PEDIATRIC CHEST DISEASES

SURFACTANT DEFICIENCY DISEASE

(SDD)
Hyaline Membrane Disease (HMD)
Most common cause of respiratory distress in
the immature infants
Absence of surfactant leads to increased
alveolar surface tension, decreased alveolar
distensibility, and persistent collapse of the
alveoli
Respiratory distress in the first 2 or 3 hours of
life
 SURFACTANT DEFICIENCY DISEASE
(SDD)
Classic Radiographic Findings
pronounced pulmonary underaeration leading
to small lung volumes
finely granular (ground-glass) appearance of
the pulmonary parenchyma
peripherally extending air-bronchograms
SURFACTANT DEFICIENCY DISEASE
(SDD)
SURFACTANT DEFICIENCY DISEASE
(SDD)
 LEAKY LUNG SYNDROME
Infants who are severely hypoxic
Especially those who require assisted
ventilator therapy with high concentration of
oxygen
oxygen toxicity leads to damage of
pulmonary capillaries increased capillary
permeability pulmonary edema
LEAKY LUNG SYNDROME
 RETAINED FLUID SYNDROME
Transient Tachypnea of the Newborn
Transient Respiratory Disease of the Newborn
Wet Lung Disease
Simply a problem of retained pulmonary fluid
and is not a true disease
Increased incidence in infants delivered by CS
 RETAINED FLUID SYNDROME
Fluid is cleared by way of the peribronchial
lymphatics lymphatics overdistend
pulmonary compliance is altered respiratory
distress
Respiratory distress usually becomes apparent
by 2-4 hrs of age or even earlier
Clearing of fluid by 24 hrs or less
 RETAINED FLUID SYNDROME
Radiographic findings
> symmetrical parahilar radiating congestion
> moderate to severe overaeration of the
lungs
> occasionally, pleural effusions
RETAINED FLUID SYNDROME
 OPAQUE RIGHT LUNG SYNDROME
Not common
Represent a combination of retained fetal lung
fluid and an obstructed lung, probably
secondary to a transient mucous plug
CS-delivered babies are more prone
Condition is entirely benign
Usually relatively asymptomatic and clears
within 24-48 hrs or sooner
 NEONATAL ASPIRATION WITH OR
WITHOUT MECONIUM
Intrauterine fetal distress fetal gasping and
passage of meconium in utero
Infants with meconium aspiration are usually
postmature, depressed, and in severe
respiratory difficulty immediately after birth
Tachypnea is the most prominent feature
Widespread air trapping is the rule and results
from the particles of meconium becoming
lodged in the small peripheral bronchi
 NEONATAL ASPIRATION WITH OR
WITHOUT MECONIUM
Complications such as pneumomediastinum
and pneumothorax are common
Radiographic findings vary with the degree of
meconium aspiration
Classic meconium aspiration
> gross overaeration of the lungs and bilateral
nodular infiltrates
> pneumomediastinum and pneumothorax
are common
NEONATAL ASPIRATION WITH OR
WITHOUT MECONIUM
 NEONATAL PNEUMONIA
Most are bacterial in origin (nonhemolytic
Streptococcus, Staphylococcus aureus, and
Escherichia coli)
Viral infections (adenovirus, herpes simplex,
influenza, and parainfluenza)
More difficult to distinguish between the
patterns of bacterial and viral infections in
neonates than infants and older children
 NEONATAL PNEUMONIA
Bacterial infections alveolar
Viral infections interstitial
Radiating parahilar streakiness and diffuse
hazy, or reticulonodular lungs favor viral
disease
Coarse, patchy parenchymal infiltrates and
consolidations (rare in neonates) favor
bacterial disease
 NEONATAL PNEUMONIA
Pleural effusions are relatively common with
bacterial infections, and quite rare with viral
infections
NEONATAL PNEUMONIA
NEONATAL PNEUMONIA
BRONCHOPULMONARY DYSPLASIA
Infants placed in positive pressure ventilation
barotrauma damage to basement
membrane of pulmonary arterioles edema
prolonged ventilator-assisted therapy
overdistention of alveolar groups bubbly
lungs
Radiographic findings depends on the size of
the bubbles and the degree of associated
interstitial inflammatory change and fibrosis
BRONCHOPULMONARY DYSPLASIA
EVENTRATION OF THE DIAPHRAGM
Unilateral or bilateral
Smooth bulge blending with the
diaphragmatic leaflet
Weakness in the diaphragm that allows
upward herniation of the underlying organs
EVENTRATION OF THE DIAPHRAGM
 DIAPHRAGMATIC HERNIA
Most often through the posterior foramina of
Bochdalek
Just lateral of the spine, more common on the
left
Degree of pulmonary hypoplasia depends on
whether herniation occurs early or late in
intrauterine life
 DIAPHRAGMATIC HERNIA
Classic radiographic appearance
> left hemithorax is filled with cyst-like
structures (loops of bowel)
> mediastinum is shifted to the right
> abdomen is relatively devoid of gas
 DIAPHRAGMATIC HERNIA
Morgagni hernias, less common
> unilateral, medial and basal, anterior
> usually not large enough to cause
respiratory distress
DIAPHRAGMATIC HERNIA
DIAPHRAGMATIC HERNIA
 PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
Manifestations of terminal airway or alveolar
overdistention and subsequent rupture of
these structures
Pulmonary Interstitial Emphysema (PIE)
> air escapes into the interstitium
> air dissects along the bronchovascular
sheaths, in a radiating fashion, to the outer
periphery of the lung
 PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
Air can decompress itself directly into the
mediastinum (pneumomediastinum) or
through the visceral pleura into the pleural
space (pneumothorax)
Radiographically
> tortuous air collections radiating outward
from the hilus of the lung, and measure 2-3
mm
 PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
Thymus gland in pneumomediastinum
> elevated
> angel wings
> spinnaker sail
> rocker-bottom thymus
Thymus gland in pneumothorax is compressed
Continuous diaphragm sign
(pneumomediastinum)
PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
PNEUMOTHORAX, PNEUMOMEDIASTINUM,
INTERSTITIAL EMPHYSEMA
 CONGENITAL CYSTIC ADENOMATOID
MALFORMATION (CCAM)
Relatively rare
Type I - numerous relatively uniform air-filled
cysts
Type II - one dominant cyst with a background
of smaller cysts
Type III - a solid lesion with numerous small
cysts that are basically fluid-filled
CONGENITAL CYSTIC ADENOMATOID
MALFORMATION (CCAM)
 BRONCHOPULMONARY FOREGUT
MALFORMATION, SEQUESTRATION, ACCESSORY
LUNG
Intertwined embryologically
Pulmonary sequestrations
> located in the lower lobes
> arterial supply is from the aorta
> venous return is directed into the pulmonary
veins, systemic vein, or portal vein
 BRONCHOPULMONARY FOREGUT
MALFORMATION, SEQUESTRATION, ACCESSORY
LUNG
Radiograpically (classic appearance)
> triangular or oval shaped basal, posterior ,
medial lung mass, more common on the left
 BRONCHOPULMONARY FOREGUT
MALFORMATION, SEQUESTRATION, ACCESSORY
LUNG
POSTNATAL PULMONARY INFECTIONS
BACTERIAL INFECTIONS & THEIR
COMPLICATIONS
> present as homogenous, lobar
consolidations or fluffy alveolar infiltrates
> usually unilobar, but can be multilobar
> little or no lobar volume loss
> consolidations begin in the periphery of the
lobe
POSTNATAL PULMONARY INFECTIONS
BACTERIAL INFECTIONS & THEIR
COMPLICATIONS
> S. pneumoniae is now the most common
causative agent
> pleural effusions and empyema common
> pneumatoceles result from bronchial
obstruction
> cavitary necrosis, leading to abscess
formation
POSTNATAL PULMONARY INFECTIONS
VIRAL INFECTIONS
> generally are infections of the bronchi and
peribronchial tissues (bronchitis)
> most common pattern parahilar
peribronchial pattern
> bilateral, symmetric, with a central
predominance
POSTNATAL PULMONARY INFECTIONS
VIRAL INFECTIONS
> bronchiolitis a serious manifestation of
viral LRTI in infants < 2 y/o
> severe bronchospasm
> almost exclusively due to respiratory
syncytial virus
> overaeration of the lungs is the rule
POSTNATAL PULMONARY INFECTIONS
VIRAL INFECTIONS
> lobar, segmental, subsegmental atelectasis
- one of the most common associated
problems
> interstitial pneumonitis
- diffuse reticulonodular or diffusely hazy
infiltrates throughout both lung fields
 TUBERCULOSIS
CONGENITAL TUBERCULOSIS
- acquired transplacentally
- primary tuberculosis lodges in the liver or
adjacent LNs rather than in the lungs
- may not become apparent until 2 or 3 wks
after birth
- usually widespread infiltrates, often nodular
or fluffy
 TUBERCULOSIS
PRIMARY POSTNATAL TUBERCULOSIS
> unilateral, hilar, or paratracheal adenopathy,
with or without associated atelectasis of the
involved lung
> Ghon focus primary tuberculous
parenchymal lesion
> Ghons complex Ghon focus+hilar LAD
> Ranke complex healed primary TB
- calcified parenchymal tuberculoma +
TUBERCULOSIS
 ASTHMA
Overaeration and parahilar peribronchial
infiltrates
Virtually indistinguishable from those seen in
viral LRTI
Areas of lobar or segmental atelectasis
 CHEST MASSES
POSTERIOR MEDIASTINAL TUMORS
> usually neurogenic in origin
> neuroblastoma-ganglioneuroma complex
most common (90% of cases)
CHEST MASSES
 CHEST MASSES
MIDDLE MEDIASTINAL MASSES
> arise from lymph nodes
> lymphoma, probably most common
> demonstrate calcification after therapy
CHEST MASSES
 CHEST MASSES
ANTERIOR MEDIASTINAL TUMORS
> dermoids, teratomas, germ cell tumors
> produces posterior and lateral displacement
of the trachea and esophagus
CHEST MASSES
 THYMUS
Classic appearance: bilateral, smoothly
outlined superior mediastinal fullness,
blending almost imperceptibly with the
cardiac silhouette
Notch
Sail sign
Wavy thymus sign due to adjacent rib
compression
On lateral projection: inferior border is distinct
slightly undulating
 THYMUS
Stress Atrophy
> secondary to some illness or drugs such as
corticosteroids or chemotherapeutic agents
Rebound Hypertrophy
> with recovery or cessation of
drugs/chemotherapy
> may be exuberant
 THYMUS
Thymoma and thymolipoma are exceptionally
rare in infants and young children
THYMUS
THYMUS
THYMUS
THYMUS