fluid filled /

33. CONGENITAL LOBAR EMPHYSEMA
• Obstructive check valve mechanism at bronchial level
• Associations: aberrant LPA, congenital anomalies
• can exert mass effect, may herniate across the midline.
*** not to mistake for a tension pneumothorax
*** chest tube increase respiratory distress

34. few days
apart
fluid-filled to
radiolucent
• Lobar predilection: LUL > RML > RUL
• Mediastinal shift
• Paucity of vessels

35. Presence of bronchovascular markings
within the overdistended lobe
Adjacent lobe collapses caudad or
cephalad but not medial towards the hilum
TREATMENT LOBECTOMY

37. CONGENITAL DIAPHRAGMATIC HERNIA
• Herniation of abdominal contents into the thorax
• Most common: Bochdalek hernia
* herniation through Lt posterior diaphragmatic defect
• Rt sided hernia rare + poor prognosis
• Complication: pulmonary hypoplasia
• Associations: bowel malrotation (95%), neural tube defects,
cardiac anomalies.

38. • Key findings: mass
in the thorax
displacing the
mediastinum
• At birth, herniated
bowels may be fluid
filled & appear
opaque

39. CONGENITAL PULMONARY AIRWAY MALFORMATION
• hamartomatous proliferation of terminal bronchioles that
communicate with the bronchial tree
• Presentation: respiratory distress after birth / recurrent
infection/ incidental finding
• surgery recommended
• Unlike CLE, CPAM no lobar predilection
• Unlike sequestration, CPAM supplied by pulmonary
circulation

40. Prognosis
depends on
size of lesion
rather than
classification

41. Few
days
6 months
HYBRID LESION:
CPAM
+
Pulmonary
sequestration

42. PULMONARY SEQUESTRATION
• Aberrant formation of segmental lung
tissue that has no connection with
the bronchial tree or pulmonary
arteries
• Arterial supply from thoracic
aorta/branches
• Intralobar 75% vs extralobar 25%
• 20% below diaphragm USG

46. BRONCHOGENIC CYST
• • Abnormal budding of tracheobronchial tree.
• middle mediastinum (65 –95%) or lung parenchyma
• If occur in the lung - central or perihilar distribution
• commonly solitary, cause compression of distal trachea or bronchi
• Does not contain air unless infected.
• well defined water atenuation or air-fluid mass
•

50. ASSESSMENT OF
LINES AND TUBES

51. UAC UVC
umbilical vein
Lt portal vein
ductus venosus
Lt hepatic vein
IVC
Courses directly cranial
Tip at cavoatrial junction
(eg L1-L2)
Courses caudally before
cranially
High position T6-9
Low position L3-4
Avoid aor)c
branches
common iliac
artery

53. ETT
1.5cm above carina
Around T2- T3

54. PICC
Tip should be at cavoatrial junction
UL : SVC
LL : IVC
😃
😱
🙅

55. NG TUBE
Tip within the stomach
Esophageal atresia with
tracheoesophageal fistula
Normal

56. INFECTIONS OF INFANTS AND
OLDER CHILDREN

57. ROLE OF IMAGING
confirmation/ exclusion
characterization & prediction of infectious agent
exclusion of other causes
reassessment when fail to resolve
evaluation of complication

58. VIRUS BACTERIA
o Small airways inflammation +
peribronchial opacities
o Symmetrical, radiating from hila
into lung
o Narrowed airway lumen
hyperinflation* + subsegmental
atelectasis
o Infants and preschool age : 95%
viral
o Inflammatory exudates + oedema
consolidation + air
bronchogram
o Lobar or segmental
o Associated with pleural effusion
o May appear round in <8y.o
o Most common: Strep. Pneumoniae
* Hyperinflation: presence of >10 posterior ribs, increased AP ratio

60. BRONCHIOLITIS
• RSV
• Infants & toddlers
• Bronchiolitis & bronchitis, sparing
lung parenchyma
• 2o bacterial infection may occur –
focal lobar consolidation + effusion

61. • Hyperinflation
• AP diameter
• Peribronchial thickening
- symmetrical
- dirty/busy perihilar
• Segmental/ subsegmental/
band atelactasis
• Small lobular air trapping

62. BACTERIAL PNEUMONIA
• Strep.Pneumoniae, Mycoplasma Pneumoniae,
Staph. Aureus
• School age children: incidence of bacterial
infection increase but mostly still viral
• Complications:
- Parapneumonic effusion – USG assessment
- Parenchymal complication – parenchymal
ischemia or infarction (CECT beneficial) →
cavitary necrosis/ lung abscess/
pneumatocele/ pulmonary gangrene.

63. ROUND PNEUMONIA
• Common in <8 y.o
• Strep. Pneumoniae
❖ Rounded opacity with poor defined
margins, several cm in diameter
❖ More commonly posteriorly & in the
lower lobes
❖ Ddx: mets, pos mediasanal
tumours

64. WHY CHILDREN?
• Underdevelopment of pores of Kohn
and canals of Lambert
Limits spread of infection
• In adults, they allow collateral air
drift between subsegments
lateral dissemination of infection
throughout a lobe lobar pneumonia

65. Resolves rapidly with treatment

66. • Most
NECROTIZING
PNEUMONIA
• Rare, manifested as a severe disease
• Mainly in infants and immunocompromised
children
• Presentation: cough, fever <1w, WCC, Hb,
serum albumin, pleural fluid pH
• Can lead to pyopneumothorax
• Most show complete recovery without surgical tx
• Ghost cavities may persist for months
• Resolve to normal CXR at long term

67. • Causes of aspiration:
- foreign body aspiration
- deglutition abnormality
- congenital structural anomaly
eg. tracheoesophageal fistula
- GERD
- neuromuscular disorder
ASPIRATION PNEUMONIA

68. • Air space opacification in a lobar or
segmental distribution
• Common sites in recumbent patient
- posterior segment of upper lobes
- superior segment of lower lobes

69. TUBERCULOSIS
• May show different pattern from adult
• Risk factors: malnourished, poor living circumstances,
immunocompromised
• Primary and miliary forms are more common in young
children

70. PRIMARY SECONDARY MILIARY
Lung focus may not be evident
until it heals
May present as:
* consolidation + hilar nodal
enlargement + effusion
• Lobar collapse
(endobronchial disease)
• isolated nodal enlargement
• Apical thick wall
cavities
(similar to adult)
• Miliary nodular
pattern
• + nodal enlargement
+ consolidation
* If seen in a child not acutely ill TB until proven otherwise

72. MEDIASTINAL MASS
IN CHILDREN

75. LYMPHOMA
HODGKIN’S LYMPHOMA NON-HODGKIN’S LYMPHOMA
3-4x more common
2nd decade 1st & 2nd decade
Thymic involvement Spares the thymus
Generally contiguous nodal groups Not contiguous, can skip a location
* Most common cause of anterior mediastinal
mass in children

76. 1) Lymphadenopathy
- mildly enlarged in single area OR
large
conglomerate masses in
multiple areas
2) Calcifications/ cystic areas
- ischaemic necrosis 2o rapid
growth
3) Thymic enlargement – minimal
enhancement, convex lobular
borders
4) Mass effect – air way narrowing,
HODGKIN’S LYMPHOMA

77. NON- HODGKIN’S LYMPHOMA

78. THYMIC HYPERPLASIA
• > 50 % increase in volume of the thymus
• most often associated with chemotherapy, esp
corticosteroids – ‘rebound’
• may be observed during chemo, after chemo
completion & occurs 3 to 10 months after the
start of chemo

79. • CT: diffuse enlargement of the thymus, preserved normal triangular shape.
• CT, MRI of PET cannot differentiate rebound hyperplasia from tumoural
infiltration
• Absence of other active disease and a gradual decrease in thymus size on
serial CT’s s rebound hyperplasia.
• The thymus usually returns to its normal size in 3 to 6 months.

80. THYMOMA
• Thymoma -20% of mediasbnal neoplasms
• Thymic carcinoma – rare <1%, more aggressive
LEFT: Thymoma. RIGHT: Thymic carcinoma.
The thymic carcinoma has invaded the SVC
(arrow).

81. GERM CELL TUMOURS
• Most common fat containing anterior mediastinal mass
• 2nd most common cause of anterior mediastinal mass
in children
• Approx. 90% benign, most arise from thymus
• On CT: a benign teratoma is
- well-defined, thick-wall cystic mass
- mixture of water, calcium, fat and soft tissue
(minimal soft tissue component)
• Size is not an indicator of malignancy.
Benign mature teratoma

82. MALIGNANT TERATOMA
• 10% of all teratomas
• irregular or nodular walls and a
predominance of soft tissue components
• pulmonary or liver metastases and chest
wall invasion
• most common non-teratomatous germ-
cell tumors: choriocarcinoma, embryonal
cell cancer and yolk-sac cancer.

83. THYMOLIPOMA
• infrequent fat-containing thymic tumor
• On CT :
- heterogeneous mass with fat + soft
tissue elements
- no calcifications
- no capsule
- no mass effect.

84. THYMIC CYST
• Congenital: persistence of
thymopharyngeal duct
• Can occur after thoracotomy.
• On CT:
- thin-walled, homogeneous masses, near
water attenuation
- if contents= proteinaceous or
hemorrhagic, higher HU

85. LYMPHANGIOMA / CYSTIC HYGROMA
• developmental tumors of the lymphatic system
• infants younger than 6 months of age.
• almost always an inferior extension of cervical lymphangioma;
isolated mediastinal involvement is rare.
• benign, but aggressive tumor - mass effect, may encase vessels and other
structures.
• On CT : nonenhancing, thin-walled, multiloculated mass with near water
attenuation

86. CT features:
Non-enhancing
thin-walled
multiloculated mass
near water attenuation.
MRI to better delineate extension
• cystic mass extending into right axilla &
mediastinum
• encases vessels
• presence of mural contrast enhancement or
internal septations suggests superimposed
infection or a hemangiomatous component.

87. In children,
thymoma, thymic carcinoma and goiter are
RARE, put them very low in your differential
diagnosis.

89. FOREGUT CYSTS

90. BRONCHOGENIC CYSTS
Well defined lesion
Water attenuation
Close proximity to trachea/ bronchus

91. ENTERIC FOREGUT CYST
• well defined lesion
• water attenuation
• lower mediastinum
• in close proximity to the
esophagus

92. MEDIASTINAL LYMPHADENOPATHY
• lymphoma or granulomatous disease, metastasis from
rhabdomyosarcoma, osteosarcoma or Wilms tumor
• On CT:
- discrete, round, soft tissue masses/ single soft tissue mass,
poorly defined margins
- Calcification: old healed granulomatous disease, fungal
infection or osteosarcoma mets
- Areas of low attenuation- TB/ fungal

95. Posterior
Mediastinal Mass
(Neural Origin)
Sympathetic ganglion
cells
neuroblastoma
ganglioneuroma
ganglioneuroblastoma
Nerve sheaths
neurofibroma
schwannoma

96. NEUROBLASTOMA
• Fusiform
• Soft tissue density
• 50% thoracic tumours –
calcifications
• grows over several
interspaces
• invades the vertebral
canal

97. On the MR-images the invasion
of the vetebral canal is better
seen (arrows).

98. OTHER NEUROGENIC TUMOURS
• ganglioneuroma, neurofibroma and rarely
schwannoma – 2nd decade
• round or oval in shape, smaller in size
than ganglion cell tumors and usually
extend over only one or two vertebrae
• may cause pressure erosion of a rib and
invade the spinal canal
Ganglioneuroma
Neurofibroma

99. NEUROENTERIC CYST
• contain neural and gastrointestinal
element.
• a/w vertebral anomalies and scoliosis.
• does not communicate with CSF.
• well demarcated
• near water attenuation value on CT and
water signal intensity on MRI

100. EXTRAMEDULLARY HAEMATOPOEISIS
• accounts for less than 0.1 % of the
lesions in the posterior mediastinum.
• formation of blood elements outside
of the bone marrow
• occurs with severe anemia
• CT: paravertebral mass and occurs
with coarse bone trabeculation in the
adjacent vertebra.

101. REFERENCES
• Core Radiology
• Paediatric Imaging The Fundamentals
• Prof Faizah’s lecture on ‘Neonatal CXR’, Radiology Survival Course 2020
• Grainger and Allison’s Diagnostic Radiology Essentials
• Radiopedia
• Radiology Assistant

102. THANK
YOU

103. HAPPY BIRTHDAY !!!!
ZAKWAN TAN HOOI LAM