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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]

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  • 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 Viralbronchiolitis

    Virus

    Bacterial

    pneumonia

    Bacterial

    pneumonia

    Bacterial

    pneumonia

    Foreign

    body

    X

    6mths-3y

    X

    6mths-3y

    Tumor TeratomaNeuro-

    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

    http://en.wikipedia.org/wiki/Paediatric_radiology

  • 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”

    [email protected]