Respiratory system in

Newborn,infant and children

Dr.Rudolf H .Pakpahan Sp.Rad
Dr. Netty D.Lubis Sp.Rad
Radiology Department
Adam Malik Hospital
Medan
Normal inspiratory chest

Thymus gland. (a) Normal appearance sail sign. (b) Normal appearance.

Hyaline membrane disease
Respiratory distress syndrome
Lung disease of premature infants due to lack of
surfactant
< 36 weeks ,< 2,5 kg
Clinical presentation:
History of prematurity
Respiratory distress
Metabolic acidosis
Cyanosis due to R- L shunt
hypothermia


Imaging findings:
Initial findings : diffuse reticular granular
opacities represent collapsed alveoli
Air bronchogram demonstrate patent bronchi
in the abnormal lung
Subsequent imaging shows significant bilateral
lung disease (white lung )

Hyaline membrane disease.
Hyaline membrane disease
a Frontal radiograph of a premature infant demonstrates ground-glassappearance of both lungs with a
normal volume.The endotracheal tube is at the carina
b Frontal magnified view of the granular
Meconium aspiraton syndrome (MAS)
Respiratory distress that occurs secondary to
intrapartum or intrauterine aspiration of
meconium
Clinical signs:
Respiratory distress : cyanosis,nasal
flaring,intercostal retractions
Presence of meconium in amniotic fluid
Usually term infants or postterm


Aspiration of meconium into lungs causes :
Air way obstruction
Surfactant dysfunction
Chemical pneumonitis
Imaging findings:
Coarse heterogenous opacities associated w increased
lung volumes bilterally
Bilateral disease usually in middle two thirds of the
lung
Usually asymmetric


Meconium aspiration.
Meconium aspiration
a Frontal radiograph shows coarse, globular, rounded
densities dispersed throughout the lungs. Lung volume is
increased
b Lateral view showing hyperexpansion and coarseness
throughout the lungs. The heart may be enlarged
(although it is not in this case) in meconium aspiration
secondary to hypoxia

Chest x ray useful to asses for complications:
ETT position
Pneumothorax
Pneumomediastinum
Pulmonary interstitial emphysema

Incorrectly positioned endotracheal tube. Note
the tip is at the level of T5 resulting in collapse of
the left lung.
Congenital lobar emphysema (CLE)
Congenital lobar hyperinflation
Infantile lobar emphysema
Progressive overdistention of a pulmonary lobe
due to obstruction
Not a specific disease but a condition that may
result from a variety of etiologies
Clinical issues:
Majority symptomatic in neonatal period and
infancy
50% present in 1
st
4 weeks ; 75% in first 6 months
Imaging findings
Initially after birth lobe may be filled with fetal lung
fluid and appear as radiodensity
Fluid eventually replaced by air :
hyperluscent,hyperexpanded lobe
Compression of ipsilateral lung
Deviation of mediastinum to contralateral
Occasonally ribs are separated and diaphragm is
depressed
Pathology : dilated alveoli,alveolar walls are thinned
but intact
Hipoplasia/agenesis
Congenital atresia of a proximal segmental
bronchus with normal distal architecture
Clinical issues:
Majority asymptomatic
Recurrent respiratory tract infections
Chronic cough,dyspnoe,wheezing
F : M = 2 : 1

pathology
Obliteration or severe narrowing of proximal
lumen segmental bronchus
Aeration of distal lung through collateral air drift
Distal lung : normal architecture
Thought to occur between 5
th
and 15
th
week of
gestation
Etiology : uncertain possibly intrauterine
interruption of arterial supply to bronchus
Imaging findings
Round or ovoid mass adjacent to the hilum
(broncocele)
Distal lung hyperinflated
Most common location : apicoposterior
segment left upper lobe
Diminished vascularity
Neonates : lobe or segment may be fluid filled
gradually replaced by air
Transient tachypnea of the newborn ( TTN )
Wet lung disease, retained lung fluid
Transient tachypnea occurs when liquid in the
fetal lung is removed slowly or incompletely from
the newborn lung and there is increased by
lymphatics and capillaries
Lack of normal thoracic comptression that normally
occurs during vaginal delivery and is bipassed via C
sections
Lack of normal breathing may occur with sedated
infants
Usually term infants
Clinical issues :
Newborns, initial mild to moderate respiratory
distress at birth or within 6 hrs
Relatively benign clinical course
11 per 1000 live births
Imaging findings:
Prominent interstitial markings with normal heart
size

Imaging findings:
Prominent interstitial markings with normal heart
size
Diffuse bilateral and somewhat symmetric
increase in lung markings
Pleural effusions may be present
Fluid in the fissures

Transient tachypnoea.
Transient tachypnea of the newborn
(retained fetal fluid)
a This frontal film of a newborn infant born by cesarean
section reveals strand-like densities extending from the
hila throughout both lungs. The heart is not enlarged.
Lung volume is increased
b Lateral film shows fluid in the major fissure (arrow)

Normal fnding after 48 hrs
Bronchopulmonary dysplasia
Chronic lung disease of infancy:
Prematurity < 32 weeks gestational age
Barotrauma : prolonged ventilation support with
large tidal volume
High inspired oxygen concentrations
Incidence is growing due to improved survival of
infants ,with surfactant deficiency and other
diseases that requires prolonged ventilation
Clinical issues
Tachypnea,tachycardia ,increased, work of
breathing,ventilator and supplemental oxygen
dependent
Usually premature infats,< 32 weeks
Increased susceptability to respiratory tract
infection
imaging
Early : homogenously increased opacities
bilaterally primarily related to retained fluid
Subsequently: heterogenous appearance with focal
lucencies separated by coarse reticular and band
like opacities of fibrosis and atelectasis
More opacities in the upper lobes with
hyperinflation at the bases
Pulmonary interstitial emphysema
a On this film of a 6-day-old premature neonate, there is interstitial air manifest as black dots. The high
pressures necessary
to ventilate the child caused air to leak into the interstitium. This may compress the bronchus and, in fact,
hinder aeration
b The lateral view showing interstitial air as small black dots. This complication of mechanical ventilation
occurs when high
pressures are used and ventilation is prolonged
Congenital diaphragmatica hernia
Herniations of abdominal contents into the chest
Prevalence 2,45 % per 10 000 births ,males>>
Bochdalek hernia: posterior hernia
Severe respiratory distress
Most commonly presents at birth
Imaging: bubble like lucencies that appear like bowel
within chest
More common on left than right
Large CDH causes compression of pulmonary
tissue and resultant pulmonary hypoplasia
X R initially after birth show hernia as
radiodense (prior to air introduced into bowel)
Later when air introduced into bowel ,appear as
air containing cystic mass resembling bowel
Decreased bowel gas in abdomen
Mediastinal shift away from hernia
Infant and children
Pleural effusion :
Abnormal accumulation of fluid in pleural space
Normal space contains 2- 10 ml fluid between
visceral and parietal layers
The pleura is a thin,serous layer that covers lung
and reflected onto the chest wall and
pericardium ( parietal pleura)
The pleural space is contigious with the interlobar
fisssures of the lungs
Major mechanism of pleural effusion
formation
hydrostatic pressure (CHF)
oncotic pressure ( hypoalbuminnemia)
permeability ( pleural inflammation or neoplasm)
Impaired lympahtic drainage caused by blockage in the
lymphatic system
Neonatal pleural effusion : may be secondary to birth
trauma of the thoracic duct
Transit of fluid from the peritoneal cavity through the
diaphragm to the pleural space
Two major types of pleural effusion
Transudates: caused by systemic or pulmonary
capillary pressure and osmotic pressure
resulting in increased filtration and decreased
absorbtion of pleural fluid
( CHF, cirrhosis,nephrotic syndrome and protein
lose enteropathy)
Exudatives : pleural surface is damaged with
associated capillary leak and increased
permeability to protein or when there is
decreased lymphatic drainage or decreased
pleural pressure
Major causes : infection,malignancy,collagen
vascular disease or acute pulmonary embolism
Protein levels > 3 g/dl,protein ratio pleural :
serum > 0,5 ,pleural lactate dehydrogenase :
serum lactate dehydrogenase > 0,6
Imaging findings
Blunting of the costophrenic sulcus on erect frontal
chest radiography or posterior sulcus on erect
lateral chest radiography
Usually has a sharply marginated,concave upward
curved border between the lung and pleural space
meniscus sign.
Smaller pleural effusion 75 ml will be apparent on
the lateral view than on frontal view with 200 ml
The most sensitive for 5 ml fluid lateral decubitus
view is the most sensitive

Pleural effusion
empyema
Pleural fluid is grossly purulent,gram stain (+)
,WBC count > 5 x 10 cells
Anerobic bacteria usually streptococci or gr (-)
rods are responsible for 75 % of cases
Chest x-ray similar to those loculated pleural
fluid collections
CT findings: may include increase density of
fluid caused by protein,cells or hemorrhage;
septations and loculations : foci of gas,thickened
enhancing pleural surface
Empyema
infected loculated fluid
Right massive pleural effusion
right lateral decubitus w right pleural effusion

Pneumothorax
Air within the pleural cavity
Communication between the outside world and
pleural space via defect in the chest wall or
through between bronchi or alveoli and the
pleural space via defect in the visceral
Free air preferentally moves to the non
dependent aspects ( apicolateral on erect or
antero medial on supine chest radiography)
Radiographic finding
Thin,sharply defined,visceral pleural white line
between radioluscent lung with vasclar marking and
and radioluscent black free air sith in the peripheral
pleural without vascular marking
On erect chest x-ray 50 ml are generally visible
at the lung apex,whereas on supine 500ml of air
needed to be visible
For subtle pneumothorax : cross table lateral chest
radiography with supine position
Major causes
Trauma (blunt or penetrating or
iatrogenic,barotrauma due to mechanical
ventilation
Idiopathic most often due to rupture of apical bleb
Obstructive lung disease
Adult respiratory syndrome
Bronchiectasis or cavitary lung disease
( TB,PCP)
Broncopulmonary fistula

Tension pneumothorax : air in the pleural space can
develop positive pressure,most often as a result
of mechanical ventilation compress the
mediastinum with result decrease of venous
return to the heart
Imaging: presence of pneumothorax with
contralateral mediastinal shift and inferior
displacement ipsilateral of diaphragm
However the diagnosis is based on clinical
finding : hypotension and tachycardia
This is medical emergency rapid
cardiopulmonary compromise and death
Right pneumothorax and chest drain.
Left-sided pneumothorax in a patient with cystic fibrosis.

Tension pneumothorax
Right Tension pneumothorax

pneumomediastinum
Air collection within the mediastinum
The causes :
air trapping : emphysema,asthma
Blunt/penetrating injury or iatrogenic to the
trachea,esophagus or bronchi
Barotrauma: mechanical
ventilation,coughing,sudden drop in
atmospheric presure
Erosion of trachea or oesophagus by tumor
Extension of air from pneumothorax or
pneumoperitoneum
Esophageal rupture :
Boerhaavesyndrome,alcoholism
Imaging : streaky linier or curvilinier lucent gas
in the mediastinm that otlines mediastinal
stuctures
Air surrounding the mediastinum.

Pneumomediastinum.
Pneumopericardium.
Pneumomediastinum

A pneumopericardium
A frontal radiograph shows air around the heart. The air
stops at the left aorticpulmonary window where the pericardium
attaches (arrow)
Pulmonary tuberculosis
Clinical isssues:
subfebrile , cough ,night sweat ,loss of
appetite,no increase of body weight
Asymptomatic
Different from adult, pediatric cases it is very
rare with hemoptysis,cough is resulting by
irritated or compression of bronchus by
enlargement of lymphnode
In teenager the symptom similar with adult.


Diagnosis is based on clinical symptoms,chest x- ray,
staining or microbial culture and contact history with
TB patient
Because the clinical symptoms are not specific and the
negative tuberculin test ,it needs radiological
examination
Imaging:
minimal lesion
Minimal lesion + hilar lymphadenopaty (primary
complex)
Calcification
Miliary type
Destroyed lung
Pleural effusion


Bilateral hilar adenopathy
Primary tuberculosis.
Pneumocystis pneumonia associated with immunosuppressed patients.
Pneumonia
Pneumonia is the inflammation of the lungs due
to infection and, in neonates,the causative agent
is generally bacterial rather than viral.
The infection is often acquired at the time of
delivery, possibly from the amniotic fluid or
birth canal, but it may also occur as a
consequence of intubation and ventilation.
The clinical and radiographic signs of neonatal
pneumonia are non-specific and the antero-
posterior chest radiograph will demonstrate ill-
defined perihilar and pulmonary opacification
Viral pneumonia
Neonatal pneumonia.

Bacterial pneumonia giving rise to the appearance of consolidation in the right lung
Consolidation in the right upper lobe
Consolidation in the right upper lobe
Post-infection bronchiectasis
(a) and (b) Right middle lobe collapse confirmed
on lateral. Note loss of right heart
border on antero-posterior projection
Foreign body
(a) and (b) Inhaled foreign body. Note the torch bulb in the right main bronchus
Foreign body
Coin identified within the neck (antero-posterior
projection). (b) Coin position confirmed
within oesophagus (lateral projection
Right hypodensity due to emphysema causing
by FB
Radiolucent foreign body in
right main bronchus. Note the increased
radiolucency of the right lung as a result
of air trapping.
Bronchial asthma
Reactive airway disease
Hyperreactive airway disease
Airway hyperreactivity
Chronic reversible paroxysmal inflammation of
the bronchi with contraction of bronchial wall
smooth muscle secondary to
hyperresponsiveness leading to obstruction of
air flow
Clinical issues:
Recurrent cough
Recurrent wheezing
Dyspnea
May show signs of precipitating infection
Use of acessory muscles to breath at rest


Radiographically :
Usually normal
Hyperlucency of lungs due to hyperinflation
Flattening of diaphragm
Complications are more frequent in younger
children because their bronchi are smaller and
hence more easily narrowed or occluded during
an exacerbation : lobar
collapse,atelectasis,pneumonia and
pneumomediastinum subcutaneus emphysema

Bronchiolitis
Viral infection of the lower respiratory tract
Most common signs/symptoms:
Cough ,wheezing
May have fever
Hypoxia /respiratory failure in severe case
Etiology of lower respiratory tract infection varies with
age:
< 2 yrs : 80 % viral
> 2yrs : 49 % viral,m .pneumonia,streptococcus pn
For all ages : 47 % viral,38% bacterial,15% mixed
viral/bacterial
Imaging findings:
Increased peribronchial markings : symmetrical
coarse linear markings radiating from the hila
into the lung
hyperinflation
Lack of focal lung consolidation( hallmark for
bacterial infection)
Subsegmental atelectasis




Acute chest syndrome
Alveolar edema
Patients with sickle cell anemia
Scaterred dense areas of consolidation
Difficult to differentiate from bacterial
pneumonia
Diaphragm paralysis
May occurred with forced delivery that causing
mechanical trauma within brachial plexus that
result C 4 T 1 damaged
Elevated diaphragm more than 2 corpus
Fluoroscopy : desynchronisation movement of
diaphragm with respiration

TERIMA KASIH