neonatal chest radiograph in the exam setting
The neonatal chest radiograph in the exam setting may strike fear into the heart of many radiology registrars, but it need not!
There are only a limited number of diagnoses that will be presented on such films and they are often highlighted by the history.
Gestation
First of all, have a look to see if the neonate is premature or not - signs of prematurity being reduction in subcutaneous fat and the lack of humeral head ossification (the latter occurs around term).
When the chest radiograph also includes the abdomen, look out for the umbilical clip. These are plastic clips used to clamp the umbilicus before it is cut at birth. The umbilical stump remains in situ for approximately 1-2 weeks and its presence helps to age the baby.
Lines and tubes
In the unwell neonate, it is likely that they will have lines and tubes - its usually worthwhile dealing with these first:
- ET tube: estimate the distance from the carina - ensure it's not down the right main bronchus
- NG tube: where is the tip? It shouldn't be at or above the GEJ, but rather projected over the stomach
- UAC (umbilical arterial catheter): it's the one that dips down into the pelvis and should have a tip above (T6-9) or below (L2-5) the renal arteries and unpaired aortic branches
- UVC (umbilical venous catheter): it should enter at the level of the umbilicus and head north with its tip at the RA/IVC junction - not in the hepatic veins (right hand side) or portal vein (left hand side)
- peripheral line (PICC): from arm, leg or scalp (!)
Many neonatal chest films have a rather enthusiastically caudal inferior border and umbilical lines can often be seen in full. For more information see the dedicated page on neonatal lines and tubes.
Diagnoses
Common things are common, and the commonest causes for respiratory distress in the immediate post-natal period can be split into causes that present in the preterm or term infant.
Preterm
- respiratory distress syndrome (RDS)
- ground-glass
- low volume lungs
Term
- transient tachypnea of the newborn (TTN)
- interstitial lines with possible small effusions
- pulmonary edema in the neonate
- usually associated with cesarian section delivery
- meconium aspiration
- bilateral patchy airspace shadowing
- commonest cause of respiratory distress in a term/postdates neonate
- large volume lungs
- air trapping with possible pneumothorax/pneumomediastinum
- small pleural effusions
If it's not one of the big-3, then you need to look for other patterns (e.g. cystic change) or predisposing factors, e.g. ventilation.
Ventilated
Ventilation may be evident by the presence of an ET tube, but remember that CPAP can be used on the neonatal unit and be the cause of ventilated associated pathology without the presence of an ET tube.
- neonatal pneumothorax
- describe the pneumothorax and explain that the apparent size of the pneumothorax under-estimates the volume of free pleural gas because the infant is supine
- look at the mediastinum and describe whether there is evidence of tension
- pulmonary interstitial emphysema (PIE)
- in the ventilated patient, gas lucencies extend to the edge of the film (i.e. they cannot be bronchi)
- look for the associated pneumothorax
In both cases, say that you'll contact the team to let them know.
Cystic changes
One cause of acute breathlessness in a neonatal patient is a mass within the hemithorax causing ipsilateral pulmonary hypoplasia/atelectasis and mediastinal shift.
- congenital diaphragmatic hernia (CDH)
- gas locules in the hemithorax
- indistinct hemidiaphragm
- congenital pulmonary airway malformation (CPAM)
- multi-cystic mass in the hemithorax
- mass effect with contra-lateral mediastinal shift
Consolidation
Confluent areas of consolidation are not particularly common in neonates, they usually have ground-glass change or patchy opacification. While confluent consolidation is not common, it may appear in an exam film.
- pulmonary sequestration
- a bit of lung that has blood supply from the aorta and whose parenchyma isn't connected to the tracheobronchial tree
- it may be consolidated and fluid-filled or undergo cystic change
- extra-lobar sequestration (the less common type) occurs in neonates
- neonatal pneumonia
- standard confluent consolidation
Other pathology
If you look at the film and you can't see anything, you need to start thinking laterally. What could they show you on a neonatal film?
- esophageal atresia
- distended pouch of gas in the upper mediastinum
- if the examiner is being kind, it will have an NG tube looped in it
- if there is gas in the stomach, there must be an accompanying congenital tracheo-esophageal fistula
- see esophageal atresia in the exam
- fractures
- birth related injury, e.g. clavicular fracture or shoulder/humerus injury
- if the child is a little older, rib fractures in non-accidental injury
Related Radiopaedia articles
Chest
- imaging techniques
- chest x-ray
- approach
- adult
- frontal projection
- lateral projection
- lateral decubitus
- congenital heart disease
- medical devices in the thorax
- common lines and tubes
- nasogastric tubes
- endotracheal tubes
- central venous catheters
- pleural catheters
- cardiac conduction devices
- prosthetic heart valve
- review areas
- pediatric
- neonatal
- adult
- airspace opacification
- differential diagnoses of airspace opacification
- lobar consolidation
- atelectasis
- mechanism-based
- morphology-based
- lobar lung collapse
- chest x-ray in the exam setting
- adult chest x-ray in the exam setting
- pediatric chest x-ray in the exam setting
- neonatal chest x-ray in the exam setting
- cardiomediastinal contour
- chest radiograph zones
- tracheal air column
- fissures
- normal chest x-ray appearance of the diaphragm
- nipple shadow
- lines and stripes
- anterior junction line
- posterior junction line
- right paratracheal stripe
- left paratracheal stripe
- posterior tracheal stripe/tracheo-esophageal stripe
- posterior wall of bronchus intermedius
- right paraspinal line
- left paraspinal line
- aortic-pulmonary stripe
- aortopulmonary window
- azygo-esophageal recess
- spaces
- signs
- air bronchogram
- big rib sign
- Chang sign
- Chen sign
- coin lesion
- continuous diaphragm sign
- dense hilum sign
- double contour sign
- egg-on-a-string sign
- extrapleural sign
- finger in glove sign
- flat waist sign
- Fleischner sign
- ginkgo leaf sign
- Golden S sign
- Hampton hump
- haystack sign
- hilum convergence sign
- hilum overlay sign
- Hoffman-Rigler sign
- holly leaf sign
- incomplete border sign
- juxtaphrenic peak sign
- Kirklin sign
- medial stripe sign
- melting ice cube sign
- more black sign
- Naclerio V sign
- Palla sign
- pericardial fat tag sign
- Shmoo sign
- silhouette sign
- snowman sign
- spinnaker sign
- steeple sign
- straight left heart border sign
- third mogul sign
- tram-track sign
- walking man sign
- water bottle sign
- wave sign
- Westermark sign
- approach
- HRCT
- chest x-ray
- airways
- bronchitis
- small airways disease
- bronchiectasis
- broncho-arterial ratio
- related conditions
- differentials by distribution
- narrowing
- tracheal stenosis
- diffuse tracheal narrowing (differential)
- bronchial stenosis
- diffuse airway narrowing (differential)
- tracheal stenosis
- diverticula
- pulmonary edema
- interstitial lung disease (ILD)
- drug-induced interstitial lung disease
- hypersensitivity pneumonitis
- acute hypersensitivity pneumonitis
- subacute hypersensitivity pneumonitis
- chronic hypersensitivity pneumonitis
- etiology
- bird fancier's lung: pigeon fancier's lung
- farmer's lung
- cheese workers' lung
- bagassosis
- mushroom worker’s lung
- malt worker’s lung
- maple bark disease
- hot tub lung
- wine maker’s lung
- woodsman’s disease
- thatched roof lung
- tobacco grower’s lung
- potato riddler’s lung
- summer-type pneumonitis
- dry rot lung
- machine operator’s lung
- humidifier lung
- shower curtain disease
- furrier’s lung
- miller’s lung
- lycoperdonosis
- saxophone lung
- idiopathic interstitial pneumonia (mnemonic)
- acute interstitial pneumonia (AIP)
- cryptogenic organizing pneumonia (COP)
- desquamative interstitial pneumonia (DIP)
- non-specific interstitial pneumonia (NSIP)
- idiopathic pleuroparenchymal fibroelastosis
- lymphoid interstitial pneumonia (LIP)
- respiratory bronchiolitis–associated interstitial lung disease (RB-ILD)
- usual interstitial pneumonia / idiopathic pulmonary fibrosis (UIP/IPF)
- pneumoconioses
- fibrotic
- non-fibrotic
- lung cancer
- non-small-cell lung cancer
- adenocarcinoma
- pre-invasive tumors
- minimally invasive tumors
- invasive tumors
- variants of invasive carcinoma
- described imaging features
- adenosquamous carcinoma
- large cell carcinoma
- primary sarcomatoid carcinoma of the lung
- squamous cell carcinoma
- salivary gland-type tumors
- adenocarcinoma
- pulmonary neuroendocrine tumors
- preinvasive lesions
- lung cancer invasion patterns
- tumor spread through air spaces (STAS)
- presence of non-lepidic patterns such as acinar, papillary, solid, or micropapillary
- myofibroblastic stroma associated with invasive tumor cells
- pleural invasion
- vascular invasion
- tumors by location
- benign neoplasms
- pulmonary metastases
- lung cancer screening
- lung cancer staging
- lung cancer staging
- IASLC (International Association for the Study of Lung Cancer) 8th edition (current)
- IASLC (International Association for the Study of Lung Cancer) 7th edition (superseeded)
- 1996 AJCC-UICC Regional Lymph Node Classification for Lung Cancer Staging
- non-small-cell lung cancer
Siehe auch:
- Lungensequester
- Ösophagusatresie
- acute respiratory distress syndrome (ARDS)
- Mekoniumaspiration
- interstitielles Lungenemphysem
- kongenitale pulmonale Atemwegsmalformation (CPAM)
- congenital tracheoesophageal fistula
- transient tachypnoea of the newborn (TTN)
- kongenitale Zwerchfellhernie
und weiter:
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