NEONATAL CHEST X-RAY

1. DR MUHAMMAD SHAHZAD
CHILDREN COMPLEX MULTAN

3. In spite of recent modalities like USG, CT
SCAN, MRI, conventional radiography is
cornerstone of imaging…

4. Chest should be straight so that both hemi
thorax can be visualized equally

5. Film should be technically satisfactory…

6. Mediastinum in neonate has much variability
and mainly consist of heart and thymus…..
Thymus can fill the whole of upper
mediastinum or is prominent on right side or
left……..

7. Apart from viewing pulmonary, cardiac, and
pleural pathology, neonatal x-ray is used to
demonstrate the position of various lines and
tubes……

8. Endotracheal intubation
A.
Preferred location is halfway between the thoracic inlet and
carina
B.
If ett is too low, it will enter into right main bronchus
C.
Chest film may show asymmetric aeration with both
hyperinflation and atelactasis
D.
If tube extends below carina and does not match tracheal air
column, suspect esophageal intubation
E.
Ett placed too high has tip above clavicle , x-ray film may show
diffuse atelactasis

9. Nasogastric tube
Tip should be in mid stomach

10. Umblical vein catheterization

At junction of inferior vena cava and right
atrium

Degree and position of patient rotation affect
how the UVC appears positioned on
radiograph……..

11. Umbilical artery catheterization

Cochrane review states that high catheters
should be used exclusively

Recent analysis showed a decreased risk of
vascular complications and no increased risk
of hypertension, necrotizing enterocolitis,
IVH or hematuria….

Low catheters are associated with increased
risk of vasospasms………..

12. PULMONARY DISEASES
A. RDS
a fine, diffuse reticulogranular pattern is
seen secondary to microatelectasis of
alveoli. The chest radiograghs reveals
radiolucent areas known as air
bronchograms, produced by air in major
airways and contrasted with the opacified
alveoli

13. B. MECONIUM ASPIRATION SYNDROME
Bilateral, patchy, coarse infiltrates and
hyperinflation of lungs are present. there
is also an increased incidence of
pneumothorax…

14. C. PNEUMONIA
Diffuse alveolar or interstitial disease that is
usually asymmetric and localized.
group b streptococcal pneumonia can
appear similar to respiratory distress
syndrome (rds).pneumatoceles ( air –
filled lung cysts ) can occur with
staphylococcal pneumonia.
Pleural effusions or empyema may occur
with any bacterial pneumonia…

16. 
Extensive bilateral (right greater than left)
streaky interstitial pulmonary opacities
with airspace opacification at the right
base. Features are non-specific.

18. 
48 hours later, there has been an
improvement in appearances with
reduction in the degree of basal
opacification.

19. D. TRANSIENT TACHYPNEA OF NEWBORN
Hyper aeration with symmetric peri hilar
interstitial infiltrates are typical.
Pleural fluid may occur as well, appear as
widening of pleural space or as
prominence of the minor fissure

21. 
Bilateral extensive interstitial and alveolar
opacities that are predominantly
perihilar.

22. 
Nasal oxygen is being delivered. The
patient is rotated. Interstitial copacity in
all areas both lungs with thickening of
horizontal fissure. Note sternal ossification
centres projected over right lung. No
effusions or pneumothorax.

24. E. BRONCHOPULMONARY DYSPLASIA
Now more commonly referred to as
chronic lung disease….
Radiographic appearance is highly
variable, from a fine, hazy appearance
of the lungs to mildly coarsened lung
markings to a coarse, cystic lung
pattern..
Typically occurring in ventilated premature
neonates.
Cld minimally requires a 7-10 days to
develop

26. 
Bronchopulmonary Dysplasia. The lungs
are usually overaerated, in this case the
left
more than the right. There are diffuse
rope-like densities separated in some
areas by zones of hyperlucency. The
densities are coalescent in many areas.
The heart borders are completely
obliterated

27. F. AIR LEAKY SYNDROMES
1.
2.
Pneumopericardium
air surrounds the heart, including the inferior border..
cardiac tamponade may result..
Pneumomediastinum
a. AP view
hyperlucent rim of air is present lateral to the
cardiac border and beneath the thymus, displacing
the thymus superiorly away from the cardiac
silhouette (“angel wing sign” )
b. lateral view
an air collection is seen either substernally (anterior
pneumomediastinum ) or in the retrocardiac area (
posterior pneumomediastinum)

28. 3.
Pneumothorax
lung is typically displaced away from
the lateral chest wall by a radiolucent
zone of air…
Adjacent lung may be collapsed with
larger pneumothoraces
small pneumothorax may be very
difficult to identify with only a subtle
zone of air peripherally, a diffusely
hyperlucent hemithorax, unusually
sharply defined cardiothymic margins or
a combination of these…

29. 4.
Tension pneumothorax
diaphragm on affected side is
depressed
mediastinum is shifted to contralateral
hemithorax.
collapse of ipsilateral lobes is evident…

30. 5.
Pulmonary interstitial emphysema
single or multiple circular radiolucencies with
well-demarcated walls are seen in a
localized or diffuse pattern..the volume of
the involved portion of the lung is usually
increased.
PIE usually occurs in ventilated preemies with
RDS within initial few days of life…..

31. G. ATELECTASIS
A decrease in lung volume or collapse of
part or all of a lung is apparent,
appearing as areas of increased
opacity. the mediastinum may be shifted
toward the side of collapse.
Compensatory hyperinflation of the
opposite lung may be present.
1. MICROATELECTASIS
non obstructed atelectasis associated
with rds..

32. 2. GENERALIZED ATELECTASIS
diffuse increase in opacity
(“whiteout”) of lungs is visible on the
chest film. It may be seen in severe
rds, airway obstruction, if the
endotracheal tube is not in the
trachea, and hypoventilation…
3. LOBAR ATELECTASIS
Atelectasis of one lobe
Most common site is right upper lobe
Right minor fissure is usually elevated
Often occur after extubation

33. H . Pulmonary hypoplasia
small lung volumes and a bell shaped
thorax are seen . The lungs usually
appear radiolucent

34. I . Pulmonary oedema
lungs appear diffusely hazy with an area
of greatest density around the hilum of
each lung. Heart size is usually
increased…

35. Cardiothoracic ratio, which normally
should be less than 0.6 is the width of the
base of the heart divided by the width of
the lower thorax
 An index more than 0.6 indicate
cardiomegaly
 Pulmonary vascularity is increased if the
diameter of descending branch of right
pulmonary artery exceeds that of
trachea…


36. A . Cardiac dextroversion.
•
•
•
Cardiac apex is on right side..
Aortic arch and stomach bubble are
On left side..
Incidence of congenital heart disease
is very high, more than 90 %.

37. B . CONGESTIVE HEART FAILURE
cardiomegaly, pulmonary venous
congestion ( engorgement and
increased diameter of the pulmonary
veins ), diffuse opacification of perihilar
region and pleural effusion are seen..

38. C . Patent ductus arteriosus
Cardiomegaly,, pulmonary edema, ductal
haze ( pulmonary edema with a patent
ductus arteriosus ), and increased
pulmonary vascular markings are
evident …

39. D . Ventricular septal defect
Cardiomegaly, an increase in pulmonary
vascular density, enlargement of the left
ventricle and left atrium, and
enlargement of the main pulmonary
artery

40. E . Coarctation of aorta
1. preductal coarctation
generalized Cardiomegaly with
normal pulmonary vascularity is seen.
2. postductal coarctation
enlarged left ventricle and left atrium
and a dilating ascending aorta are
present

41. F . Tetrology of fallot
heart is boot shaped
normal left atrium and left ventricle is
associated with an enlarged,
hypertrophied right ventricle and a small
or absent main pulmonary artery. There is
decreased pulmonary vascularity. A right
aortic arch occur in approx 25% of
patients

42. G . TRANSP0SITION OF GREAT ARTERIES
Cardiomegaly, enlarged right atrium and
right ventricle, narrow mediastinum and
increase pulmonary vascular markings
But in most cases, chest film appears
normal.

43. H . TOTAL ANOMALOUS PULMONARY
VENOUS RETURN
Pulmonary venous marking are
increased…
Cardiomegaly is minimal or absent..
Congestive heart failure and pulmonary
edema may be present…esp with type 3
TAPVR ( subdiaphragmatic )

44. I . Hypoplastic left heart syndrome
chest film may be normal at first
may show cardiomegaly and pulmonary
congestion and enlargement of right
atrium and ventricle…

45. J . Tricuspid atresia
Heart size is usually normal or small, the
main pulmonary artery is concave and
pulmonary vascularity is decreased

46. Truncus arteriosus
cardiomegaly, increased pulmonary
vascularity , and enlargement of left
atrium.
a right aortic arch occur in 30% of
patients….

47. I . ATRIAL SEPTAL DEFECT
•
•
•
•
varying degrees of enlargement of
right atrium and ventricle is seen
aorta and left ventricle is small
pulmonary artery is large
increased pulmonary vascularity is
evident

48. M . Ebstein anomaly
Gross cardiomegaly and decreased
pulmonary vascularity are
apparent
Right heart border is prominent as a result
of right atrial enlargement

49. N . Valvular pulmonic stenosis
Heart size and pulmonary blood flow is
usually normal unless the stenosis is
severe.
Dilatation of main pulmonary artery is
main chest film finding

50. thanks