Lung- and airway emergencies
Charlotte de Lange,MD,PhD
Pediatric Radiology unit,
Oslo University Hospital, Norway
5th Nordic course - Emergency Radiology
Oslo 18-21.5.2015 [email protected]
How come pediatric lung/airway
emergencies are so important
and demand rapid treatment?
www.consultant360.com
More acute emergencies than adults!
Physiology, anatomy and pathology
specific for children
Smaller, flexible airways
collateral ventilation
Large tongue
Increased metabolic rate
Rapid hemodynamic/ respiratory decompensation!
75%
44%
Airway emergencies
Upper
Lower
Traumatic
Non-traumatic
Non-traumatic
lung and lower airway emergencies
Lung and airway emergencies in different age groups
Age/
pathology
Neonate(0-1 mth)
Infant(1-23 mths)
Preschool
child (2-5 y)
Child(6-12y)
Adoles.(13-18y)
Infection Viral
bronchiolitis
Virus
Bacterial
pneumonia
Bacterial
pneumonia
Bacterial
pneumonia
Foreign
body
X
6mths-3y
X
6mths-3y
Tumor Teratoma
Neuro-
blastoma
Lymphoma
Leukemia
Histiocytosis
Lymphoma
Leukemia
Histiocytosis
Lymphoma
Leukemia
Congen .
anomalies
Heart/
lung/vasc./
tracheobron.
anomalies
Diaphr.hernia
Heart/
lung/vasc. /
tracheobron.
anomalies
Diaphr.hernia
Airleaks x x x spont.
de Lange C, Insights Imaging 2011
Clinical presentation
Stridor, cough
Wheezing
Swallowing difficulty
Respiratory distress
Tachypnea
Nasal flaring
Intercostal retractions
Hemoptysis
Failure to thrive
Fever, pain, sepsis
or
Asymptomatic!!
Chest x-ray
Ultrasonography
Computed tomography(CT)
CT/HRCT, MDCT, CTA
Magnetic resonance imaging (MRI), MRA
(PET-CT, Scintigraphy)
ALARA principle (As Low As Reasonably Acheiveable)
Imaging
en.wikipedia.org
cough
at night / with exercise
wheezing
~10-20% chest pain
Chest x-ray if complications are suspected
(air leaks/ infection)
Asthma
Pulmonary infection and
complications
Virus > Bacteriae
(airways) (alveoli)
NB! Overlapping imaging findings
Girl 3 y Boy 4 y
Viral infection Bacterial lobar pneumonia
30% of viral infections – normal x-ray findings (Durand et al 2005)
Complications to infection:
Parapneumonic effusion/ Empyema
Boy 6 y - pneumonia left lower lobe
and pleural effusion
Chest x-ray
US
CT, iv C
2-12 % parapneumonic effusion -few need drainage (Bradley 2011, Elllis 2002)
(Up to date guidelines, 2013)
Boy 13 y - ALL treatment with Asparginase,
central venous line - slight chest pain
CE CTUS w doppler
Pulmonary thrombo embolismBabyn P , Pediatr Radiol 2005 - PTE in children
Uderzo C Jclin Oncol 1995 - 2.9% of ALL pat develpped PTE
Goldenberg NA,NEJM 2005 - Predictors for outcome of ped. PTE
Victoria T Pediatr Radiol 2009- Evaluation for PTE in children with clinical suspicon
Air leaks
Pneumothorax-
neonates and ...
Adolescents
Pneumothorax/ pneumomediastinum/
subcutaneous emphysema
Chest x-ray, US
(expiratory AP views)
CT only in selected cases!
Masses
Vascular malformations
Fibromatosis
Lymphoma/leukemia
Neuroblastoma
Teratoma
Vascular malformations Boy 8 months - rapidly growing tumor in the axilla
Lymphatic
malformation
CT
Cor
MRI Ax -STIR
Boy 8 y – Previous asthma - chest pain
with increasing respiratory distress
Chest CT = acute imaging of airways
T cell lymphoma/ leukemia
Acute fatal outcome!
Congenital anomalies
Heart
Lung
Vascular
Tracheobronchial
Vascular ringschest x-ray
upper GI series
CTA/ MRA
Boy 6 months - stridor
Double aortic arch
“Always look at the airways”
Boy 1 y - Viral inf. with severe breathing problems
Tracheal deviation? Tracheo-bronchomalacia?
Bronchography/
CT – VR 3DTracheal bronchus with
stenosis and malacia
Foreign body aspiration airway/oesophagus etc
Foreign body aspirationGirl 2 y -
cough/ wheezing last 2 weeks
Chest x-ray + fluoroscopy
Medistinal shift
Airtrapping of the ipsilateral side
Diaphragmatic restricted motion
Bronchoscopy - diagnosis/treatm.
Girl 3 y. Cough for 9 mths
before first x-ray
Corpus alienum
Summary
Lung and airway emergencies in children
-respiratory and swallowing difficulties
Radiology is important for a rapid diagnosis
Radiography - still first choice
(US, CT, MRI)
”Always look at the airways”
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