Imaging of Respiratory System(Paediatrics)

Imaging Modalities in Respiratory System

1)Plain radiography (Chest X-Ray)2)Computed tomography (CT scan)3)Ultrasound of thorax4)Positron emission tomography (PET scan)

Normal Anatomy of the Lung

Parietal pleura

Superior lobe of left lung

Oblique fissure of left lung

Inferior lobe of left lung

Lingula

Superior lobe of right lung

Minor / horizontal fissure

Middle lobe of right lung

Major / oblique fissure

Inferior lobe of right lung

How to look at chest x-ray1) Check the ID of patient (name, RN, date)2) Determine the projection (AP/PA), orientation (L/R),

penetration and exposure of CXR3) Look at the:- Lung fields- Trachea- Hilum- Mediastinum- Heart- Diaphragm- Costophrenic angle- Ribs, scapulae & vertebra- Soft tissue

Example of CXR of an 11 yo girl

1) ID of patient2) PA/AP?3) Lung field4) Trachea5) Hilum6) Heart & mediastinum7) Diaphragm & costophrenic angle8) Bones9) Soft tissue10) Area below diaphragm

Common diseases of the respiratory system inpaediatrics:1)Pneumonia2)Bronchiolitis3)Bronchial Asthma4)Respiratory Distress Syndrome 5)Meconium Aspiration Syndrome6)Croup7)Acute Epiglottitis

Bronchopneumonia

Patchy opacitiespresent bilaterally on both lungs

Silhouette sign

Air bronchogram

Lobar Pneumonia

Heterogenous opacity at the right lower zone of the lung

Silhouette sign

Staphylococcal Pneumonia

Pneumatocele(cavity containing air and fluid)

Air-fluid level

Diffuse opacities on both lungs

Silhouette sign

Bronchiolitis

Hyperinflated lung

Flattened diaphragm

Collapse of the right upper lobe and left lower lobe of the lung

Bronchial Asthma

Flattened right hemidiaphragm

Hyperinflated lung

Increased in radiolucency

Increased rib space

Meconium Aspiration Syndrome

Bilateral diffuse opacities

Pneumothorax

Visceral pleural line

Respiratory Distress Syndrome

Ground glass / diffuse granular appearance

Acute Epiglottitis

Thumb sign(enlarged epiglottis)

Thickening of the aryepiglottic fold

Croup

Steeple shaped trachea (subglottic oedema)

Imaging of Cardiovascular System(Paediatrics)

Normal Anatomy of the Heart

Arch of aorta

Pulmonary trunk

Left ventricle

Right atrium

Right ventricle

Superior vena cava

Common congenital heart disease in paediatrics1)Atrial Septal Defect2)Ventricular Septal Defect3)Coarctation of the Aorta4)Tetralogy of Fallot5)Aortic Stenosis6)Pulmonary Stenosis7)Transposition of Great Vessels

Imaging Modalities in Cardiovascular System

1)Plain chest radiography2)Echocardiography3)Radionuclide studies

Atrial Septal Defect (ASD)

Increased pulmonary vascular markings

Atrial Septal Defect

Lateral view of CXR shows enlargement of right atrium and ventricle

Ventricular Septal Defect

Cardiomegaly

Increased pulmonary vascular markings

Coarctation of Aorta

Cardiomegaly(left ventricle hypertrophy)

Rib-notching(due to development of large collateral intercostal arteries running under the ribs posteriorly to bypass obstruction

Tetralogy of Fallot

Uptilted apex (Boot shaped heart)

Pulmonary artery ‘bay’(concavity of left heart border)

Oligaemic lung field (decreased pulmonary vascular marking)

Aortic Stenosis

Enlarged left atrium

Cardiomegaly

Dilated ascending aorta

Pulmonary Stenosis

Post stenotic dilatation of pulmonary artery

Transposition of Great Vessels

‘Egg on side’ appearance(due to AP relationship of great vessels and hypertrophied right ventricle)

Narrow upper mediastinum

Increased pulmonary vascular marking

SummaryCommon Respiratory Disease Features on CXR

1) Pneumonia a) Opacities on lung field (diffuse/localised)b) Air bronchogramc) Silhouette sign

2) Bronchiolitis a) Hyperinflated lungb) Lobar collapsed / consolidation

3) Bronchial Asthma a) Hyperinflated lung- Flattened diaphragm- Increased lung radiolucency- Elongated heart- Increased rib space / increase in number of

ribs ant or postb) Opacities (if secondary to lung infection)

4) Acute Epiglottitis a) Thumb sign (lateral cervical spine x-ray)

5) Croup a) Steeple shaped trachea

6) Respiratory Distress Syndrome a) Ground glass / diffuse granular appearance

7) Meconium Aspiration Syndrome

a) Diffuse opacities (collapse / consolidation) b) Hyperinflated lungc) Pneumothorax / Pneumomediastinumd) Area of air trapping (emphysema)

Common Congenital Heart Disease Features on CXR

1) Atrial Septal Defect a) Cardiomegalyb) Increased pulmonary vascular markingsc) Enlarged pulmonary arteries

2) Ventricular Septal Defect (large) Similar with ASD +/- pulmonary oedema

3) Persistent Ductus Arteriosus (large) Similar with VSD

4) Aortic Stenosis a) Cardiomegalyb) Post-stenotic dilatation of ascending aorta

5) Pulmonary Stenosis a) Cardiomegalyb) Post-stenotic dilatation of pulmonary artery

6) Coarctation of Aorta a) Cardiomegalyb) Rib-notching (> 8yo)c) ‘3’ sign

7) Tetralogy of Fallot a) Boot shaped heart (uptilted apex)b) Small heartc) Pulmonary artery bayd) Oligaemic lung field

8) Transposition of Great Vessel a) ‘Egg on side’ cardiac contourb) Narrow pediclec) Increased pulmonary vascular markings

By Chuah Sean YewYear 5 Group 2 of 2010/2011

Paediatrics Radiology Case Presentation

A cyanosed baby boy

History• 7 hours OL/Term/3.2kg/boy, DOA:28/9/10• Born via ELLSCS for 2 previous scars• Apgar score 9 at 1 min, 10 at 5 min.• Cyanosed at 30 min, grunting, poor perfusion,

CRT 3-4 s, RR 60bpm, given NS bolus 10cc/kg stat

• Referred to HUSM, not ventilated• IV C-pen and gentamycin stat given

• Mother was 32 years old, Para 3, O +ve, VDRL non reactive, anemia in pregnancy, no risk of sepsis

• On arrival to casualty, baby is cyanosed and desaturated due to ETT dislodged. ETT reinserted, baby turned pink, SaO2 98%, transferred to NICU in ventilator.

• PE: sedated, pink, tachypnoeic, AFNT, capillary refill time 2 s, good pulse volume, CVS normal, lungs clear, abdomen soft not distended, UAC and UVC inserted

• ABG: pH: 7.143 pCO2: 55.5 pO2: 61.7 BE: -6.4 HCO3 = 18.2

Hazy opacity with air bronchogram

Silhouette sign

UVC in liver

UAC in L2

• Diagnosis: congenital bronchopneumonia with impending persistent pulmonary hypertension

• Plan:- Keep NBM- IVD 8cc/hour- Continue IV midazolam- Continue IV dopamine- Monitor SaO2, BP- Keep MAP more than 50- Monitor blood gas- Monitor urine output- Continue antibody

• 2nd day of admission (29/9/10):- SpO2 : 70%- HR: 160- BP: 80/41

Plan:- IV dormicum- IV morphine- IV dobutamine & dopamine (20 mcg/kg/min)- IV adrenaline- IV MgSO4- IV C penicillin & gentamycin

Visceral pleural line

Deep sulcus sign

Collapsed lung tissue

Pneumothorax with no mediastinal shift at the right lung

Chest tube

Pneumothorax improving

• On third day of admission, NO was started.

• On 6th day of admission (3/10/10), chest tube is off.

• On 5/10/10, the special reviewed the x ray on 3/1010, found out that the pneumonia worsened. Start IV tazocin and IV amikacin.

Worsening of pneumonia

Blunting of costophrenic angle

Generalized opacity of both lungs

Air bronchogram

Pleural effusion?

CVS CASE PRESENTATION

A. HISTORY• Name: NHM• 15 years old Malay girl• Form 3 student• Uneventful antepartum, intrapartum & postpartum history• No family history of heart disease• Diagnosed of tetralogy of Fallot (TOF) at 5 months old when

she presented with fever and vomiting after feeding• 3 monthly follow up at HUSM paediatric clinic• Not on any medication nor underwent any surgical

treatment

• Had multiple admission into paediatric ward: - hypercyanotic spells due to increased exertion- partial exchange transfusion for polycythaemia

• Otherwise she was functionally well and went to school as normal child.

• Since 2 years ago, hypercyanotic spells became more frequent when she attained menarche with irregular and prolonged menses

• Symptoms: SOB, palpitation, chest discomfort, dizziness and body weakness

• Started on tablet propanolol 20mg bd 1 year ago• Also took tablet ferrous fumarate and folate for anemia• Planned for heart operation at IJN on July last year but it was

cancelled due to her low platelet count

• Admitted on 2/10/10 due to SOB at rest, headache, giddiness, lethargy and reduced effort tolerance

• No fever, URTI or UTI symptoms, orthopnoea and paroxysmal nocturnal dyspnoea

• Currently, the patient just finished her PMR papers in the ward this week, now under further monitoring

B. PHYSICAL EXAMINATION• Vital signs:

BP – 116/80 mmHgPR – 92 bpm with normal rhythm and good volumeRR – 20 breaths/minTemp – 37oCSPO2 – 40%

• Alert and conscious• Palms: pale, warm and moist• Hands: peripheral cyanosis and clubbing• Eyes: pale conjunctiva, no jaundice• Cyanosis of lips• JVP not elevated• No pitting edema

• Inspection: - the chest was moving symmetrically with each respiration- no surgical scar, skin discolouration, dilated veins, visible pulsation

• Palpation:- apex beat was displaced at 5th intercostal space, anterior axillary line- heaving apex beat- thrills at left sternal edge and pulmonary area

• Auscultation:- S1S2 was heard with normal intensity- pansystolic murmur at left sternal edge and pulmonary area

C. DIAGNOSIS1. Hypercyanotic spell secondary to exam stress2. Underlying TOF3. Anemia secondary to prolonged menses

D. MANAGEMENT• Vital signs monitoring• O2 support

• IV maintenance fluid• Continue propanolol 20 mg bd• Continue haematinics

Upturned apex

A bay in the region of the main pulmonary artery?

Boot-shaped heart

Small pulmonary vessels

Cardiomegaly cannot be assured because this is an AP film