Pediatric Airway and Chest

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1 Pediatric Airway and Chest UW Radiology Review 2015 Jonathan Swanson, MD Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU 1

2 Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU Case 1: 2 year old with stridor 2

3 Case 1: 2-year-old with stridor What is the most likely underlying diagnosis? A. Epiglottitis B. Retropharyngeal Abscess C. Bacterial tracheitis D. Croup E. Laryngeal hemangioma 2 year old with Stridor 3

4 Viral Croup AKA acute laryngotracheobronchitis Peak Age: 6 month to 3 years Etiology: Parainfluenza Mycoplasma and RSV, other etiologies Role of Imaging DDX: Infection Croup Epiglottitis Stridor Retropharyngeal Abscess Acute Bacterial Tracheitis Hemangioma Foreign body 4

5 Normal Soft Tissue Neck Epiglottitis Images courtesy of Stephen Done, MD 5

6 Acute Epiglottitis Etiology and Epidemiology: Historic vs. Current Imaging Clues: Enlarged epiglottis AND aryepiglottic folds Required Reporting: Airway at risk Omega epiglottis 6

7 6 year old with stridor and fever Bacterial Tracheitis Epidemiology: Typical age 6-10 years Imaging Clue: Tracheal Membranes Reporting Responsibilities: Requires emergent airway management Endoscopy for definitive diagnosis 7

8 9-year-old with Fever & Stridor Retropharyngeal Abscess 8

9 Retropharyngeal Abscess DDX: Suppurative node, RTP edema, lymphatic malformation Complications: Vascular Embolic Danger zone Reporting Responsibilities: Extent of inflammation Complications Is there something to drain? Phelgmon/Edema Hoang JK et al. Multiplanar CT and MRI of collections in the RTP space: Is it an abscess. AJR 2011; 196:

10 7 month old with persistent stridor Subglottic Hemangioma 10

11 Subglottic Hemangioma Epidemiology: Infant less than 6 months Cutaneous Hemangiomas in 50% PHACES association Treatment options Propranolol, steroids, surgical 11

12 Case 2: 1-Year-Old with Stridor Case 2: 1-Year-Old with Stridor Given these two views, which side of the esophagus is most likely to be injured? A. Right lateral B. Anterior C. Left lateral D. Posterior 12

13 1 Year Old with Stridor 13

14 Button Battery Button Battery Ingestion 3 N s : Negative Narrow Necrotic Size Matters: 20 mm lithium most common to stick in esophagus Imaging Protocol Neck, esoophagus, and abdomen See 14

15 Standard Coin 15

16 Case 3: Sudden Onset of Wheezing and Tachypnea in a 20 month old 16

17 Case 3: Sudden Onset of Wheezing and Tachypnea in a 20-month-old What is the next step to work up possible foreign body? A. Decubitus Chest Radiographs B. Inspiration/Expiration C. Fluoroscopy (diaphragm) D. Bronchoscopy E. Institution Dependent Sudden Onset of Wheezing and Tachypnea in a 20 Month Old 17

18 Airway Foreign Bodies Age Range: 9m-13y Peak: 1-3y Types Vegetable: 84% Radiopaque: 11% Others: 5% Site Right: 55% Left: 33% Bilateral: 7% Trachea: 5% Reed J. Can Assoc Radiol 28: ,

19 Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU 19

20 Case 4: Premature Newborn with Respiratory Distress Case 4: Premature Newborn with Respiratory Distress What is the most likely diagnosis? A. Neonatal pneumonia B. Respiratory distress syndrome C. Transient tachypnea of the newborn D. Meconium Aspiration 20

21 Diffuse opacification in the Neonate Chest DDX: Respiratory Distress Syndrome Neonatal Pneumonia Meconium Aspiration Transient Tachypnea of the Newborn The First Breath Karlberg P, et al. J Pediatr, 1960;56:

22 Case 4: Premature Newborn with Respiratory Distress Respiratory Distress Syndrome Early tachypnea, retractions Require prompt support Radiography: Low, low-normal lung volume Diffuse fine granularity Air bronchograms No pleural fluid Detect complications Confused with: pneumonia, TTN 22

23 Newborn with Transient Tachypnea Transient Tachypnea of the Newborn (TTN) Tachypnea, ± cyanosis Accentuation of normal Radiography: Normal to increased lung volume Increase in linear markings Fuzzy vessel margins Pleural fluid Confused with: CHF, pneumonia Diagnosis: Clearing in 1-3 days 23

24 Newborn with Mild Tachypnea TTN Day of Life 0 Day of Life 2 Newborn with Meconium aspiration 24

25 Meconium Aspiration Acute respiratory distress, hypoxia, hypercarbia pulmonary hypertension Partial or complete airway obstruction Chemical pneumonia Radiography: Patchy, heterogeneous opacities Hyperinflation Air leak is common Neonatal Pneumonia 25

26 Neonatal Pneumonia Prenatal, perinatal and postnatal Pathogen: Viral, bacterial (Group B Strep) Imaging: Patchy densities May be RDS-like Pleural fluid ± 26

27 Case 5: 1-day-old with Respiratory Distress Case 5: 1-day-old with Respiratory Distress What is the best test to confirm this critical finding? A. Decubitus chest x-ray B. Chest CT C. Renal Ultrasound D. Upper GI 27

28 1 day old with Respiratory Distress Medial Pneumothorax Moskowitz P, et al. Radiology

29 Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU 29

30 Outline Stridor and Foreign Bodies Neonatal Chest Pediatric Chest: Beyond the NICU Case 6: 5-month-old with persistent tachypnea 30

31 Case 6: 4-month-old with persistent tachypnea What is the most likely diagnosis given this pattern on HRCT? A. Bronchiolitis obliterans B. Pulmonary interstitial glycogenosis (PIG) C. ABCA3 Surfactant deficiency D. Neuroendocrine hyperplasia of infancy (NEHI) Infant with persistent oxygen requirement 31

32 4-month-old with NEHI Same 4-month-old with NEHI 32

33 Neuroendocrine hyperplasia of infancy (NEHI) Definition Form of childhood ILD Clinical course Prolonged with gradual improvement over time Not improved by steroids Imaging Findings GGO in perimediastinal distribution and in the lingula and right middle lobe Airtrapping Neuroendocrine hyperplasia of infancy Bombesin Bombesin Courtesy of Gail Deutsch, MD, Dept of Pathology, Seattle Children s Hospital 33

34 Neuroendocrine hyperplasia of infancy Courtesy of Gail Deutsch, MD, Dept of Pathology, Seattle Children s Hospital 9-year-old with bronchiolitis obliterans 34

35 Bronchiolitis obliterans Fibroblastic reparative response to small airways leads to luminal occlusion Etiologies: Viruses adenovirus, influenza GVHD, Stevens-Johnson Imaging: Mosaic attenuation, hyperlucency, pulmonary vascular attenuation Prior infection, persistent shortness of breath 35

36 Swyer-James Syndrome Definition: Variation of bronchiolitis obliterans Results from viral injury to the developing lung (before the age of 8) Imaging findings: Unilateral transradiancy reflects a combination of hypoplasia of the pulmonary vasculature and obliterative bronchiolitis Bronchiolitis obliterans is bilateral, but asymmetric 36

37 Case 7: 2-year-old with fever and weight loss Case 7: 2-year-old with fever and weight loss In this pediatric patient, what is the most likely diagnosis? A. Congenital heart disease B. Normal thymus C. Anterior mediastinal mass D. Neuroblastoma 37

38 Case 7: 2-year-old with fever and weight loss Normal Thymus 38

39 Normal Pediatric Chest Fever and Cough 39

40 Case 8: 4 Year Old with Cough and Low Grade Fever 40

41 The next best step in diagnosis for this patient is: The next best step in diagnosis for this patient is: A. Follow-up chest x-ray B. CT CAP C. MRI of chest and spine D. Bone Scan and MIBG Case 8: 4 Year Old with Cough and Low Grade Fever 41

42 Round Pneumonia Pseudotumor Usually in child < 8-10 years of age Clinically distinguishable - fever S. pneumoniae Imaging: Chest radiograph follow up to demonstrate expected evolution What we learned Stridor differential Button battery 3 N s Neonatal diffuse lung disease look for the effusion Specific patterns in pediatric HRCT Round pneumonia image gently 42

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