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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
October 2019
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.
Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and soon… Tanzania and Brazil.
 Cases submitted this week will be distributed next week.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.
Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!
10 year old female with history
of severe scoliosis.
What are the pulmonary
complications associated with
severe scoliosis?
After stage I of the repair
13 year old female
presented to the
emergency
department after
a car accident with
complaint of Chest
Pain
Dx: ?
13 year old female
presented to the
emergency
department after
a car accident with
complaint of Chest
Pain
Dx: L apical
penumothorax
After placement of
L sided pigtail
catheter
15 year old male with history of
Pierre Robin Syndrome, skeletal
dysplasia, and asthma
presented to the emergency
department for one day of
chest tightness and shortness
of breath. Initial ED vital signs
Heart Rate: 133
Respiratory Rate: 26
SpO2: 93%
Blood Pressure: 122/77
Dx: ?
15 year old male with history of
Pierre Robin Syndrome, skeletal
dysplasia, and asthma
presented to the emergency
department for one day of
chest tightness and shortness
of breath. Initial ED vital signs
Heart Rate: 133
Respiratory Rate: 26
SpO2: 93%
Blood Pressure: 122/77
Dx: R penumothorax
Notice the flattening of the R
hemidiaphragm, which suggests
a degree of tension physiology
After placement of R
sided pigtail catheter
15 year old male with
presented to the Emergency
Department after stab wound
to the R posterior shoulder.
Vital Signs: Stable
Physical Exam: Decreased
breath sounds on R
EFAST: No lung sliding on R
Dx: ?
15 year old male with
presented to the Emergency
Department after stab wound
to the R posterior shoulder.
Vital Signs: Stable
Physical Exam: Decreased
breath sounds on R
EFAST: No lung sliding on R
Dx: R pneumothorax with
subcutaneous emphysema
After
placement of R
sided pigtail
catheter with
residual 10 mm
apical PTX
Pediatric Pneumothorax - Diagnosis
• In the case of spontaneous pneumothorax:
• Children are typically 10-17 year old males with a history of asthma or tobacco abuse
• Most patients will present with acute onset of chest pain and shortness of breath,
although the majority actually present in a delayed fashion
• Diagnostic tools:
• Supine CXR has only ~50% sensitivity, increases wot ~90% with use of erect CXR
• Ultrasound has an ~90% sensitivity, which may increase to 99% when used by a trained
and experienced operator
Pediatric EM Morsels – Spontaneous pneumothorax
When using M mode, the “barcode sign” indicates a
PTX while the “seashore sign” or “waves on a beach”
indicates normally aerated lung
Click here for a
demonstration of
thorax ultrasound by
Dr. Tony Weeks
Pediatric Pneumothorax - Treatment
• When preforming open thoracostomy, remember that the small rib
spaces may prevent you from inserting your finger into the intercostal
space. The narrow intercostal space also exposes the neurovascular
bundle, making complications more likely
• The pediatric mediastinum is more mobile, and the intrathoracic
pressures are more readily transmitted to the right atrium, making it
more likely that these patient will have decreased cardiac output or
tension physiology
• Despite this, emergent thoracostomy is rarely required in children!
• Does it need to be drained?
• Small pneumothoraces (some have said up to 20%, but no good pediatric studies
available) can be managed conservatively
Pediatric EM Morsels – Traumatic pneumothorax
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 Morsels – PigTail Catheter
From April’s
Presentation!
14 year old female with history
of scoliosis who presented to
the emergency department
with shortness of breath, cough
and intermittent fever.
Dx: ?
14 year old female with history
of scoliosis who presented to
the emergency department
with shortness of breath, cough
and intermittent fever.
Dx: Paraneumonic Effusion
After left sided video
assisted thoracoscopic
surgery with persistent
left sided chest tube
Notice decreased size of
left sided loculated
pleural effusion
One month post-procedure
patient seen in follow-up with
small residual left sided pleural
effusion with no residual
airspace consolidation
7 year old male with past medical history of
SMA, tracheomalacia, trach/vent dependence
presented to the emergency department with 3
days of shortness of breath, fever, and cough.
Initial ED vital signs:
HR: 150
RR: 18
BP: 105/80
SpO2: 93%
AP CXR shows no significant
consolidation
Lateral CXR shows no dense RLL
retrocardiac opacity consistent
with pneumonia
Lesson: If no consolidation seen on AP
and clinical picture fits, obtain lateral
film to evaluate retrocardiac space!
Case 1: 2 week old male presented to the
emergency department with tachypnea
and increased work of breathing.
ED Vital Signs:
HR: 166
BP: 82/69
SpO2: 96%
RR: 81
Afebrile
AP CXR shows significantly
enlarged cardiac silhouette
Case 2: 2 week old male
presented to the emergency
department with intermittent
increased work of breathing.
ED Vital Signs:
HR: 163
BP: 63/39
SpO2: 96%
RR: 42
Afebrile
AP CXR shows mild
cardiomegaly
What is the next step?
Obtain an echocardiogram to better evaluate cardiac function
Echocardiograms
Case 1
• Severe pulmonary hypertension
with R heart dilation and flattened
interventricular septum
• Severe tricuspid regurgitation
• Moderate mitral valve
regurgitation
• Patent foramen ovale with right-to-
left shunting
• Small patent ductus arteriosus with
primary right to left shunting
Case 2
• Normal echocardiogram
What’s the difference
between these two CXRs?
What’s the difference
between these two CXRs?
It’s the thymus!
Differentiating the Thymic Shadow
“thymic sail sign” is a triangular extension of the
normal thymus laterally
The anterior reflections
of the ribs produce a wavy
contour of the thymus
known as the “thymus
wave sign”
The inferior margin of the
thymus merges with the
margin of the cardiac
silhouette, producing the
“notch sign”
Manchanda, Smita, et al. “Imaging of the Pediatric Thymus: Clinicoradiologic Approach.” World Journal of Clinical
Pediatrics, Baishideng Publishing Group Inc, 8 Feb. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5296624/.
From April’s
Presentation!
Notch Sign
Wave sign
Review the CXR from Case 2 with the thymic
shadow indications in mind:
Follow-up from Case #1
• Congestive heart failure in the newborn period is rare, and most often
related to congenital structural heart disease, however the differential
diagnosis is broad and includes arrhythmias, congenital or acquired
myopathies, sepsis, severe anemia, or conditions leading to high-output
heart failure
• Causes of high output heart failure in the pediatric population includes
AVM (hemangiomas, venous malformations), cirrhosis, carcinoid
syndrome hyperthyroidism, myeloproliferative disorders, Beriberi, sepsis,
mitochondrial disease, and many others
Merritt, Chris, et al. “A Neonate With High-Outflow Congestive Heart Failure and Pulmonary
Hypertension Due to an Intracranial Arteriovenous Malformation.” Pediatric Emergency Care,
vol. 27, no. 7, 2011, pp. 645–648., doi:10.1097/pec.0b013e3182225679.
Follow-up from Case #1
• Vein of Galen aneurysmal malformations are rare congenital anomalies that constitute 1% of
all intracranial vascular malformations
• Due to a persistent embryonic median vein of prosencephalon
• In utero, the placental circulation provides a low-resistance path preventing cardiac damage from fluid
overload
• With loss of the placenta at birth, up to 70% of the cardiac output is directed to the low resistant Vein of
Galen Malformation AV shunt which allows direct return of large flow volume to the right heart
Gupta, AK, Varma, DR Vein of Galen malformations: Review.. Neurol India. (2004). 52 43–53
Li, AH, Armstrong, D, terBrugge, KG Endovascular treatment of vein of Galen aneurysmal malformation: Management strategy and 21-year
experience in Toronto.. J Neurosurg Pediatr. (2011). 7 3–10
MRA from our case
showing dilation of the
median prosencephalic
vein draining in to a
persistent falcine sinus =
Vein of Galen
Malformation
Our Last Case Is An Adult
Example Of New Disease State
That Is Being Seen In Both
Adults And Children!
33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia
Bilateral Airspace
Disease On CXR
Diagnosis?
E-Cigarette Associated Pneumonitis
33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia
33 Year Old With A History Of Vaping Presents With Severe Dyspnea
E-Cigarette Associated Pneumonitis
E-Cigarette
Associated
Pneumonitis
3 Days Later
Symptoms
Improved
Published On September 6, 2019, at NEJM.org
E-Cigarette Associated Lung Injury
• Between 2017 and 2018, the prevalence of e-cigarette use increased
from 11.7% to 20.8% amongst U.S. high school students.
• Pulmonary illnesses related to e-cigarettes have been reported, but
no larger series have been described previously.
• In July 2019, the Wisconsin Department of Health Serves received
reports of pulmonary disease associated with vaping.
• The authors describe the demographic and outcome characteristics of
53 patients; representing the largest published case series to date.
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
Demographic Characteristics (n=53)
Median age 19 (16-53)
Male sex 83%
White race 82%
Reported nicotine use 61%
Reported THC use 80%
Reported nicotine & THC use 44%
Symptoms Reported On Presentation
Median duration of symptoms 6 days (0-61)
Any Respiratory Symptoms
Shortness of breath
Chest pain
Cough
Hemoptysis
98%
87%
55%
83%
11%
Subjective fever 81%
Chills 58%
Nausea 70%
Vomiting 66%
Vital Signs At Presentation
Temperature >38° C 29%
Heart rate >100 beats/min 64%
Respiratory rate >20 breaths/min 82%
Oxygen saturation:
≥95%
89-94%
≤88%
31%
38%
31%
Initial Laboratory Results
WBC >11000/mm3 87%
WBC >80% neutrophils 94%
ESR >30 mm/hr 93%
Initial Radiographic Finding
Abnormal chest X-ray 91%
Abnormal chest CT 100%
Bilateral infiltrates on CT 100%
Treatment
Antibiotics during hospitalization 90%
Steroids during hospitalization 92%
IV steroids during hospitalization 83%
Clinical Course
Hospitalization 94%
Non-invasive ventilation 36%
Endotracheal intubation 32%
Death 1/53 (2%)
Published On September 6, 2019, at NEJM.org
Identical To Our Patient!
The Vapors Are Viscous!
E-cigarette liquids have been shown to contain a variety of chemicals
that may have adverse health effects:
• Propylene glycol
• Glycerin
• Polycyclic aromatic hydrocarbons
• Volatile organic and inorganic chemicals
• Toxic metals
• Flavoring compounds that may cause adverse effects
Monitoring The Future Survey™
National survey of 8th, 10th and 12th graders assessing vaping trends:
2017
2018
2019
43,703
44,482
43,531
Prevalence of use more than doubled between 2017 and 2019!
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
n integrated view of the
ydiseaseoutbreak since
ted online information
ncluding news aggrega-
and validated official
assified the data by dis-
me.3
Figure1 shows the
ed and suspected cases
ease from vaping over
States. The first 8 sus-
ed byour onlinemining
g) on July 25, 2019, in
8, a total of 119 con-
eshad been detected in
more than doubled by
ing a total of 288 cases
ptember 11, cases had
nning 39 states and the
compoundsof e-cigaretteliquids, adulteration of
devices with tetrahydrocannabinol (THC)–based
oilsor vitamin E, and useof black market vaping
products.1,4
Findingsfrom thisreport suggest that
vaping-associated pulmonary disease cases have
reached epidemic proportions. Incident cases con-
tinueto rise. Further surveillanceis necessary to
monitor the development and spread of this vap-
ing-related outbreak.
Yulin Hswen, M.P.H., Sc.D.
John S. Brownstein, Ph.D.
Innovation Program, Boston Children’sHospital
Boston, MA
yuh958@mail.harvard.edu
Disclosure forms provided by the authors are available with
thefull text of thisletter at NEJM.org.
This letter was published on September 20, 2019, at NEJM.org.
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October Cases
Summary of this month’s diagnoses
• Scoliosis
• Pneumothorax
• Parapneumonic Effusion
• Cardiomegaly
• Vaping associated lung injury

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

  • 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 October 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 soon… Tanzania and Brazil.  Cases submitted this week will be distributed next week.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  • 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  • 5. 10 year old female with history of severe scoliosis. What are the pulmonary complications associated with severe scoliosis?
  • 6. After stage I of the repair
  • 7. 13 year old female presented to the emergency department after a car accident with complaint of Chest Pain Dx: ?
  • 8. 13 year old female presented to the emergency department after a car accident with complaint of Chest Pain Dx: L apical penumothorax
  • 9. After placement of L sided pigtail catheter
  • 10. 15 year old male with history of Pierre Robin Syndrome, skeletal dysplasia, and asthma presented to the emergency department for one day of chest tightness and shortness of breath. Initial ED vital signs Heart Rate: 133 Respiratory Rate: 26 SpO2: 93% Blood Pressure: 122/77 Dx: ?
  • 11. 15 year old male with history of Pierre Robin Syndrome, skeletal dysplasia, and asthma presented to the emergency department for one day of chest tightness and shortness of breath. Initial ED vital signs Heart Rate: 133 Respiratory Rate: 26 SpO2: 93% Blood Pressure: 122/77 Dx: R penumothorax Notice the flattening of the R hemidiaphragm, which suggests a degree of tension physiology
  • 12. After placement of R sided pigtail catheter
  • 13. 15 year old male with presented to the Emergency Department after stab wound to the R posterior shoulder. Vital Signs: Stable Physical Exam: Decreased breath sounds on R EFAST: No lung sliding on R Dx: ?
  • 14. 15 year old male with presented to the Emergency Department after stab wound to the R posterior shoulder. Vital Signs: Stable Physical Exam: Decreased breath sounds on R EFAST: No lung sliding on R Dx: R pneumothorax with subcutaneous emphysema
  • 15. After placement of R sided pigtail catheter with residual 10 mm apical PTX
  • 16. Pediatric Pneumothorax - Diagnosis • In the case of spontaneous pneumothorax: • Children are typically 10-17 year old males with a history of asthma or tobacco abuse • Most patients will present with acute onset of chest pain and shortness of breath, although the majority actually present in a delayed fashion • Diagnostic tools: • Supine CXR has only ~50% sensitivity, increases wot ~90% with use of erect CXR • Ultrasound has an ~90% sensitivity, which may increase to 99% when used by a trained and experienced operator Pediatric EM Morsels – Spontaneous pneumothorax When using M mode, the “barcode sign” indicates a PTX while the “seashore sign” or “waves on a beach” indicates normally aerated lung Click here for a demonstration of thorax ultrasound by Dr. Tony Weeks
  • 17. Pediatric Pneumothorax - Treatment • When preforming open thoracostomy, remember that the small rib spaces may prevent you from inserting your finger into the intercostal space. The narrow intercostal space also exposes the neurovascular bundle, making complications more likely • The pediatric mediastinum is more mobile, and the intrathoracic pressures are more readily transmitted to the right atrium, making it more likely that these patient will have decreased cardiac output or tension physiology • Despite this, emergent thoracostomy is rarely required in children! • Does it need to be drained? • Small pneumothoraces (some have said up to 20%, but no good pediatric studies available) can be managed conservatively Pediatric EM Morsels – Traumatic pneumothorax
  • 18. 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 Morsels – PigTail Catheter From April’s Presentation!
  • 19. 14 year old female with history of scoliosis who presented to the emergency department with shortness of breath, cough and intermittent fever. Dx: ?
  • 20. 14 year old female with history of scoliosis who presented to the emergency department with shortness of breath, cough and intermittent fever. Dx: Paraneumonic Effusion
  • 21. After left sided video assisted thoracoscopic surgery with persistent left sided chest tube Notice decreased size of left sided loculated pleural effusion
  • 22. One month post-procedure patient seen in follow-up with small residual left sided pleural effusion with no residual airspace consolidation
  • 23. 7 year old male with past medical history of SMA, tracheomalacia, trach/vent dependence presented to the emergency department with 3 days of shortness of breath, fever, and cough. Initial ED vital signs: HR: 150 RR: 18 BP: 105/80 SpO2: 93% AP CXR shows no significant consolidation
  • 24. Lateral CXR shows no dense RLL retrocardiac opacity consistent with pneumonia Lesson: If no consolidation seen on AP and clinical picture fits, obtain lateral film to evaluate retrocardiac space!
  • 25. Case 1: 2 week old male presented to the emergency department with tachypnea and increased work of breathing. ED Vital Signs: HR: 166 BP: 82/69 SpO2: 96% RR: 81 Afebrile AP CXR shows significantly enlarged cardiac silhouette
  • 26. Case 2: 2 week old male presented to the emergency department with intermittent increased work of breathing. ED Vital Signs: HR: 163 BP: 63/39 SpO2: 96% RR: 42 Afebrile AP CXR shows mild cardiomegaly
  • 27. What is the next step? Obtain an echocardiogram to better evaluate cardiac function
  • 28. Echocardiograms Case 1 • Severe pulmonary hypertension with R heart dilation and flattened interventricular septum • Severe tricuspid regurgitation • Moderate mitral valve regurgitation • Patent foramen ovale with right-to- left shunting • Small patent ductus arteriosus with primary right to left shunting Case 2 • Normal echocardiogram
  • 30. What’s the difference between these two CXRs? It’s the thymus!
  • 31. Differentiating the Thymic Shadow “thymic sail sign” is a triangular extension of the normal thymus laterally The anterior reflections of the ribs produce a wavy contour of the thymus known as the “thymus wave sign” The inferior margin of the thymus merges with the margin of the cardiac silhouette, producing the “notch sign” Manchanda, Smita, et al. “Imaging of the Pediatric Thymus: Clinicoradiologic Approach.” World Journal of Clinical Pediatrics, Baishideng Publishing Group Inc, 8 Feb. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5296624/. From April’s Presentation!
  • 32. Notch Sign Wave sign Review the CXR from Case 2 with the thymic shadow indications in mind:
  • 33. Follow-up from Case #1 • Congestive heart failure in the newborn period is rare, and most often related to congenital structural heart disease, however the differential diagnosis is broad and includes arrhythmias, congenital or acquired myopathies, sepsis, severe anemia, or conditions leading to high-output heart failure • Causes of high output heart failure in the pediatric population includes AVM (hemangiomas, venous malformations), cirrhosis, carcinoid syndrome hyperthyroidism, myeloproliferative disorders, Beriberi, sepsis, mitochondrial disease, and many others Merritt, Chris, et al. “A Neonate With High-Outflow Congestive Heart Failure and Pulmonary Hypertension Due to an Intracranial Arteriovenous Malformation.” Pediatric Emergency Care, vol. 27, no. 7, 2011, pp. 645–648., doi:10.1097/pec.0b013e3182225679.
  • 34. Follow-up from Case #1 • Vein of Galen aneurysmal malformations are rare congenital anomalies that constitute 1% of all intracranial vascular malformations • Due to a persistent embryonic median vein of prosencephalon • In utero, the placental circulation provides a low-resistance path preventing cardiac damage from fluid overload • With loss of the placenta at birth, up to 70% of the cardiac output is directed to the low resistant Vein of Galen Malformation AV shunt which allows direct return of large flow volume to the right heart Gupta, AK, Varma, DR Vein of Galen malformations: Review.. Neurol India. (2004). 52 43–53 Li, AH, Armstrong, D, terBrugge, KG Endovascular treatment of vein of Galen aneurysmal malformation: Management strategy and 21-year experience in Toronto.. J Neurosurg Pediatr. (2011). 7 3–10 MRA from our case showing dilation of the median prosencephalic vein draining in to a persistent falcine sinus = Vein of Galen Malformation
  • 35. Our Last Case Is An Adult Example Of New Disease State That Is Being Seen In Both Adults And Children!
  • 36. 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia Bilateral Airspace Disease On CXR Diagnosis?
  • 37. E-Cigarette Associated Pneumonitis 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia
  • 38. 33 Year Old With A History Of Vaping Presents With Severe Dyspnea E-Cigarette Associated Pneumonitis
  • 40. Published On September 6, 2019, at NEJM.org
  • 41. E-Cigarette Associated Lung Injury • Between 2017 and 2018, the prevalence of e-cigarette use increased from 11.7% to 20.8% amongst U.S. high school students. • Pulmonary illnesses related to e-cigarettes have been reported, but no larger series have been described previously. • In July 2019, the Wisconsin Department of Health Serves received reports of pulmonary disease associated with vaping. • The authors describe the demographic and outcome characteristics of 53 patients; representing the largest published case series to date.
  • 43. Demographic Characteristics (n=53) Median age 19 (16-53) Male sex 83% White race 82% Reported nicotine use 61% Reported THC use 80% Reported nicotine & THC use 44%
  • 44. Symptoms Reported On Presentation Median duration of symptoms 6 days (0-61) Any Respiratory Symptoms Shortness of breath Chest pain Cough Hemoptysis 98% 87% 55% 83% 11% Subjective fever 81% Chills 58% Nausea 70% Vomiting 66%
  • 45. Vital Signs At Presentation Temperature >38° C 29% Heart rate >100 beats/min 64% Respiratory rate >20 breaths/min 82% Oxygen saturation: ≥95% 89-94% ≤88% 31% 38% 31%
  • 46. Initial Laboratory Results WBC >11000/mm3 87% WBC >80% neutrophils 94% ESR >30 mm/hr 93% Initial Radiographic Finding Abnormal chest X-ray 91% Abnormal chest CT 100% Bilateral infiltrates on CT 100%
  • 47. Treatment Antibiotics during hospitalization 90% Steroids during hospitalization 92% IV steroids during hospitalization 83% Clinical Course Hospitalization 94% Non-invasive ventilation 36% Endotracheal intubation 32% Death 1/53 (2%)
  • 48. Published On September 6, 2019, at NEJM.org Identical To Our Patient!
  • 49. The Vapors Are Viscous! E-cigarette liquids have been shown to contain a variety of chemicals that may have adverse health effects: • Propylene glycol • Glycerin • Polycyclic aromatic hydrocarbons • Volatile organic and inorganic chemicals • Toxic metals • Flavoring compounds that may cause adverse effects
  • 50. Monitoring The Future Survey™ National survey of 8th, 10th and 12th graders assessing vaping trends: 2017 2018 2019 43,703 44,482 43,531 Prevalence of use more than doubled between 2017 and 2019!
  • 52. n integrated view of the ydiseaseoutbreak since ted online information ncluding news aggrega- and validated official assified the data by dis- me.3 Figure1 shows the ed and suspected cases ease from vaping over States. The first 8 sus- ed byour onlinemining g) on July 25, 2019, in 8, a total of 119 con- eshad been detected in more than doubled by ing a total of 288 cases ptember 11, cases had nning 39 states and the compoundsof e-cigaretteliquids, adulteration of devices with tetrahydrocannabinol (THC)–based oilsor vitamin E, and useof black market vaping products.1,4 Findingsfrom thisreport suggest that vaping-associated pulmonary disease cases have reached epidemic proportions. Incident cases con- tinueto rise. Further surveillanceis necessary to monitor the development and spread of this vap- ing-related outbreak. Yulin Hswen, M.P.H., Sc.D. John S. Brownstein, Ph.D. Innovation Program, Boston Children’sHospital Boston, MA yuh958@mail.harvard.edu Disclosure forms provided by the authors are available with thefull text of thisletter at NEJM.org. This letter was published on September 20, 2019, at NEJM.org.
  • 57. Summary of this month’s diagnoses • Scoliosis • Pneumothorax • Parapneumonic Effusion • Cardiomegaly • Vaping associated lung injury