PEDS CHEST
LINES & TUBES
UAL: Umbilical artery -> internal iliac artery -> aorta -> high position T6-T10 (preferred) or low position L3-L5
Avoid renal arterial thrombosis
Omphalocele is a contraindication.
UVC: Umbilical vein -> L portal vein -> ductus venosus -> hepatic vein -> IVC @ level of diaphragm
Ideal spot is at IVC-Right atrium junction; clot forming in a portal vein branch can cause lobar atrophy
PICC: SVC or IVC
ETT: in between thoracic aperture and 1 cm above carina
Chest drainage tube: midaxillary line via the 4th-6th intercostal space; apical anterior in those w/ PTX
ECMO:
Veno-Arterial (VA): RA + aorta (near origin of innominate a., "overlies the region of the AoA"); Heart & lung support (bypasses heart)
MC VA-ECMO circuit: venous tip in RA at post 8/9 rib + arterial tip in CCA origin at 2/3 post rib; Carotid artery and R jugular vein are sacrificed.
Complication: stroke 2/2 carotid artery ligation, hemorrhage 2/2 AC
Veno-Venous (VV): RA + RA (dual lumen): lung support
**Lung whiteout is normal: decreased airway pressure -> atelectasis -> fetal physiology -> o2 tension changes causing edema like pattern
AIRWAY / OBSTRUCTION
NEONATAL / ICU
CONGENITAL / NEOPLASM / MISC
Hyperinflated vs not hyperinflated
Count ribs: >6 ant or 8 Post at the diaphragm is too much
Diaphragm flattening, horizontal appearance of ribs, increased lucency under heart
TTN: Nml to hyperinflated; prominent interstitial pattern +/- pleural effusions; transient and mild; not likely to require intubation.
SDD: low lung volumes, lack of pleural fluid, diffuse GGO;
If treated, look for inhomogeneous areas of normal appearing lung on background of GGO
MAS: term infant; hyperinflation, ropey perihilar opacities; barotrauma is common (PTX, PIE, PM); asymmetric coarse lung markings b/l; ple eff is uncommon; PTX can be seen; prognosis depends on degree of aspiration and distress; can have chronic residual lung dz.
GBS neonatal PNA: low lung volumes; inhomogeneous opacities, pleural effusions
CLE: 50% <4 wk, 75% <6 months; LUL > RML > RUL; cause found in 50% w/ others likely 2/2 malacia/stenosis of bronchial cartilage; condition resulting from variety of etiologies; assoc w congenital heart dz.
Airspace opacification before fetal fluid clears on 1st day -> hyperaeration after fluid cleared and air-trapping
BPD/CLDoP: premature infancts born <32 wks; uncommon >= 34 wks; typically not seen until 3-4 wks of life; diffuse distribution; bubbly lungs
PIE: barotrauma in first week of life in premature newborns typically on ventilatory support; irregular branching linear lucencies, unilateral or focal; rapid onset
Newborn lungs are extremely noncompliant and susceptible to gas dissection into interstitium -> cause
Other forms of barotrauma (PTX, pneumomediastinum) are common.
CCAMs: localized mass w cystic and/or solid components; solid mass initially bc multiple cysts are fluid filled; local mass effect; subtypes are based on size of cysts (1 [2-10 cm], numerous small, 3 appears solid w many microcysts); can be assoc w deletions on chromo 18, type 2 lesions are associated w other congenital anomalies. risk for becoming infected and small risk of malignant degeneration (rhabdomyosarcoma)
CF: bronchiectasis (cylindrical -> varicoid); apical predominance; hyperinflation, pulm arterial hypertension, mucus plugging, infertile male (no vas deferens).
Primary ciliary dyskinesia: similar to CF but with lower lobe predominance; 50% have Kartageners, infertile male (bad cilia no swim); women are subfertile.
Asthma: increased peribronchial markings + hyperinflation
Viral infection / bronchiolitis: increased peribronchial markings + hyperinflation (80% of lower respiratory tract infections <2 yo)
Bacterial PNA: focal lung consolidation + pleural effusion; look for complications like bronchopleural fistula, tenson hydro-ptx
Can be nonspecific b/l diffuse symmetric granular type
Pleural effusion is more often seen w GBS PNA (25% of cases)
L-2-R shunts: increase pulm arterial flow mimics increased peribronchial markings. Cardiomegaly.
Aspirated bronchial foreign body: asymmetric hyperinflation
Acute chest / SC: MC in kids (2-4 yo) than adults; leading cause of death in SC; opacities on CXR; big heart, bone infarcts at humeral head; H shaped vertebra on LXR; cholecystectomy clips.
Theory: rib infarct -> decreased breathing -> atelectasis and infection; microvascular occlusion and infarction
PRIMARY LUNG TUMORS
Developmental/congenital lung lesions will be present on mid-second trimester US (2TUS).
Hx normal 2TUS + lung mass -> primary tumor
Lung mass on 2TUS -> congenital malformation
Pleuropulmonary blastoma (PPB): MC primary lung malignancy in children (<2 yo); cystic, mixed, solid; not present on 2TUS; malignant; usually right sided, pleural based and without chest wall invasion or calcification. No rib invasion (unlike Askin/Ewing sarcoma of chest wall)
Solid types tend to have mets to brain and bones
Cystic type occurs in kids <1 yo; typically more benign.
Inflammatory myofibroblastic tumor: MC primary lung mass in children; benign; solid masses, typically lobulated and calcified; lower lobe predominance; Look like fluid T2WI bc they are composed of myxoid stroma. Can look like a sequestration (arterial supply) or the solid types of PPB.
CARDIAC ANOMALIES
Pseudo-coarctation: elongation and kinking of Ao w/o BFo bstruction
AoC: Assc w PDA, BAV, VSD, ToGV
HLHS: infants w CHF 2/2 hypoplasia of left sided structures (LA, LV, AoA), enlarged pulm artery and R chambers
Truncus arteriosus: pulm arteries arise from common aortic trunk
PDA: late first week of life
Functionally closed 18-24 hrs after birth; anatomically closed 1 month; left open by postnatal hypoxia.
ASD: older children; hyperexpansion, vascular congestion
RSNA CONGENITAL VARIANT AORTIC ARCH.pdfVASCULAR RINGS & SLINGS
Pulmonary sling: only variant that goes b/n esophagus and trachea; assoc w/ tracheal stenosis and other cardiopulmonary and systemic anomalies (hypoplastic R lung, horseshoe lung, TEF, imperforate anus, complete tracheal rings. Tx is controversial but typically involves surgical repositioning.
Double AoA: MC sx vascular ring anomaly
L arch w aberrant R subclavian artery: MC AoA anomaly but not the most sx; Dysphagia Lusoria (trouble swallowing 2/2 vascular variant; Diverticulum of Kommerell: aneurysmal dilatation of the prox portion of an aberrant R subclavian artery.
CASES
PEDS CORE REVIEW CHEST.pdfPEDS CORE REVIEW CARDIAC.pdf