This presentation will help all the medical students to give a basic idea of all the common abnormalities seen on chest X-ray in pediatric age group.

1. ABNORMAL X-RAYS
Dr. Kaustubh Mohite

2. Quick Recap……
Before starting to read any X-ray:
■ Patient identification details.
■ Confirming the view (PA, AP, Lateral).
■ Breath (Inspiration or Expiration).
■ Penetration (Under or Over-exposed).
■ Rotation.

3. Points to be covered in all X-rays:
■ Trachea and major bronchi.
■ Hilar structures.
■ Lung Zones.
■ Pleura and pleural spaces.
■ Diaphragm.
■ Costophrenic recesses and angles
 Heart size and contours.
 Mediastinal contours.
 Soft tissues.
 Bones.

4. 4 Pattern approach
Whenever you see an area of increased density within the lung, it must be the
result of one of these four patterns:
1. Consolidation
2. Interstitial
3. Nodule / mass
4. Atelectasis

5. Alveoli filled with fluid, pus, blood, cells
or other substances
resulting in lobar,
diffuse or multifocal
ill-defined opacities
Involvement of the
supporting tissue of the
lung parenchyma resulting in fine or
coarse reticular opacities or small nodules.
Space occupying lesion either
solitary or multiple.
Collapse of a part of the
lung due to a decrease in
the amount of air in the alveoli resulting
in volume loss and increased density.
Types of Infiltrates

6. Consolidation

7. Key features:
■ ill-defined homogeneous opacity obscuring vessels
■ Silhouette sign: loss of lung/soft tissue interface
■ Air-bronchogram
■ Extension to the pleura or fissure, but not crossing it
■ No volume loss

8. Lobar Consolidations
The findings are:
■ increased density with ill-defined
borders in the left lung
■ the heart silhouette is still visible,
which means that the density is in the
lower lobe
■ air-bronchogram

9. • On the chest x-ray there is an
ill-defined area of increased
density in the right upper lobe
without volume loss.
• The right hilus is in a normal
position.
• Notice the air-bronchogram
(arrow).

10. Diffuse Consolidation
Most common cause – Congestive Heart Failure .
The findings are:
• bilateral perihilar consolidation with air
bronchograms and ill-defined borders
• an increased heart size
• subtle interstitial markings
• probably a large vascular pedicle

11. Diffuse consolidation in bronchopneumonia
This patient had fever and cough.
• Unlike lobar pneumonia, which starts in the
alveoli, bronchopneumonia starts in the airways
as acute bronchitis.
• It will lead to multifocal ill-defined densities.
When it progresses, it can produce diffuse
consolidation.
• The disease does not cross the fissures, but
usually starts in multiple segments.

12. Batwing Consolidation:
• Bilateral perihilar consolidation
• Sparing peripheral lungs (d/t better lymphatic
drainage)
• Seen in:
• Pulmonary edema
• Bronchopneumonia
• Viral Pneumonia
Reverse Batwing Consolidation:
• Peripheral or Sub-pleural consolidation
• Seen in:
• Bronchoalveolar carcinoma
• Sarcoidosis
• Organizing Pneumonia
• Eosinophilic Pneumonia

13. Interstitial

14. ■ Investigation of choice for ILD – HRCT
■ Difficult to diagnose ILD based onCXR
■ On a CXR the most common pattern is reticular.
The ground-glass pattern is frequently not detected on a chest x-ray.
The cystic pattern is also difficult to appreciate on a chest x-ray.
When the cysts have thick walls like in Langerhans cell histiocytosis or
honeycombing, it frequently presents as a reticular pattern on a CXR.

15. Reticular pattern
The findings are:
•Normal old film on top.
•Reticular pattern especially in the basal parts of
the lung.
•Some Kerley B lines are seen.
•Increased heart size.
•Pulmonary vessels are somewhat more prominent
compared to the old film.

16. Kerley B Lines
• These are thin lines 1-2 cm in length in
the periphery of the lung(s).
• They are perpendicular to the pleural
surface and extend out to it.
• They represent thickened subpleural
interlobular septa and are usually seen
at the lung bases.

17. Nodular / Mass

18. Solitary Pulmonary Nodules
■ A solitary pulmonary nodule is defined as a discrete, well- marginated, rounded
opacity less than or equal to 3 cm in diameter.
■ It has to be completely surrounded by lung parenchyma, does not touch the hilum or
mediastinum and is not associated with adenopathy, atelectasis or pleural effusion.
■ Lesions smaller than 3 cm are most commonly benign granulomas, while lesions larger
than 3 cm are treated as malignancies until proven otherwise and are called masses.
■ Most common – Granuloma
■ Less common – Bronchial carcinoma, Metastasis,Organizing Pneumonia, Hamartoma

19. Multiple Masses

20. Atelectasis

21. ■ Atelectasis or lung-collapse is the result of loss of air in a lung or part of the lung with
subsequent volume loss due to airway obstruction or compression of the lung by
pleural fluid or a pneumothorax.
The key-findings on the X-ray are:
■ Sharply-defined opacity obscuring vessels without air-bronchogram.
■ Volume loss resulting in displacement of diaphragm, fissures, hilum or mediastinum.

22. Lobar Atelectasis

23. Right Upper Lobe Atelectasis
Findings:
1.Triangular density
2. Elevated right hilus
3. Obliteration of the retrosternal clear
space (arrow)
4. A common finding in atelectasis of the
right upper lobe is 'tenting' of the
diaphragm

24. Right Middle LobeAtelectasis
Findings:
• Blurring of the right heart border
(silhouette sign)
• Triangular density on the lateral view
as a result of collapse of the middle
lobe.
• Usually right middle lobe atelectasis
does not result in noticeable
elevation of the right diaphragm.

25. Right Lower Lobe Atelectasis
Findings:
• Notice the abnormal right border of the
heart.
• The right interlobar artery is not visible,
because it is surrounded by the collapsed
lower lobe, which is adjacent to the right
atrium.
• On a follow-up chest film the atelectasis
has resolved.
• Notice the reappearance of the right
interlobar artery (red arrow) and the
normal right heart border (blue arrow).

26. Left Upper Lobe Atelectasis
Findings:
• Minimal volume loss with elevation of the
left diaphragm
• Band of increased density in the
retrosternal space, which is the collapsed left
upper lobe
• Abnormal left hilus, i.e. possible
obstructing mass

27. Left Lower Lobe Atelectasis
Findings:
• Triangular density seen through
the cardiac shadow.
• Due to abnormality located
posterior to the heart.
• This is confirmed on the lateral
view.
• The contour of the left diaphragm
is lost when you go from anterior
to posterior.

28. TotalAtelectasis
• The chest x-ray shows
total atelectasis of the
right lung due to mucus
plugging.
• Notice the displacement
of the mediastinum to
the right.
• Re-aeration on follow-
up chest film after
treatment with a suction
catheter.
• The mediastinum has
regained its normal
position.

29. What seems abnormal….
Thymic shadow:Thymic sail sign Pneumomediastinum: Spinnaker sail sign

30. Abnormal X-
Rays
Neonatal
Respiratory
Distress
Medical
causes
Surgical
causes
Childhood
Diseases

31. Neonatal
Respiratory distress
Medical causes
•1.TransientTachypnea of Newborn
•2. Meconium aspiration
•3. Neonatal Pneumonia
•4. RDS (Surfactant deficiency)
Surgical causes
1. Congenital diaphragmatic Hernia
2. Cong.Cystic Adenomatoid Malformation
3. Congenital Lobar Emphysema
4. Pulmonary Sequestration

32. TTN
■ Delayed Clearance of pulmonary fluid.
■ Normal respiration for first hour, then gradually develops mild distress
by 4-6 hours, peaks at 24 hours and recovers by 48 – 72 hours.
■ CXR – findings of fluid overload with vascular congestion and small
pleural effusion.
■ CXR clears up by 48 – 72 hours.

33. Day 1 – mild vascular congestion
with pleural effusion
Day 2 – fluid overload has
resolved and CXR in normal

34. MeconiumAspiration Syndrome
■ 10% live births – Meconium stained liquor.
■ 1% - Meconium aspiration syndrome.
■ Confirmed by visualization of meconium below the vocal cords.
■ CXR – reflects underlying pathology
■ Complete obstruction of bronchi – atelectasis and compensatory
hyperinflation of the unaffected region.
■ Barotrauma in common.

35. • Diffuse, asymmetric patchy infiltrates
• Areas of Consolidation
• Hyperinflation

36. Neonatal Pneumonia
May have varied findings:
■ Diffuse reticulonodular densities similar to RDS.
■ Patchy, asymmetric infiltrates with hyper-inflation as in MAS.
May be associated with small pleural effusion.

37. Patchy, asymmetric opacities with
small right pleural effusion

38. Respiratory Distress Syndrome
■ Surfactant deficiency.
■ Presents immediately after birth with respiratory compromise.
■ Findings:
– Diffuse symmetric reticulo-granular densities.
– Prominent central air bronchogram.
– Features of generalized hypoventilation.

39. Premature neonate with RDS prior to intubation with
marked air bronchogram and diffuse symmetric
reticulo-granular opacities.

40. Complications of Respiratory Distress
■ There is a very fine line to maintain a balance between the ventilatory
needs of the infants and complications as a result of positive pressure
ventilation.
■ Lungs with low compliance or with high mean airway pressures lead to
barotrauma.

41. Pneumothorax
• The least dependent portion of neonatal
chest in anterior, lower chest.
• Pneumothorax appears as unusually shard
cardiac border or an unusually sharp and
lucent costophrenic angle on a supineCXR.
• Deep Sulcus Sign.

42. Pneumothorax seen on supineCXR confirmed by left decubitus X-ray.

43. Pulmonary Interstitial Emphysema
■ Results from rupture of the alveoli with air accumulating in the peri-bronchial and
perivascular spaces.
■ Linear lucencies radiating from the hilum.
■ May be cystic in nature.
■ Indicates the poor compliance of the lungs.
■ Frequently follows pneumothorax.

44. Unilateral PIE with Pneumothorax
If you look closer, the left lung demonstrates
the streaky lucencies of air in interstitium
(red arrows) complicated by a pneumothorax
(yellow arrow)

45. Patent DuctusArteriosus
■ Ductus Arteriosus normally closes by 1-2 days after birth.
■ If pulmonary resistance remains high, the ductus may remain open with right to left
shunt.
■ With ventilatory therapy, pulmonary resistance decreases and hence ductus may
switch to a left to right shunt resulting in increased pulmonary blood flow.

46. CXR shows enlarged heart and significant vascular congestion resulting from PDA

47. Chronic Lung Disease (CLD)
Bronchopulmonary Dysplasia (BPD)
■ Long term sequelae of respiratory distress syndrome.
■ Due to Oxygen toxicity and prolonged positive pressure ventilation.
■ Def – Continued O2 needs and CXR abnormalities beyond 28 days of life or 36 wks
gestational age.

48. Cystic interstitial pulmonary disease reflecting severe form of CLD

49. Surgical Causes:
Congenital Diaphragmatic Hernia (CDH)
■ Defect in diaphragm with herniation of abdominal contents in thoracic cavity.
■ Mass effect leads to severe respiratory distress from pulmonary hypoplasia.
■ Bochdalek Hernia – most common defect.
Posterior and lateral diaphragm
More commonly on left.
■ Morgagni Hernia – anterior and medial
May present later in life
More common on the right because of heart and pericardium

50. Bowel loops seen in left thoracic cavity with shift of mediastinum to the right

51. Congenital Cystic Adenomatoid
Malformation (CCAM)
■ Hamartoma of the lung.
■ Presentation: Large cystic lesion to a grossly solid appearing lesion
■ Types:
– Type 1: most common, contains a dominant cyst > 2 cm, surrounded by multiple
smaller cysts.
– Type 2: uniform smaller cysts up to 2 cm.
– Type 3: least common, contains microscopic cysts.

52. Type 1 CCAM on CXR with a large dominant cyst containing as air fluid level

53. Congenital Lobar Emphysema
■ Overexpansion of one or more lobes
■ Most common in left upper lobe.
■ Initial findings – solid mass on both prenatal and postnatalCXR d/t delayed clearance
of pulmonary fluid.
■ Later – fluid slowly resorbs, leaving behind classic hyperlucent lobe.

54. Initial stage Later stage

55. Pulmonary Sequestration
■ Lung tissue that is not connected to tracheobronchial tree.
■ Sequestration has a systemic arterial supply instead of a pulmonary arterial supply.
■ 2 types:
– Intralobular (within the normal lung pleura)
– Extralobular (has its own separate pleura, causes mass effect over adjoining lung)