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Newborn Chest    Janet R Reid MD, FRCPCChildren’s Hospital of Philadelphia     Fellow Radiology Lecture Series 2012
Part I  Common PatternsFellow Radiology Lecture Series 2012
Ground Glass                 Clinical Clue:                 Gestational age: RDS                 always in premature      ...
Fine Reticular                 Clinical Clue:                 History of C-Section in                 TTN                 ...
Coarse Reticular                    Clinical Clue:                    Thick meconium at birth;                    fetal di...
Mass                        Clinical Clue:                        Presence and                        appearance on prenat...
Multiple Lucencies                         Clinical Clue:                         Growth pattern on                       ...
Increased Blood Flow                      Clinical Clue:                      Murmur                      Xray Clue:      ...
Case: Newborn child (3 hours old) with grunting             and nasal flaring           Fellow Radiology Lecture Series 2012
Ground Glass                  Clinical Clue:                  Gestational age:                  RDS always in premature   ...
Cases: 2 premature newborns with respiratory            distress/same pattern       A                                     ...
Cases: 2 premature newborns with respiratory            distress/same pattern      RDS                          Pneumonia ...
RDS                               • Alveolar collapse                               • Interstitial thickening             ...
RDS                        • Symmetric ground glass                        • Air bronchograms                        • Low...
Case: Full term newborn admitted to NICU with               labored breathing           Fellow Radiology Lecture Series 2012
Coarse Reticular:              Differential Diagnosis• Meconium  Aspiration• Pneumonia                            No pleur...
Meconium Aspiration                          •   Full term, fetal distress                          •   Bile acids        ...
Meconium Aspiration                          •   Subsegmental collapse                          •   Compensatory overinfla...
Neonatal Pneumonia                • Airspace filling                • E Coli; Streptococcus; Staphylococcus               ...
Neonatal Pneumonia                                 •Patchy asymmetric                                 densities           ...
Case: Term child born by C Section     Fellow Radiology Lecture Series 2012
Fine Reticular:             Differential Diagnosis• Transient  tachypnea of the  newborn (retained  fetal lung liquid)• Pu...
Transient Tachypnea                          •Caesarian section                          •Lack of squeezing of chest      ...
Transient Tachypnea                   • Interstitial edema                   • Possible cardiomegaly                   • P...
Cases: 2 preterm children with respiratory distress             Fellow Radiology Lecture Series 2012
Multiple Lucencies:            Differential Diagnosis• Congenital  Diaphragmatic                        Mass effect;      ...
Cases: 2 preterm children with respiratory distress         CDH                                  PIE             Fellow Ra...
CDH                           •Foramen of Bochdalek                           •Failure of mesenchymal                     ...
CDH                     • More commonly left-sided                     • Stomach, intestine, liver, spleen                ...
PIE                           • RDS, pressure ventilation                           • “Air block”                         ...
PIE          • Multiple dark distinct rounded lucencies          • Ventilator settings “going up”          • Can progress ...
Case: Asymptomatic newborn• Chest mass          Fellow Radiology Lecture Series 2012
Mass:           Differential Diagnosis• Congenital  Diaphragmatic                       Where is the  Hernia              ...
Sequestration                        • Present prenatally                        • Diagnosis: Doppler or MRI              ...
CCAM/CPAMFellow Radiology Lecture Series 2012
Bronchogenic CystFellow Radiology Lecture Series 2012
Mass:              Differentiating Features• Congenital Diaphragmatic Hernia:  • Prenatal diagnosis (fetal MRI)  • Respira...
Cases: Two full term newborns with tachypnea          A                                  B          Fellow Radiology Lectu...
Cases: Two full term newborns with tachypnea       • In edema the vessels are indistinct       • With shunt vascularity, t...
Part II Additional PatternsFellow Radiology Lecture Series 2012
Focal Lucency                             PNEUMOMEDIASTINUM                             • Uplifted thymus                 ...
Focal Lucency                                PNEUMOTHORAX                                PNEUMOTHORAX                     ...
Small Thorax                         PULMONARY HYPOPLASIA                        • Dysplastic, obstructed or              ...
Asymmetric VentilationCHRONIC LUNG DISEASE OF CHRONIC LUNG DISEASE OF         PREMATURITY         PREMATURITY• Air trappin...
Opaque HemithoraxA                                   B Fellow Radiology Lecture Series 2012
Opaque Hemithorax PULMONARY AGENESIS PULMONARY AGENESIS                      ATELECTASIS                                  ...
Summary• There are several common patterns of  disease on newborn chest radiographs• One can differentiate between disease...
Summary   GROUND GLASS              FINE RETICULAR         COARSE RETICULAR• Gestational age: RDS    • History of C-Sectio...
Summary        MASS              MULTIPLE LUCENCIES         INCREASED FLOW• Presence and           • Growth pattern on    ...
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Newborn chest reid

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Newborn chest reid

  1. 1. Newborn Chest Janet R Reid MD, FRCPCChildren’s Hospital of Philadelphia Fellow Radiology Lecture Series 2012
  2. 2. Part I Common PatternsFellow Radiology Lecture Series 2012
  3. 3. Ground Glass Clinical Clue: Gestational age: RDS always in premature Xray Clue: Pleural effusion rare in RDSRDS vs Group B Strep infectionFellow Radiology Lecture Series 2012
  4. 4. Fine Reticular Clinical Clue: History of C-Section in TTN Xray Clue: Cardiomegaly more pronounced in Heart DiseaseTransient tachypnea vs edemaFellow Radiology Lecture Series 2012
  5. 5. Coarse Reticular Clinical Clue: Thick meconium at birth; fetal distress Xray Clue: Effusion more common in pneumoniaMeconium aspiration vs pneumonia Fellow Radiology Lecture Series 2012
  6. 6. Mass Clinical Clue: Presence and appearance on prenatal US Xray Clue: Doppler showing systemic vesselSequestration vs bronchogenic cyst Fellow Radiology Lecture Series 2012
  7. 7. Multiple Lucencies Clinical Clue: Growth pattern on prenatal US; RDS Xray Clue: Location of stomach bubbleDiaphragmatic hernia vs cystic adenomatoid malformation (vs pulmonary interstitial emphysema) Fellow Radiology Lecture Series 2012
  8. 8. Increased Blood Flow Clinical Clue: Murmur Xray Clue: Distinctness of vessels Intracardiac Shunt vs Edema Fellow Radiology Lecture Series 2012
  9. 9. Case: Newborn child (3 hours old) with grunting and nasal flaring Fellow Radiology Lecture Series 2012
  10. 10. Ground Glass Clinical Clue: Gestational age: RDS always in premature Xray Clue: Pleural effusion rare in RDSRDS vs Group B Strep infection Fellow Radiology Lecture Series 2012
  11. 11. Cases: 2 premature newborns with respiratory distress/same pattern A B Fellow Radiology Lecture Series 2012
  12. 12. Cases: 2 premature newborns with respiratory distress/same pattern RDS Pneumonia Fellow Radiology Lecture Series 2012
  13. 13. RDS • Alveolar collapse • Interstitial thickening • Epithelial injury • Bronchiolar distensionFellow Radiology Lecture Series 2012
  14. 14. RDS • Symmetric ground glass • Air bronchograms • Low lung volumes • NO PLEURAL EFFUSIONFellow Radiology Lecture Series 2012
  15. 15. Case: Full term newborn admitted to NICU with labored breathing Fellow Radiology Lecture Series 2012
  16. 16. Coarse Reticular: Differential Diagnosis• Meconium Aspiration• Pneumonia No pleural effusion• Partially treated RDS Full Term• Transient Tachypnea Rarely Fellow Radiology Lecture Series 2012
  17. 17. Meconium Aspiration • Full term, fetal distress • Bile acids • Small airway inflammation • Thick exudate • Obstruction Fellow Radiology Lecture Series 2012
  18. 18. Meconium Aspiration • Subsegmental collapse • Compensatory overinflation • Coarse lines • PTX (25%) Fellow Radiology Lecture Series 2012
  19. 19. Neonatal Pneumonia • Airspace filling • E Coli; Streptococcus; Staphylococcus • No clinical markers • Prolonged rupture of membranes Fellow Radiology Lecture Series 2012
  20. 20. Neonatal Pneumonia •Patchy asymmetric densities •Hyperinflation •Pleural effusion Fellow Radiology Lecture Series 2012
  21. 21. Case: Term child born by C Section Fellow Radiology Lecture Series 2012
  22. 22. Fine Reticular: Differential Diagnosis• Transient tachypnea of the newborn (retained fetal lung liquid)• Pulmonary edema Heart usually bigger• Pneumonia No clinical or radiographic improvement Fellow Radiology Lecture Series 2012
  23. 23. Transient Tachypnea •Caesarian section •Lack of squeezing of chest during delivery •Fluid in interstitium and airspaces Fellow Radiology Lecture Series 2012
  24. 24. Transient Tachypnea • Interstitial edema • Possible cardiomegaly • Pleural effusion • Rapid improvement in 24 hours Fellow Radiology Lecture Series 2012
  25. 25. Cases: 2 preterm children with respiratory distress Fellow Radiology Lecture Series 2012
  26. 26. Multiple Lucencies: Differential Diagnosis• Congenital Diaphragmatic Mass effect; stomach up Hernia Mass effect; stomach down• Congenital Cystic Adenomatoid Malformation Prematurity; day 3• Pulmonary ventilation Interstitial Emphysema Fellow Radiology Lecture Series 2012
  27. 27. Cases: 2 preterm children with respiratory distress CDH PIE Fellow Radiology Lecture Series 2012
  28. 28. CDH •Foramen of Bochdalek •Failure of mesenchymal induction •Mass effectFellow Radiology Lecture Series 2012
  29. 29. CDH • More commonly left-sided • Stomach, intestine, liver, spleen •>35% associated heart disease • Pulmonary hypoplasia • Contralateral lung: prognosisFellow Radiology Lecture Series 2012
  30. 30. PIE • RDS, pressure ventilation • “Air block” • Interstitium and lymphaticsFellow Radiology Lecture Series 2012
  31. 31. PIE • Multiple dark distinct rounded lucencies • Ventilator settings “going up” • Can progress to PTX, pneumomediastinum, pneumoperitoneum, pneumopericardium, parenchymaFellow Radiology Lecture Series 2012
  32. 32. Case: Asymptomatic newborn• Chest mass Fellow Radiology Lecture Series 2012
  33. 33. Mass: Differential Diagnosis• Congenital Diaphragmatic Where is the Hernia stomach?• Diaphragm Possible Eventration• Cystic Adenomatoid Not cystic Malformation• Bronchogenic Cyst Location• Sequestration Possible Fellow Radiology Lecture Series 2012
  34. 34. Sequestration • Present prenatally • Diagnosis: Doppler or MRI • Systemic arterial supply • Systemic (ELS) or pulmonary (ILS) venous drainageFellow Radiology Lecture Series 2012
  35. 35. CCAM/CPAMFellow Radiology Lecture Series 2012
  36. 36. Bronchogenic CystFellow Radiology Lecture Series 2012
  37. 37. Mass: Differentiating Features• Congenital Diaphragmatic Hernia: • Prenatal diagnosis (fetal MRI) • Respiratory distress • High position of the stomach• Diaphragm Eventration: • Cannot differentiate from CDH with imaging• Cystic Adenomatoid Malformation: • Prenatal diagnosis; US; CT• Bronchogenic Cyst: • Usually mediastinal or right-sided parenchymal Fellow Radiology Lecture Series 2012
  38. 38. Cases: Two full term newborns with tachypnea A B Fellow Radiology Lecture Series 2012
  39. 39. Cases: Two full term newborns with tachypnea • In edema the vessels are indistinct • With shunt vascularity, they are big and distinct • In both there is usually cardiomegaly Edema Shunt Fellow Radiology Lecture Series 2012
  40. 40. Part II Additional PatternsFellow Radiology Lecture Series 2012
  41. 41. Focal Lucency PNEUMOMEDIASTINUM • Uplifted thymus • Can progress to PTX, pneumoperitoneum, pneumopericardium, parenchymaFellow Radiology Lecture Series 2012
  42. 42. Focal Lucency PNEUMOTHORAX PNEUMOTHORAX • Spontaneous or related to ventilation • ALWAYS UNDER TENSIONFellow Radiology Lecture Series 2012
  43. 43. Small Thorax PULMONARY HYPOPLASIA • Dysplastic, obstructed or absent kidneys • Oligohydramnios leads to pulmonary hypoplasiaFellow Radiology Lecture Series 2012
  44. 44. Asymmetric VentilationCHRONIC LUNG DISEASE OF CHRONIC LUNG DISEASE OF PREMATURITY PREMATURITY• Air trapping• Atelectasis• Cysts Fellow Radiology Lecture Series 2012
  45. 45. Opaque HemithoraxA B Fellow Radiology Lecture Series 2012
  46. 46. Opaque Hemithorax PULMONARY AGENESIS PULMONARY AGENESIS ATELECTASIS ATELECTASIS • Pleural rind • +/- Air bronchograms • No lung markings • ET tubePulmonary Agenesis Atelectasis Fellow Radiology Lecture Series 2012
  47. 47. Summary• There are several common patterns of disease on newborn chest radiographs• One can differentiate between diseases based on clinical and radiographic clues• Important to adopt a differential diagnosis to include 2 “top contenders” for each pattern• Use ultrasound and prenatal MRI in pediatric chest disease Fellow Radiology Lecture Series 2012
  48. 48. Summary GROUND GLASS FINE RETICULAR COARSE RETICULAR• Gestational age: RDS • History of C-Section • Thick meconium atalways in premature in TTN birth; fetal distress • Cardiomegaly more • Effusion more• Pleural effusion rare pronounced in Heart common inin RDS Disease pneumonia RDS vs GBS TTN vs Edema Meconium vs Infection Pneumonia Fellow Radiology Lecture Series 2012
  49. 49. Summary MASS MULTIPLE LUCENCIES INCREASED FLOW• Presence and • Growth pattern on • Murmurappearance on prenatal US; RDSprenatal US• Doppler showing • Location of stomach • Distinctness ofsystemic vessel bubble vessels Sequestration vs CDH vs CCAM vs PIE Edema vs L-->Rbronchogenic cyst Shunt Fellow Radiology Lecture Series 2012

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