Neonatal X-rays

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Neonatal X-rays : 

Neonatal X-rays DR.MAULIK SHAH MD.(PED) ASSOCIATE PROFESSOR –PEDIATRICS M.P.SHAH MEDICAL COLLEGE JAMNAGAR (GUJRAT)

Welcome to a BLACK & WHITE world..! : 

UMBILICAL LINES Basics HOW TO READ SKELETAL QUIZ AIR LEAKS ET TUBE Parenchymal DISEASE ABDOMINAL BIRTH TRAUMA Welcome to a BLACK & WHITE world..!

Why do we need it ? : 

To confirm the cause of respiratory distress. To find cause for resp.deterioration in patient. To confirm tube/lines placement. To note Cardiac situs and pulm.vascularity. To note injury in Birth trauma. As a part of skeletal survey. Why do we need it ?

How to read ? : 

How to read ? Examine the entire film “ABCF" approach A – Abdomen B – Bone C – Chest F- Foreign bodies

‘A ‘ for Abdomen : 

‘A ‘ for Abdomen Diaphragm position Fundal gas shadow Liver position Bowel gas pattern Free intraperitoneal air Abdominal situs Abnormal calcifications Vertebral anamalies Abdominal findings are missed often as we are ‘ target(chest) oriented ‘….!!!

‘B’ for BONES : 

‘B’ for BONES Fractures Lytic or blastic lesions Metabolic bone diseases Most newborn X-Rays are AP films so vertebral columns are much clearly visible.

‘C’ for CHEST : 

‘C’ for CHEST Trachea Mediastinum Lungs Pulmonary vascularity, Pleura

What’s normal ? : 

What’s normal ? Cylindrical chest Horizontal Ribs Thymus (CT ratio – 0.6) Diaphragm position(6/8) Foreign bodies in right places

What’s normal ? : 

What’s normal ?

What’s normal ? : 

What’s normal ? inspiration expiration mid expiration

Prominent Thymus : 

Prominent Thymus ‘sail sign ‘

Rotated x ray : 

Rotated x ray

Skin folds producing shadows : 

Skin folds producing shadows ???

Lordotic view of normal xray : 

Lordotic view of normal xray

What is hyper inflation? : 

What is hyper inflation? Lung expansion > 6 rib ant/ 8 rib post. Flattening of diaphragm Increased Leucency of lungs. Air under heart. Herniating lung to opposite side More horizontal ribs

RDS : 

RDS Small volume lungs Reticulo Granular opacities Homogenous "ground glass" opacity Air bronchograms

Surfactant makes a difference…! : 

Surfactant makes a difference…! A miraculous drug given…

D/Ds for RDS : 

D/Ds for RDS Pneumonia Pulmo.Edema(PDA) Pulm.Hemorrhage Under ventilated TTNB

‘CPAP BELLY’ : 

‘CPAP BELLY’

Transient Tachypnoea of the Newborn : 

Transient Tachypnoea of the Newborn Increased central vascular markings ("star-burst" appearance) Hyperaeration Normal / Increased Lung Volume Evidence of interstitial and pleural fluid Prominent interlobar fissures Mild Cardiomegaly

MAS : 

MAS Hyperinflation Coarse infiltrates Widespread consolidation Pleural effusions Air Leaks.

Patent Ductus arteriosus : 

Patent Ductus arteriosus

Pneumonia : 

Pneumonia

Pneumonias : 

Pneumonias Patchy alveolar / interestitial involvement Consolidation Usually preserved or normal lung volume.

Listeria pneumonia in MAS : 

Listeria pneumonia in MAS

E.Coli pneumonia with effusion : 

E.Coli pneumonia with effusion

Slide 27: 

Single XRAY is not diagnostic at times continuous follow up clinically is mandatory.

Pneumo mediastinum : 

Pneumo mediastinum What’s this ?

Pneumo pericardium : 

Pneumo pericardium

Pneumothorax : 

Pneumothorax

Pneumo thorax : 

Pneumo thorax Hyper expansion Increased transleucency Abcence of pulm.markings Collapsed lung Shift of mediastium (if unilateral) Presence of air under neath.

AIR LEAKS : 

A MAULIK SHAH PRESENTATION AIR LEAKS

Pulmonary interstitial Emphysema : 

Pulmonary interstitial Emphysema

Congenital Lobar Emphysema (CLE) : 

Congenital Lobar Emphysema (CLE) overdistension of a lobe. left upper lobe (43% ) right middle lobe (32% ) right upper lobe (20% ) mediastinal shift DD: CCAM CDH Lung Cyst

CCAM : 

CCAM

CCAM : 

CCAM Multiple large air or fluid filled cysts Mediastinal shift compression of adjacent lung Three types Type I –commonest DD: CDH Sequastration Infected pneumatocele

Congenital diaphragmatic hernia : 

Congenital diaphragmatic hernia Anterior aspect R L

Congenital diaphragmatic hernia : 

Congenital diaphragmatic hernia Cystic-bubles In Chest. Mediastinal Shift D/D Bochdalek Hernia Morgagni Hernia Eventration Cyst. Adenomatous Malformation Congenital lobar emphysema

CDHlook at the NG tube coiling : 

CDHlook at the NG tube coiling

Congenital diaphragmatic hernia : 

Congenital diaphragmatic hernia

NEC : 

NEC

RADIOLOGICAL FINDINGS : 

RADIOLOGICAL FINDINGS Pneumatosis Intestinalis hydrogen gas within the bowel wall product of bacterial metabolism a. linear streaking pattern more diagnostic b. bubbly pattern appears like retained meconium less specific a maulik shah presentation

Slide 43: 

Pneumatosis Intestinalis

Slide 44: 

Bell stage 2 – pneumatosis intestinalis

Bell stage III -Pneumo peritonium : 

Bell stage III -Pneumo peritonium Portal Venous Gas extension of pneumatosis intestinalis into the portal venous circulation linear branching lucencies overlying the liver and extending to the periphery associated with severe disease and high mortality Portal Gas pneumoperitonium

Bell stage III -Pneumo peritonium : 

Bell stage III -Pneumo peritonium a maulik shah presentation

Pneumo peritoneum Intestinal Perforation : 

Pneumo peritoneum Intestinal Perforation

Duodenal atresia : 

Duodenal atresia "double bubble“ a distended stomach and the blind-ended duodenum.  association with trisomy -21. 2 1

Tracheo Esophageal Fistula : 

Tracheo Esophageal Fistula

Severe TOF : 

Severe TOF

Inguinal hernia : 

Inguinal hernia

Birth trauma : 

Birth trauma FRACTURE CLAVICLE A linear lucency at the lateral one third of the clavicle. more frequently on the right side.

Fracture humerus : 

Fracture humerus

Phrenic nerve palsy : 

Phrenic nerve palsy Elevated hemi diaphragm(>2 space). Shift of mediastinum. Associated birth trauma.

Neuro Muscular Paralysis : 

Neuro Muscular Paralysis Bell shaped thorax Soft tissue edema Decreased or absent bowel gas

Absent clavicle Cleido cranial dysostosis : 

Absent clavicle Cleido cranial dysostosis

Osteogenesis imperfecta : 

Osteogenesis imperfecta 4 recognised types

Cranio syno stosisno visible sutures : 

Cranio syno stosisno visible sutures

Wormian bones : 

Wormian bones

Wormian bones : 

Wormian bones P - Pyknodysostosis O - Osteogenesis imperfecta R - Rickets K - Kinky hair syndrome C - Cleidocranial dysostosis H - Hypothyroidism / Hypophosphatasia O - Otopalatodigital syndrome P - Primary acroosteolysis (Hajdu-Cheney)/ Pachydermoperiostosis / Progeria S - Syndrome of Downs

Pulmonary Hypoplasia Due to Skeletal Dysplasia : 

Pulmonary Hypoplasia Due to Skeletal Dysplasia

FOREIGN BODIES : 

FOREIGN BODIES Endotracheal tube (ETT) tip: beneath the thoracic inlet and above the carina Nasogastric tube (NGT) tip: within the stomach Central venous line tip placed from subclavian/jugular/antecubital approaches should be within the superior vena cava (SVC) Central venous line tips (femoral ) in the inferior vena cava (IVC) [below L3] or at the junction of the inferior vena cava and right atrium (RA) Umbilical artery catheter (UAC) tip: high [between T7 and T11] or low [below L3]. Umbilical venous catheter (UVC) tip: at the junction of the right atrium (RA) and the superior vena cava (SVC).

Endo tracheal tube placement : 

Endo tracheal tube placement Correct position 2 cm above carina In middle 1/3 of trachea.

Abnormal et tube placement : 

Abnormal et tube placement HIGH TOO LOW On RIGHT LOW

UAC : 

UAC High: T6- T9 Lower : L3 – L4

UVC correct position : 

UVC correct position 0.5 -1 cm above the diaphragm(in IVC)

UAC - UVC : 

UAC - UVC The UAC -T6: OK The UVC is at T7. Ideally, both should be above the diaphragm.  The UAC should be between T6 and T9 1. The UVC should be in the IVC as it enters the right atrium.

UAC HIGH : 

UAC HIGH

UAC & UVC – both low : 

UAC & UVC – both low

So many foreign bodies : 

So many foreign bodies Ductal clip

DIAGNOSIS ? : 

DIAGNOSIS ?

QUIZ -1 : 

QUIZ -1

HMD with High ET : 

HMD with High ET Low Lung Volume Horizontal Ribs Reticulogranular Opacity Bilateral No Fluid ? Preterm Age High Et Tube

QUIZ -2 : 

QUIZ -2

Low ET – low UVC in ? HMD : 

Low ET – low UVC in ? HMD Normal-Lung Volume Horizontal Ribs Reticulogranular Opacity Bilateral basal No Fluid ? Preterm Age ET – too low One line above diaphragm & one below diaphram.

ET too low : 

ET too low

Pneumo mediastinum with THYMUS right lobe elevated : 

Pneumo mediastinum with THYMUS right lobe elevated

Respiratory distress with low UAC : 

Respiratory distress with low UAC Low-Lung Volume Horizontal Ribs Some patchy Opacity present No Fluid/Air leak ? Preterm Age ET – OK One line below diaphram curves & goes up - UAC.

Right pneumothorax : 

Right pneumothorax

WHAT WRONG ? : 

WHAT WRONG ?

HMD with low ET : 

HMD with low ET

HMD – high NG & radio contrast in lower intestine : 

HMD – high NG & radio contrast in lower intestine

PIE – RT pneumo thorax – High ET : 

PIE – RT pneumo thorax – High ET

Low ET- LOW UVC : 

Low ET- LOW UVC

ET right main bronchus(too low) : 

ET right main bronchus(too low)

PIE on left , right PneumothoraxHigh ET Position : 

PIE on left , right PneumothoraxHigh ET Position

Pneumo Mediastinumthymus pushed up by air on right : 

Pneumo Mediastinumthymus pushed up by air on right

UVC IVC …RA… ? ASDUAC high in aorta … possibly in arch : 

UVC IVC …RA… ? ASDUAC high in aorta … possibly in arch

PIE – high ET : 

PIE – high ET

Situs Invertus : 

Situs Invertus R

CDH : 

CDH

Wrong Et Placement IN HMD : 

Wrong Et Placement IN HMD

STAGE 4 RDS : 

STAGE 4 RDS

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