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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: May Cases

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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:
• Recurrent pneumothorax
• Parapneumonic effusion
• Pediatric ARDS
• Septic pulmonary emboli
• RUl Pneumonia
• GSW with pulmonary hemorrhage

Published in: Education
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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: May Cases

  1. 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 May 2020
  2. 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. 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. 4. Normal CXR For Your Reference
  5. 5. HPI: 3-year-old previously healthy male presented with respiratory distress in the setting fever and cough. Pulmonary exam showed tight lungs, decreased movement to bases and increased work of breathing with diffuse retractions and tachypnea.
  6. 6. HPI: 3-year-old previously healthy male presented with respiratory distress in the setting fever and cough. Pulmonary exam showed tight lungs, decreased movement to bases and increased work of breathing with diffuse retractions and tachypnea. Pneumomediastinum Dx: Pneumomediastinum due to viral bronchiolitis
  7. 7. Pneumothorax Dx: Spontaneous Pneumothorax HPI: Late preterm newborn with respiratory distress/grunting at 20min of life treated with CPAP
  8. 8. Mediastinal Shift Dx: Tension Pneumothorax Attempted needle decompression, subsequently patient developed hypoxia to 89%, bradycardia, and worsening tachypnea. Repeat CXR shows… Worsening Pneumothorax
  9. 9. Proceeded to pigtail thoracostomy Resolution of Pneumothorax
  10. 10. HPI: 4-year-old female admitted for MRSA sepsis with ARDS from hip septic arthritis and osteomyelitis. Patient intubated and on oscillator with acute episode of desaturation which persisted despite bagging. Vital signs: HR: 118 BP: 70/42 SpO2 on 100% FiO2: 61%
  11. 11. HPI: 4-year-old female admitted for MRSA sepsis with ARDS from hip septic arthritis and osteomyelitis. Patient intubated and on oscillator with acute episode of desaturation. Mediastinal Shift Left Sided Pneumothorax Dx: Tension Pneumothorax Deep Sulcus Sign
  12. 12. Spontaneous Pneumothorax• Etiology: • May be primary or secondary • 94% occur in patients >10yrs old, 80% in males • Presentation: • Presentation is often delayed • Most patients presents with acute onset chest pain or shortness of breath • Activities which increase intrathoracic pressure increase symptoms • Diagnosis: • Ultrasound: ~90% sensitive (may be higher based on operator) • Supine CXR: ~50% sensitive • Erect CXR: has increased sensitivity (~90%) • Management: 100% O2 therapy is recommended for PTX less than 15-20% Dotson K, Timm N, Gittelman M. Is Spontaneous Pneumothorax Really a Pediatric Problem? A National Perspective. Pediatric Emer Care 2012; 28(4): 340-344. Dotson K, Johnson LH. Pediatric Spontaneous Pneumothorax. Pediatric Emer Care 2012; 28(7): 715-723. From: Pediatric EM Morsels™
  13. 13. Spontaneous Pneumothorax Dotson K, Timm N, Gittelman M. Is Spontaneous Pneumothorax Really a Pediatric Problem? A National Perspective. Pediatric Emer Care 2012; 28(4): 340-344. Dotson K, Johnson LH. Pediatric Spontaneous Pneumothorax. Pediatric Emer Care 2012; 28(7): 715-723. Secondary Spontaneous Pneumothorax Chronic Lung Pathology Asthma Cystic Fibrosis Emphysema Connective Tissue Disorder Marfan Syndrome Ehlers-Danlos Syndrome Lupus Infection Malignancy Foreign Body Congenital Malformation Catamenial (associated with menses) From: Pediatric EM Morsels™
  14. 14. HPI: 13-year-old previously healthy female presented for evaluation of intermittent chest tightness x 1 month with three days of cough. Respiratory rate 22, SpO2 97% on room air but speaking in 2- 3-word sentences Dx: Spontaneous Pneumothorax
  15. 15. Pigtail tube thoracostomy preformed resulting in resolution of pneumothorax and improvement of symptoms
  16. 16. Patients spontaneous pneumothorax thought to be secondary to apical blebs. Underwent bilateral apical blebectomy with mechanical pleurodesis after recovery from her initial PTX But that’s not the end of her story….
  17. 17. Patient returned 2 years later with shortness of breath and cough without shortness of breath. SpO2 100% on room air, heart rate 109 Dx: Recurrent Pneumothorax
  18. 18. Pigtail chest tube thoracostomy performed, post-procedural CXR shows… Dx: Small Apical Pneumothorax
  19. 19. During hospitalization, patient developed recurrent subjective SOB during CT scan which showed… Dx: Recurrent Pneumothorax
  20. 20. Patient returned from CT scan and chest tube reconnected to wall suction. Patient in no respiratory distress and endorsing improvement of her shortness of breath. Dx: Resolution of Pneumothorax
  21. 21. Patient underwent R video assisted thoracoscopic surgery with bulbectomy, pleurectomy and pleurodesis during this hospitalization. But that’s not the end of her story….
  22. 22. Patient returned 1 month later with recurrent shortness of breath and right sided chest pain. Patient in no respiratory distress. SpO2 100% on room air with mild tachypnea and tachycardia. Dx: Recurrent Pneumothorax
  23. 23. Patient had another pigtail thoracostomy preformed and was admitted for recurrent pneumothorax. She underwent talc pleurodesis and was seen by genetics for evaluation for possible connective tissue disorder given recurrent pneumothoraces. But that’s not the end of her story….
  24. 24. Patient returned 6 months later after acute onset of L upper back pain and shortness of breath when bending over. She was again noted to be mildly tachycardic and tachypnea, but breathing comfortably with SpO2 100% on room air Dx: Left Sided Pneumothorax Given the patient was breathing comfortably on room air without vital sign abnormality she was discharged home.
  25. 25. Patient returned 1 year later with recurrent shortness of breath and left sided chest pain. Patient again in no respiratory distress. SpO2 100% on room air with mild tachypnea and tachycardia. Dx: Recurrent Left Pneumothorax
  26. 26. Admitted for observation. Repeat CXR 1 day later showed increase in size of PTX and thus she underwent thoracoscopy, lysis of pleural adhesions, apical blebectomy and creation of pleural tent Dx: Recurrent Left Pneumothorax
  27. 27. Patient discharged in stable condition approximately 6 days after her surgery. But that’s not the end of her story….
  28. 28. Patient represented 2 days after discharge with recurrent shortness of breath and left sided chest pain. Again vital signs stable other than mild tachycardia. Dx: Recurrent Left Pneumothorax
  29. 29. Patient admitted to the surgical service for observation and underwent tube thoracostomy for her recurrent L sided pneumothorax. Chest tube removed on hospital day 3 and discharged home in stable condition But that’s not the end of her story….
  30. 30. Patient represented 1 month later with left sided chest pain. Vital signs all within normal limits. Dx: Recurrent Left Pneumothorax Last but not least…
  31. 31. Patient admitted to the surgical service for observation and underwent repeat CXR with resolution of pneumothorax and discharge in stable condition the next day She continues to have no known etiology for her recurrent pneumothoraces.
  32. 32. Recurrent PTX • Recurrence rates in the pediatric population is estimated at approximately 61% • Management of recurrent PTX is controversial and often at the discretion of the managing surgical service • In a retrospective study of patients with primary spontaneous pneumothorax, 92 patients required thoroscopic surgery1 • Surgical indications included failed non-operative management (32.7%), recurrent ipsilateral PTX (36.4%) • Bulla was identified in 91.8% of cases • Authors concluded that early thoracoscopic mechanical pleurodesis and stapled bullectomy after thoracostomy tube insertion could be offered as a primary option for management of large PSP in pediatric population, since most of these patients had bulla identified as the culprit of the disease. • Another retrospective study analyzed the 36 patients admitted for spontaneous pneumothorax2 • VATS was preformed in 14 of these patients for persistent air leak (57%) and recurrent pneumothorax (43%) • Patients undergoing surgery had longer hospitalizations, but lower recurrence rates • Authors concluded that VATS is successful, efficient, and safe method of treatment for spontaneous pneumothorax, due to its significantly lower rate of recurrence in comparison with chest tube insertion. 1. Yeung F, et al. “Surgical Intervention for Primary Spontaneous Pneumothorax in Pediatric Population: When and Why?”. Journal of Laparoendosc Adv Surg Tech 2017;27(8):841-844 2. Pogorelic Z, et al. “Management of the Pediatric Spontaneous Pneumothorax: The Role of Video Assisted Thoracoscopic Surgery. J Laparoendosc Adv Surg Tech 2020
  33. 33. HPI: 2-month-old previously healthy male presented to the emergency department in respiratory distress. Noted to have increased work of breathing with hypoxia, requiring 10L by HFNC to maintain oxygen saturations Rightward shift of mediastinal structures Extensive left sided airspace opacity Dx: Consolidation vs atelectasis vs large pleural effusion
  34. 34. What can we use in this unstable patient to further classify the airspace opacity? Ultrasound!!!
  35. 35. HPI: 2-month-old previously healthy male presented to the emergency department in respiratory distress with left sided consolidation on CXR. Ultrasound used to further differentiate. Spleen Diaphragm Lung tissue floating in fluid Dx: Pleural Effusion
  36. 36. HPI: 2-month-old previously healthy male presented to the emergency department in respiratory distress. Noted to have a large left pleural effusion. Chest tube placed with exudative pleural effusion. Patchy consolidation on L with resolution of L pleural effusion Dx: Parapneumonic effusion
  37. 37. Pediatric Chest Tube Recommendations • Consider what is it you have to drain • Acute blood or air can easily be drained with a pigtail catheter • If it is expected to be viscous, you may need a small caliber thoracostomy tube, however Chien-Heng found no difference between drainage and hospitalization days when using a pigtail catheter versus thoracostomy tube for drainage of parapneumonic effusion1 • Be nice – anesthetize and sedate if needed • Be safe – Use a flexible tipped guidewire and US for guidance • Aim high – above 6th intercostal space 1. Lin, Chien-Heng, et al. “Comparison of Pigtail Catheter with Chest Tube for Drainage of Parapneumonic Effusion in Children.” Pediatrics and Neonatology, U.S. National Library of Medicine, Dec. 2011, www.ncbi.nlm.nih.gov/pubmed/22192262. Pediatric EM Morsles – PigTail Catheter
  38. 38. HPI: 11-month-old previously healthy female presented with respiratory distress in the setting of RSV bronchiolitis progressive to septic shock, ARDS and pulmonary hemorrhage. CXR upon admission to our facility.
  39. 39. HPI: 11-month-old previously healthy female presented with respiratory distress in the setting of RSV bronchiolitis progressive to septic shock, ARDS and pulmonary hemorrhage. CXR upon admission to our facility. RUL opacification consistent with pulmonary hemorrhage Extensive bilateral ground glass opacities Small, bilateral pleural effusions
  40. 40. Patient developed worsening respiratory distress with SpO2 in the 80s while on 100% FiO2 with hypotension requiring pressor support and decision was made to proceed with ECMO. CXR obtained at the time of ECMO cannulation. Extensive bilateral pulmonary opacities
  41. 41. Pediatric ARDS: Definition Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731
  42. 42. Pediatric ARDS: Management Basics Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731 • Tidal Volume: • 3– 6 mL/kg predicted body weight for patients with poor respiratory system compliance • 5–8 mL/kg ideal body weight (physiologic range) for patients with better preserved respiratory compliance • Plateau Pressure: 28 cm H2O, allowing for slightly higher plateau pressures (29 –32 cm H2O) for patients with increased chest wall elastance • PEEP: Titrate to avoid alveolar collapse at end expiration • moderately elevated levels of PEEP (10 – 15 cm H2O) should be titrated in patients with severe PARDS to the observed oxygenation and hemodynamic response • PEEP levels > 15 cm H2O may be needed for severe PARDS with attention paid to limiting the peak airway pressure • Recruitment Strategies: No convincing data. Recommend Careful recruitment maneuvers by slow, incremental and decremental PEEP steps in an attempt to improve severe oxygenation failure • Gas Exchange • Permissive hypoxemia • Mild PARDS with PEEP <10 cm H2O, the SpO2 goal should generally be 92–97%. • Severe PARDS with PEEP >10 cm H2O, SpO2 of 88 –92% “should be considered” after PEEP has been optimized with recommendation to monitor central venous saturation when SpO2 <92% • Permissive hypercapnia with goal pH 7.15 – 7.30
  43. 43. Pediatric ARDS: Management with HFOV 1. Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731 2. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 2013;368(9):806-813 3. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013;368(9):795-805 4. Bateman ST, Borasino S, Asaro LA, Cheifetz IM, Diane S, Wypij D, Curley MAQ, RESTORE Study Investigators. Early high frequency oscillatory ventilation in pediatric acute respiratory failure: a propensity score analysis. Am J Respir Crit Care Med 2016;193(5):495-503 • High-Frequency Oscillatory Ventilation (HFOV) theoretically provides a lung-protective ventilation strategy by preventing atelectrauma and maintaining airway recruitment via a constant applied airway pressure and preventing volutrauma by avoiding alveolar overdistention via the delivery of VT less than anatomic dead space • Two adult RCTs have evaluated the differences between HFOV and lung- protective conventional ventilation in adults with early moderate to severe ARDS. • OSCAR: no significant difference in all cause 30d mortality and in-hospital mortality between HFOV and control group2 • OSCILLATE studied early use of HFOV in patients with high initial mean airway pressure to promote lung recruitment and found an increase in mortality with HFOV as compared with the lung-protective conventional group3 • There are no pediatric RCTs • Bateman et al published a secondary propensity score analysis of the 353 subjects enrolled in the RESTORE study who were managed with HFOV and found early application of HFOV was associated with significantly longer duration of mechanical ventilation and greater use of sedation and pharmacologic paralysis, but no mortality association was note4 • Recommendation: HFOV should be considered as an alternative ventilatory mode for those patients with moderate-to-severe PARDS in whom plateau airway pressures exceed 28 cm H2O in the absence of clinical evidence of reduced chest-wall compliance
  44. 44. Pediatric ARDS: Adjunct Treatments Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731 • Other adjunctive treatments which may be considered in select patient populations but whose routine use is not recommended include: • Corticosteroids • iNO • Prone positioning • Exogenous surfactant • Neuromuscular blockage
  45. 45. HPI: 11-year-old previously healthy male presented to the emergency department for evaluation of L hip septic arthritis. Patient was taken to the OR by orthopedics. Postoperatively he was noted to be progressively more hypotensive. CXR obtained:
  46. 46. HPI: 11-year-old previously healthy male presented to the emergency department for evaluation of L hip septic arthritis. Patient was taken to the OR by orthopedics. Postoperatively he was noted to be progressively more hypotensive. Bilateral nodular patchy airspace opacities
  47. 47. What’s the Differential? DDx Bilateral Airspace Opacities Infection Bacterial Fungal Viral Fluid Pulmonary Edema Blood Pulmonary Contusion Pulmonary hemorrhage Autoimmune Goodpasture Syndrome Granulomatosis with Polyangitis Sarcoidosis Emboli DDx Nodular Opacities Infection Bacterial (TB) Fungal (Aspergillus, PJP) Autoimmune Goodpasture Syndrome Granulomatosis with Polyangitis Sarcoidosis Emboli Septic Pulmonary Emboli Malignancy Pulmonary metastasis Bronchoalveolar Carcinoma Pulmonary Lymphoma Karposi Sarcoma
  48. 48. To further narrow down the differential, CT obtained Dx: Septic Pulmonary Emboli Extensive nodular, peribronchial airspace opacities throughout both lungs, some of which demonstrate central cavitation
  49. 49. HPI: 4-year-old previously healthy female presented to the Emergency Department for evaluation of five days of fever, cough, nausea/vomiting. Vital signs: HR 170s BP: 120/63 RR: 55 SpO2: 91%
  50. 50. HPI: 4-year-old previously healthy female presented to the Emergency Department for evaluation of five days of fever, cough, nausea/vomiting Bilateral patchy airspace opacities Dx: ARDS
  51. 51. HPI: 6-month-old ex 25wk premie with chronic lung disease of prematurity presented to the Emergency Department for evaluation of cough and increasing oxygen requirements after hospitalization 2 weeks prior for viral URI. Vital signs: HR 180s BP: 115/89 RR: 52 SpO2: 98% on 0.25L (on 0.15L at home)
  52. 52. HPI: 6-month-old ex 25wk premie presented to the Emergency Department for evaluation of cough and increasing oxygen requirements Bilateral perihilar patchy airspace opacities RUL Consolidation Dx: Viral bronchiolitis with superimposed RUL PNA
  53. 53. Unfortunately, the patient became progressively more hypoxic with increased work of breathing despite significant HFNC support and the decision was made to proceed with intubation. Post intubation CXR ETT terminates 8mm below carina Dx: R Mainstem Intubation Left lobe atelectasis
  54. 54. HPI: 3-year-old male with no significant past medical history presented to the emergency department for evaluation of GSW to the neck. Vital signs: HR 180s BP: 60/40 RR: 22 GCS: 7-8
  55. 55. HPI: 3-year-old male with no significant past medical history presented to the emergency department for evaluation of GSW to the neck. Vital signs: HR 180s BP: 60/40 RR: 22 GCS: 7-8
  56. 56. HPI: 3-year-old male with no significant past medical history presented to the emergency department for evaluation of GSW to the neck. Vital signs: HR 180s BP: 60/40 RR: 22 GCS: 7-8 Dx: GSW to right chest with resultant rib fractures and pulmonary hemorrhage Right 1st and 2nd posterior rib fractures RUL consolidation consistent with pulmonary hemorrhage
  57. 57. Summary Of This Month’s Diagnoses • Recurrent pneumothorax • Parapneumonic effusion • Pediatric ARDS • Septic pulmonary emboli • RUL pneumonia • GSW with pulmonary hemorrhage

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