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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